Modelling eating practices in non-fatal acute coronary syndrome or stroke development: a case/case-control study.

BACKGROUND AND AIMS: Although significant evidence exists regarding the role of specific foods and dietary patterns on the development of cardiovascular disease, the influence of eating practices has not been thoroughly examined and understood. The aim of the present work was to evaluate the independent role of eating practices on the likelihood of developing an acute coronary syndrome (ACS) or ischemic stroke. METHODS AND RESULTS: During 2009-2010, 1000 participants were enrolled; 250 were consecutive patients with a first ACS, 250 were consecutive patients with a first ischemic stroke and 500 were population-based control subjects (250 age-sex matched one-for-one with ACS patients, and 250 age-sex matched one-for-one with stroke patients). Eating practices were evaluated using a special questionnaire. Socio-demographic, clinical, psychological, dietary and other lifestyle characteristics were also measured. After controlling for potential confounding factors, each 20 min prolongation of dinner-to-sleep time was associated with 10% lower likelihood of ischemic stroke (95%CI: 0.83-0.98). Furthermore, eating practices related to stress (i.e., eating while being stressed, eating while working at the same time, skipping a meal due to work obligations) were associated with higher likelihood of having an ACS. Finally, eating while watching television was associated with lower likelihood of having an ACS (OR: 0.46, 95%CI: 0.27-0.78) or stroke event (OR: 0.42, 95%CI: 0.23-0.77). CONCLUSION: Results of this work, present novel information, indicating the significance of eating practices, in addition to dietary patterns, regarding the development of coronary heart disease and stroke, and could be used in the primary prevention of CVD.

Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review.

OBJECTIVES: Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH. METHODS: The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with >100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model. RESULTS: We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29). CONCLUSIONS: In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome.

Significance of aphasia after first-ever acute stroke: impact on early and late outcomes.

BACKGROUND: We assessed the incidence and determinants of aphasia attributable to first-ever acute stroke. We also investigated early and long-term mortality and 1-year dependence in post-stroke patients. METHODS: A 10-year prospective hospital-based study was conducted in the prefecture of Athens, Greece. RESULTS: In total, 2,297 patients were included in the study, of whom 806 (35.1%) had aphasia. The presence of aphasia was independently associated with increasing age (OR: 1.19 per 10-year increase, 95% CI: 1.12-1.21) and atrial fibrillation (OR: 1.35, 95% CI: 1.08-1.67), and inversely associated with Scandinavian Stroke Scale (SSS) score (OR: 0.55 per 10-point increase, 95% CI: 0.52-0.59) and hypertension (OR: 0.77, 95% CI: 0.63-0.96). One-year dependence score (calculated with the modified Rankin score) was higher in aphasic patients compared to non-aphasics (p < 0.001). Moreover, severity of aphasia (estimated with a subscale of SSS) was found as an independent predictor of 1-year dependence. Most of the deaths in the aphasic patients were attributed to infections and neurological damage. Using the Kaplan-Meier limit method, the unadjusted probability of 10-year mortality was demonstrated to increase with the severity of aphasia (log-rank test: 233.9, p < 0.001) and, even after adjustment for several other factors, severity of aphasia remained an independent predictor of 10-year mortality. CONCLUSIONS: Increasing age, atrial fibrillation and severity of stroke were associated with the risk of aphasia after stroke. Severity of aphasia is a strong predictor of long-term mortality and dependence of post-stroke patients.

Incidence and predictors of post-stroke aphasia: the Arcadia Stroke Registry.

BACKGROUND AND PURPOSE: Aphasia is an important post-stroke sequela. We estimated the prevalence and main determinants of post-stroke aphasia in the prefecture of Arcadia, Greece. METHOD: Prospective population-based study of Arcadia residents diagnosed with first ever stroke. within a 2 year period. Associations of aphasia with potential predictors were analysed by logistic regression in: (i) the entire cohort and (ii) the sub-cohort of patients who were alive 28 days post-stroke. Multivariate regression models were adjusted for left hemispheric stroke localization and modified Rankin Scale 28 days post-stroke (MRS-1mo). RESULTS: Of 555 subjects, 126 (22.7%) suffered from aphasia. When only the 405 survivors were considered, 77 (19.0%) suffered from aphasia. In adjusted multivariate models of the entire cohort, factors conferring significantly higher risk for aphasia included female gender, diabetes mellitus (borderline significance) and heart disease. In adjusted multivariate models of survivors, only diabetes was associated with significantly higher risk for aphasia. CONCLUSIONS: Female gender, diabetes and heart disease were independent prospective predictors of aphasia. The study offers a quantitative estimate of the public health problem of post-stroke aphasia in Greece and suggests that the role of diabetes in post-stroke aphasia may be more important than previously appreciated.

