[Acute ischemic stroke in cancer patients. A case-control study]. / Accidente cerebrovascular isquémico en pacientes con cáncer. Un estudio caso-control.

One in 10 patients with ischemic stroke has comorbid cancer. Our goal was to compare stroke patients with cancer against those without cancer in terms of clinical and radiological features, and the underlying mechanism. We conducted a retrospective case-control study in patients admitted with ischemic stroke between July 2013 and September 2018. Cases had a concomitant diagnosis of cancer and acute ischemic stroke, controls only of ischemic stroke. Age, gender, vascular risk factors (VRF), pattern of ischemic lesion in neuroimaging, etiology and clinical outcome were compared between groups. Fifty-seven cases were identified, 61% were male (n = 35), and mean age was 75 ± 11. Fiftytwo had known oncologic disease at the onset of stroke. Most of them had solid tumors (91%, n = 52), and 54% (n = 31) had a non-metastatic tumor at the time of stroke. Prevalence of common VRF between groups was not significantly different. Previous deep venous thrombosis and pulmonary thromboembolism were more frequent in the cancer cohort (8% vs. 1%, p = 0.01). The average NIHSS was 3.8 ± 4 in the cancer group and 9 ± 7 in the control group (p = 0.01). Small artery disease as the etiology of stroke was significantly less common in the cancer group (2% vs. 26%, p = 0.001). Regarding neuroimaging, the embolic pattern was more frequent in patients with cancer (82% vs. 35%, p = 0.001). In these patients recurrence and mortality at 90 days was three and six times higher (10% vs. 3%, and 18% vs. 3%. p = 0.08 and 0.001, respectively).

Aproximadamente uno de cada 10 pacientes que sufre un accidente cerebrovascular isquémico (ACVi) padece cáncer concomitantemente. Nuestro objetivo fue evaluar características clínicoradiológicas del ACVi en pacientes con cáncer y compararlas con otros sin cáncer. Fue un estudio caso-control retrospectivo que incluyó pacientes con ACVi entre julio 2013 y septiembre 2018. Los casos tenían diagnóstico de cáncer y ACVi, y los controles solamente ACVi. Se comparó edad, sexo, factores de riesgo vascular, patrones radiológicos de lesiones, etiología y evolución clínica entre ambos grupos. Hubo 57 casos, 61% (n = 35) eran varones. La edad media fue 75 ± 11 años, sin diferencias en prevalencia de factores de riesgo vascular. En los casos hubo más pacientes con antecedentes de trombosis venosa profunda y/o tromboembolismo pulmonar (8% vs. 1%, p = 0.01). En 52 se conocía la presencia del cáncer antes del ACVi. El 91% se trató de tumores sólidos (n = 52) y en 54% el tumor no presentaba metástasis. El puntaje NIHSS promedio fue 3.8 ± 4 en los casos, y 9 ± 7 en los controles (p = 0.01). Las lesiones de pequeña arteria fueron menos frecuentes en los casos (2% vs. 26%, p = 0.001). Las lesiones de aspecto embólico fueron más comunes entre los casos (82% vs. 35%, p = 0.001). Aquellos con cáncer tuvieron menor NIHSS, menor frecuencia de lesiones de pequeña arteria, y mayor frecuencia de lesiones de aspecto embólico. La recurrencia a 90 días fue 3 veces mayor y la mortalidad 6 veces mayor en pacientes con cáncer (10% vs. 3%, y 18% vs. 3%. p = 0.08 y 0.001 respectivamente).

Accidente cerebrovascular isquémico en pacientes con cáncer. Un estudio caso-control / Acute ischemic stroke in cancer patients. A case-control study

