Janine Gronewold

Coronary Artery Calcification Is an Independent Stroke Predictor in the General Population

Background and Purpose— Coronary artery calcification (CAC) is a noninvasive marker of plaque load that predicts myocardial infarcts in the general population. Herein, we investigated whether CAC predicts stroke events in addition to established risk factors that are part of the Framingham risk score. Methods— A total of 4180 subjects from the population-based Heinz Nixdorf Recall study (45–75 years of age; 47.1% men) without previous stroke, coronary heart disease, or myocardial infarction were evaluated for stroke events over 94.9±19.4 months. Cox proportional hazards regressions were used to examine CAC as stroke predictor in addition to established vascular risk factors (age, sex, systolic blood pressure, low-density lipoprotein, high-density lipoprotein, diabetes mellitus, smoking, and atrial fibrillation). Results— Ninety-two incident strokes occurred (82 ischemic, 10 hemorrhagic). Subjects suffering a stroke had significantly higher CAC values at baseline than the remaining subjects (median, 104.8[Q1;Q3, 14.0;482.2] vs 11.2[0;106.2]; P<0.001). In a multivariable Cox regression, log10(CAC+1) was an independent stroke predictor (hazards ratio, 1.52 [95% confidence interval, 1.19–1.92]; P=0.001) in addition to age (1.35 per 5 years [1.15–1.59]; P<0.001), systolic blood pressure (1.25 per 10 mm Hg [1.14–1.37]; P<0.001), and smoking (1.75 [1.07–2.87]; P=0.025). CAC predicted stroke in men and women, particularly in subjects <65 years of age and independent of atrial fibrillation. CAC discriminated stroke risk specifically in participants belonging to the low (<10%) and intermediate (10%–20%) Framingham risk score categories. Conclusions— CAC is an independent stroke predictor in addition to classical risk factors in subjects at low or intermediate vascular risk.

The prevalence, severity, and association with HbA1c and fibrinogen of cognitive impairment in chronic kidney disease

Cognitive impairment is a frequent finding in patients with chronic kidney disease (CKD). We examined cognitive performance in a prospective study of 119 patients with CKD stages 3-5 (including dialysis) and 54 control patients of the same age without CKD but with similar vascular risk profiles. Analysis included a comprehensive test battery evaluating memory, information processing speed, executive function, language, and visuoconstructive function, in addition to depression and anxiety. Thirty percent of patients with CKD had cognitive deficits (one or more s.d. below control patient performance). Cognitive deficits (T-value related to published norm values) were mild but significantly decreased to 48.8 in patients with stage 3-5 CKD not requiring hemodialysis and 47.2 in patients with stage 5D disease requiring hemodialysis, compared with 51.5 in control patients. Linear regressions among patients with CKD (forced entry strategy) showed that age (β=-0.50 per s.d.), HbA1c (β=-0.18 per s.d.), and fibrinogen (β=-0.18 per s.d.) predicted cognitive performance. Interestingly, HbA1c discriminated cognition in all age groups, while fibrinogen differentiated cognition particularly in patients over 70 years of age. Thus, our cross-sectional study suggests the severity of cognitive impairment in CKD is mild. As such, longitudinal studies are required to further characterize the role of cognitive deficits in CKD.

Ankle–brachial index predicts stroke in the general population in addition to classical risk factors