Low triiodothyronine: a strong predictor of outcome in acute stroke patients.

BACKGROUND: Low triiodothyronine (T3) has been associated with increased short-term mortality in intensive care unit patients and long-term mortality in patients with heart disease. The objective of this study was to investigate possible associations of thyroid hormone status with clinical outcome in patients admitted for acute stroke. MATERIALS AND METHODS: A total of 737 consecutive patients with acute first ever stroke who presented within 24 h from symptoms' onset were studied. Total T3, thyroxin (T4) and thyroid-stimulating hormone (TSH) levels were assessed in the morning following admission. Cases with T3 values < or = 78 ng dL(-1) (1.2 nmol L(-1)) (median) were characterized as 'low T3'. Cases with T4 values < or = 4.66 microg dL(-1) (60 nmol L(-1)) were characterized as 'low T4'. Basic and clinical characteristics, stroke risk factors, and brain imaging were evaluated. Neurological impairment was assessed using the Scandinavian Stroke Scale. RESULTS: Four hundred and seventeen (56%) patients had T3 values < or = 78 ng dL(-1) and 320 had normal T3 values. The 1-year mortality was 27.34% for low T3 and 19.37% for normal T3 cases (P = 0.006). A smaller percentage of patients with low T3 values were independent at 1 year compared to those with normal T3 values [54.2% vs. 68.7%, chi(2) = 12.09, P < 0.001, odds ratio (OR) = 0.53, 95% confidence interval (CI) 0.37-0.76]. Cox regression analysis revealed that increased age, haemorrhagic stroke, low Scandinavian Stroke Scale score, increased glucose and low T3 values (hazards ratio 0.69, CI = 0.48-0.98, P = 0.041) were significant predictors of 1-year mortality. CONCLUSIONS: A high proportion of patients with acute stroke were found soon after the event with low T3 values. The low-T3 syndrome is an independent predictor of early and late survival in patients with acute stroke, and predicts handicap at 1 year.

Twenty four hour pulse pressure predicts long term recurrence in acute stroke patients.

OBJECTIVES: The impact of different blood pressure (BP) components during the acute stage of stroke on the risk of recurrent stroke is controversial. The present study aimed to investigate by 24 hour BP monitoring a possible association between acute BP values and long term recurrence. METHODS: A total of 339 consecutive patients with first ever acute stroke underwent 24 hour BP monitoring within 24 hours of ictus. Known stroke risk factors and clinical findings on admission were documented. Patients given antihypertensive medication during BP monitoring were excluded. The outcome of interest during the one year follow up was recurrent stroke. The Cox proportional hazard model was used to analyse association of casual and 24 hour BP recordings with one year recurrence after adjusting for stroke risk factors, baseline clinical characteristics, and secondary prevention therapies. RESULTS: The cumulative one year recurrence rate was 9.2% (95% CI 5.9% to 12.3%). Multivariate Cox regression analyses revealed age, diabetes mellitus, and 24 hour pulse pressure (PP) as the only significant predictors for stroke recurrence. The relative risk for one year recurrence associated with every 10 mm Hg increase in 24 hour PP was 1.323 (95% CI 1.019 to 1.718, p = 0.036). Higher casual PP levels were significantly related to an increased risk of one year recurrence on univariate analysis, but not in the multivariate Cox regression model. CONCLUSIONS: Elevated 24 hour PP levels in patients with acute stroke are independently associated with higher risk of long term recurrence. Further research is required to investigate whether the risk of recurrent stroke can be reduced to a greater extent by decreasing the pulsatile component of BP in patients with acute stroke.

Common carotid artery intima-media thickness for the risk assessment of lacunar infarction versus intracerebral haemorrhage.

