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1.
Clin Rehabil ; 38(3): 414-426, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38058183

RESUMEN

OBJECTIVE: To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic. DESIGN: Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis. SETTING: Nine Early Supported Discharge service sites in Ireland. PARTICIPANTS: Purposive sampling identified 16 healthcare professionals. RESULTS: Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families. CONCLUSIONS: Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.


Asunto(s)
COVID-19 , Accidente Cerebrovascular , Humanos , Irlanda , Alta del Paciente , Pandemias , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Investigación Cualitativa , Atención a la Salud , COVID-19/epidemiología
2.
Eur Heart J Suppl ; 26(Suppl 3): iii96-iii98, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-39055583

RESUMEN

We participated in the UK and Republic of Ireland May Measurement Month 2021 (MMM21) campaign to raise awareness about blood pressure (BP) measurement and the dangers posed by elevated BP and hypertension. In addition, the campaign aimed to collect and report levels of BP awareness and control in the community setting. The MMM21 campaign set up opportunistic community screening sites at hospitals, general practice (GP) surgeries, community pharmacies, gyms, and various other public places. The campaign screened 1322 participants (mean age 46 years, 55% women) and found that 522 (39.5%) had hypertension (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg or on antihypertensive medication) at the time of testing. Of the 522 participants identified with hypertension, only 47.2% were aware of their condition. Of those on antihypertensive medication, only 45.7% had controlled BP (systolic BP < 140 mmHg and diastolic BP < 90 mmHg), and of all hypertensives, only 19.0% were controlled. Our UK and Ireland data continue to shed further light on low levels of awareness and control of hypertension in the UK and Ireland community setting. This evidence supports a critical need to further highlight the importance of identifying and taking action against raised BP.

3.
Cerebrovasc Dis ; 51(2): 178-187, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-34496366

RESUMEN

INTRODUCTION: The 5-year recurrence risk after ischaemic stroke and transient ischaemic attack (TIA) is 25-30%. Although inflammation may be a target for prevention trials, the contribution of plaque inflammation to acute cerebrovascular events remains unclear. We investigated the association of acute inflammatory cytokines and high-sensitivity C-reactive protein (CRP) with recently symptomatic carotid atherosclerosis in a prospective cohort study. METHODS: Blood and Imaging markers of TIA BIO-TIA) is a multicentre prospective study of imaging and inflammatory markers in patients with TIA. Exclusion criteria were infection and other co-morbid illnesses associated with inflammation. CRP and serum cytokines (interleukin [IL]-6, IL-1ß, IL-8, IL-10, IL-12, interferon-γ [IFN-γ] and tumour necrosis factor-α [TNF-α]) were measured. All patients had carotid imaging. RESULTS: Two hundred and thirty-eight TIA cases and 64 controls (TIA mimics) were included. Forty-nine (20.6%) cases had symptomatic internal carotid artery stenosis. Pro-inflammatory cytokine levels increased in a dose-dependent manner across controls, TIA without carotid stenosis (CS), and TIA with CS (IL-1ß, ptrend = 0.03; IL-6, ptrend < 0.0001; IL-8, ptrend = 0.01; interferon (IFN)-γ, ptrend = 0.005; TNF-α, ptrend = 0.003). Results were unchanged when DWI-positive cases were excluded. On multivariable linear regression, only age (p = 0.01) and CS (p = 0.04) independently predicted log-IL-6. On multivariable Cox regression, CRP was the only independent predictor of 90-day stroke recurrence (adjusted hazard ratio per 1-unit increase 1.03 [95% CI: 1.01-1.05], p = 0.003). CONCLUSION: Symptomatic carotid atherosclerosis was associated with elevated cytokines in TIA patients after controlling for other sources of inflammation. High-sensitivity CRP was associated with recurrent ischaemic stroke at 90 days. These findings implicate acute plaque inflammation in the pathogenesis of cerebral thromboembolism and support a rationale for randomized trials of anti-inflammatory therapy for stroke patients, who were excluded from coronary trials.


