L. Vaidyanathan

Statins in Ischemic Stroke: Just Low-Density Lipoprotein Lowering or More?

BACKGROUND Statins have been shown to improve the functional outcome of patients after an ischemic stroke. We hypothesized that daily statin intake improves functional outcome after an acute ischemic stroke in patients with low-density lipoprotein (LDL) less than or equal to 100 mg/dL. METHODS This was a prospective cohort study during a 22-month period of patients presenting with an acute ischemic stroke and lipid profiles measured. The functional disability was determined using modified Rankin scale score (0-2 good outcome, 3-6 bad outcome) at discharge. Chi-square test for binary data and nonparametric tests for nonnormally distributed variables were used for analysis. RESULTS Of 508 patients, 207 presented with an LDL of 100 mg/dL or less and were included in the analysis. There was no significant difference in admission stroke severity (National Institutes of Health Stroke Scale [NIHSS]; P = .18), age (P = .31), and sex (P = .06) between those taking statins and not taking statins. Patients with LDL less than or equal to 100 mg/dL and taking statins (n = 100) were significantly more likely to have a good functional outcome (odds ratio 1.91; 95% confidence interval 1.05-3.47) when compared with those not on the medication. After adjusting for age, sex, and NIHSS, statin intake still predicted a better functional outcome (P < .0001). CONCLUSION Daily statin intake appears to result in a better functional outcome after an ischemic stroke in patients with ideal LDL levels (<or=100 mg/dL) before and after adjusting for age and stroke severity. Pleiotropic effects of statins may play a role in this.

Knowledge of signs, treatment and need for urgent management in patients presenting with an acute ischaemic stroke or transient ischaemic attack: A prospective study

Objective: To assess stroke awareness among patients presenting to the emergency department with an acute ischaemic stroke or transient ischaemic attack (TIA). Methods: A consecutive cohort of patients presenting with a cerebrovascular event was prospectively enrolled over a 15-month period and questionnaires were administered. If the patient was unable to respond to the questions or answer the questionnaire, it was administered to the primary caregiver. Comprehension of having a cerebrovascular event, reason for delay in presentation, mode of arrival and knowledge of treatment modalities were determined. Results: Only 42% of 400 patients thought they were having a stroke or TIA. The median time to presentation was 3.4 h. Delayed presentation was almost equal in men and women. When asked about onset, 19.4% thought that a stroke came on gradually and only 51.9% thought immediate presentation was crucial. 20.8% of patients had heard of thrombolysis. Conclusion: Community knowledge of ischaemic stroke needs to be enhanced so that individuals present earlier, leading to timely management.

Rhythm Control With Electrocardioversion for Atrial Fibrillation and Flutter

SYSTEMATIC REVIEW SOURCE This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Mead GE, Elder AT, Flapan AD, et al. Electrical cardioversion for atrial fibrillation and flutter. Cochrane Database Syst Rev. 2005;(3): CD002903. The Annals’ EBEM editors helped prepare the abstract of this Cochrane systematic review, as well as the Evidence-Based Medicine Teaching Points.

Dobutamine-induced complete heart block.

Dobutamine is commonly administered as a pharmacologic stressor in patients with limitations precluding exercise testing. The case report presented is one of transient complete heart block resulting from dobutamine sestamibi stress testing. Shortly after initiating the dobutamine infusion, the patient became pale and presyncopal, with hypotension and a heart rate of 50 beats per minute. Subsequently, third-degree heart block developed which lasted transiently and resolved. Subsequent cardiac evaluation of the patient revealed no cardiac etiology for her symptoms. Though bradycardia is infrequently noted in patients receiving dobutamine during stress electrocardiogram, complete heart block is a possibility during dobutamine-induced stress echocardiography and must be recognized as a potential risk.

The Triglyceride Paradox in Stroke Survivors: A Prospective Study

Objective. The purpose of our study was to understand the association between serum triglycerides and outcomes in acute ischemic stroke (AIS) patients. Methods. A cohort of all adult patients presenting to the Emergency Department (ED) with an AIS from March 2004 to December 2005 were selected. The lipid profile levels were measured within 24 hours of stroke onset. Demographics, admission stroke severity (NIHSS), functional outcome at discharge (modified Rankin Scale (mRS)), and mortality at 3 months were recorded. Results. The final cohort consisted of 334 subjects. A lower level of triglycerides at presentation was found to be significantly associated with worse National Institutes of Health Stroke Scale (NIHSS) (P = 0.004), worse mRS (P = 0.02), and death at 3 months (P = 0.0035). After adjusting for age and gender and NIHSS, the association between triglyceride and mortality at 3 months was not significant (P = 0.26). Conclusion. Lower triglyceride levels seem to be associated with a worse prognosis in AIS.

