Yk Wong

Prognostic implications of surrogate markers of atherosclerosis in low to intermediate risk patients with Type 2 Diabetes

BackgroundType 2 diabetes mellitus (T2DM) patients are at increased risk of developing cardiovascular events. Unfortunately traditional risk assessment scores, including the Framingham Risk Score (FRS), have only modest accuracy in cardiovascular risk prediction in these patients.MethodsWe sought to determine the prognostic values of different non-invasive markers of atherosclerosis, including brachial artery endothelial function, carotid artery atheroma burden, ankle-brachial index, arterial stiffness and computed tomography coronary artery calcium score (CACS) in 151 T2DM Chinese patients that were identified low-intermediate risk from the FRS recalibrated for Chinese (<20% risk in 10 years). Patients were prospectively followed-up and presence of atherosclerotic events documented for a mean duration of 61 ± 16 months.ResultsA total of 17 atherosclerotic events in 16 patients (11%) occurred during the follow-up period. The mean FRS of the study population was 5.0 ± 4.6% and area under curve (AUC) from receiver operating characteristic curve analysis for prediction of atherosclerotic events was 0.59 ± 0.07 (P = 0.21). Among different vascular assessments, CACS > 40 had the best prognostic value (AUC 0.81 ± 0.06, P < 0.01) and offered significantly better accuracy in prediction compared with FRS (P = 0.038 for AUC comparisons). Combination of FRS with CACS or other surrogate vascular markers did not further improve the prognostic values over CACS alone. Multivariate Cox regression analysis identified CACS > 40 as an independent predictor of atherosclerotic events in T2DM patients (Hazards Ratio 27.11, 95% Confidence Interval 3.36-218.81, P = 0.002).ConclusionsIn T2DM patients identified as low-intermediate risk by the FRS, a raised CACS > 40 was an independent predictor for atherosclerotic events.

Long-term prognostic implications of visit-to-visit blood pressure variability in patients with ischemic stroke.

BACKGROUND Blood pressure (BP) variability (BPV) is a novel risk factor for the development of atherosclerotic diseases. High BPV has recently been shown to predict all-cause and cardiovascular mortality in patients with lacunar infarct. Whether BPV has prognostic implications in patients with ischemic stroke subtypes, other than those due to small-vessel occlusion, remains uncertain. METHODS We prospectively followed up the clinical outcome of 632 consecutive ischemic stroke patients without atrial fibrillation. The average BP and BPV, as determined by the coefficient of variation of the systolic and diastolic BP, were recorded during a mean 12 ± 6 outpatient clinic visits. RESULTS The average age of the population was 71 ± 11 years. After a mean of 76 ± 18 months of follow-up, 161 patients died (26%); 35% (n = 56 of 161) of these deaths were due to cardiovascular causes. Sixteen percent and 5% developed recurrent stroke and acute coronary syndrome (ACS), respectively. After adjusting for mean systolic BP and confounding variables, patients with high systolic BPV were at significantly greater risk of cardiovascular mortality (hazards ratio (HR) = 2.36; 95% confidence interval (CI) = 1.02-5.49; P < 0.05). High systolic BPV also predicted all-cause mortality after adjusting for mean systolic BP (HR = 1.79; 95% CI = 1.16-2.75; P < 0.05). There was no association between systolic BPV and nonfatal recurrent stroke or nonfatal ACS. Raised diastolic BPV did not predict recurrent nonfatal stroke, nonfatal ACS, or mortality. CONCLUSIONS Visit-to-visit systolic BPV predicts long-term all-cause and cardiovascular mortality in patients with ischemic stroke without atrial fibrillation, independent of other conventional risk factors, including average BP control.