Resumen Aproximadamente uno de cada 10 pacientes que sufre un accidente cerebrovascular isquémico (ACVi) padece cáncer concomitantemente. Nuestro objetivo fue evaluar características clínicoradiológicas del ACVi en pacientes con cáncer y compararlas con otros sin cáncer. Fue un estudio caso-control retrospectivo que incluyó pacientes con ACVi entre julio 2013 y septiembre 2018. Los casos tenían diagnóstico de cáncer y ACVi, y los controles solamente ACVi. Se comparó edad, sexo, factores de riesgo vascular, patrones radiológicos de lesiones, etiología y evolución clínica entre ambos grupos. Hubo 57 casos, 61% (n = 35) eran varones. La edad media fue 75 ± 11 años, sin diferencias en prevalencia de factores de riesgo vascular. En los casos hubo más pacientes con antecedentes de trombosis venosa profunda y/o tromboembolismo pulmonar (8% vs. 1%, p = 0.01). En 52 se conocía la presencia del cáncer antes del ACVi. El 91% se trató de tumores sólidos (n = 52) y en 54% el tumor no presentaba metástasis. El puntaje NIHSS promedio fue 3.8 ± 4 en los casos, y 9 ± 7 en los controles (p = 0.01). Las lesiones de pequeña arteria fueron menos frecuentes en los casos (2% vs. 26%, p = 0.001). Las lesiones de aspecto embólico fueron más comunes entre los casos (82% vs. 35%, p = 0.001). Aquellos con cáncer tuvieron menor NIHSS, menor frecuencia de lesiones de pequeña arteria, y mayor frecuencia de lesiones de aspecto embólico. La recurrencia a 90 días fue 3 veces mayor y la mortalidad 6 veces mayor en pacientes con cáncer (10% vs. 3%, y 18% vs. 3%. p = 0.08 y 0.001 respectivamente).

Abstract One in 10 patients with ischemic stroke has comorbid cancer. Our goal was to compare stroke patients with cancer against those without cancer in terms of clinical and radiological features, and the underlying mechanism. We conducted a retrospective case-control study in patients admitted with ischemic stroke between July 2013 and September 2018. Cases had a concomitant diagnosis of cancer and acute ischemic stroke, controls only of ischemic stroke. Age, gender, vascular risk factors (VRF), pattern of ischemic lesion in neuroimaging, etiology and clinical outcome were compared between groups. Fifty-seven cases were identified, 61% were male (n = 35), and mean age was 75 ± 11. Fiftytwo had known oncologic disease at the onset of stroke. Most of them had solid tumors (91%, n = 52), and 54% (n = 31) had a non-metastatic tumor at the time of stroke. Prevalence of common VRF between groups was not significantly different. Previous deep venous thrombosis and pulmonary thromboembolism were more frequent in the cancer cohort (8% vs. 1%, p = 0.01). The average NIHSS was 3.8 ± 4 in the cancer group and 9±7 in the control group (p = 0.01). Small artery disease as the etiology of stroke was significantly less common in the cancer group (2% vs. 26%, p = 0.001). Regarding neuroimaging, the embolic pattern was more frequent in patients with cancer (82% vs. 35%, p = 0.001). In these patients recurrence and mortality at 90 days was three and six times higher (10% vs. 3%, and 18% vs. 3%. p = 0.08 and 0.001, respectively).

Hemodynamic Determinants of the Biologic Variation of N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Stable Systolic Chronic Heart Failure.

BACKGROUND CONTEXT: Biologic variation of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in chronic heart failure (CHF) may affect blood levels and risk stratification. The sources of NT-proBNP variation are unknown. METHODS AND RESULTS: We performed NT-proBNP measurements and clinical and hemodynamic assessments in 50 patients with heart failure with reduced ejection fraction (HFrEF) who met criteria for clinical stability over 2 time intervals. Hemodynamic variables were measured with the use of inert gas rebreathing and impedance cardiography. Heart rhythm was monitored with the use of external electrocardiographic event recorders throughout the study. Determinants of NT-proBNP-levels and both absolute (ΔNT-proBNPabs) and relative (ΔNT-proBNP%) changes at 1-week and 2-week intervals were identified with the use of univariable and multivariable linear mixed-effects models and linear regression analyses, respectively. Clinical and hemodynamic variables did not significantly change between study visits. The individual variation of NT-proBNP at 2 weeks was 9.2% (range 3.9%-18.6%). Weight and glomerular filtration rate were independently associated with baseline NT-proBNP concentrations (P = .01 and P = .005, respectively). There was no relationship between absolute and relative changes of NT-proBNP at 1-week intervals and changes in clinical and hemodynamic variables. Absolute change of NT-proBNP at 2-week intervals was associated with absolute change in left cardiac work index (P = .008), and relative change in NT-proBNP at 2-week intervals was determined by relative change of thoracic fluid content index (P = .008) and diastolic blood pressure (P = .01). The coefficients of determination (R2) for the multivariable models with Δ1wkNT-proBNPabs, Δ2-weeksNT-proBNPabs, Δ1wkNT-proBNP%, and Δ2wksNT-proBNP% as dependent variables were 0.21, 0.19, 0.10, and 0.32, respectively. CONCLUSIONS: In patients with stable HFrEF, changes in clinical and hemodynamic variables only marginally contribute to the variation of NT-proBNP.

