Evolución del grado de conocimiento de la enfermedad en pacientes que han sufrido un ictus isquémico / Evolution of the degree of disease knowledge in subjects who have suffered an ischaemic stroke

INTRODUCCIÓN: La demora hasta la demanda de la atención médica en pacientes que sufren un episodio de enfermedad cerebrovascular (ECV) depende, en gran parte, del conocimiento que existe de la enfermedad. Pretendemos estudiar la evolución del conocimiento de los pacientes que ingresaron por un ictus isquémico. PACIENTES Y MÉTODOS: Se utilizó una entrevista estructurada para conocer el grado de conocimiento de la ECV (terminología, factores de riesgo, síntomas y actitud) de los pacientes ingresados por ictus isquémico sin trastorno del lenguaje ni alteración cognitiva en dos períodos de tiempo diferenciados: enero de 2011 y diciembre de 2013 (n = 295), y octubre de 2015 y diciembre de 2016 (n = 325). RESULTADOS: Se observó un mejor conocimiento de la enfermedad a lo largo del tiempo, tanto en el número de términos reconocidos ­–4,1 (desviación estándar: 2) frente a 4,8 (desviación estándar: 1,7); p < 0,001– como en el buen conocimiento de los síntomas (más de tres factores y menos de dos distractores) (56,6 frente a 69,8%; p < 0,001). La proporción de pacientes que llamaron directamente al 112 fue significativamente mayor (17,3 frente a 24,6%; p = 0,003), así como el reconocimiento del término ictus (51,9 frente a 74,5%; p < 0,001). No hubo diferencias en el grado de conocimiento de los factores de riesgo. La mejoría en el grado de conocimiento no se tradujo en una disminución en la demora entre el inicio de los síntomas y la llegada al hospital. CONCLUSIÓN: Pese a la mejoría en el conocimiento de la ECV, todavía se deben hacer esfuerzos para mejorar la actitud frente a la ECV y disminuir la demora hasta la llegada al hospital

INTRODUCTION: The delay in seeking medical care in patients who suffer a cerebrovascular disease (CVD) event depends, largely, on knowledge of the disease. Our aim is to study the evolution of the knowledge of patients admitted to hospital due to an ischaemic stroke. PATIENTS AND METHODS: A structured interview was used to determine the level of knowledge of CVD (terminology, risk factors, symptoms and attitude) of patients admitted due to an ischaemic stroke without language impairment or cognitive impairment in two distinct time periods: January 2011 and December 2013 (n = 295), and October 2015 and December 2016 (n = 325). RESULTS. Better knowledge of the disease was observed over time, both in the number of terms recognised 4.1 (standard deviation: 2) vs. 4.8 (standard deviation: 1.7); p < 0.001 and in a good knowledge of symptoms (more than three factors and less than two distractors) (56.6 vs. 69.8%; p < 0.001). The proportion of patients who called the emergency services directly was significantly higher (17.3 vs. 24.6%; p = 0.003), as was the recognition of the term stroke (51.9 vs. 74.5%; p < 0.001). There was no difference in the degree of knowledge of risk factors. Improvement in knowledge did not translate into a decrease in the delay between symptom onset and arrival at the hospital. CONCLUSION. Despite improved knowledge of CVD, further efforts still need to be made to improve attitudes towards CVD and reduce the delay prior to hospital arrival

Stroke Risk Analysis, a System With a High Detection Rate of Atrial Fibrillation in Stroke and Transient Ischemic Attack.

Background and Purpose- Stroke Risk Analysis (SRA) comprises an algorithm for automated analysis of ECG monitoring, enabling the detection of paroxysmal atrial fibrillation (pxAF) and identifying patterns indicating a high risk of atrial fibrillation (R_AF). We compared Holter-enabled continuous ECG monitoring in combination with SRA (hSRA) with standard continuous ECG monitoring for pxAF detection in patients with acute ischemic stroke. Also, we sought to identify whether the detection of R_AF patterns during the first cycle (first 2 hours) of hSRA recording was associated with the detection of pxAF during the Stroke Unit stay. Methods- We enrolled 524 consecutive patients admitted in the Stroke Unit with acute ischemic stroke or transient ischemic attack with neither history of AF nor AF at admission into a prospective multicentric observational analytic clinical study with intrapatient comparison, who received both continuous ECG monitoring as well as hSRA up to 7 days. Investigators were blinded to hSRA results unless pxAF was detected on SRA. Results- Of the 524 consecutive acute stroke patients (median age, 70.0 years; 60% male; acute ischemic stroke 93%, transient ischemic attack 7%), 462 were eligible and included in the study. Among 462 patients with hSRA available for 66 hours, AF was documented by hSRA in 79 patients (17.1%). From this group, 45 AF cases (9.7%) were confirmed after review by an independent and blinded cardiologist. continuous ECG monitoring detected 21 AF cases (4.3%; P<0.0001). hSRA detected R_AF patterns in 92 patients. 35 out of the 92 R_AF patients showed an episode of AF during the Stroke Unit stay. Predictive values of R_AF patterns within the first cycle of hSRA were: sensitivity 71%, specificity 86%, positive predictive value 38%, and negative predictive value 96%. Conclusions- Automated analysis using SRA technology strongly improves pxAF detection in acute ischemic stroke patients compared with continuous ECG monitoring. The predictive value of a R_AF pattern, as detected by hSRA during the first few hours after admission, deserves further investigation.