Visit-to-visit blood pressure variability as a prognostic marker in patients with cardiovascular and cerebrovascular diseases – Relationships and comparisons with vascular markers of atherosclerosis

BACKGROUND Visit-to-visit blood pressure variability (BPV) is a simple surrogate marker for the development of atherosclerotic diseases, cardiovascular and all-cause mortality. Nevertheless, the relative prognostic value of BPV in comparison with other established vascular assessments remain uncertain. METHODS We prospectively followed-up 656 high-risk patients with diabetes or established cardiovascular or cerebrovascular diseases for the occurrence of major adverse cardiovascular events (MACEs). Baseline brachial endothelial function, carotid intima-media thickness (IMT) and plaque burden, ankle-brachial index and arterial stiffness were determined. Visit-to-visit BPV were recorded during a mean 18 ± 9 outpatient clinic visits. RESULTS After a mean 81 ± 12 months follow-up, 123 patients (19%) developed MACEs. Patients who developed a MACE had significantly higher systolic BPV, more severe endothelial function, arterial stiffness and systemic atherosclerotic burden compared to patients who did not develop a MACE (all P<0.01). BPV significantly correlated with all of the vascular assessments (P<0.01). A high carotid IMT had the greatest prognostic value in predicting development of a MACE (area under receiver operating characteristic curve (AUC) 0.69 ± 0.03, P<0.01). A high BPV also had moderate prognostic value in prediction of MACE (AUC 0.65 ± 0.03, P<0.01). After adjustment of confounding factors, a high BPV remained a significant independent predictor of MACE (hazards ratio 1.67, 95% confidence interval 1.14-2.43, P<0.01). CONCLUSIONS Compared with established surrogate markers of atherosclerosis, visit-to-visit BPV provides similar prognostic information and may represent a new and simple marker for adverse outcomes in patients with vascular diseases.

Mediterranean-Style Diet Is Associated With Reduced Blood Pressure Variability and Subsequent Stroke Risk in Patients With Coronary Artery Disease

BACKGROUND AND PURPOSE The Mediterranean-style diet is widely advocated for the prevention of cardiovascular diseases (CVD). Meanwhile, blood pressure variability (BPV) is a novel risk factor for CVD. It is unknown whether dietary pattern plays a role in modulating BPV. METHODS We prospectively followed-up 274 consecutive patients with stable coronary artery disease (CAD). The Mediterranean diet score (MDS) was derived for all individuals upon recruitment, blood pressure (BP) was measured during each subsequent clinic visit and the visit-to-visit BPV was calculated. The occurrence of major adverse cardiovascular events (MACEs) and all-cause mortality was monitored. RESULTS After a mean follow-up of 77±12 months, 16.1% of the study population developed MACEs. About 11.3% died from all causes. Patients who developed MACEs or all-cause mortality had a greater systolic BPV compared to those who did not develop an adverse event. Patients who developed a MACE had a lower MDS and further analysis revealed those who developed a stroke had a lower MDS compared with those who did not develop a stroke, but there were no significant differences in MDS between CAD patients with or without subsequent acute coronary syndrome, cardiovascular, or all-cause mortality. After adjusting for confounding variables, a high MDS was an independent predictor for low systolic BPV (B -0.74, 95% confidence interval -1.27 to -0.21, P < 0.01) and was noted to be protective against subsequent development of stroke (hazards ratio 0.48, 95% confidence interval 0.24 to 0.94, P = 0.03). CONCLUSIONS Among patients with CAD, a higher MDS is associated with a lower visit-to-visit BPV and with lower stroke risk.

Visit-to-visit systolic blood pressure variability predicts all-cause and cardiovascular mortality after lacunar infarct

Both blood pressure (BP) and its variability (BPV) are established risk factors for development of atherosclerotic disease and are associated with an increased risk for cardiovascular and all‐cause mortality. The prognostic implications of outpatient clinic visit‐to‐visit BPV amongst patients with lacunar infarction are nevertheless unknown.

Garlic intake is an independent predictor of endothelial function in patients with ischemic stroke.