Biological variation of the cardiac index in patients with stable chronic heart failure: inert gas rebreathing compared with impedance cardiography.

AIMS: In chronic heart failure (CHF), changes in cardiac function define the course of the disease. The cardiac index (CI) is the most adequate indicator of cardiac function. Interpretation of serial CI measurements, however, requires knowledge of the biological variation of CI. Because measurements of CI can be confounded by the clinical situation or the method applied, biological variation might be subject to the same confounders. METHODS AND RESULTS: We prospectively included 50 CHF patients who met rigid criteria for clinical stability. CI was measured by both inert gas rebreathing (IGR) and impedance cardiography (ICG) in weekly intervals over 3 weeks-each measurement performed at rest (IGRrest/ICGrest) and during low-exercise 10 Watt pedalling (IGR10W/ICG10W). Intra-class correlation coefficients (ICCs), reference change values, and minimal important differences of CI were determined for IGRrest, ICGrest, IGR10W, and ICG10W. Impedance cardiography and IGR showed moderate agreement at rest (20% (6-36)) and good agreement at 10 Watt (-4% (-23-16)). Depending on time interval, measurement modality for CI, and mode, ICC ranged between 0.42 and 0.78, ICC values for IGR were lower than those for ICG. Reference change value ranged between 3 and 15%, and minimal important difference ranged between 0.2 and 0.5 L/min/m2. Values for IGR were lower at rest and higher at 10 Watt than those for ICG. CONCLUSION: Non-invasive measurements of CI are stable over time. Measurement modalities for CI, however, are not interchangeable. Biological variation is less pronounced when obtained by ICG. The influence of low-level exercise on stability of CI depends on the measurement modality.

High-sensitivity cardiac troponin T and N-terminal pro-B-type natriuretic peptide predict mortality in stable coronary artery disease: results from the Ludwigshafen Risk and Cardiovascular Health (LURIC) study.

BACKGROUND: The simultaneous assessment of high-sensitivity cardiac troponin T (hscTnT) and NT-proBNP for predicting death in stable coronary artery disease (CAD) has yet not been examined. We investigated the additional contribution of hscTnT to the risk of mortality prediction of NT-proBNP in patients with stable CAD. METHODS: We studied 1469 patients with stable CAD enrolled in the Ludwigshafen Risk and Cardiovascular Health Study (LURIC). hscTnT and NT-proBNP were measured in baseline samples using immunoassays (Roche Diagnostics, Germany). RESULTS: Thirty-five percent (n=525) of the patients died during a median follow-up of 7 and a half years. In total 59.0% of the non-survivors and 25.2% of the survivors exhibited concentrations of hscTnT≥14 ng/L. Logistic regression analysis identified hscTnT and NT-proBNP as independent risk markers for short-term (1-year follow-up) and long-term (9-years follow-up) mortality. ROC curve analysis determined optimal univariate cut-offs at 14 ng/L and 443 µg/L for hscTnT (AUC 0.725, p<0.0001) and NT-proBNP (AUC 0.742, p<0.0001), respectively. Kaplan-Meier survival analysis based on optimized cut-offs for the simultaneous determination of both biomarkers confirmed the usefulness of additive hscTnT especially in prediction of short-term mortality. The prognostic benefit of the combined assessment of hscTnT and NT-proBNP could be confirmed by a significantly increased reclassification index (NRI) of 24.2%. CONCLUSIONS: The majority of non-survivors exhibited increased hscTnT concentrations above 14 ng/L. The simultaneous determination of NT-proBNP and hscTnT was superior for risk stratification compared to determining either marker alone. Especially the prediction of the clinically important 1-year mortality was significantly improved by addition of hscTnT to NT-proBNP.