Displaying One Session

Scientific Communications
Session Type
Scientific Communications
Room
Hall G
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM

OPTIMAL COMBINATION MEDICATION TREATMENT IMPROVES SURVIVAL AT ONE-YEAR FOLLOWING ISCHAEMIC STROKE/TIA: LINKED REGISTRY AND PHARMACEUTICAL CLAIMS STUDY

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
02:30 PM - 02:40 PM

Abstract

Group Name

On Behalf of the Australian Stroke Clinical Registry Consortium

Background And Aims

Prescription of multiple classes of medications (antihypertensive, antithrombotic and lipid-lowering) is recommended in clinical guidelines for ischemic stroke (IS) and transient ischemic attack (TIA) to prevent further vascular events. We aimed to determine the association between optimal combination medication treatment (supply of all three classes, “optimal treatment”) and survival after IS/TIA.

Methods

Cohort of patients with first-ever IS/TIA from the Australian Stroke Clinical Registry (2010-2014) linked with pharmaceutical claims data. We excluded patients who died within 30 days of admission. Cox regression was used to determine associations between optimal treatment and 1-year (from day 30 to 395) survival using landmark methods, adjusting for socio-demographics (age, sex, socioeconomic position) and clinical characteristics (stroke type, discharge destination).

Results

Among 8136 survivors with first-ever IS/TIA satisfying inclusion criteria (45% female, median age 74 years), 75.5% received ≥1 medication class, and 34.0% had optimal treatment. Patients with optimal treatment (N=2765) were more often aged ≥75 years (51.3% vs 44.3%; p<0.001), discharged directly home (65.8% vs 49.5%; p<0.001) and experienced a less severe stroke (53.2% vs 43.5%; p<0.001), than those without optimal treatment. Compared to no medication, treatment with two medications was associated with a 42% lesser risk of death (95%CI: 27-55%); and optimal treatment, a 68% lesser risk of death (95% CI: 49-65%). Survival was similar between those with one or no medication.

Conclusions

Patients with stroke/TIA who received optimal combination medication treatment within 30-days of admission had greater one-year-survival. Further research is required to understand reasons for sub-optimal medication treatment.

Trial Registration Number

Not applicable

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EFFECT OF PAST AND CONCURRENT ELEVATED BLOOD PRESSURE ON WHITE MATTER HYPERINTENSITIES: AN ANALYSIS OF THE UK BIOBANK COHORT.

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
02:40 PM - 02:50 PM

Abstract

Background And Aims

White matter hyperintensities (WMHs) are associated with 30% of strokes and 40% of dementia. WMHs increase with age, hypertension and cerebrovascular dysfunction but the temporal relationships are poorly understood. The aim was to determine the associations between WMHs and concurrent and past systolic (SBP) or diastolic (DBP) blood pressure.

Methods

UK Biobank is a prospective community-based cohort of >500,000, 40-69-year-old people, 20,200 of whom had MRI 4-12 years after baseline. Associations between concurrent and past SBP and DBP values and WMH load (a logit-transformed value normalised by white matter volume) were analysed using linear models adjusted for age, sex and cardiovascular risk factors, and longitudinally for time since baseline. Analyses were repeated after stratifying by age and BP values, separately for SBP and DBP as well as for pre-hypertension (>130/80mmHg) and hypertension (>140/90mmHg).

Results

In 16,727 participants, WMHs increased with age, SBP and DBP (Fig.1) even in pre-hypertension (Fig.2). WMHs were more strongly associated with concurrent SBP than DBP (β=0.088, 95%CI 0.069-0.107 versus 0.049, 0.031-0.068) but more strongly with past DBP than SBP (0.080, 0.048-0.111 versus 0.060, 0.026-0.093), particularly under 50 years (Fig.3). The population attributable fraction of WMHs in the top decile due to SBP >120mmHg was 21.9% (concurrent) and 40.3% (past).

Conclusions

WMHs were strongly associated with elevated BP, even in pre-hypertension, with the population burden of severe WMHs related to concurrent SBP>120mmHg in 22% of cases. WMHs were strongly associated with past DBP, especially in mid-life. Long-term prevention of WMH may require intensive control of even mildly-elevated mid-life BP.

figure 1 wmhs by sbp dbp and age group.pngfigure 2 wmhs by hypertension medication and age group.pngfigure 3 standardised effect size in fully-adjusted model.png

Trial Registration Number

N/A

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MELATONIN PREVENTS MICE CORTICAL ASTROCYTES FROM HEMIN-INDUCED TOXICITY THROUGH ACTIVATING NRF2/HO-1 SIGNALING IN VITRO

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
02:50 PM - 03:00 PM
Presenter

Abstract

Group Name

The Ruijin Trial Investigators.