Asunto(s)
Isquemia Encefálica , Enfermedades de las Arterias Carótidas , Estenosis Carotídea , Ataque Isquémico Transitorio , Accidente Cerebrovascular Isquémico , Placa Aterosclerótica , Accidente Cerebrovascular , Isquemia Encefálica/complicaciones , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Ensayos Clínicos como Asunto , Citocinas , Humanos , Inflamación/complicaciones , Interleucina-6 , Interleucina-8 , Ataque Isquémico Transitorio/complicaciones , Ataque Isquémico Transitorio/etiología , Placa Aterosclerótica/complicaciones , Estudios Prospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Factor de Necrosis Tumoral alfa
4.
Eur Heart J Suppl ; 23(Suppl B): B147-B150, 2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-34054372

RESUMEN

In the UK, heart and circulatory diseases account for 29% of all deaths (14% through coronary heart disease and 8% through stroke). In 2015, the prevalence of hypertension was 20% in the UK and 23% in the Republic of Ireland. In 2019, 14% of people registered with a UK general practice had hypertension and yet it was the attributable risk factor for around half of all deaths from coronary heart disease or stroke. We participated in May Measurement Month 2019 to increase awareness of blood pressure (BP) measurement, and to identify the proportion of undiagnosed hypertension and degree of uncontrolled hypertension in the community. The 2019 campaign set up screening sites within the community at places of worship, supermarkets, GP surgeries, workplaces, charity events, community pharmacies, gyms, and various other public places. We screened 10194 participants (mean age 51 ± 18 years, 60% women) and found that 1013 (9.9%) were on antihypertensive treatment, while 3408 (33.4%) had hypertension. Of the 3408 participants with hypertension, only 33.5% were aware of their condition despite 98.8% having previous BP measurements. In those on antihypertensive medication, only 38.2% had controlled BP (<140 and <90 mmHg). Our UK and Republic of Ireland data demonstrate concerning levels of undiagnosed hypertension and sub-optimal BP control in many individuals with a diagnosis. This evidence supports a critical need for better systematic community and primary care screening initiatives.

5.
Stroke ; 51(3): 838-845, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31948355

RESUMEN

Background and Purpose- In randomized trials of symptomatic carotid endarterectomy, only modest benefit occurred in patients with moderate stenosis and important subgroups experienced no benefit. Carotid plaque 18F-fluorodeoxyglucose uptake on positron emission tomography, reflecting inflammation, independently predicts recurrent stroke. We investigated if a risk score combining stenosis and plaque 18F-fluorodeoxyglucose would improve the identification of early recurrent stroke. Methods- We derived the score in a prospective cohort study of recent (<30 days) non-severe (modified Rankin Scale score ≤3) stroke/transient ischemic attack. We derived the SCAIL (symptomatic carotid atheroma inflammation lumen-stenosis) score (range, 0-5) including 18F-fluorodeoxyglucose standardized uptake values (SUVmax <2 g/mL, 0 points; SUVmax 2-2.99 g/mL, 1 point; SUVmax 3-3.99 g/mL, 2 points; SUVmax ≥4 g/mL, 3 points) and stenosis (<50%, 0 points; 50%-69%, 1 point; ≥70%, 2 points). We validated the score in an independent pooled cohort of 2 studies. In the pooled cohorts, we investigated the SCAIL score to discriminate recurrent stroke after the index stroke/transient ischemic attack, after positron emission tomography-imaging, and in mild or moderate stenosis. Results- In the derivation cohort (109 patients), recurrent stroke risk increased with increasing SCAIL score (P=0.002, C statistic 0.71 [95% CI, 0.56-0.86]). The adjusted (age, sex, smoking, hypertension, diabetes mellitus, antiplatelets, and statins) hazard ratio per 1-point SCAIL increase was 2.4 (95% CI, 1.2-4.5, P=0.01). Findings were confirmed in the validation cohort (87 patients, adjusted hazard ratio, 2.9 [95% CI, 1.9-5], P<0.001; C statistic 0.77 [95% CI, 0.67-0.87]). The SCAIL score independently predicted recurrent stroke after positron emission tomography-imaging (adjusted hazard ratio, 4.52 [95% CI, 1.58-12.93], P=0.005). Compared with stenosis severity (C statistic, 0.63 [95% CI, 0.46-0.80]), prediction of post-positron emission tomography stroke recurrence was improved with the SCAIL score (C statistic, 0.82 [95% CI, 0.66-0.97], P=0.04). Findings were confirmed in mild or moderate stenosis (adjusted hazard ratio, 2.74 [95% CI, 1.39-5.39], P=0.004). Conclusions- The SCAIL score improved the identification of early recurrent stroke. Randomized trials are needed to test if a combined stenosis-inflammation strategy improves selection for carotid revascularization where benefit is currently uncertain.