Age- and Sex-Specific Risk Profiles and In-Hospital Mortality in 13,932 Spanish Stroke Patients.

BACKGROUND: In-hospital stroke death rate is an important sanitary issue. Despite advances in the acute phase management of stroke patients, mortality and disability rates remain high. In aging populations and with different mortality between the sexes in general, the study of sex- and age-related differences becomes increasingly relevant for optimization of post-acute clinical care of stroke patients. METHODS: We designed a cohort follow-up study with 13,932 consecutive ischemic stroke (IS) patients from 19 Spanish hospitals. Data was obtained from the Spanish Stroke Registry; transient ischemic attacks and ages <18 years were excluded. Patients were organised by age group and sex. We compared female and male patient cohorts within and across age groups univariately and used multivariable logistic regression to adjust for confounders in differential in-hospital mortality. RESULTS: The median (percentiles 2.5 and 97.5%) age was 78 (41-92) years old for women and 71 (41-92) for men. IS women were more likely to be older, to exhibit cardio-embolic aetiology, and less likely to have been admitted to a stroke unit or to have had a stroke code activated. Both pre-stroke modified Rankin Scale and National Institute of Health Stroke Scale (NIHSS) scores at admission increased significantly with age and were higher in women than those in men. Differences in distributions of common risk factors for IS and of in-hospital outcomes between women and men actually changed with patient's age. It is to be noted here that although there were no statistically significant differences (p > 0.05) between the sexes within any age group, in-hospital mortality appeared significantly higher in women than that in men when analysed overall, due to confounding. Death was more closely related to stroke in women than in men and occurred earlier. Although there were some age-specific sex differences between the predictors for in-hospital mortality, stroke severity measured by NIHSS was the main predictor of in-hospital mortality for both sexes. Topographic classifications - partial anterior circulatory infarct and total anterior circulatory infarct - were significant prognostic factors for men aged <60 years and for those in the 60-69 years range respectively. CONCLUSION: Although most of our findings were consistent with previous studies, it is important to take into account and highlight differences in in-hospital mortality between the sex and age group. Not to account for age-related differences between the sexes can give false results that may mislead management decisions. As most deaths in women were related to stroke, it is important to improve their early management, stroke code activation, access to stroke units and/or revascularisation therapies, especially in the older age groups.

Skin Autofluorescence Measurement in Subclinical Atheromatous Disease: Results from the ILERVAS Project.

AIM: Advanced glycation end-products (AGEs) have been involved in the atherogenic process in the high-risk population. The goal of this study was to demonstrate that AGEs are related to subclinical atheromatous disease in subjects with low to moderate vascular risk. METHODS: A cross-sectional study in which 2,568 non-diabetic subjects of both sexes without cardiovascular disease were included. Subcutaneous content of AGEs was assessed by skin autofluorescence (SAF) and subclinical atheromatous disease was measured by assessing the atheromatous plaque burden in carotid and femoral regions using ultrasonography. In addition, serum pentosidine, carboxymethyl-lysine (CML) and AGE receptors (RAGE) were assessed in a nested case-control study with 41 subjects without plaque and 41 individuals subjects with generalized disease. RESULTS: Patients with atheromatous plaque had a higher SAF than those with no plaque (1.9 [1.7 to 2.3] vs. 1.8 [1.6 to 2.1] arbitrary units (AU), p＜0.001). The SAF correlated with the total number of affected regions (r= 0.171, p＜0.001), increasing progressively from 1.8 [1.6 to 2.1] AU in those without atheromatous disease to 2.3 [1.9 to 2.7] AU in patients with ≥ 8 plaques (p＜0.001). A correlation was also observed between SAF and the total plaque area (r=0.113, p＜0.001). The area under the Receiver Operating Characteristic curve was 0.65 (0.61 to 0.68) for identifying male subjects with atheromatous disease. The multivariable logistic regression model showed a significant and independent association between SAF and the presence of atheromatous disease. However, no significant differences in serum pentosidine, CML, and RAGE were observed. CONCLUSIONS: Increased subcutaneous content of AGEs is associated with augmented atheromatous plaque burden. Our results suggest that SAF may provide clinically relevant information to the current strategies for the evaluation of cardiovascular risk, especially among the male population.

