Pulse pressure variability is associated with unfavorable outcomes in acute ischaemic stroke patients treated with intravenous thrombolysis.

BACKGROUND AND PURPOSE: Blood pressure (BP) variability has been associated with worse neurological outcomes in acute ischaemic stroke (AIS) patients receiving treatment with intravenous thrombolysis (IVT). However, no study to date has investigated whether pulse pressure (PP) variability may be a superior indicator of the total cardiovascular risk, as measured by clinical outcomes. METHODS: Pulse pressure variability was calculated from 24-h PP measurements following tissue plasminogen activator bolus in AIS patients enrolled in the Combined Lysis of Thrombus using Ultrasound and Systemic Tissue Plasminogen Activator for Emergent Revascularization (CLOTBUST-ER) trial. The outcomes of interest were the pre-specified efficacy and safety end-points of CLOTBUST-ER. All associations were adjusted for potential confounders in multivariable regression models. RESULTS: Data from 674 participants was analyzed. PP variability was identified as the BP parameter with the most parsimonious fit in multivariable models of all outcomes, and was independently associated (P < 0.001) with lower likelihood of both 24-h neurological improvement and 90-day independent functional outcome. PP variability was also independently related to increased odds of any intracranial bleeding (P = 0.011) and 90-day mortality (P < 0.001). Every 5-mmHg increase in the 24-h PP variability was independently associated with a 36% decrease in the likelihood of 90-day independent functional outcome (adjusted odds ratio 0.64, 95% confidence interval 0.52-0.80) and a 60% increase in the odds of 90-day mortality (adjusted odds ratio 1.60, 95% confidence interval 1.23-2.07). PP variability was not associated with symptomatic intracranial bleeding at either 24 or 36 h after IVT administration. CONCLUSIONS: Increased PP variability appears to be independently associated with adverse short-term and long-term functional outcomes of AIS patients treated with IVT.

Availability of secondary prevention services after stroke in Europe: An ESO/SAFE survey of national scientific societies and stroke experts.

BACKGROUND: Recurrent stroke is associated with increased disability and cognitive impairment, but the availability of secondary prevention measures after transient ischaemic attack (TIA) or stroke in Europe is uncertain. This limits prioritisation of investment and development of national stroke strategies. METHODS: National stroke representatives throughout Europe were surveyed. Consensus panels reported national data if available, or else expert opinion, estimating the availability of each intervention by quintiles of patients, dichotomised for analysis at 60%. Countries were classified into tertiles of gross domestic product per capita. RESULTS: Of 50 countries, 46 responded; 14/45 (31%) had national stroke registries and 25/46 (54.3%) had national stroke strategies incorporating secondary prevention. Respondents reported that the majority of TIA patients were assessed by specialist services within 48 hours in 74.4% of countries, but in nine countries more than 20% of patients were seen after more than seven days and usually assessed by non-specialists (7/46 countries). Eighty percent of countries deferred blood pressure assessment to primary care, whilst lifestyle management programmes were commonly available in only 46% of countries. Although basic interventions were widely available, interventions frequently not available to more than 60% of patients included: ambulatory cardiac monitoring (40% countries); prescription (26%) and continuation (46%) of statins; blood pressure control at follow-up (44%); carotid endarterectomy within one month (15%); face-to-face follow-up in hospital (33%); direct oral anticoagulants (21%). Gross domestic product per capita and reimbursement of interventions were the commonest predictors of availability of interventions. CONCLUSIONS: Provision of secondary prevention varied, with gaps in care prevalent throughout Europe, particularly in lower income countries.

D-dimer levels and stroke progression in patients with acute ischemic stroke and atrial fibrillation.

BACKGROUND: Patients with acute ischemic stroke and atrial fibrillation are at increased risk of stroke progression and recurrence. We sought to assess whether D-dimer and other markers of hemostatic activation could predict these adverse events in such patients. METHOD: Blood samples were obtained from patients included in the Heparin in Acute Embolic Stroke Trial. Stroke progression was defined as a ≥3-point worsening on the Scandinavian Stroke Scale during the first 48 h after randomization. Blood samples were analyzed for D-dimer, prothrombin fragment 1 + 2, soluble fibrin monomer, and C-reactive protein. RESULTS: A total of 382 patients were included in the analyses. Levels of D-dimer and other markers of hemostatic activation were not significantly higher in patients with stroke progression than in other patients (D-dimer median values: 1025 ng/ml vs 970 ng/ml, P = 0.73). The same was true for recurrent stroke (D-dimer: 720 ng/ml vs 973 ng/ml, P = 0.96), and the combined endpoint of stroke progression, recurrent stroke, and death (D-dimer: 991 ng/ml vs 970 ng/ml, P = 0.91). Multivariable analyses did not alter the results. CONCLUSION: D-dimer and other markers of hemostatic activation were not associated with stroke progression, recurrent stroke, or death in patients with acute ischemic stroke and atrial fibrillation.