Asunto(s)
Estenosis Carotídea , Placa Aterosclerótica , Tomografía de Emisión de Positrones , Accidente Cerebrovascular , Anciano , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/fisiopatología , Femenino , Fluorodesoxiglucosa F18/administración & dosificación , Humanos , Inflamación , Masculino , Persona de Mediana Edad , Placa Aterosclerótica/diagnóstico por imagen , Placa Aterosclerótica/fisiopatología , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/fisiopatología
6.
Eur Heart J Suppl ; 22(Suppl H): H132-H134, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32884493

RESUMEN

Raised blood pressure (BP) was the biggest contributor to the global burden of disease in 2017, with lack of awareness and adequate control of BP identified as the main drivers of this disease burden. In 2017, an opportunistic BP screening and awareness campaign called May Measurement Month (MMM) in the UK and Republic of Ireland (RoI) highlighted that levels of undiagnosed hypertension and uncontrolled hypertension in the community screened were approximately 23% and 40%, respectively. MMM18 was undertaken to further the campaign's efforts to increase awareness and create an evidence base of population risk associated with high BP. MMM18 BP screenings were conducted in the community at places of worship, supermarkets, GP surgeries, workplaces, community pharmacies, gyms, and various other public places. A total of 5000 volunteers, aged 47.3 (±17.2) years, 60% female were screened. Of all 5000 individuals screened, 1716 (34.3%) were hypertensive, of which only 51.3% were aware of their condition, 42.8% on antihypertensive treatment, and only 51.5% of those on medication controlled to target BP of <140/90 mmHg. Furthermore, obese, overweight, and underweight participants all had significantly higher BP values compared to individuals with a healthy body mass index (BMI). The 2018 MMM campaign in the UK and the RoI confirmed approximately one in three adults were hypertensive, with more than half having uncontrolled BP. In addition, these findings show that people with low BMI are at risk of having high BP. Finally, with only one in two people aware of their high BP, awareness remains a significant public health concern.

7.
Stroke ; 50(7): 1766-1773, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31167623

RESUMEN

Background and Purpose- Plaque inflammation contributes to stroke and coronary events. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) identifies plaque inflammation-related metabolism. Almost no prospective data exist on the relationship of carotid 18F-FDG uptake and early recurrent stroke. Methods- We did a multicenter prospective cohort study BIOVASC (Biomarkers/Imaging Vulnerable Atherosclerosis in Symptomatic Carotid disease) of patients with carotid stenosis and recent stroke/transient ischemic attack with 90-day follow-up. On coregistered carotid 18F-FDG PET/computed tomography angiography, 18F-FDG uptake was expressed as maximum standardized uptake value (SUVmax) in the axial single hottest slice. We then conducted a systematic review of similar studies and pooled unpublished individual-patient data with 2 highly similar independent studies (Dublin and Barcelona). We analyzed the association of SUVmax with all recurrent nonprocedural stroke (before and after PET) and with recurrent stroke after PET only. Results- In BIOVASC (n=109, 14 recurrent strokes), after adjustment (for age, sex, stenosis severity, antiplatelets, statins, diabetes mellitus, hypertension, and smoking), the hazard ratio for recurrent stroke per 1 g/mL SUVmax was 2.2 (CI, 1.1-4.5; P=0.025). Findings were consistent in the independent Dublin (n=52, hazard ratio, 2.2; CI, 1.1-4.3) and Barcelona studies (n=35, hazard ratio, 2.8; CI, 0.98-5.5). In the pooled cohort (n=196), 37 recurrent strokes occurred (29 before and 8 after PET). Plaque SUVmax was higher in patients with all recurrence ( P<0.0001) and post-PET recurrence ( P=0.009). The fully adjusted hazard ratio of any recurrent stroke was 2.19 (CI, 1.41-3.39; P<0.001) and for post-PET recurrent stroke was 4.57 (CI, 1.5-13.96; P=0.008). Recurrent stroke risk increased across SUVmax quartiles (log-rank P=0.003). The area under receiver operating curve for all recurrence was 0.70 (CI, 0.59-0.78) and for post-PET recurrence was 0.80 (CI, 0.64-0.96). Conclusions- Plaque inflammation-related 18F-FDG uptake independently predicted future recurrent stroke post-PET. Although further studies are needed, 18F-FDG PET may improve patient selection for carotid revascularization and suggest that anti-inflammatory agents may have benefit for poststroke vascular prevention.


Asunto(s)
Estenosis Carotídea , Fluorodesoxiglucosa F18/administración & dosificación , Placa Aterosclerótica , Tomografía de Emisión de Positrones , Accidente Cerebrovascular , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Inflamación/complicaciones , Inflamación/diagnóstico por imagen , Inflamación/epidemiología , Masculino , Persona de Mediana Edad , Placa Aterosclerótica/complicaciones , Placa Aterosclerótica/diagnóstico por imagen , Placa Aterosclerótica/epidemiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología
8.
J Geriatr Psychiatry Neurol ; 32(5): 275-281, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31167593