BACKGROUND AND PURPOSE: Arterial hypertension is the major risk factor for intracerebral haemorrhage (ICH) and lacunar infarction (LI) and both types of cerebral lesions originate from pathology of the same deep perforating small arteries. We aimed to evaluate the relationship between vascular risk factors including common carotid artery intima-media thickness (CCA-IMT) with LI versus ICH. METHODS: We prospectively collected data from 159 first ever stroke patients (67 cases with ICH and 92 cases with LI) with documented history of hypertension. All subjects underwent B-mode ultrasonographic measurements of the CCA-IMT. Logistic regression modelling was used to determine the factors (established vascular risk factors, severity and duration of hypertension, concomitant medications and CCA-IMT) that may significantly differentiate LI from ICH. RESULTS: Patients with LI had significantly (p=0.002) larger CCA-IMT values (0.926 mm, 95% CI: 0.881-0.971) than subjects with ICH (0.815 mm, 95% CI: 0.762-0.868) even after adjusting for baseline characteristics and cardiovascular medications. The multivariate logistic regression procedure selected CCA-IMT, diabetes mellitus and hypercholesterolaemia as the only independent factors able to discriminate between LI and ICH. The risk for LI versus ICH increased continuously with increasing CCA-IMT. For each increment of 0.1 mm in CCA-IMT the probability of suffering from LI versus ICH increased by 36.6% (95 % CI: 13%-65.2%, p=0.001) even after adjustment for cardiovascular risk factors. CONCLUSIONS: Increased CCA-IMT values are a factor favouring LI over ICH in hypertensive patients. The measurement of CCA-IMT may be a useful non-invasive diagnostic tool for the risk assessment of LI with respect to ICH in such patients.

Spontaneous subarachnoid haemorrhage in the era of transition from surgery to embolization. A study of the overall outcome.

The aim of the investigation was to evaluate the outcome of spontaneous subarachnoid haemorrhage, in the era of new techniques, patient centralization and subspecialization, by taking into account the local conditions in Greece. A prospective observational study was conducted during a 4-year period. All patients with a first-ever spontaneous subarachnoid haemorrhage were enrolled. Clinical, management and outcome data were recorded. Two-hundred-and-eighteen consecutive patients with an 81% good, medium clinical grade (Hunt & Hess I-III) were identified. Rebleed and rebleed leading to death rates were 22 and 11%, respectively. Permanent deficit or death from vasospasm was 15%. Twenty-eight per cent of the study population died early, were unsuitable for further management (poor clinical status, advanced age) or declined angiography or treatment, and another 22% had a negative angiogram. The remaining 50% underwent intervention (neurosurgical/endovascular), for obliteration of an aneurysm. The overall favourable 6-month outcome was 59%, whereas the favourable outcome of the intervention group was 70%. Our results confirm the findings of previous series. The relatively worse results are due to delayed referral, and lack of availability of surgical or endovascular management in the early post-haemorrhage period (28% of the patients), particularly in potentially salvageable cases. On the basis of these observations, we recommend early intervention (surgery or embolization) and centralization/subspecialization, in order to improve the outcome.

Factors influencing acute blood pressure values in stroke subtypes.

The aim of this prospective observational study was to determine the association of acute blood pressure values with independent factors (demographic, clinical characteristics, early complications) in stroke subgroups of different aetiology. We evaluated data of 346 first-ever acute (<24 h) stroke patients treated in our stroke unit. Casual and 24-h blood pressure (BP) values were measured. Stroke risk factors and stroke severity on admission were documented. Strokes were divided into subgroups of different aetiopathogenic mechanism. Patients were imaged with CT-scan on admission and 5 days later to determine the presence of brain oedema and haemorrhagic transformation. The relationship of different factors to 24-h BP values (24-h BP) was evaluated separately in each stroke subgroup. In large artery atherosclerotic stroke (n=59), history of hypertension and stroke severity correlated with higher 24-h BP respectively. In cardioembolic stroke (n=87), history of hypertension, stroke severity, haemorrhagic transformation and brain oedema were associated with higher 24-h BP, while heart failure with lower 24-h BP. History of hypertension and coronary artery disease was related to higher and lower 24-h BP, respectively, in lacunar stroke (n=75). In patients with infarct of undetermined (n=57) cause 24-h BP were mainly influenced by stroke severity and history of hypertension. An independent association between higher 24-h BP and history of hypertension and cerebral oedema was documented in intracerebral haemorrhage (n=68). In conclusion, different factors influence acute BP values in stroke subtypes of different aetiology. If the clinical significance of these observations is verified, a differentiated approach in acute BP management based on stroke aetiology may be considered.

U-shaped relationship between mortality and admission blood pressure in patients with acute stroke.