The impact of blood pressure hemodynamics in acute ischemic stroke: a prospective cohort study

ObjectiveTo assess relationships between blood pressure hemodynamic measures and outcomes after acute ischemic stroke, including stroke severity, disability and death.MethodsThe study cohort consisted of 189 patients who presented to our emergency department with ischemic stroke of less than 24 hours onset who had hemodynamic parameters recorded and available for review. Blood pressure (BP) was non-invasively measured at 5 minute intervals for the length of the patients emergency department stay. Systolic BP (sBP) and diastolic BP (dBP) were measured for each patient and a differential (the maximum minus the minimum BP) calculated. Three outcomes were studied: stroke severity, disability at hospital discharge, and death at 90 days. Statistical tests used included Spearman correlations (for stroke severity), Wilcoxon test (for disability) and Cox models (for death).ResultsLarger differentials of either dBP (p = 0.003) or sBP (p < 0.001) were significantly associated with more severe strokes. A greater dBP (p = 0.019) or sBP (p = 0.036) differential was associated with a significantly worse functional outcome at hospital discharge. Those patients with larger differentials of either dBP (p = 0.008) or sBP (0.007) were also significantly more likely to be dead at 90 days, independently of the basal BP.ConclusionA large differential in either systolic or diastolic blood pressure within 24 hours of symptom onset in acute ischemic stroke appears to be associated with more severe strokes, worse functional outcome and early death

Role of Abciximab in the Management of Acute Ischemic Stroke

This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Ciccone A, Abraha I, Santilli I. Glycoprotein IIb-IIIa inhibitors for acute ischaemic stroke. Cochrane Review 2006; Issue 4. Chichester, UK: John Wiley and Sons. DOI:10.1002/14651858.CD005208.pub2. The Annals’ EBEM editors helped prepare the abstract of this Cochrane systematic review, as well as the Evidence-Based Medicine Teaching Points.

Fred M. Smith, MD.

In 1918, Fred M. Smith made pioneering observations on the electrocardiographic (ECG) abnormalities following experimental ligation of the coronary arteries in dogs. This research and related clinical observations led Smith and his mentor, Chicago internist James B. Herrick, to advocate using the ECG as a tool to help doctors diagnose acute coronary thrombosis. Born on a farm in Yale, Illinois on May 31, 1888, Smith received his medical degree from Chicago’s Rush Medical School in 1914. He spent the next 2 years in postgraduate training at the Presbyterian Hospital in that city.1–3 It was during this period that he began working with Herrick, a prominent internist who had already published classic papers describing sickle cell anemia and coronary thrombosis.4 Herrick, who was very interested in coronary heart disease, encouraged Smith to study the ECG abnormalities associated with experimental coronary occlusion. This groundbreaking research changed the approach to the diagnosis of myocardial infarction in humans. English physician William Heberden described angina pectoris in 1772, but it would be almost 140 years before Herrick published the first article describing the pathophysiology and clinical picture of acute coronary thrombosis.5 One of Herrick’s main conclusions—that acute coronary thrombosis was not invariably fatal—had almost no immediate impact on practice, because doctors had no objective means to differentiate this event from other serious clinical conditions.6 Smith’s animal research provided the vital clue that led to the conclusion that the ECG could help doctors diagnose acute coronary thrombosis. Other investigators had studied various physiological and pathological effects of experimental coronary occlusion in the late nineteenth century, but they did not have a method to evaluate the heart’s electrical system. Willem Einthoven invented a string galvanometer that could record the ECG in 1902, and this instrument was first used in the United States 7 years later. The recognition of the importance of the ECG in the diagnosis of coronary artery disease would stimulate the diffusion of the technique into clinical practice during the 1920s. Smith published his classic paper, ‘‘The Ligation of Coronary Arteries with Electrocardiographic Study’’ in 1918.7 In this paper, he reported his experiments on 66 anesthetized dogs in whom various coronary artery branches were ligated. Smith recorded ECGs before and, at varying intervals, after the ligations. Some of the dogs survived for weeks making it possible to record serial ECG tracings. Tracings following ligation of either branch of the left coronary artery revealed T-wave patterns that ‘‘were among the most constant and most reliable’’ ECG abnormalities. Typically, the T-waves went from a ‘‘strongly positive peak to a markedly negative, and then a slower return to the positive or isoelectric form.’’7 (quote from p. 19). He concluded that the severity of the ECG changes following coronary ligation varied directly with the size of the arterial branch occluded. A clinician as well as a researcher, Smith proposed that the consistent finding of abnormal T-wave morphology ‘‘may be of considerable value from a diagnostic point of view, at least as concerns the left coronary artery.’’ In his final paragraph, Smith alerted readers to a forthcoming case report. ‘‘In fact,’’ he wrote, ‘‘one case in man, which will be reported later, was observed in which a clinical diagnosis of coronary thrombosis was made by Dr. James B. Herrick which was later verified at necropsy. The T-wave of the ECG of the patient ran a course similar to that of the dogs previously described. In other cases believed to be coronary thrombosis, similar changes in the ECG have been seen but no verification of the diagnosis has been made, the patients either living or no necropsy having been obtained.’’7 (quotes from p. 27). Later in 1918, Herrick reported 3 patients who he believed had died as a result of coronary thrombosis, including the man Smith mentioned in his paper.8 This 42-year-old physician with no prior cardiac history presented with severe chest pain radiating to his arms and hypotension. The man’s symptoms improved, and he was seen as an outpatient 2 wk later by Smith, who was then functioning as an assistant in Herrick’s practice. Smith suspected the man had survived an episode of acute coronary thrombosis. Herrick saw the patient subsequently and agreed. An ECG recorded 41 d after the event thought to represent acute coronary thrombosis revealed T-wave inversions almost identical to those Smith had recorded in the dogs with experimental coronary ligation. The doctor-patient died suddenly several months later as he was beginning to recover from pneumonia. An autopsy revealed a scarred left ventricle and old thrombi in the left anterior descending and circumflex coronary arteries. In 1923, Smith reported the ECG findings in 10 patients with ‘‘typical manifestations of coronary artery occlusion’’ and in 1 man whose left anterior descending coronary artery was ligated during emergency surgical repair of a stab wound of the heart. He concluded, ‘‘Experimental and clinical observations justify the belief that the ECG