RESUMEN

AIM: To explore the impact of cognitive impairment poststroke on outcomes at 5 years. METHODS: Five-year follow-up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) prospective cohort. Two hundred twenty-six ischemic stroke survivors completed Montreal Cognitive Assessments at 6 months poststroke. Outcomes at 5 years included independence in activities of daily living, receipt of informal care, quality of life, and depressive symptoms. Data were analyzed using logistic and linear regression models. Adjusted odds ratios (ORs; 95% confidence interval [CI]) and ß coefficients (95% CI) are reported. RESULTS: One hundred one stroke survivors were followed up at 5 years. Cognitive impairment at 6 months was independently associated with worse quality of life (B [95% CI]: -0.595 [-0.943 to -0.248]), lower levels of independence (B [95% CI]: -3.605 [-5.705 to -1.505]), increased likelihood of receiving informal care (OR [95% CI]: 6.41 [1.50-27.32]), and increased likelihood of depressive symptoms (OR [95% CI]: 4.60 [1.22-17.40]). Conclusion: Cognitive impairment poststroke is associated with a range of worse outcomes. More effective interventions are needed to improve outcomes for this vulnerable group of patients.


Asunto(s)
Disfunción Cognitiva/etiología , Calidad de Vida/psicología , Accidente Cerebrovascular/complicaciones , Anciano , Disfunción Cognitiva/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Accidente Cerebrovascular/mortalidad , Análisis de Supervivencia
9.
Eur Heart J Suppl ; 21(Suppl D): D121-D123, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-31043898

RESUMEN

Elevated blood pressure (BP), or hypertension, is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and acting as a stimulus to improving screening programmes worldwide. In the United Kingdom (UK) nearly 1 in 5 people, and in the Republic of Ireland (RoI) 3 out of 10, have hypertension, of which a large proportion remains undiagnosed. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed a standardized protocol. Screenings sites in hospitals, universities, shopping centres, workplaces, sports clubs, community centres, GP practices, and pharmacies were set up across the UK and RoI as part of this initiative. Seven thousand seven hundred and fourteen individuals were screened during MMM17. After multiple imputation, 3099 (40.3%) had hypertension. Of individuals not receiving antihypertensive medication, 1406 (23.4%) were hypertensive. Of individuals receiving antihypertensive medication, 682 (40.5%) had uncontrolled BP. MMM17 was the largest BP screening campaign ever undertaken in the UK and RoI. These data prove for the first time that a relatively inexpensive, volunteer based, convenience sampling of screening BP in the community identified two out of five individuals as hypertensive, with one in four not receiving treatment. Of major concern is that these data demonstrate that of those individuals receiving treatment, two out of five still did not have controlled BP.

10.
JAMA ; 322(5): 409-420, 2019 08 06.
Artículo en Inglés | MEDLINE | ID: mdl-31386134

RESUMEN

Importance: Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes. Objective: To evaluate the association of BP indexes with death and a composite CV event. Design, Setting, and Participants: Longitudinal population-based cohort study of 11 135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016). Exposures: Blood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings). Main Outcomes and Measures: Multivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC). Results: Among 11 135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P < .001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP. Conclusions and Relevance: In this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small.


Asunto(s)
Monitoreo Ambulatorio de la Presión Arterial , Enfermedades Cardiovasculares/epidemiología , Hipertensión/complicaciones , Adulto , Presión Sanguínea/fisiología , Determinación de la Presión Sanguínea/métodos , Enfermedades Cardiovasculares/etiología , Ritmo Circadiano , Femenino , Humanos , Hipertensión/diagnóstico , Hipertensión/mortalidad , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Factores de Riesgo
11.
Br J Nutr ; 119(6): 658-663, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-29553033

RESUMEN

Dietary nitrate has been shown to increase nitrate/nitrite levels and decrease blood pressure (BP) in multiple populations. There are few reports among hypertensives and these reports have provided conflicting evidence. We aimed to assess the effect of daily nitrate compared with placebo in subjects with uncontrolled hypertension (HTN). On day 0, hypertensives wore an ambulatory BP monitor (ABPM) for 24 h and blood was taken. Subjects were then randomised to 7-d nitrate-rich beetroot juice (NO3 -) (12·9 mmol nitrate) followed by 7-d nitrate-depleted beetroot juice (0·5 mmol nitrate) or vice versa. ABPM and blood were assessed before and after both conditions. In all, twenty subjects with treated yet uncontrolled HTN entered and completed the trial (mean age=62·5 years, mean BMI=30·7 kg/m2). Baseline BP was 137/80 (sd 7/7) mmHg. Dietary nitrate was well tolerated and resulted in significantly increased plasma nitrite (P=0·0004) and decreased 24-h systolic BP and diastolic BP compared with placebo (-8 mmHg; P=0·012 and -4 mmHg; P=0·018, respectively). Our results support the existing data suggesting an anti-hypertensive effect of dietary nitrate in treated yet uncontrolled hypertensives. Targeted dietary strategies appear promising contributors to BP control.