OBJECTIVE: To evaluate the relationship between systolic blood pressure (SBP) or diastolic blood pressure (DBP) on admission and early or late mortality in patients with acute stroke. DESIGN: Prospective study of hospitalized first-ever stroke patients over 8 years. SETTING: Stroke unit and medical wards in a University hospital. SUBJECTS: A total of 1121 patients admitted within 24 h from stroke onset and followed up for 12 months. MAIN OUTCOME MEASURES: Mortality at 1 and 12 months after stroke in relation to admission SBP and DBP. RESULTS: Early and late mortality in patients with acute ischaemic or haemorrhagic stroke in relation to admission SBP and DBP followed a 'U-curve pattern'. After adjusting for known outcome predictors, the relative risk of 1-month and 1-year mortality associated with a 10-mmHg SBP increase above 130 mmHg (U-point of the curve) increased by 10.2% (95% CI: 4.2-16.6%) and 7.2% (95% CI: 2.2-12.3%), respectively. For every 10 mmHg SBP decrease, below the U-point, the relative risk of 1-month and 1-year mortality rose by 28.2% (95% CI: 8.6-51.3%) and 17.5% (95% CI: 3.1-34.0%), respectively. Low admission SBP-values were associated with heart failure (P < 0.001) and coronary artery disease (P = 0.006), whilst high values were associated with history of hypertension (P < 0.001) and lacunar stroke (P < 0.001). Death due to cerebral oedema was significantly (P = 0.005) more frequent in patients with high admission SBP-values, whereas death due to cardiovascular disease was more frequent (P = 0.004) in patients with low admission SBP-values. CONCLUSION: Acute ischaemic or haemorrhagic stroke patients with high and low admission BP-values have a higher early and late mortality. Coincidence of heart disease is associated with low initial BP-values. Death due to neurological damage from brain oedema is associated with high initial BP-values.

Reproducibility of ambulatory blood pressure measurements in essential hypertension.

BACKGROUND: Data on the reproducibility of serial measurements of ambulatory blood pressure in hypertensive patients are lacking. The purpose of this study was to examine (1) the reproducibility of four consecutive ambulatory blood pressure measurements, and (2) the reproducibility of nocturnal falls in blood pressure in hypertensive patients. METHODS: Twenty patients with mild to moderate essential hypertension underwent four separate ambulatory blood pressure monitorings, on the same day of the week, at 30-day intervals. Antihypertensive therapy was discontinued for 2 weeks before each recording. Comparing the mean values of blood pressure over 24h, as well as diurnal, nocturnal and hourly periods, among the four recordings determined the reproducibility of blood pressure measurements. A day/night difference in mean systolic and in mean diastolic blood pressure defined the nocturnal fall in blood pressure. RESULTS: No significant differences were observed in either hourly, 24-h, diurnal or nocturnal systolic blood pressure, diastolic blood pressure and heart rate, or in the nocturnal fall in systolic and diastolic blood pressure among the four recordings. CONCLUSIONS: Hourly systolic blood pressure, diastolic blood pressure, heart rate, and nocturnal fall in blood pressure were reproducible in four ambulatory blood pressure monitorings recorded over 4 months. These findings suggest that ambulatory blood pressure monitoring is a reliable tool to monitor blood pressure changes.

Prognosis of stroke in the south of Greece: 1 year mortality, functional outcome and its determinants: the Arcadia Stroke Registry.

OBJECTIVES: For Greece, data on incidence of stroke, type of stroke, and prognosis of stroke is limited. Recently, results on incidence of stroke were published. Here 1 year mortality, functional outcome after a first ever stroke, and determinants of the prognosis are described. METHODS: A population based registry was established in the Arcadia area, located in eastern central Peloponessos in southern Greece. Between 1 November 1993 and 31 October 1995, 555 patients with a first ever stroke were identified using information from death certificates, hospital records, public health centres and general practitioners. Extensive information on cardiovascular risk factors and stroke characteristics was obtained. After 1 year a modified Rankin score was determined in all surviving patients. RESULTS: After 1 year of follow up, 204 (36.8%) patients died. The probability of survival 1 year after stroke was higher for cerebral infarction than for intracerebral haemorrhage; 67.8% (95% confidence interval (95% CI) 64-72) and 46.4% (35-57), respectively. Of the survivors, 68.9% had either no symptoms or symptoms that would not interfere with their capacity to look after themselves (Rankin score 0 to 2). Increasing age and low Glasgow coma scale score were the most powerful predictors of death within 1 year (p<0.01), whereas increasing age, atrial fibrillation, and low Glasgow coma scale score were the most important predictors of functional outcome 1 year after a stroke (p<0.01). CONCLUSIONS: One year mortality from stroke in Greece is similar to that of other industrialised countries. The most important factors that affect the prognosis of a patient with a first ever stroke are increasing age, stroke severity, and atrial fibrillation.