Background And Aims

Secondary injury mediated by oxidative stress leads to deterioration of neurological function after intracerebral hemorrhage (ICH). Cortical astrocytes are one of the most important cells in the central nervous system (CNS), which play key roles in maintaining redox homeostasis by providing oxidative stress defense.Hemin is a product of hemoglobin degradation, which has strong toxicity and can induce reactive oxygen species (ROS). Melatonin (Mel) and its metabolites are well tolerated without toxicity, prevent tissue damage as well as effectively assist in scavenging free radicals.

Methods

We evaluated the hemin neurotoxicity to astrocytes and the resistance of Mel-treated astrocytes to hemin neurotoxicity.

Results

And we found Mel induced PKCα phosphorylation (p-PKC), nuclear translocation of Nrf2 in astrocytes, and upregulation of HO-1, which contributed to the reduction of ROS accumulation and cell apoptosis. Nrf2 and HO1 protein expression upregulated by Mel were decreased after administration of PKC inhibitor, Ro 31-8220 (Ro 31). Luzindole (Luz), a melatonin receptor inhibitor, suppressed p-PKCα,HO-1 and Nrf2 expression upregulated by Mel and increased cell apoptosis rate. The upregulation of HO-1 induced by Mel was depressed by knocking down Nrf2 expression by siRNA, which also decreased the resistance of astrocytes to toxicity of hemin.

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Conclusions

Meltonin activates astrocytes through PKCα/Nrf2/HO-1 signaling pathwayto acquire resistance to toxicity of hemin and resist from oxidative stress and apoptosis.The positive effect of Mel on PKCα/Nrf2/HO-1 signaling pathway may become a new target for neuroprotection after intracerebral hemorrhage.

Trial Registration Number

Not applicable.

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STROKE SURVIVORS’ MEDICATION BELIEFS AND ADHERENCE TO MEDICATIONS FOR SECONDARY PREVENTION OF STROKE

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
03:00 PM - 03:10 PM

Abstract

Background And Aims

Patients who experience a minor stroke have an 11% risk of a further stroke within 90 days. Antithrombotic, antihypertensive and cholesterol-lowering medications are routinely prescribed to reduce this risk. This study examines the impact of a patient centred educational exchange (PC3EE)1 on medication beliefs, and adherence to each class of secondary preventative medication.

Methods

Patients diagnosed with a minor stroke were randomised to receive the PC3EE with usual care (intervention) or usual care alone (control). The PC3EE was conducted at the bedside before discharge and by telephone 10 days from discharge. Adherence was determined using dispensing data from the Australian Pharmaceutical Benefits Scheme and the proportion of days covered (PDC) calculated. The Beliefs about Medications Questionnaire-Specific2 was used to evaluate medication necessity or concerns beliefs.

Results

Out of 200 patients randomised, 94 in each arm obtained at least one class of medication over 90 days. The median (IQR) PDC percent for all classes over 90 days were; intervention group 89.4% (76.7-100%) and control group 87% (66.5-99%) (p=0.15). There was no difference in beliefs between groups at baseline but at the 90-day median (IQR) interview necessity scores were significantly higher in the intervention group 19.0 (17.0-20.0) compared to control group 18.0(15.0-20.0) p=0.02. Necessity scores correlated with adherence for antithrombotic but not antihypertensive or cholesterol-lowering medications.

Conclusions

Interventions to increase adherence should consider that stroke survivor's medication beliefs and adherence can differ between classes of secondary prevention medications.

1. Coombes JA, et al BMJ Open 2018;8:e022225

2. Horne R, et al Psychology and Health 1999;14:1-24

Trial Registration Number

ACTRN1265000888561

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SECONDARY PREVENTION IN STROKE BY A PRIMARY HEALTH CARE APPROACH: AN OPEN LABEL CLUSTER RANDOMISED TRIAL

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
03:10 PM - 03:20 PM

Abstract

Background And Aims

Health systems in India are unprepared to address the growing burden of stroke. Task-shifting interventions for noncommunicable disease management to non-physician community health workers (CHW) may help address this gap. Aim: To evaluate whether a CHW based intervention will improve risk factor control and lifestyle modifications among the rural stroke survivors.

Methods

A open label cluster-randomized trial was conducted in the rural health blocks of Thiruvananthapuram , Kerala from December 2017 to 2018. Sixteen rural health blocks were randomised 1:1 to a CHW-based intervention and standard of care alone. A training was given to CHW in the intervention health blocks to make regular visits to the stroke survivors and advise regarding risk factor control . The primary outcome measure was control of risk factors at 3 and 6 months .