BACKGROUND Predictors of future stroke events gain importance in vascular medicine. Herein, we investigated the value of the ankle-brachial index (ABI), a simple non-invasive marker of atherosclerosis, as stroke predictor in addition to established risk factors that are part of the Framingham risk score (FRS). METHODS 4299 subjects from the population-based Heinz Nixdorf Recall study (45-75 years; 47.3% men) without previous stroke, coronary heart disease or myocardial infarcts were followed up for ischemic and hemorrhagic stroke events over 109.0±23.3 months. Cox proportional hazard regressions were used to evaluate ABI as stroke predictor in addition to established vascular risk factors (age, sex, systolic blood pressure, LDL, HDL, diabetes, smoking). RESULTS 104 incident strokes (93 ischemic) occurred (incidence rate: 2.69/1000 person-years). Subjects suffering stroke had significantly lower ABI values at baseline than the remaining subjects (1.03±0.22 vs. 1.13±0.14, p<0.001). In a multivariable Cox regression, ABI predicted stroke in addition to classical risk factors (hazard ratio=0.77 per 0.1, 95% confidence interval=0.69-0.86). ABI predicted stroke events in subjects above and below 65 years, both in men and women. ABI specifically influenced stroke risk in subjects belonging to the highest (>13%) and intermediate (8-13%) FRS tercile. In these subjects, stroke incidence was 28.13 and 8.13/1000 person-years, respectively, for ABI<0.9, compared with 3.97 and 2.07/1000 person-years for 0.9≤ABI≤1.3. CONCLUSIONS ABI predicts stroke in the general population, specifically in subjects with classical risk factors, where ABI identifies subjects at particularly high stroke risk.

Thoracic aortic calcification is associated with incident stroke in the general population in addition to established risk factors

AIMS The aorta is a major source of cerebral thromboembolism, but its role in stroke pathogenesis is not well understood due to its poor accessibility for non-invasive imaging. We examined whether thoracic aortic calcification (TAC), a marker of aortic plaque load, is associated with stroke in addition to established risk factors. METHODS AND RESULTS A total of 3930 subjects from the population-based Heinz Nixdorf Recall study (45-75 years; 47.1% men) without previous stroke, coronary heart disease, or myocardial infarction were evaluated for incident stroke events over 109.0 ± 23.3 months. Cox proportional hazards regressions were used to examine associations with stroke of TAC in addition to established risk factors (age, sex, systolic blood pressure, LDL, HDL, diabetes, and smoking) and coronary artery calcification (CAC). 101 incident strokes occurred during the follow-up period. Subjects suffering a stroke had significantly higher TAC values at baseline than the remaining subjects (median = 83.1 [Q1;Q3 = 4.7;472.9] vs. 15.7 [0.0;117.1]; P < 0.001). In a multivariable Cox proportional hazards regression, log(TAC + 1) (hazards ratio [HR] = 1.09 [95% confidence interval = 1.00-1.19]; P = 0.044) was associated with stroke in addition to established risk factors. Further analyses revealed that log(DTAC + 1), i.e. calcification of the descending aorta (1.11 [1.02-1.20]; P = 0.016), but not log(ATAC + 1), i.e. calcification of the ascending aorta (1.02 [0.93-1.11]; P = 0.713), was associated with stroke. The HR for log(TAC + 1) decreased to 1.06 (0.97-1.16; P = 0.202), when log(CAC + 1) was also inserted into multivariable analyses. CONCLUSION Calcification of the thoracic aorta, more specifically its descending segment, is associated with incident stroke in addition to established risk factors. CAC outperforms aortic calcification as a stroke predictor.

Physical, Cognitive and Emotional Factors Contributing to Quality of Life, Functional Health and Participation in Community Dwelling in Chronic Kidney Disease