First-stroke recovery process: the role of family social support.

OBJECTIVE: To determine the role of family social support in three stroke rehabilitation variables (functional status, depression, social status) during a 6-month recovery period. DESIGN: Assessment of first-stroke patients' functional status, depression, and social status before discharge and at 1, 3, and 6 months after stroke onset, in comparison with the amount of family social support received. The family social support scale--compliance, instrumental, and emotional support--was employed in the first month. SETTING: A university hospital and patients' residences. PATIENTS: A consecutive sample of 43 first-stroke patients meeting the inclusion criteria. MAIN OUTCOME MEASURES: Changes of patients' rehabilitation variables over the 6-month period were tested by use of repeated multivariate analysis of variance measures. RESULTS: Observers of functional, depression, and social status changes were blind to patient grouping according to levels of family support. These three variables were significantly affected by higher levels of support (p = .001, p = .001, p = .020, respectively), but a significant interaction was found only with regard to functional status adjusted for initial stroke severity (p = .019). Patients with moderate/severe stroke and high levels of social support attained a significantly better and progressively improving functional status than those with less support. CONCLUSIONS: High levels of family support--instrumental and emotional--are associated with progressive improvement of functional status, mainly in severely impaired patients, while the psychosocial status is also affected.

The Athens stroke registry: results of a five-year hospital-based study.

The advent and wide application of new technology, especially noninvasive techniques, has enabled physicians to more completely investigate and clarify the etiopathogenic mechanisms of stroke. Such data have not been available until recently for Southeastern Europe. In addition, during the last decades, strategies for the modification of risk factors and primary prevention may have changed the prevalence of each subgroup of stroke as well. We investigated 1, 042 consecutive patients who had first strokes, during a period of 5 years (from June 1992 to May 1997) and classified them prospectively based on etiopathogenic mechanisms. Patients with transient ischemic attacks and subarachnoid hemorrhage were excluded. There were 613 male and 429 female patients, with a mean age of 70.2 +/- 11.9 years. Forty-six percent of the patients arrived within 3 h from stroke onset. The probable mechanisms were: large-artery atherosclerosis, 156 (15%); lacunes, 177 (17%); cardioembolic, 335 (32.1%); infarct of unknown cause, 182 (17.5%); miscellaneous causes, 35 (3.3%), and intracerebral hemorrhage (ICH), 157 (15.1%). In the cardioembolic group, nonvalvular atrial fibrillation (NVAF) was the probable cause in 225 patients, especially in patients older than 75 years (65%). The overall hospital mortality was 15.2% (from 0.6% for lacunar stroke to 34% for ICH). In our population, cardioembolism is the most frequent subtype of stroke. NVAF is the most likely source, especially in older patients.

Stroke incidence and case fatality in southern Greece: the Arcadia stroke registry.

BACKGROUND AND PURPOSE: For Greece, information on incidence of stroke and distribution of type of stroke has not been reported. We determined the incidence of first-ever stroke in men and women, the incidence of stroke by type, and the associated case fatality. METHODS: A population-based registry was established in the Arcadia province, located in eastern central Peloponessos, in the southern part of Greece. Between November 1, 1993, and October 31, 1995, all subjects with a first-ever stroke were identified. For case ascertainment, information from death certificates, hospital records, public health centers, and general practitioners was used. RESULTS: During a 24-month period, 555 subjects with a first-ever stroke were registered. The incidence rates (per 100 000) by age group (18 to 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, >/=85 years) for men were 5, 31, 113, 240, 662, 1275, and 3218, respectively. For women, the rates were 11, 18, 48, 196, 478, 1166, and 2137, respectively. Age- and sex-standardized to the European population, the annual incidence rate for subjects aged 45 to 84 years was 319.4/100 000 (95% CI, 283 to 356). In men, cerebral infarction was diagnosed in 81% of cases, intracerebral hemorrhage in 16%, and subarachnoid hemorrhage in 2%. For women, these figures were 85%, 12%, and 3%, respectively. The 28-day case fatality rate was 26.6% (95% CI, 22.9% to 30.2%), with no differences between men and women. Case-fatality increased with age and was higher for intracerebral hemorrhage than for cerebral infarction. CONCLUSIONS: The incidence of stroke in our population-based study ranks low part compared with other European studies. The distribution of stroke types and case fatality rate appear to be similar to those of other industrialized countries.