Predictors of outcomes following catheter-based therapy for acute stroke.

BACKGROUND: Timely reperfusion directly impacts favorable neurologic outcomes in acute ischemic stroke (AIS) patients. Most strokes present outside the 3-4.5 h window for intravenous thrombolysis (IV-tPA). Catheter-based therapy (CBT) is commonly used in patients not eligible for timely IV-tPa, but variables that predict good neurologic outcomes are poorly understood. METHODS: Results of 124 consecutive AIS patients who received CBT at Ochsner Medical Center from 2006 and 2012 are reported. A modified Rankin score (mRs) of ≤ 2 at 90 day post-CBT was used as the primary measurement of a good neurologic outcome. All-cause mortality during the index hospitalization, ≤30 days from treatment, and at 1 year were reported. Results are reported as those treated by Interventional Cardiologists (IC) or by Neurointerventionalists (NI). RESULTS: The mean age was 65 ± 16 years of which 48% (n = 52) were male. The mean NIHSS was 15.0 ± 7.5. Thrombolysis in cerebral infarction (TICI) ≥2 flow was achieved in 80% (n = 100). Good neurologic outcome was observed in 64% (n = 37 of 58) of patients 65 years or younger while in those older than 65, only 36% (n = 24 of 66) had the same outcome (P = 0.002). Mortality at 30 days for the two age groups were 21% (n = 12) vs. 50% (n = 33) (P = <0.001) respectively. A good neurologic outcome at 90 days was seen in 57% of patients with restoration of TICI ≥ 2 flow compared to 17% with TICI < 2 flow (P = <0.001). Those with failed reperfusion (TICI<2 flow) had 30-day mortality rate of 54% (13 of 24) vs. 20% (19 of 97) in those with TICI ≥ 2 flow (P = <0.001). At 90 days, there was no significant differences in patient outcomes between IC (n = 58) and NI (n = 66) treated patients. CONCLUSION: Successful revascularization with CBT leads to a good neurologic outcome in selected stroke patients. Medical co-morbidities and increased age > 65 years contributed to poor outcomes. To support broadening the number of physicians qualified to perform catheter-based stroke interventions, this study demonstrates that IC participating on a stroke team achieve comparable outcomes to NI.

Hyperacute T-waves: Wolff-Parkinson-White pattern or acute coronary syndrome?

BACKGROUND: Pre-excitation syndromes can elicit electrocardiogram (ECG) abnormalities that are nearly identical to those associated with acute myocardial ischemia. In the presence of atypical symptoms, stable hemodynamics, and unremarkable levels of cardiac enzymes, the decision whether to subject these patients to coronary angiography, or even non-invasive testing, can be difficult. OBJECTIVE: To understand that pre-excitation syndrome can mimic acute myocardial injury, but should not preclude a complete ischemic work-up. CASE REPORT: A 53-year-old man with Wolff-Parkinson-White pattern and coronary artery disease risk factors presented with new-onset substernal chest pain. A baseline ECG was significant for hyperacute T waves. After refusing cardiac catheterization, he was admitted to the cardiac care unit for intravenous heparin and eptifibatide. Although his stay was unremarkable and resting echocardiogram showed normal contractility and valve function, treadmill stress testing was negative for ischemic change, but revealed ST-segment depression with maximum stress in the lateral precordial leads. This was thought to be a "false positive" secondary to his conduction abnormality. CONCLUSION: No reliable algorithm exists for making an ECG diagnosis of myocardial infarction in the presence of a pre-excitation syndrome. Similarly, current non-invasive modalities have limitations in detecting jeopardized myocardium. If acute or hyperacute injury is suspected, the patient should be emergently referred for cardiac catheterization.

Three in one: safety, efficacy, and patient acceptability of triple fixed-dose combination medicine in the management of hypertension.

Hypertensive patients whose blood pressures are more than 20 mmHg above their goal will often require three or more medications. Careful selection of medications whose actions are complementary or have an improved adverse effect profile when combined can affect not only the blood pressure but also patient acceptance, thus improving persistence in taking the medications as prescribed. This review will highlight the three single-pill three-drug combinations currently available in the US and will address their efficacy, safety, and tolerability. All three include the dihydropyridine calcium-channel blocker, amlodipine, and the thiazide diuretic, hydrochlorothiazide. They each contain a different renin-angiotensin system blocker. One includes the angiotensin-receptor blocker, olmesartan, while another contains valsartan. The third combination includes the direct renin inhibitor, aliskiren. All three fixed-dose combinations (FDC) at maximum doses of each component lowers the blood pressure of patients with stage II hypertension by 37 to 40 mmHg systolic and 21 to 25 mmHg diastolic, which is superior to any two of the components that comprise the three-drug FDC. These drugs are effective in males and females, the elderly, diabetics, minority populations, and patients with metabolic syndrome. Triple-drug FDCs are well tolerated with a low incidence of adverse effects, the most common being peripheral edema related to amlodipine. Extrapolation of data from two-drug FDC suggests that medication compliance (adherence and persistence) should be better with these FDCs than with the individual components taken as separate medications, although additional studies are necessary to confirm this.

Dysfunctional high-density lipoprotein and atherosclerosis.

High-density lipoprotein (HDL) is well established as a negative risk factor for the development of atherosclerosis. Epidemiologic, pathologic, and experimental studies have demonstrated a role for HDL in protection from coronary artery disease. HDL has been demonstrated to reduce the risk from atherosclerosis by multiple pathophysiologic mechanisms. Low-density lipoprotein is a metabolic end product that can be recognized and cleared by specific hepatic receptors with excretion into the bile. However, low-density lipoprotein may also be scavenged in the periphery by the monocyte-macrophage system, with subsequent generation of lipid-laden foam cells. HDL may reduce the atherosclerotic burden by multiple potential mechanisms. HDL can interact with the foam cell to remove cholesterol via receptor-mediated binding, passive diffusion, and alteration of intracellular cholesterol trafficking by ATP binding cassettes. The process of reverse cholesterol transport is a major mechanism by which HDL can remove cholesterol from the periphery, allowing it to be cleared by the liver and then excreted into the bile. However, HDL exhibits multiple additional potential beneficial physiologic effects. Endothelial function and repair is potentiated by HDL. Normal HDL has significant anti-inflammatory and antioxidant activity. Prostacyclin production and improvement in fibrinolytic balance is also attributed to normally functioning HDL. HDL is also intimately related to the metabolism of other circulating lipoproteins. However, multiple clinical studies have identified individuals with a significant atherosclerotic burden despite normal or elevated levels of HDL cholesterol. Clinical conditions associated with inflammation and oxidative stress have adversely altered the normal functions of HDL. Clinical assays have been developed to assess the functionality of HDL. Dysfunctional HDL may be returned to normal by diet, exercise, degree of fat intake, and pharmacologic approaches. Orally active mimetic proteins are in development and have shown clinical promise.