Metabolomic Estimation of the Diagnosis and Onset Time of Permanent and Transient Cerebral Ischemia.

Determining the time of stroke onset in order to apply recanalization therapies within the accepted therapeutic window and the correct diagnosis of transient ischemic attack (TIA) are two common clinical problems in acute cerebral ischemia management. Therefore, biomarkers helping in this conundrum could be very helpful. We developed mouse models of distal middle cerebral artery occlusion mimicking TIA and ischemic stroke (IS), respectively. Plasma samples were analyzed by metabolomics at 6, 12, 24, and 48 h post onset in order to find TIA- and time-related stroke biomarkers. The results were validated in a second experimental cohort. Plasma metabolomic profiles identified time after stroke events with a very high accuracy. Specific metabolites pointing to a recent event (< 6 h) were identified. A multivariate (partial least square discriminant analyses [PLS-DA]) model was also able to separate samples from TIA, IS, and sham events with high accuracy and to obtain specific metabolites for each time point. The combination of mice models of focal ischemia with plasma metabolomics allows the discovery of candidate biomarkers for the diagnosis and estimation of onset time of stroke and TIA diagnosis.

Influence of Hospital Type on Outcomes of Individuals Aged 80 and Older with Stroke Treated Using Intravenous Thrombolysis.

OBJECTIVES: The aim of the study was to confirm the safety and effectiveness of using intravenous thrombolysis (IVT) with individuals aged 80 and older in routine practice in different hospital settings. DESIGN: Observasional registry. SETTING: Prospective multicenter population-based registry of acute stroke patients treated with reperfusion therapies in Catalonia, Spain (Sistema Online d'Informació de l'Ictus Agut). PARTICIPANTS: Individuals treated only with IVT (N = 3,231; 1,189 (36.8%) aged ≥80). MEASUREMENTS: Symptomatic intracranial hemorrhage, mortality, and favorable outcome (modified Rankin Scale (mRS) score = 0-2) at 3 months were evaluated according to hospital characteristics. Treating hospitals were classified in three categories: comprehensive stroke centers (CSCs), primary stroke centers (PSCs), and community hospitals operating a telestroke system (TS). First individuals aged 80 and older were compared with those younger than 80, and then participants aged 80 and older were focused on. RESULTS: Participants aged 80 and older had significantly higher baseline National Institute of Health Stroke Scale (NIHSS) scores, longer onset to treatment times, and worse outcomes than younger participants. For participants aged 80 and older, 90-day mortality was 23.2%, with 38.7% having favorable outcomes at 3 months. Symptomatic intracranial hemorrhage (SICH; Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy definition) was observed in 4.7% of subjects. None of the risk factors differed significantly between participants treated in different types of hospitals. Basal stroke severity measured according to NIHSS score was not significantly different either. The three different types of hospitals achieved similar outcomes, although the TS and PSC hospitals had significantly higher proportions of SICH (6.3% and 6.3%, respectively) than the CSC (3.2%). CONCLUSION: Older adults with acute stroke treated with IVT had similar outcomes regardless of hospital characteristics.

A Current Estimation of the Early Risk of Stroke after Transient Ischemic Attack: A Systematic Review and Meta-Analysis of Recent Intervention Studies.