Asunto(s)
Monitoreo Ambulatorio de la Presión Arterial , Hipertensión/tratamiento farmacológico , Nitratos/administración & dosificación , Anciano , Alanina Transaminasa/sangre , Fosfatasa Alcalina/sangre , Antihipertensivos/administración & dosificación , Bilirrubina/sangre , Presión Sanguínea/efectos de los fármacos , Índice de Masa Corporal , Proteína C-Reactiva/metabolismo , Colesterol/sangre , Estudios Cruzados , Método Doble Ciego , Femenino , Humanos , Hipertensión/sangre , Estilo de Vida , Masculino , Persona de Mediana Edad , Nitratos/sangre , Nitritos/sangre , Obesidad/sangre , Obesidad/tratamiento farmacológico , Resultado del Tratamiento , Triglicéridos/sangre
12.
J Stroke Cerebrovasc Dis ; 27(9): 2466-2473, 2018 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-29803601

RESUMEN

BACKGROUND: The aim of this study was to examine predictors of mortality in patients 5 years after ischemic stroke, focusing on cognitive impairment, vulnerability, and vascular risk factors assessed at 6 months post stroke. MATERIALS AND METHODS: Patients from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort were followed up 5 years post ischemic stroke. Vascular risk factors, cognitive impairment, and vulnerability were assessed at 6 months post stroke. Cognitive impairment was assessed using a cutoff score lower than 26 on the Montreal Cognitive Assessment (MoCA). Vulnerability was defined as a score of 3 or higher on the Vulnerable Elders Scale (VES). Mortality and date of death were ascertained using hospital records, death notifications, and contact with general practitioners. Predictors of mortality were explored using multivariate Cox proportional hazards models. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. RESULTS: Sixty-three of 256 patients (24.6%) assessed at 6 months post stroke had died within 5 years. Cognitive impairment (HR [95% CI]: 2.19 [1.42-3.39]), vulnerability (HR [95% CI]: 5.23 [2.92-9.36]), atrial fibrillation (AF) (HR [95% CI]: 2.31 [1.80-2.96]), and dyslipidemia (HR [95% CI]: 1.90 [1.10-3.27]) were associated with increased risk of 5-year mortality. DISCUSSION: Vulnerability, cognitive impairment, AF, and dyslipidemia at 6 months were associated with increased risks of mortality 5 years post ischemic stroke. CONCLUSION: Identification and management of these risk factors should be emphasized in poststroke care.


Asunto(s)
Isquemia Encefálica/complicaciones , Isquemia Encefálica/mortalidad , Disfunción Cognitiva/etiología , Disfunción Cognitiva/mortalidad , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/mortalidad , Anciano , Isquemia Encefálica/psicología , Isquemia Encefálica/rehabilitación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Análisis Multivariante , Modelos de Riesgos Proporcionales , Factores de Riesgo , Prevención Secundaria , Accidente Cerebrovascular/psicología , Rehabilitación de Accidente Cerebrovascular
13.
Clin Exp Pharmacol Physiol ; 44(12): 1272-1278, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24283851

RESUMEN

The term 'masked hypertension phenomenon' was first described by the late Professor Thomas Pickering and is commonly defined as having a normal clinic blood pressure (BP) but an elevated 'out of office' reading. In the main, these elevated readings have been provided through ambulatory BP monitoring (ABPM), but sometimes home BP monitoring is used. It is now largely accepted that ABPM gives a better classification of risk than clinic BP. Thus, the elevated ABPM levels should relate to higher cardiovascular risk, and it follows that these people may be regarded as being genuinely hypertensive and at higher cardiovascular risk. The problem for clinical practice is how to identify and manage these individuals. The phenomenon should be suspected in individuals who have had an elevated clinic BP at some time, in young individuals with normal or normal-high clinic BP who have early left ventricular hypertrophy, in individuals with a family history of hypertension in both parents, patients with multiple risks for cardiovascular disease and perhaps diabetic patients. Masked hypertension appears to be more prevalent in individuals of male gender, with younger age, higher heart rate, obesity or high cholesterol levels and in smokers. Those with masked hypertension are at higher risk of events such as stroke and have a higher prevalence of target organ damage, for example, nephropathy. In conclusion, most of the debate around this topic relates to its reliable identification. Given the higher ambulatory mean blood pressure values there is an increased cardiovascular risk making this diagnosis important.


