"The Triptan's Hangover": A Multicentric Cross-sectional Observational Study of the Adverse Events of Triptans in Patients With Migraine.

ABSTRACT: The emergence of triptans represented a breakthrough in the treatment of migraine, but in clinical practice, patients describe symptoms that resemble those of a hangover after taking them. We propose the use of the Hangover Symptoms Scale (HSS) to evaluate this syndrome in patients that take triptans, which may help identify patients at higher risk of presenting these adverse effects that may interfere with therapeutic compliance.A cross-sectional observational pilot study with prospective data collection through a clinical-demographic questionnaire and the HSS was carried out on patients with migraine treated in headache units in 3 tertiary hospitals in Madrid.Sixty-six patients were included in the study. The median HSS was 4 and all symptoms were present in at least 15% of the patients, with difficulty to concentrate being the most frequent (57.6%). No significant differences were found between the presence of a higher HSS score and the sociodemographic characteristics of the patient or his migraine. The presence of aura was associated with a higher percentage of trembling (P = 0.029) and fatigue (nonvisual, polymodal auras; P = 0.017).According to our study, triptans are responsible for a set of symptoms overlapping with those that occur during a hangover. Therefore, we propose that the HSS could be a useful tool for the evaluation and quantification of these effects in patients receiving triptans. In addition, we found that clinical features could be more frequently associated with the appearance of these adverse effects that, however, are not related to any particular patient profile.

Prehospital selection of thrombectomy candidates beyond large vessel occlusion: M-DIRECT scale.

OBJECTIVE: Current prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C. METHODS: In this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort). RESULTS: The M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts. CONCLUSIONS: The M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.

Is There a Characteristic Clinical Profile for Patients with Dementia and Sundown Syndrome?

BACKGROUND: Sundown syndrome (SS) is the onset or worsening of behavioral symptoms in the evening in patients with dementia. OBJECTIVE: To identify the differential clinical profile of patients with dementia who present SS. METHODS: A cross-sectional, case-control observational study was conducted by retrospectively reviewing the medical records of patients with dementia in a specialized Memory Unit. We compared the characteristics of patients with and without SS, including sociodemographic variables, etiology, and severity of the dementia, behavioral symptoms, sleep disorders (considering insomnia and hypersomnia), other diseases and treatments employed. We identified the factors related to SS and conducted a logistic regression analysis to establish a predictive nomogram. RESULTS: Of the 216 study patients with dementia, 41 (19%) had SS. There was a predominance of women (2.4:1), advanced age (p = 0.0001), dependence (p < 0.0001), institutionalization (p < 0.0001), caregiver burden (p < 0.0001), anxiety (p < 0.0001), delirium (p < 0.0001), hallucinations (p < 0.0001), wandering (p < 0.0001), Lewy body dementia (p = 0.05), higher Global Deterioration Scale score (GDS; p < 0.0001), and sleep disorders (p < 0.0001). The multivariate analysis revealed that age (p = 0.048), GDS score (p = 0.01), and the presence of insomnia or hypersomnia (p < 0.0001) independently defined the presence of SS. We established a predictive nomogram for developing SS in patients with dementia, with a predictive capacity of 80.1%. CONCLUSION: In our study, age, a higher score on the GDS, and the presence of insomnia or hypersomnia are differential clinical characteristics of patients with SS. We defined a nomogram that helps predicting the occurrence of SS in patients with dementia.

[Compliance with the measures for preventing vascular risk factors in hospitalised patients with acute stroke. Analysis of a national multi-centre registry: EPICES registry (III)]. / Cumplimiento de las medidas de prevención de factores de riesgo vascular en pacientes ingresados con ictus agudo. Análisis de un registro multicéntrico: registro EPICES (III).

INTRODUCTION: Pharmacological and dietary measurements, as well as life style, to control risk factors are efficient procedures to prevent cerebrovascular diseases, though their implementation in the clinics seems not optimal. AIM: To identify the fulfillment of preventive measurements on a sample of 6197 hospitalized stroke patients, attended by neurologists. PATIENTS AND METHODS: Analysis of a secondary objective of the EPICES registry. Primary prevention was considered in patients without previous record of transitory ischemic attack, stroke, coronary diseases and/or peripheral arterial disease (n = 3977); secondary prevention was considered in patients with record of coronary and/or peripheral arterial disease, but without record of cerebrovascular disease (n = 1047); neurological secondary prevention was considered in patients with a record of transitory ischemic attack and/or stroke, independently of the presence of coronary and/or peripheral arterial disease (n = 1173). RESULTS: Secondary prevention and neurological secondary prevention were more efficient than primary prevention (p = 0.028 and p < 0.0001, respectively). Control was higher in centers with some type of structure to assist stroke patients (p < 0.0001). Influence of age in the taking of therapeutic decisions followed a similar pattern in all three types of prevention, with a significant reduction on anticoagulation for patients older than 80 years. CONCLUSION: The EPICES registry confirms the poor control of risk factors for cerebrovascular diseases. Globally it demonstrated that the objectives that imply the modification of lifestyle are fulfilled worse than pharmacological preventive measurements.