ObjetivesTo investigate the effects of garlic on endothelial function in patients with ischemic stroke (ISS). Design: Cross-sectional study.Participants125 Chinese patients with prior ISS due to athero-thrombotic disease were recruited from the outpatient clinics during July 2005 to December 2006.MeasurementsDaily allium vegetable intake (including garlic, onions, Chinese chives and shallots) was ascertained by means of a validated food frequency questionnaire for Chinese and brachial artery flow-mediated dilatation (FMD) was measured using high-resolution ultrasound in all subjects.ResultsThe mean age of the study population was 65.9±11.1 years and 69% were males. Mean allium vegetable intake and garlic intake of the study population was 7.5±12.7g/day and 2.9±8.8g/day respectively. Their mean FMD was 2.6±2.3%. Daily intake of total allium vegetable (r=0.36, P<0.01) and garlic (r=0.34, P<0.01) significantly correlated with FMD. Using the median daily allium intake as cut-off (3.37g/day), patients with a low allium intake <3.37g/day was noted to have a lower FMD compared to those with a normal allium intake (2.1±2.1% versus 3.0±2.4%, P<0.05). After adjusting for confounding factors, multi-variate analysis identified that daily allium vegetable (B=0.05, 95% confidence interval: 0.02, 0.09, P<0.01) and garlic (B=0.07, 95% confidence interval: 0.02, 0.12, P<0.01) intake, but not onions, Chinese chives and shallots were independent predictors for changes in FMD in patients with ISS.ConclusionsDaily garlic intake is an independent predictor of endothelial function in patients with ISS and may play a role in the secondary prevention of atherosclerotic events.

Stroke Patients with a Past History of Cancer Are at Increased Risk of Recurrent Stroke and Cardiovascular Mortality

Background and Purpose Cancer patients are at increased risk of cardiovascular and cerebrovascular events. It is unclear whether cancer confers any additional risk for recurrent stroke or cardiovascular mortality after stroke. Methods This was a single center, observational study of 1,105 consecutive Chinese ischemic stroke patients recruited from a large stroke rehabilitation unit based in Hong Kong. We sought to determine whether patients with cancer are at higher risk of recurrent stroke and cardiovascular mortality. Results Amongst 1,105 patients, 58 patients (5.2%) had cancer, of whom 74% were in remission. After a mean follow-up of 76±18 months, 241 patients developed a recurrent stroke: 22 in patients with cancer (38%, annual incidence 13.94%/year), substantially more than those without cancer (21%, 4.65%/year) (p<0.01). In a Cox regression model, cancer, age and atrial fibrillation were the 3 independent predictors of recurrent stroke with a hazard ratio (HR) of 2.42 (95% confidence interval (CI): 1.54–3.80), 1.01 (1.00–1.03) and 1.35 (1.01–1.82) respectively. Likewise, patients with cancer had a higher cardiovascular mortality compared with those without cancer (4.30%/year vs. 2.35%/year, p = 0.08). In Cox regression analysis, cancer (HR: 2.08, 95% CI: 1.08–4.02), age (HR: 1.04, 95% CI 1.02–1.06), heart failure (HR: 3.06, 95% CI 1.72–5.47) and significant carotid atherosclerosis (HR: 1.55, 95% CI 1.02–2.36) were independent predictors for cardiovascular mortality. Conclusions Stroke patients with a past history of cancer are at increased risk of recurrent stroke and cardiovascular mortality.

Long‐Term Prognostic Implications of Cerebral Microbleeds in Chinese Patients With Ischemic Stroke

Background This study was performed to determine the clinical correlates and long‐term prognostic implications of microbleed burden and location in Chinese patients with ischemic stroke. Methods and Results We recruited 1003 predominantly Chinese patients with ischemic stroke who received magnetic resonance imaging at the University of Hong Kong. We determined the clinical correlates of microbleeds and the long‐term risks (3126 patient‐years of follow‐up) of recurrent ischemic stroke and intracerebral hemorrhage (ICH) by microbleed burden (0 versus 1, 2–4, and ≥5) and location, adjusting for age, sex, and vascular risk factors and stratified by antithrombotic use. Microbleeds were present in 450 of 1003 of the study population (119/450 had ≥5, 187/450 had mixed location). Having ≥5 microbleeds was independently associated with prior antiplatelet and anticoagulant use, whereas microbleeds of mixed location were independently associated with hypertension and prior anticoagulant use (all P<0.05). Microbleed burden was associated with an increased risk of ICH (microbleed burden versus no microbleeds: 1 microbleed: multivariate hazard ratio: 0.59 [95% confidence interval, 0.07–5.05]; 2–4 microbleeds: multivariate hazard ratio: 2.14 [95% confidence interval, 0.50–9.12]; ≥5 microbleeds: multivariate hazard ratio: 9.51 [95% confidence interval, 3.25–27.81]; P trend<0.0001), but the relationship of microbleed burden and risk of recurrent ischemic stroke was not significant (P trend=0.054). Similar findings were noted in the 862 of 1003 patients treated with antiplatelet agents only (ICH: P trend<0.0001; ischemic stroke P trend=0.096). Multivariate analysis revealed that, independent of vascular risk factors, antithrombotic use, and other neuroimaging markers of small vessel disease, having ≥5 microbleeds (multivariate hazard ratio: 6.08 [95% confidence interval, 1.11–33.21]; P=0.037) was identified as an independent predictor of subsequent ICH, but neither microbleed burden nor location was predictive of recurrent ischemic stroke risk. Conclusions In Chinese patients with ischemic stroke, a high burden of cerebral microbleeds was significantly associated with an increased risk of ICH; however, neither microbleed location nor burden was associated with recurrent ischemic stroke risk.