Asunto(s)
Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Hipertensión Enmascarada/diagnóstico , Hipertensión Enmascarada/tratamiento farmacológico , Antihipertensivos/administración & dosificación , Monitoreo Ambulatorio de la Presión Arterial , Femenino , Humanos , Masculino , Hipertensión Enmascarada/epidemiología , Hipertensión Enmascarada/etiología , Prevalencia , Factores de Riesgo
14.
Stroke ; 47(1): 244-6, 2016 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-26585395

RESUMEN

BACKGROUND AND PURPOSE: Few recent studies have investigated the rates and predictors of early and late stroke recurrence using prospective population-based methodology. We investigated recurrent stroke at 2 years in the North Dublin Population Stroke Study (NDPSS). METHODS: Patients were ascertained from December 2005 to 2006 from overlapping community and hospital sources using hot and cold pursuit. Stroke recurrence, survival, and functional outcome were ascertained at 72 hours, 7 days, 28 days, 90 days, 1 year, and 2 years. RESULTS: Of 567 patients, cumulative 2-year stroke recurrence rate was 10.8% and case fatality was 38.6%. Recurrence subtype was associated with initial stroke subtype (P<0.001). On multivariable Cox regression, hyperlipidemia (adjusted hazard ratio, 3.32; P=0.005) and prior stroke (adjusted hazard ratio, 2.92; P=0.01) were independent predictors of 2-year recurrence in 28-day survivors. CONCLUSIONS: Despite rigorous ascertainment, recurrent stroke rates were lower in current study than in earlier studies. Our data suggest that large sample sizes may be needed for future secondary prevention trials in patients treated with modern preventive medications.


Asunto(s)
Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/epidemiología , Vigilancia de la Población , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Irlanda/epidemiología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Recurrencia , Resultado del Tratamiento
15.
Lancet ; 385(9978): 1634-41, 2015 Apr 25.
Artículo en Inglés | MEDLINE | ID: mdl-25620016

RESUMEN

BACKGROUND: Hypertension contributes to cardiovascular morbidity and mortality. We assessed the safety and efficacy of a central iliac arteriovenous anastomosis to alter the mechanical arterial properties and reduce blood pressure in patients with uncontrolled hypertension. METHODS: We enrolled patients in this open-label, multicentre, prospective, randomised, controlled trial between October, 2012, and April, 2014. Eligible patients had baseline office systolic blood pressure of 140 mm Hg or higher and average daytime ambulatory blood pressure of 135 mm Hg or higher systolic and 85 mm Hg or higher diastolic despite antihypertensive treatment. Patients were randomly allocated in a 1:1 ratio to undergo implantation of an arteriovenous coupler device plus current pharmaceutical treatment or to maintain current treatment alone (control). The primary endpoint was mean change from baseline in office and 24 h ambulatory systolic blood pressure at 6 months. Analysis was by modified intention to treat (all patients remaining in follow-up at 6 months). This trial is registered with ClinicalTrials.gov, number NCT01642498. FINDINGS: 83 (43%) of 195 patients screened were assigned arteriovenous coupler therapy (n=44) or normal care (n=39). Mean office systolic blood pressure reduced by 26·9 (SD 23·9) mm Hg in the arteriovenous coupler group (p<0·0001) and by 3·7 (21·2) mm Hg in the control group (p=0·31). Mean systolic 24 h ambulatory blood pressure reduced by 13·5 (18·8) mm Hg (p<0·0001) in arteriovenous coupler recipients and by 0·5 (15·8) mm Hg (p=0·86) in controls. Implantation of the arteriovenous coupler was associated with late ipsilateral venous stenosis in 12 (29%) of 42 patients and was treatable with venoplasty or stenting. INTERPRETATION: Arteriovenous anastomosis was associated with significantly reduced blood pressure and hypertensive complications. This approach might be a useful adjunctive therapy for patients with uncontrolled hypertension. FUNDING: ROX Medical.


Asunto(s)
Derivación Arteriovenosa Quirúrgica/métodos , Hipertensión/terapia , Arteria Ilíaca/cirugía , Vena Ilíaca/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Femenino , Humanos , Análisis de Intención de Tratar , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven
16.
Cerebrovasc Dis ; 42(3-4): 247-54, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27189709