[Cost-effectiveness analysis of using high doses of atorvastatin for the secondary stroke prevention in Spain]. / Estudio coste-efectividad del uso de dosis altas de atorvastatina en la prevención secundaria del ictus en España.

AIM: To estimate the cost-effectiveness of atorvastatin at high doses (80 mg/day) for the reduction of the risk of fatal and nonfatal stroke in patients with recent cerebrovascular accident or transient ischemic attack (TIA) and without coronary heart disease in Spain using data from the SPARCL study. PATIENTS AND METHODS: A discrete event simulation was developed to represent the natural evolution of a cohort of 1000 patients following a stroke or TIA. The risk for fatal and non fatal cardiovascular events was calculated from the clinical characteristic of patients in the SPARCL study for both treatment arms (atorvastatin 80 mg/day and placebo). Survival time, quality-adjusted-life-years (QALY), clinical events, and medical direct costs for a period of 5 years with a 3% per year discount were calculated for the two alternatives. A probabilistic sensitivity analysis was made running 1000 simulations. RESULTS: Compared to placebo, atorvastatin 80 mg/day prevented 22 strokes (14 nonfatal and 8 fatal), 22 myocardial infarctions (19 nonfatal and 3 fatal), 33 TIAs, 8 unstable angina episodes and 37 re-vascularisations per 1000 patients over 5 years. The incremental cost effectiveness ratio after 1000 simulations was 9914 euros (95% CI = 5717 to 26,082) per QALY. The acceptability curve showed 99% of the simulations falling below an acceptability threshold of 30,000 euros/QALY. CONCLUSIONS: Compared with placebo, use of high dose atorvastatin (80 mg/day) for secondary stroke prevention is not only of significant clinical benefit but can also be considered cost effective in Spain. It produces important benefits in health with an incremental cost within reasonable limits.

Blood pressure as a risk factor for stroke and the impact of antihypertensive treatment.

We review hypertension and blood pressure levels as risk factors for stroke and the impact of antihypertensive treatment on the prevention of first stroke event and of recurrent stroke, not only with respect to the prevention of vascular events but also the prevention of cognitive deterioration, dementia, and physical disability. We review whether pharmacological blockage of the renin-angiotensin system has additional long-term effects over that of control of blood pressure levels alone, and the benefit of treatment with antihypertensive drugs in normotensive patients. Therapeutic objectives for blood pressure levels after stroke are defined together with recommendations of drugs and doses which have been demonstrated to have the greatest benefit in the prevention of stroke.

Lipids and stroke: the opportunity of lipid-lowering treatment.

Dyslipemia is a clear risk factor (RF) for ischemic heart disease and peripheral artery disease, but its relation with ischemic stroke (IS) is not so clear. HMG-CoA reductase inhibitor drugs or statins (simvastatin, atorvastatin, pravastatin) reduce the relative risk of IS by between 18 and 51% in patients with IHD, in patients with high vascular disease risk and in hypertensive patients with other RFs, acute coronary syndrome, and type 2 diabetes mellitus. According to the guidelines for use, statins are indicated in the majority of patients with IS since the risk is equivalent to that of IHD or high vascular disease risk. In view of the existing clinical evidence of benefit, it would not seem unreasonable to proceed with treatment of patients using statins while awaiting specific studies justifying their use. The non-lipid-lowering mechanisms of the statins and results of studies, such as the Heart Protection Study, provide evidence for widening the indications of statins beyond the prevention of dyslipemia, as a new therapeutic approach in the prevention of IS in patients with plasma levels of total cholesterol or low density lipoproteins currently considered within the normal distribution. The neuroprotective role, which these drugs may play in the acute phase of cerebral ischemia, remains to be clarified, but very recent evidence suggests that such patients may also benefit.

Organization of medical care in acute stroke: importance of a good network.

Stroke is a medical emergency which requires hospital care. Therapeutic and effective organizative measures, such as thrombolysis and stroke units, are available, but early attention is required, as the benefits are time dependent (therapeutic window). To achieve this objective, a high level of organization and coordination is required between the various steps of care. The chain of attention in acute stroke (from symptom onset till stroke unit admission) is a complex process. The main points are reviewed: delay in attention, knowledge and attitude towards stroke, emergency transportation, neurological attention, educational campaigns, clinical protocols and pathways, stroke codes, and existing resources for care. The organization must be modified to have the resources for care necessary for attending acute stroke available, if we want to achieve the real objective of maximum benefit for our patients as set out in the Declaration of Helsingborg.