Prognostic indicators of neuromuscular disorders for palliative care referral

BACKGROUND Most of the neuromuscular disorders (NMDs) have poor prognosis and lead to various symptoms amendable to palliative care. However, the suitable time of referral is uncertain. METHODS A retrospective study was conducted to describe the trajectories of NMDs. Early death within one year after NMD diagnosis was set as the outcome. Total of 86 adult NMD patients were recruited in a university hospital. Demographic variable including gender, age at diagnosis and early-onset symptoms including dyspnea, dysphagia, loss of mobility, constipation, mood and sleep disorders, and pain were correlated with the outcome. Prediction models for early death were tested. RESULTS Age at NMD diagnosis, early-onsets dyspnea, dysphagia, constipation and impaired mobility were found to have statistically significant correlation with early death. A prediction model consisted of these four factors had area under receiver operating characteristic (ROC) curve of 0.919. CONCLUSIONS Elder age at NMD diagnosis, early-onset dyspnea, dysphagia, constipation and impaired mobility within the first year after NMD diagnosis may predict mortality within the first year after diagnosis. It may provide guidance to clinicians for early palliative care referral in this patient group.

Cancer patients are at increased risk of recurrent stroke and cardiovascular mortality

WCN 2013 No: 1538 Topic: 3 — Stroke Stroke awareness in Munich and Moscow Y. Fris, P. Kamchatnov, R. Kalla. The Russian National Research Medical University, Moscow, Russia; Ludwig–Maximilians-University Munich, Klinikum Groshadern, Munich, Germany Background: Different data of public stroke awareness in several researches may result from different methods of investigations. Objectives: We aimed to compare the stroke awareness among patients in Moscow and Munich. Material andmethods: 180 patients in Moscow (48% female, mean age 63.09 ± 13.83) and 180 patients in Munich (47.8% female, mean age 61.12 ± 14) hospitals, divided into three groups (after stroke, high risk of stroke and without risk of stroke) answered 33 questions, including 4 open-ended questions about stroke symptoms (SS) and risk factors (RF). Results: In group of patients without risk of stroke the difference in number of SS named was not significant. In group of patients with high risk of stroke the awareness of SS (1.96 ± 1.28 in Munich and 1.03 ± 1.07 in Moscow, p = 0.000) and the awareness of stroke RF (2.25 ± 1.29 in Munich and 1.34 ± 1.2 in Moscow, p = 0.000) were better among patients in Munich. In group of patients with stroke in anamnesis the awareness of SS (2.08 ± 0.99 inMunich and 1.25 ± 0.89 in Moscow, p = 0.000) was also better among patients in Munich. The difference in awareness of stroke RF in this group was not significant. The direct dialogue with the doctor and specialized brochure was named as most preferable forms of increasing the knowledge of risk factors and stroke symptoms. Conclusion: The educational activities inMoscow should be focused on patients with high risk of stroke and should increase the recognition of stroke onset and highlight the importance of early hospitalization. doi:10.1016/j.jns.2013.07.814 Abstract — WCN 2013 No: 1550 Topic: 3 — Stroke Arterial CNS involvement in Behcets disease WCN 2013 No: 1550 Topic: 3 — Stroke Arterial CNS involvement in Behcets disease G. Akman-Demir, E. Shugaiv, M. Kurtuncu, M. Mutlu, N. YesilotBarlas, E. Tuzun, O. Coban, S. Bahar. Department of Neurology, Istanbul Bilim University Medical School, Turkey; Department of Neurology, Istanbul University Faculty of Medicine, Turkey; Department of Neurology, Istanbul University School of Medicine, Istanbul, Turkey Background and objective: Although Behcet disease (BD) tends to involve vascular structures, the incidence of arterial involvement is far behind that of venous involvement. In this study, we evaluated all the cases with BD and arterial CNS involvement. Methods: All the files of Neuro-Behcet outpatient clinic of Istanbul Medical Faculty were retrospectively evaluated. Demographical findings, clinical characteristics and radiological findings were evaluated. Results: Between 1984 and 2011 there were 18 cases with BD and cranial arterial involvement out of 400 patients with neurological involvement. 