OBJECTIVE: Recent studies have demonstrated that there is a decrease in the risk of subsequent stroke after transient ischemic attack (TIA) when urgent care (UC) is administered. However, no meta-analysis has been developed with contemporaneous TIA studies. We perform a systematic review and a meta-analysis to establish the risk of early stroke recurrence (SR) considering data from studies that offered UC to TIA patients. METHODS: We searched for studies, without language restriction, from January 2007 to January 2015 according to PRISMA guidelines. We included studies with TIA patients who underwent UC and reported the proportion of SR at 90 days. We excluded studies that were centered on less than 100 patients and cohorts including both stroke and TIA, if stroke risk after TIA was not described. For its relevance, we included the TIAregistry.org study published in 2016. We performed both fixed and random effects meta-analyses to determine SR and assess sources of heterogeneity. RESULTS: From 4,103 identified citations, we selected 15 papers that included 14,889 patients. There was great variation in terms of the number of patients included in each study, ranging from 115 to 4,160. Seven studies were TIA clinic based. The mean age and the percentage of men were similar among studies, ranging from 62.4 to 73.1 years and 45.1-62%, respectively. The reported risk of stroke ranged from 0 to 1.46% 2 days after TIA (9 studies included), 0-2.55% 7 days after TIA (11 studies included), 1.91-2.85% 30 days after TIA (4 studies included), and 0.62-4.76% 90 days after TIA (all studies included). The pooled stroke risk was 3.42% (95% CI 3.14-3.74) at 90 days, 2.78% (95% CI 2.47-3.12) at 30 days, 2.06% (95% CI 1.83-2.33) at 7 days and 1.36% (95% CI 1.15-1.59) at 2 days. Although we did not find statistically significant heterogeneity in SR among studies, those with a higher proportion of patients with motor weakness had a significantly higher risk of SR. No statistically significant association was observed between TIA clinic management and SR. CONCLUSION: The pooled early SR is lower than in previous meta-analyses and homogeneous for all studies with an urgent assessment and management strategy regardless of vascular risk factors and clinical characteristics. Therefore, the best setting for TIA management can be individualized for each center.

Metabolomics Predicts Neuroimaging Characteristics of Transient Ischemic Attack Patients.

BACKGROUND: Neuroimaging is essential for the diagnosis and prognosis of transient ischemic attack (TIA). The discovery of a plasmatic biomarker related to neuroimaging findings is of enormous interest because, despite its relevance, magnetic resonance diffusion weighted imaging (DWI) is not always available in all hospitals that attend to TIA patients. METHODS: Metabolomic analyses were performed by liquid chromatography coupled to mass spectrometry in order to establish the metabolomic patterns of positive DWI, DWI patterns and acute ischemic lesion volumes. We used these methods with an initial TIA cohort of 129 patients and validated them with a 2nd independent cohort of 152 patients. FINDINGS: Positive DWI was observed in 115 (40.9%) subjects and scattered pearls in one arterial territory was the most frequent lesion pattern (35.7%). The median acute ischemic lesion volume was 0.33 (0.15-1.90)cm3. We detected a specific metabolomic profile common to both cohorts for positive DWI (11 molecules including creatinine, threoninyl-threonine, N-acetyl-glucosamine, lyso phosphatidic acid and cholesterol-related molecules) and ischemic lesion volume (10 molecules including lysophosphatidylcholine, hypoxanthine/threonate, and leucines). Moreover lysophospholipids and creatinine clearly differed the subcortical DWI pattern from other patterns. INTERPRETATION: There are specific metabolomic profiles associated with representative neuroimaging features in TIA patients. Our findings could allow the development of serum biomarkers related to acute ischemic lesions and specific acute ischemic patterns.

Metabolomics predicts stroke recurrence after transient ischemic attack.

OBJECTIVE: To discover, by using metabolomics, novel candidate biomarkers for stroke recurrence (SR) with a higher prediction power than present ones. METHODS: Metabolomic analysis was performed by liquid chromatography coupled to mass spectrometry in plasma samples from an initial cohort of 131 TIA patients recruited <24 hours after the onset of symptoms. Pattern analysis and metabolomic profiling, performed by multivariate statistics, disclosed specific SR and large-artery atherosclerosis (LAA) biomarkers. The use of these methods in an independent cohort (162 subjects) confirmed the results obtained in the first cohort. RESULTS: Metabolomics analyses could predict SR using pattern recognition methods. Low concentrations of a specific lysophosphatidylcholine (LysoPC[16:0]) were significantly associated with SR. Moreover, LysoPC(20:4) also arose as a potential SR biomarker, increasing the prediction power of age, blood pressure, clinical features, duration of symptoms, and diabetes scale (ABCD2) and LAA. Individuals who present early (<3 months) recurrence have a specific metabolomic pattern, differing from non-SR and late SR subjects. Finally, a potential LAA biomarker, LysoPC(22:6), was also described. CONCLUSIONS: The use of metabolomics in SR biomarker research improves the predictive power of conventional predictors such as ABCD2 and LAA. Moreover, pattern recognition methods allow us to discriminate not only SR patients but also early and late SR cases.