Results

Of the 234 patients recruited, the mean age (SD) was 59.43 (11.07) years.. The control of systolic blood pressure and fasting blood sugar at 3 and 6 months of follow up decreased significantly as compared to baseline in both the intervention and control groups. All smokers quit smoking in the intervention arm compared to half of those in the control group who continued smoking. At 3 months follow up , more of study participants in the intervention arm were visited by a health worker as compared to control arm.(61 % vs 12.5%,p=0.000)

Conclusions

CHW based intervention approach has the potential to improve risk factor control in rural stroke survivors and is feasible in low and middle income countries.

Trial Registration Number

Not applicable

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A RANDOMIZED TRIAL OF SCREENING FOR ATRIAL FIBRILLATION IN THE ELDERLY: PRIMARY RESULTS OF THE SCREEN-AF TRIAL

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
03:20 PM - 03:30 PM

Abstract

Group Name

for the SCREEN-AF Investigators and Coordinators

Background And Aims

Atrial fibrillation (AF) is a common treatable risk factor for stroke. However, it is uncertain whether screening for AF in asymptomatic individuals is effective.

Methods

This investigator-initiated randomized trial recruited individuals from primary care practices in Canada and Germany aged ≥75 years with hypertension and no history of AF or anticoagulant use. Eligible participants were assigned a 2-week wearable ECG (Zio XT patch) at baseline and at 3 months (screening group) or usual care (control group). The primary outcome was AF detected within 6 months by study monitors (≥5 minutes) or clinically. Secondary outcomes included device adherence and anticoagulation at 6 months.

Results

From March 2015- April 2019, we enrolled 856 participants from 48 practices: age 80.0 ±4.0 years; 56.9% female; median CHA2DS2-VASc score 4 points (IQR 4-5). Median ECG wear time was 27.4 days (IQR 18.4-28.0). AF was detected in 23/434 participants (5.3%) in the screening group vs. 2/422 (0.5%) in the control group; p<0.0001. Median duration of the longest device-detected AF episode per patient was 5.0 hours (IQR 2.8-9.9 hours; range 5 min.-13.9 days); median number of AF episodes per patient was 2 (IQR 1-3; range 1-76). Anticoagulation was initiated in 80% of patients with screen-detected AF. At 6 months, anticoagulant use was greater in the screening group (4.1% vs. 0.9%; p=0.003). No patient had a major bleed.

Conclusions

Among older community-dwelling individuals, AF screening with wearable ECGs was feasible, superior to standard care for detecting actionable AF (number needed to screen=21), and prompted anticoagulation with the potential to avert future strokes.

Trial Registration Number

ClinicalTrials.gov Identifier: NCT02392754

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GLP-1 RECEPTOR AGONISTS FOR STROKE PREVENTION IN DIABETES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
03:30 PM - 03:40 PM

Abstract

Background And Aims

Randomized controlled clinical trials (RCT) have demonstrated varied efficacy of glucagon-like peptide-1 receptor (GLP-1R) agonists for cardiovascular outcomes. We sought to evaluate the efficacy and safety of GLP-1R agonists among patients with Type 2 diabetes mellitus (DM) for stroke prevention.

Methods

We conducted a systematic review and meta-analysis of RCTs reporting the following outcomes among patients with Type 2 DM treated with GLP-1R agonists (vs. placebo): nonfatal or fatal strokes, all-cause or cardiovascular mortality, myocardial infarction (MI) and major adverse cardiovascular events (MACE). We pooled odds ratios (OR) using random-effect models, and assessed the heterogeneity using Cochran Q and I2 statistics.

Results

We identified 8 RCTs, comprising 56,251 patients. In comparison to placebo, GLP-1R agonists reduced nonfatal strokes (OR=0.84; 95%CI=0.76-0.94, p=0.002; I2=0%) and all strokes (OR=0.84; 95%CI=0.75-0.93, p=0.001; I2=0%). Overall, GLP-1R agonists reduced MACE by 13% (OR=0.87; 95%CI=0.81-0.94, p=0.0003; I2=42%), cardiovascular mortality by 12% (OR=0.88; 95%CI=0.81-0.95; p=0.002; I2=0%) and all-cause mortality by 12% (OR=0.88; 95%CI=0.82-0.95, p=0.0007; I2=15%). Additional analyses demonstrated that GLP-1R agonists reduced the risk of incident MACE (OR=0.86; 95%CI=0.80-0.92; p<0.0001; I2=0%) among patients with prior history of MI or nonfatal strokes, however no association was noted for the recurrence of nonfatal strokes (OR=0.87; 95%CI=0.67-1.15; p=0.33; I2=0%).