RESUMEN

BACKGROUND AND PURPOSE: Stroke is the third leading cause of death and disability. Few studies have assessed the profile and adequacy of access to rehabilitation services after ischaemic stroke both in the inpatient and community setting. The objectives of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) study were to assess the disability and rehabilitation profile, adherence with rehabilitation recommendations and needs of patients 6 months following hospital admission for stroke. METHODS: A rehabilitation prescription was completed before hospital discharge for each participant, and adherence to this prescription was assessed at 6 months to determine whether patients received their recommended rehabilitation needs. RESULTS: Two hundred and fifty six patients were recruited to ASPIRE-S. The average age was 69 (SD 12.8). A majority (n = 221, 86%) were referred to the hospital multidisciplinary team, 59% (n = 132) were referred to all services (physiotherapy (PT), occupational therapy (OT), speech and language therapy (SLT)). Fifty-four percent (n = 119) of patients (seen by the multidisciplinary team) were referred for further rehabilitation in the community on discharge. Of these 119 patients, 112 (95%) recalled receiving community rehabilitation services. However, while most (68%) patients were referred for several disciplines (PT, OT, SLT), the most commonly recalled therapy (55%) was from a single discipline. The most commonly recommended frequency of therapy required was on a weekly basis. Sixty-one patients (51%) reported a delay in services, with some still awaiting services at 6 months. CONCLUSION: Results from this prospective study revealed that a significant number of patients (57%) did not receive the therapy recommended on discharge. Future initiatives should include the development of policies, which support more effective, equitable multidisciplinary rehabilitation for stroke patients in the community.


Asunto(s)
Servicios de Salud Comunitaria , Prestación Integrada de Atención de Salud , Accesibilidad a los Servicios de Salud , Prevención Secundaria/métodos , Rehabilitación de Accidente Cerebrovascular/métodos , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Evaluación de la Discapacidad , Femenino , Humanos , Irlanda , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Alta del Paciente , Estudios Prospectivos , Recuperación de la Función , Recurrencia , Derivación y Consulta , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento
17.
Circulation ; 130(6): 466-74, 2014 Aug 05.
Artículo en Inglés | MEDLINE | ID: mdl-24906822

RESUMEN

BACKGROUND: Data on risk associated with 24-hour ambulatory diastolic (DBP24) versus systolic (SBP24) blood pressure are scarce. METHODS AND RESULTS: We recorded 24-hour blood pressure and health outcomes in 8341 untreated people (mean age, 50.8 years; 46.6% women) randomly recruited from 12 populations. We computed hazard ratios (HRs) using multivariable-adjusted Cox regression. Over 11.2 years (median), 927 (11.1%) participants died, 356 (4.3%) from cardiovascular causes, and 744 (8.9%) experienced a fatal or nonfatal cardiovascular event. Isolated diastolic hypertension (DBP24≥80 mm Hg) did not increase the risk of total mortality, cardiovascular mortality, or stroke (HRs≤1.54; P≥0.18), but was associated with a higher risk of fatal combined with nonfatal cardiovascular, cardiac, or coronary events (HRs≥1.75; P≤0.0054). Isolated systolic hypertension (SBP24≥130 mm Hg) and mixed diastolic plus systolic hypertension were associated with increased risks of all aforementioned end points (P≤0.0012). Below age 50, DBP24 was the main driver of risk, reaching significance for total (HR for 1-SD increase, 2.05; P=0.0039) and cardiovascular mortality (HR, 4.07; P=0.0032) and for all cardiovascular end points combined (HR, 1.74; P=0.039) with a nonsignificant contribution of SBP24 (HR≤0.92; P≥0.068); above age 50, SBP24 predicted all end points (HR≥1.19; P≤0.0002) with a nonsignificant contribution of DBP24 (0.96≤HR≤1.14; P≥0.10). The interactions of age with SBP24 and DBP24 were significant for all cardiovascular and coronary events (P≤0.043). CONCLUSIONS: The risks conferred by DBP24 and SBP24 are age dependent. DBP24 and isolated diastolic hypertension drive coronary complications below age 50, whereas above age 50 SBP24 and isolated systolic and mixed hypertension are the predominant risk factors.


Asunto(s)
Monitoreo Ambulatorio de la Presión Arterial/métodos , Presión Sanguínea/fisiología , Hipertensión/diagnóstico , Hipertensión/epidemiología , Vigilancia de la Población/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Resultado del Tratamiento , Adulto Joven
18.
Stroke ; 46(12): 3488-93, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26470776