4were female and 14weremale (M:F = 3.5). Their age at arterial CNS involvement ranged between 25 and 64 years (median: 42; 42.5 ± 11.7). 15 had presented with acute hemiparesis/hemiplegia, accompanied by aphasia in two, ataxia in one, crossed brainstem syndrome in two patients. One patient had an asymptomatic intracranial aneurysm. One patient presented with seizures due to ACA infarct, and one patient presented with multiple cranial neuropathies due to external carotid aneurysm. One of the female patients had an underlying rheumatic mitral stenosis, and 3 patients were over age 50 which may suggest that stroke may not be directly associated to BD in those 4 cases. In 2 patients vasculitic involvement could be shown on angiography. In the remaining patients no other etiologies were found. Conclusions: Arterial CNS involvement is rarely seen in BD. A minority of those cases could be shown to have vasculitis. Other etiological factors unrelated to BD should be sought exclusively in such cases before attributing the stroke to BD. doi:10.1016/j.jns.2013.07.815 Abstract — WCN 2013 No: 1572 Topic: 3 — Stroke Cancer patients are at increased risk of recurrent stroke and cardiovascular mortality WCN 2013 No: 1572 Topic: 3 — Stroke Cancer patients are at increased risk of recurrent stroke and cardiovascular mortality K.K. Lau, Y.-K. Wong, K.-H. Chan, K.-C. Teo, S.F.-K. Hon, W. Mak, R.T.-F. Cheung, S.-L. Ho, L.S.-W. Li, H.-F. Tse, C.-W. Siu. The University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region Background: Cancer patients are at increased risk of cardiovascular and cerebrovascular events. However, the risk of recurrent stroke or cardiovascular mortality amongst cancer patients with stroke is currently unknown. Objective: To determine the risk of recurrent stroke and cardiovascular mortality in cancer patients with ischemic stroke. Patients and methods: This is a single center, observational study comparing the clinical characteristics and outcome of 58 ischemic stroke patients with cancer to 1047 ischemic stroke patients without cancer recruited from 2004 to 2008. Mean follow-up period was 76 ± 18months. Primary endpoint was recurrent stroke and secondary endpoint was cardiovascular mortality. Results: The three most common malignancies were breast (17%), colorectal (14%) and nasopharynx (13%). 26% of cancer subjects had active malignancy and 7% had metastatic disease. 22 patients with cancer (38%, 13.94 per 100 patient-years) and 219 patients without cancer (21%, 4.65 per 100 patient-years) developed a recurrent stroke (p b 0.01). 13 patients with cancer (22%, 4.3 per 100 patientyears) and 143 patients without cancer (14%, 2.35 per 100 patientyears, p = 0.08) died due to cardiovascular causes. After adjusting for age, gender, cardiovascular risk factors and co-morbidities, cancer was an independent predictor for recurrent stroke (HR 2.68; 95% CI: 1.58 to 4.54, p b 0.01) and cardiovascular mortality (HR 2.17; 95% CI: 1.12 to 4.22, p= 0.02). Conclusion: Stroke patients with underlying cancer are at increased risk of developing recurrent stroke and cardiovascular mortality. doi:10.1016/j.jns.2013.07.816 Abstracts / Journal of the Neurological Sciences 333 (2013) e152–e214 e204