Conclusions

GLP-1R agonists treatment among patients with type 2 DM is beneficial for primary stroke, MACE and cardiovascular mortality prevention. Further RCTs are needed to evaluate their role for secondary stroke prevention.

Trial Registration Number

Not applicable

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RATES OF MASKED HYPERTENSION AFTER TIA AND STROKE: CENTRALLY OBSERVED HOME TELEMETRIC MONITORING OF BLOOD PRESSURE TO MANAGE INTENSIVE TREATMENT (COMMIT) STUDY

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
03:40 PM - 03:50 PM

Abstract

Group Name

The Oxford Vascular Study

Background And Aims

The prevalence of hypertension is often underestimated, due in part to reliance on single clinic readings. “Masked” hypertension (clinic BP <140/90, mean home BP >135/85 mmHg) has a prevalence of approximately 15% in primary care, and is associated with a similar vascular risk to that of sustained hypertension. We studied masked hypertension after TIA or non-disabling stroke.

Methods

After prescription of antihypertensive therapy if required at initial assessment, consecutive eligible patients with an acute TIA/non-disabling stroke in a population-based study (Oxford Vascular Study) measured their BP three times daily at home with a Bluetooth-equipped monitor. Measurements were transmitted automatically to a secure web page. Masked hypertension was based on all measurements during the first three days after clinic assessment.

Results

1656 patients (mean/SD age=69.7/13.1) were recruited, of whom 836 (50.5%) were already taking antihypertensive treatment at baseline (mean/SD 1.9/0.9 agents). Of 409 patients with a clinic BP <140/90 mmHg, 243 had no history of hypertension and were not on treatment. Masked hypertension was found on home-monitoring in 59 (24.3%) of this group. Of 166 patients with a clinic BP <140/90 mmHg who were already on antihypertensive drugs, 60 (36.1%) had masked uncontrolled hypertension on home-monitoring. Masked hypertension (undiagnosed or uncontrolled) was associated with high-normal (130-139/85-89 mmHg) clinic BP (OR=1.76, 95%CI=1.13-2.73, p=0.012), prior vascular disease (OR=2.22, 1.11-5.48, p=0.026) and hyperlipidaemia (OR=2.08, 1.02-2.25, p=0.038) after adjusting for age, sex and antihypertensive treatment at baseline.

Conclusions

Masked hypertension on home telemetric BP-monitoring is common after TIA and stroke, potentially undermining secondary prevention.

Trial Registration Number

Not applicable

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STROKE PREVENTION CLINIC REFERRALS WERE ASSOCIATED WITH REDUCTION IN MORTALITY DUE TO CARDIOVASCULAR DEATH AND OTHER DISEASES AFTER ISCHEMIC STROKE AND TRANSIENT ISCHEMIC ATTACK

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
02:30 PM - 04:00 PM
Room
Hall G
Lecture Time
03:50 PM - 04:00 PM
Presenter

Abstract

Background And Aims

Stroke prevention clinic referrals (SPC) are associated with reduced all-cause mortality after ischemic stroke and transient ischemic attack (TIA). We hypothesized that the reduction in death associated with SPC referral is driven by a reduction in cardiovascular (CV) and stroke deaths.

Methods

We used the Ontario Stroke Registry to identify a cohort of ischemic and TIA in Ontario, Canada (Apr 2002 – Mar 2013). The risk and cause of death were determined through linkages to the Office of the Registrar General Deaths database until Dec 2015. The causes of death were classified as stroke, non-stroke CV and non-CV. Using propensity score methods to adjust for baseline differences, we calculated the 2-year sub-distribution hazard ratios (sdHR) in patients with and without SPC referral for each cause of death.

Results

Of 59,509 first-time ischemic stroke/TIA survivors (61% ischemic), 28,244 (47%) patients were referred to SPC at discharge. After accounting for patient characteristics (sex, age, ethnicity, time of hospital arrival, stroke severity, comorbidities, medications, in-hospital care, and discharge modified Rankin Scale scores), we matched 17,450 pairs. SPC referral was associated with lower incidence of death in all categories: stroke(sdHR=0.71, 95%CI:0.62-0.81), non-stroke CV (sdHR=0.83, 95%CI:0.75-0.92), and non-CV (sdHR=0.81, 95%CI:0.75-0.87).

Conclusions

Our finding of a reduction in both stroke and cardiovascular deaths suggests that SPC referral may be associated with a decrease in vascular adverse events. However, the association between SPC referral and non-cardiovascular death suggests residual confounding between the treatment groups. Further work is needed to determine the effect of stroke secondary preventive care on post-stroke mortality.

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