RESUMEN

BACKGROUND AND PURPOSE: Demographic trends in atrial fibrillation (AF) incidence may yield a substantial rise in the societal burden of AF-related stroke (AF-stroke). Accurate population-wide outcome data are essential to inform health service planning to improve AF-stroke prevention, and provision of rehabilitation, nursing home, and community supports for AF-stroke survivors. METHODS: We investigated rates and determinants of 5-year fatality, stroke recurrence, functional outcomes, and prescribing of secondary prevention medications in AF-stroke in the North Dublin Population Stroke Study. Ascertainment included hot and cold pursuit using multiple overlapping sources. Survival analysis was performed using lifetables and Kaplan-Meier survival curves, and Cox proportional hazard modeling was performed to identify predictors of death and recurrent stroke. RESULTS: Five hundred sixty-eight patients with new stroke were identified, including 177 (31.2%) AF-stroke. At 5 years, 39.2% (confidence interval, 31.5-46.8) of ischemic AF-stroke patients were alive. Congestive heart failure, hypertension, age <65, 65-74 years, and ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack or thromboembolism, vascular disease and female sex (CHA2DS2-VASc) score (hazard ratio [HR], 1.34; P<0.001), CHADS2 score (HR 1.42, P=0.004), National Institute of Health Stroke Scale (HR, 1.09; P<0.0001), and subtherapeutic international normalized ratio (<2.0) at stroke onset (HR, 3.29; P=0.003) were independently associated with 5-year fatality, whereas warfarin (HR, 0.40; P=0.001) and statin use after index stroke (HR, 0.52; P=0.005) were associated with improved survival. The 5-year recurrence rate after ischemic AF-stroke was 21.5% (confidence interval, 14.5-31.3). Trends toward greater risk of recurrence were observed for persistent AF (HR, 3.09; P=0.07) and CHA2DS2-VASc score (HR, 1.34; P=0.07). Nursing home care was needed for 25.9% of patients. CONCLUSIONS: AF-stroke is associated with considerable long-term morbidity, fatality, stroke recurrence, and nursing home requirement. Adequately resourced national AF strategies to improve AF detection and prevention are needed.


Asunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Vigilancia de la Población , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Irlanda/epidemiología , Masculino , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento
19.
Curr Hypertens Rep ; 17(9): 585, 2015 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-26228235

RESUMEN

Raised blood pressure is the leading attributable risk factor for global morbidity and mortality. Real world data demonstrates that half of treated patients are at elevated cardiovascular risk because of inadequately controlled BP. In addition to pharmacotherapy, certain interventional strategies to reduce blood pressure and cardiovascular risk in hypertension can be considered according to international guidelines. One of the newer technologies entering this field is a proprietary arteriovenous coupler device that forms a fixed flow arteriovenous conduit in the central vasculature. In this review, we examine the development of and rationale for the creation of a central arteriovenous anastomosis in patients with hypertension and review the proposed mechanisms by which it may ameliorate hypertension. We critically review the clinical trial evidence base to date and postulate on future therapeutic directions.


Asunto(s)
Anastomosis Arteriovenosa , Hipertensión , Envejecimiento , Anastomosis Arteriovenosa/fisiopatología , Presión Sanguínea/fisiología , Humanos , Hipertensión/complicaciones , Hipertensión/tratamiento farmacológico , Factores de Riesgo , Rigidez Vascular
20.
BMC Neurol ; 15: 216, 2015 Oct 23.
Artículo en Inglés | MEDLINE | ID: mdl-26492943

RESUMEN

BACKGROUND: Survivors of ischaemic stroke (IS) are at high-risk for future vascular events. Comprehensive information on the adequacy of secondary prevention after IS is lacking despite the knowledge that appropriate secondary prevention improves long-term patient outcomes. ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) aimed to prospectively assess secondary prevention in patients 6 months following IS. METHODS: Consenting patients admitted with IS to three Dublin hospitals were recruited over 1 year, from October 2011. At 6 months post IS a comprehensive assessment was completed, modelled on the EUROASPIRE protocol for evaluation of the adequacy of secondary prevention in post-discharge cardiac patients. This assessment included measurements of blood pressure, body mass index and fasting lipid and glucose profiles. Secondary preventive medications and smoking status were also documented. RESULTS: Three hundred two patients (58 % male) participated, of whom 256 (85 %) were followed-up at 6 months. Mean age was 69 years (range 22-95). At follow-up, 68 % of patients had a BMI >25 kg/m(2) and 16.4 % were still smoking. Almost two-thirds (63.4 %) had a blood pressure >140/90 and 23 % had low-density-lipoprotein >2.5 mmol/L. 28 % of diabetic patients had HbA1c ≥ 7 %. Ninety seven percent of patients were on anti-platelet and/or anticoagulant therapy. Of those with atrial fibrillation, 82 % were anti-coagulated (mean INR of 2.4). Ninety-five percent were on lipid-lowering therapy and three-quarters were on anti-hypertensive therapy. CONCLUSION: This prospective multi-centre survey of IS patients demonstrated a high prevalence of remaining modifiable risk factors at 6 months post stroke, despite the widespread prescription of secondary preventive medications. There is scope to improve preventive measures after IS (in particular blood pressure) by incorporating evidence-based guidelines into quality assurance cycles in stroke care.


Asunto(s)
Isquemia Encefálica/prevención & control , Evaluación de Resultado en la Atención de Salud/métodos , Prevención Secundaria/métodos , Accidente Cerebrovascular/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Adulto Joven
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