Background Quality of life (QoL) impairment is a well-known consequence of chronic kidney disease (CKD). The factors influencing QoL and late life functional health are poorly examined. Methods Using questionnaires combined with neuropsychological examinations, we prospectively evaluated physical, cognitive, and emotional factors influencing QoL, functional health and participation in community dwelling in 119 patients with CKD stages 3–5 including hemodialysis (61.5±15.7years; 63% men) and 54 control patients of the same age without CKD but with similar cardiovascular risk profile. Results Compared with control patients, CKD patients showed impairment of the physical component of QoL and overall function, assessed by the SF-36 and LLFDI, whereas disability, assessed by LLFDI, was selectively impaired in CKD patients on hemodialysis. Multivariable linear regressions (forced entry) confirmed earlier findings that CKD stage (β = −0.24; p = 0.012) and depression (β = −0.30; p = 0.009) predicted the QoL physical component. Hitherto unknown, CKD stage (β = −0.23; p = 0.007), cognition (β = 0.20; p = 0.018), and depression (β = −0.51; <0.001) predicted disability assessed by the LLFDI, while age (β = −0.20; p = 0.023), male gender (B = 5.01; p = 0.004), CKD stage (β = −0.23; p = 0.005), stroke history (B = −9.00; p = 0.034), and depression (β = −0.41; p<0.001) predicted overall function. Interestingly, functional health deficits, cognitive disturbances, depression, and anxiety were evident almost only in CKD patients with coronary heart disease (found in 34.2% of CKD patients). The physical component of QoL and functional health decreased with age and depressive symptoms, and increased with cognitive abilities. Conclusions In CKD, QoL, functional health, and participation in community dwelling are influenced by physical, cognitive, and emotional factors, most prominently in coronary heart disease patients.

B-type natriuretic peptide predicts stroke of presumable cardioembolic origin in addition to coronary artery calcification

B‐type natriuretric peptide (BNP) is a marker of cardiac dysfunction that is released from myocytes in response to ventricular wall stress. Previous studies suggested that BNP predicts stroke events in addition to classical risk factors. It was suggested that the BNP‐associated risk results from coronary atherosclerosis or atrial fibrillation.

Coronary Artery Calcification, Intima-Media Thickness, and Ankle-Brachial Index Are Complementary Stroke Predictors

Background and Purpose— Coronary artery calcification (CAC), a marker of coronary atherosclerosis, predicts stroke in addition to established risk factors. Whether CAC’s predictive value can be improved by peripheral atherosclerosis markers, namely carotid intima-media thickness (CIMT) and ankle-brachial index (ABI), was unknown. Methods— A total of 3289 participants of the population-based Heinz Nixdorf Recall study (45–75 years; 48.8% men) without previous stroke or coronary heart disease were evaluated for incident stroke for 9.0±1.9 years. CAC, CIMT, and ABI were examined as stroke predictors. Results— Eighty-four strokes occurred during follow-up. In multivariable Cox proportional hazard regressions, CAC (hazard ratio, 1.45 [95% confidence interval, 1.11–1.88] per SD increase in ln(CAC+1); SD, 2.40), CIMT (1.34 [1.08–1.66] per SD increase; SD, 0.127 mm), and ABI (1.55 [1.32–1.82] per SD decrease; SD, 0.148) were associated with stroke in addition to established risk factors. When combined with each other, ln(CAC+1)’s hazard ratio remained similar when CIMT (1.41 [1.09–1.83]) was inserted into the multivariable model, but slightly decreased when ABI (1.31 [1.01–1.72]) or CIMT and ABI (1.29 [0.99–1.68]) were included. Although CAC alone did not significantly elevate the area under the curve in Harrell’s c-statistics (by 0.009; P=0.379) in addition to established risk factors, the combination of CAC and ABI increased area under the curve (by 0.029; P=0.047), as did ABI (by 0.025; P=0.038) but not CIMT (by 0.002; P=0.795) alone. The combination of CAC and ABI also resulted in significant category-free net reclassification and integrated discrimination improvement. Conclusions— CAC, CIMT, and ABI provide complementary information about stroke risk. ABI, which is distinctive in a small subpopulation, had the highest and CIMT, which is distributed across a larger range of values, had the lowest predictive value.

