Prevention and Risk Factor Reduction
By Matthew E. Fink, MD, Editor
Feil Professor and Chairman, Department of Neurology, and Assistant Dean of Clinical Affairs, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a consultant for Procter & Gamble.
Oral Anticoagulation Treatment
Alessandro Biffi, from Boston, presented the results of a meta-analysis of several longitudinal studies of primary intracerebral hemorrhage conducted in Germany and Boston, as well as a multicenter study (ERICH), to determine whether resumption of oral anticoagulation treatment (OAT) after a primary intracerebral hemorrhage is associated with good long-term outcomes. A decision to resume anticoagulation treatment after intracerebral hemorrhage, particularly after lobar hemorrhages related to cerebral amyloid angiopathy, is a therapeutic dilemma. The investigators analyzed individual patient data from more than 1,000 patients from the combined studies. They determined whether at one year from the time of intracerebral hemorrhage OAT was associated with 1) mortality and 2) favorable functional outcome as determined by the modified Rankin scale of 0-3. Non-lobar and lobar intracerebral hemorrhage cases were analyzed separately using a Cox regression model, adjusted for intracerebral hemorrhage volume and various hemorrhage risk scores for bleeding (CHADS2 and HAS-BLED). There were 641 non-lobar hemorrhages (28% resumed OAT) and 386 lobar hemorrhages (23% resumed OAT). Among all intracerebral hemorrhage survivors who resumed oral antithrombotic therapy, hemorrhage volume and bleeding risk scores were not associated with a decision to resume antithrombotic therapy. Discharge modified Rankin score was associated with antithrombotic therapy resumption in lobar hemorrhages only. In a multivariable analysis, OAT resumption after non-lobar intracerebral hemorrhage was associated with a decreased mortality (hazard ratio [HR], 0.22; P < 0.0001) and improved functional outcome (HR, 5.12; P < 0.0001). OAT resumption after lobar intracerebral hemorrhage was associated with decreased mortality (HR, 0.25; P < 0.0001) and favorable functional outcome (HR, 4.89; P < 0.0001). Based on this meta-analysis of prospective studies of intracerebral hemorrhage, the investigators concluded that OAT resumption is associated with decreased mortality and favorable outcome after both non-lobar and lobar intracerebral hemorrhages. However, randomized, clinical trials will be necessary to determine the true risks and benefits of OAT resumption after intracerebral hemorrhage.
Electronic Cigarettes and Stroke
Ali Sifat, from Amarillo, TX, presented the results of an animal study on the effects of electronic cigarette (E-cigarette) exposure to nicotine as a risk factor for stroke severity. The risks of cigarette smoking and increased risk in frequency and severity of stroke are well known. The growing use of E-cigarettes has not been studied and the effects in humans are unknown. The investigators studied effects of E-cigarettes on a mouse model of ischemic stroke, looking at stroke outcome and brain glucose utilization. Nicotine was administered to mice either by an osmotic pump or via E-cigarette vapor delivered by an electronic nicotine delivery system similar to human E-cigarette use. A right middle cerebral artery occlusion then was induced, followed by reperfusion at 24 hours. Glucose utilization was estimated using radiolabeled-glucose, and infarct size was evaluated by pathologic analysis. Nicotine exposure for seven and 14 days resulted in a significant reduction in glucose influx rate across the blood brain-barrier, with a 49% reduction after 14 days of nicotine exposure. This effect was observed with nicotine infusion or E-cigarette exposure. Patients exposed to nicotine via E-cigarettes developed worse stroke outcomes and worse neurological deficits compared to those who were not exposed to nicotine. Although this should be studied in a human model, from a cerebrovascular mechanism, it is believed that nicotine exposure via E-cigarettes is not safer than tobacco smoking and may pose a similar, if not higher, risk for stroke severity. The investigators believe this may be related to the enhanced glucose deprivation related to intense nicotine exposure.
Blood Pressure Control in African Americans
May Nguyen-Huynh, from Oakland, CA, presented results from a clinical trial aimed at improving blood pressure control among African Americans. Working in the Kaiser Permanente system in California, investigators noted that although this integrated healthcare system succeeds with having a high overall rate of hypertension control, African Americans still have poor blood pressure control compared to whites. To modify lifestyle differences, the investigators developed a clinical trial aimed at 1) reducing salt intake, 2) intensifying blood pressure management, and 3) rolling out specific lifestyle interventions with personal attention to individual patients. Primary care physicians and their panels of African-American patients were randomized and stratified to three arms: 1) usual care, 2) enhanced monitoring of blood pressure management protocol, or 3) culturally tailored lifestyle coaching focused on healthy diet (DASH). Patients who had blood pressure readings of ≥ 140/90 mmHg were qualified to be recruited into this study. The intervention lasted 12 months. The primary outcome was the rate of successful blood pressure control from time of enrollment to 15 months post-enrollment. After 12 months of intervention, patients in the usual care group showed a 62.1% rate of good blood pressure control, while patients in the enhanced monitoring group had a 64.1% rate of good blood pressure control, but this was not a statistically significant difference between the two groups. In the group that received lifestyle coaching intervention, the rate of good blood pressure control increased to 69.3%, which was a statistically significant improvement compared to the usual care group. The investigators concluded that individual and intensive lifestyle coaching can make a significant difference in improving diet, improving adherence to medication use, and ultimately improving blood pressure control, which over time will reduce the risk of stroke.
These articles are based on the editor's personal interactions as a participant at the International Stroke Conference in Houston, Feb. 22-24, 2017. All interpretations and opinions are exclusively those of the editor.
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