Stroke Horizon Scanning Bulletin Volume 11 Issue 11

Statin-based therapy for primary and secondary prevention of ischemic stroke: A meta-analysis and critical overview

Source British Journal of Neuroscience Nursing

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Date of publication: 29^th October 2019

Publication type: Journal Article

In a nutshell:

Abstract

Background and aims

To reassess the effect of statin-based lipid-lowering therapy on ischemic stroke in primary and secondary prevention trials with regard to achieved levels of low-density lipoprotein-cholesterol in view of the availability of novel potent hypolipidemic agents.

Methods

English literature was searched (up to November 2018) for publications restricted to trials with a minimum enrolment of 1000 and 500 subjects for primary and secondary prevention, respectively, meeting the following criteria: adult population, randomized controlled design, and recorded outcome data on ischemic stroke events. Data were meta-analyzed and curve-estimation procedure was applied to estimate regression statistics and produce related plots.

Results

Four primary prevention trials and four secondary prevention trials fulfilled the eligibility criteria. Lipid-lowering therapy was associated with a lower risk of ischemic stroke in primary (risk ratio, RR 0.70, 95% confidence interval, CI, 0.60–0.82; p < 0.001) and in the secondary prevention setting (RR 0.80, 95% CI 0.70–0.90; p < 0.001). Curve-estimation procedure revealed a linear relationship between the absolute risk reduction of ischemic stroke and active treatment-achieved low-density lipoprotein-cholesterol levels in secondary prevention (adjusted R-square 0.90) in support of “the lower the better” hypothesis for stroke survivors. On the other hand, the cubic model followed the observed data well in primary prevention (adjusted R-square 0.98), indicating greater absolute risk reduction in high-risk cardiovascular disease-free individuals.

Conclusions

Statin-based lipid-lowering is effective both for primary and secondary prevention of ischemic stroke. Most benefit derives from targeting disease-free individuals at high cardiovascular risk, and by achieving low treatment targets for low-density lipoprotein-cholesterol in stroke survivors.

Length of publication: Online article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Long-term Outcomes of Critically Ill Patients With Stroke Requiring Mechanical Ventilation.

Source: American Journal of Critical Care

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Date of publication: November 2019

Publication type: Online Article

In a nutshell:

Background

Data on outcomes of critically ill patients requiring mechanical ventilation at the onset of stroke are limited. Objective To assess the hospital and long-term functional outcomes of patients with stroke who require mechanical ventilation.

Methods

This retrospective single-center cohort study performed from 1994 to 2008 involved adult patients within 7 days of stroke onset and who required intensive care unit admission and mechanical ventilation.

Results

A total of 274 patients requiring mechanical ventilation at the onset of stroke were analyzed. Indications for intubation included coma in 195 patients (71%). The median (interquartile range) score on the Glasgow Coma Scale at admission to the intensive care unit was 6 (3-9). Forty-four patients (16%) had sepsis at intensive care unit admission. The overall hospital mortality rate was 53%. After adjustment for confounders, severity of illness at admission as assessed by the Simplified Acute Physiology Score II (odds ratio, 1.07; 95% CI, 1.05-1.10), anisocoria (odds ratio, 5.26; 95% CI, 1.76-15.80), and sepsis at intensive care unit admission (odds ratio, 0.40; 95% CI, 0.19-0.85) were associated with outcome. At 1 year, median (interquartile range) modified Rankin Scale score was 6 (2-6). Only 89 patients (32%) exhibited mild to moderate neurologic impairment.

Conclusion

In this study, adult patients requiring mechanical ventilation at the onset of stroke experienced high 1-year mortality, with survivors having poor functional status.

Length of publication: Online article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

An interdisciplinary approach to inhospital stroke improves stroke detection and treatment time

Source: Journal of NeuroInterventional Surgery (JNIS)

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Date of publication: November 2019

Publication type: Journal Article

In a nutshell:

Abstract

Background Inhospital stroke (IHS) is associated with high morbidity and mortality, likely related to multiple factors, including delayed time to recognition, associated comorbidities, and initial care from non-stroke trained providers. We hypothesized that guided revision of a formalized ‘stroke code’ system can improve diagnosis and time to thrombolysis and thrombectomy.

Methods IHS activations occurring at a comprehensive stroke center between 2013 and 2016 were retrospectively analyzed to guide revisions of an established stroke code protocol to improve provider communication and time to imaging, reduce stroke mimic rate, and improve the use of parallel processing. After protocol implementation, we prospectively collected data between 2016 and 2017 for comparison with the pre-implementation group, including diagnostic accuracy and relevant time points (code call to examination, examination to imaging, and imaging to intervention). We report descriptive statistics for comparison of patient characteristics and time metrics (time to imaging and reperfusion after IHS activation). Multivariable regression analysis was performed to identify independent predictors of stroke mimics and time metrics.

Results There were 136 cases in the pre-implementation group and 69 in the post-implementation group. A reduction in stroke mimics (52% vs 33%, P=0.01) occurred after protocol initiation. Mean time to imaging after stroke code call was 7.6 min shorter (P=0.026) and mean time from imaging to acute reperfusion therapy was 45.7 vs 19.8 min (P=0.05) in the pre- versus the post-implementation group.

Conclusion Revision of an existing IHS protocol was associated with a lower rate of stroke mimics, and a shorter time to intravenous and intra-arterial intervention.

Length of publication: Online Article

Some important notes:  Please contact your local NHS library for the full text of this article. Follow this link to find your local NHS library.

Difficulty sleeping linked with raised risk of heart attack and stroke

Source: NHS Behind the Headlines

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Date of publication: 7^th November 2019

Publication type: News Article

In a nutshell:

“Can’t sleep? Insomnia means you’re at risk of heart attack and stroke,” warns The Sun.

Insomnia is a common problem. Symptoms can include trouble getting to sleep, trouble staying asleep or waking too early, and this can make it hard to focus during the day. The condition is often linked to anxiety or stress.

A study of almost half a million people in China found that those who reported trouble getting to sleep, waking too early or not being able to function properly in the daytime had a small increased risk of having a heart attack or stroke over 10 years, compared to those without sleep problems

Length of publication: News Article

Treatment to ward off stroke less effective in women

Source: Stroke

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Date of publication: 14^th November 2019

Publication type: News Article

In a nutshell:

Women are at higher risk for stroke and have different stroke symptoms than men. New research suggests another difference: less benefit from a surgery used to treat carotid artery disease, a key risk factor for stroke.

The disease, also called carotid stenosis, is marked by fatty deposits, called plaque, that build up inside the neck arteries and increase stroke risk. Surgery to remove the plaque, a procedure called an endarterectomy, is used to reduce this risk. The researchers found that among participants with symptoms from the plaque buildup, endarterectomy was more effective in men, with 11.1% of women having a stroke within five years of the surgery, compared to 8.9% of men.Length of publication: Online article

Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England: a discrete event simulation.

Source: BMC Health Services Research

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Date of publication: 8^th November 2019

Publication type: Journal Article

In a nutshell:

Background

We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30.

Methods

We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year’s incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30.

Results

Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155–249) to 165 (IQR 105–224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0–1) and 30 fewer dependent/dead patients (mRS 3–6) per year. The net addition of 6 centres generates 190 QALYs (95%CI − 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5.

Conclusion

Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required.Length of publication: Online article