Intima-media thickness predicts stroke risk in the Heinz Nixdorf Recall study in association with vascular risk factors, age and gender

BACKGROUND AND PURPOSE Individual risk stratification requires reliable information on preexisting vascular disease. The intima-media thickness of the common carotid artery (CIMT) is a non-invasively accessible marker of atherosclerosis, which can be used for risk evaluation. METHODS In a sample of 3669 initially stroke-free subjects aged 45-75 years belonging to the population-based Heinz Nixdorf Recall cohort, the predictive value of CIMT for incident stroke was evaluated over 85.3 ± 17.4 months in addition to established risk factors. RESULTS In a multivariable Cox regression analysis with traditional cardiovascular risk factors including age, gender, systolic blood pressure, LDL and HDL, diabetes, body mass index, smoking and CIMT, CIMT was a moderate stroke predictor (hazard ratio = 1.20 per 0.1 mm, 95% confidence interval = 1.01-1.44; p = 0.043), additional to e.g. age (1.46 per 5 years, 1.21-1.75; p < 0.001), systolic blood pressure (1.16 per 10 mm Hg, 1.04-1.30; p = 0.008) and current smoking (1.93, 1.12-3.31; p = 0.014). CIMT was associated with stroke risk in subjects above but not below 65 years. CIMT predicted stroke events in men, but not women. CIMT discriminated stroke incidence specifically in subjects belonging to the highest Framingham risk score tercile. CONCLUSIONS CIMT is a moderate independent stroke predictor, which discriminates stroke incidence in subjects at high vascular risk.

Identification of hospitalized elderly patients at risk for adverse in-hospital outcomes in a university orthopedics and trauma surgery environment

Background As a consequence of demographic changes, hospitals are confronted with increasing numbers of elderly patients, who are at high risk of adverse events during hospitalization. Geriatric risk screening followed by comprehensive geriatric assessment (CGA) and treatment has been requested by geriatric societies and task forces to identify patients at risk. Since empirical evidence on factors predisposing to adverse hospital events is scarce, we now prospectively evaluated implications of geriatric risk screening followed by CGA in a university hospital department of orthopedics and trauma surgery. Methods Three hundred and eighty-one patients ≥75 years admitted to the Department of Orthopedics and Trauma Surgery of the University Hospital Essen received Identification of Seniors at Risk (ISAR) Screening followed by CGA via a geriatric liaison service in case of positive screening results. Associations between ISAR, CGA, comorbid risk factors and diseases, length of hospital stay, number of nursing and physiotherapy hours, and falls during hospital stay were analyzed. Results Of 381 ISAR screenings, 327 (85.8%) were positive, confirming a high percentage of patients at risk of adverse events. Of these, 300 CGAs revealed 82.7% abnormal results, indicating activities of daily living impairment combined with cognitive, emotional or mobility disturbances. Abnormal CGA resulted in a longer hospital stay (14.0±10.3 days in ISAR+/CGA abnormal compared with 7.6±7.0 days in ISAR+/CGA normal and 8.1±5.4 days in ISAR-, both p<0.001), increased nursing hours (3.4±1.1 hours/day in ISAR+/CGA abnormal compared with 2.5±1.0 hours/day in ISAR+/CGA normal and 2.2±0.8 hours/day in ISAR-, both p<0.001), and increased falls (7.3% in ISAR+/CGA abnormal, 0% in ISAR+/CGA normal, 1.9% in ISAR-). Physiotherapy hours were only significantly increased in ISAR+/CGA abnormal (3.0±2.7 hours) compared with in ISAR+/CGA normal (1.6±1.4 hours, p<0.001) whereas the comparison with ISAR- (2.4±2.4 hours) did not reach significance (p = 0.368). In multivariable regressions, the CGA domains activities of daily living impairment (assessed by Barthel-Index) and signs of depression (assessed by geriatric depression scale) predicted longer length of hospital stay. High ISAR score, and impairment in activities of daily living and cognition (assessed by mini-mental state examination and clock-drawing test) predicted increased nursing hours, and impairment in activities of daily living and mobility predicted increased physiotherapy hours. Conclusions An abnormal geriatric screening and assessment is associated with longer hospital stay, more nursing and physiotherapy hours, and more falls.

Supporting Elderly Patients at Risk in Hospital Environments

Copyright: