Welcome to the WSC 2021 Interactive Program

Background and Aims

A significant proportion of the burden of non-communicable disease in adults has its roots in adolescence and this is particularly true for cardiovascular disease and stroke. Detection of risk factors, early stages of disease and laboratory abnormalities at young ages may aid disease prevention and management.

Methods

We systematically assessed the frequency of yet unknown medical conditions that require further diagnostic work-up or intervention (life-style counselling or pharmacotherapy) in 2088 adolescents sampled from the general population considering previously diagnosed physician-confirmed diseases. The easy-to-administer health screening included medical history taking, fasting blood analysis, and blood pressure and body measurements, and was performed at schools.

Results

Adolescents were on average 16.4 (SD 1.1) years old and 56.4 percent were female. The health screening newly detected relevant medical conditions in 45.4 [95% CI, 43.3–47.6] percent (55.8 [95% CI, 52.5–59.0] percent in boys and 37.4 [95% CI, 34.6–40.2] percent in girls). The most prevalent previously unknown medical conditions were vascular risk factors like elevated blood pressure (16.7%) and hypertension (10.2%), metabolic syndrome (3.0%), hypercholesterolemia (7.6%) and hypertriglyceridemia (9.6%). On the other hand, impaired fasting glucose and pre-diabetes were rare in this community-based sample of adolescents as were endocrine and other abnormalities (all <1.0%) except for subclinical hypothyroidism (5.7%) and hyperuricemia (7.8%).

Conclusions

Health screening in adolescence has a high diagnostic yield for previously unknown vascular risk factors, is feasible in the school setting, and may provide an opportunity for guideline-recommended targeted prevention in the young.

Background and Aims

It is unclear if survivors of stroke or transient ischaemic attack (TIA) understand information provided by their doctor about prescribed secondary prevention medications. We investigated whether survivors understand their doctors’ explanation of their medications and the association with medication adherence and perceived risk factor control.

Methods

Cross-sectional survey, co-designed with consumers, was administered among survivors of stroke/TIA from the Australian Stroke Clinical Registry at two years post-admission (Victoria and Queensland, 2016). Participants reported whether they understood the explanation from their doctor about each prescribed secondary prevention medication (antihypertensive, antithrombotic or lipid-lowering). Multivariable logistic regression was used to assess associations between understanding of doctors’ explanations and self-reported medication adherence and risk factor control.

Results

Overall 632/1455 eligible survivors completed the survey (median age 69 years; 37% female). Most participants reported using medications (76% antihypertensive; 84% antithrombotic; 76% lipid-lowering). The majority of medication users understood their doctor’s explanation (75% antihypertensive; 66% antithrombotic; 74% lipid-lowering). Compared to participants who did not understand, those who did were more likely to report 30-day adherence for antihypertensive (adjusted odds ratios [aOR]: 2.04; 95% CI: 1.24-3.34), antithrombotic (aOR: 2.13; 95% CI: 1.38-3.28) and lipid-lowering medications (aOR: 1.85; 95% CI: 1.15-2.97). Understanding information about medications was also associated with self-reported control of blood pressure (aOR: 12.27; 95% CI: 6.76-22.25) and cholesterol (aOR: 9.72; 95% CI: 5.53-17.10).

Conclusions

Understanding of information about medications may promote medication adherence and risk factor control after stroke. More efforts are needed to improve patient education of medications after stroke.

Background and Aims

General practitioners use chronic disease management plans (CDMPs) to manage the healthcare of people with chronic diseases who require a structured approach. We aimed to determine whether treatment with CDM plans reduces all-cause readmission costs in patients with stroke or TIA.

Methods

Secondary data linkage analyses were conducted using the cohort of the cluster-randomised trial (STAND FIRM). Participants aged ≥18 years admitted for stroke or TIA were recruited from four hospitals in Melbourne. Person-level data from the trial were linked to datasets on CDM plan use and hospitalisations. Costs of readmissions from index discharge to two years were estimated using information from the 2015 National Hospital Costs Data Collection in AUD. The cost of same-day and multiday readmissions were estimated applying the average cost of same day separations and average cost per day for overnight separations, respectively. Median regression was used to compare readmission costs between those who used CDMPs for two years and those who did not.

Results

Among 563 participants recruited (median age 70 years, 64% male), 323 used CDMPs and 422 had at least one all-cause readmission within two years after hospital discharge. The median length of stay was three days (interquartile range 2-11 days). The median cost of readmissions was $4,358 (interquartile range $2,638-$19,268). The between-group difference was not significant (adjusted for age, sex and comorbidity profile ß=$-1,004, 95% CI $-4,399; $2,391, p value 0.56).

Conclusions

Treatment with CDMPs was not significantly associated with reduced readmission costs in patients with stroke or TIA.

Background and Aims

To describe the characteristics of ischemic stroke (IS) in patients with active cancer (AC) and to identify AC markers in patients with cryptogenic stroke (CS).

Methods

Analysis of a prospective registry of IS patients admitted to a Stroke unit between May-2019 and January-2021. AC cases were identified and compared to the rest of the cohort (non-active cancer [NAC]). Additionally, the characteristics of CS with and without AC were compared.

Results

1,931 IS were included, 61 patients (3.1%) had AC. Non-lacunar and cryptogenic stroke were more frequent in the AC compared to the NAC group (85.7% vs 62.6%, p=0.001 and 49.2% vs 30.4%, p=0.003). No small vessel disease etiology was observed in the AC group (0% vs 22%, p<0.0001). Stroke were more severe in patients with CS + AC compared with CS without AC (median NIHSS 6 and 4, p=0.03). Additionally, Patients with CS + AC had lower hemoglobin levels (median 11.95 g/dL vs 13.8 g/dL, p=0.022) and higher C-reactive protein (CRP) (1.19 mg/dL vs 0.39 mg/dL, p=0.014) and D-Dimer (842 ng/mL vs 272 ng/mL, p<0.0001) compared with CS without AC. The AUC in the ROC analysis was 0.722 (95% CI 0.604 - 0.851) for D-Dimer and 0.725 (0.628 - 0.822) for RCP. Sensitivity and specificity for D-Dimer ≥420 ng/mL was 74.1% and 70%, and 65.5% and 70.7% for RCP ≥0.805 mg/dL.

Conclusions

Cryptogenic stroke is more frequent in patients with active cancer. Increased D-Dimer and RCP may help predict the presence of active cancer in patients with cryptogenic stroke.

Background and Aims

Vascular calcification is assumed to contribute to cardiovascular disease and mortality. Matrix Gla protein, a vitamin K-dependent protein, is a potent inhibitor of vascular calcification. This study aims to investigate whether circulating desphospho-uncarboxylated MGP (dp-ucMGP) reflecting insufficient vitamin K status is associated with incident cardiovascular disease and mortality in the general population.

Methods

Plasma dp-ucMGP was measured in samples taken in 2000 from 685 participants of the prospective population-based Bruneck Study (age, mean±SD, 66.1±10.2; 51.8% female). Cox proportional hazard models were employed to assess the association between dp-ucMGP and incident CVD and all-cause mortality, and to determine potential interactions with predicted 10-year CVD risk according to the Framingham Risk Score.

Results

During a 10-year follow-up, 118 participants experienced a CVD event (17.3%) and 153 (22.4%) participants died. In fully adjusted models, circulating dp-ucMGP levels were significantly associated with higher CVD risk, with an HR per SD of 1.34 (95%CI: 1.08-1.65; p=0.008), and all-cause mortality (HR per 1-SD of 1.54; 95% CI: 1.27–1.86; p<0.001). The effect of dp-ucMGP on CVD was stronger in individuals with low predicted cardiovascular risk as compared to those with high predicted cardiovascular risk (p value for interaction =0.004). For the outcome all-cause mortality, a formal interaction test was nonsignificant (p value for interaction =0.192).

Conclusions

Plasma level of dp-ucMGP is associated with incident CVD and all-cause mortality in the general community. Future studies should determine the impact of vitamin K supplementation on dp-uc-MGP levels and CVD risk.

Background and Aims

Selecting the optimal antiplatelet therapy in ischemic stroke patients while on single antiplatelet therapy (SAPT) before stroke for long-term outcomes remains to be elucidated. This study aimed to evaluate the effect of multiple antiplatelet therapy on recurrent ischemic stroke and composite and safety outcomes in acute non-cardioembolic ischemic stroke already on SAPT using the linked big dataset on stroke in Korea.

Methods

We identified 9,284 acute non-cardioembolic ischemic stroke patients with SAPT history from January 2008 to December 2014. The included patients were categorized into three groups including SAPT, dual antiplatelet therapy (DAPT), and triple antiplatelet therapy (TAPT) according to antiplatelet therapy after acute stroke. Recurrent ischemic stroke, composite outcomes including ischemic stroke, myocardial infarction, intracerebral hemorrhage and death, and major bleedings at 1 year were outcomes.

Results

Among patients, 59.9% continued SAPT, 39.2% were treated with DAPT, and 0.9% were treated with TAPT. Compared with maintaining SAPT, no difference was observed in the risks of 1-year recurrent stroke (DAPT, HR, 1.08 [95% CI, 0.92–1.27], P = 0.339; TAPT, HR, 0.71 [95% CI, 0.27–1.91], P = 0.500) and 1-year composite outcomes according to the antiplatelet agents. However, the DAPT and TAPT groups showed an increased risk of major bleeding (DAPT, HR, 1.21 [95% CI, 0.87–1.68], P = 0.248; TAPT, HR, 4.57 [95% CI, 1.98–10.54], P < 0.001).

Conclusions

Adding antiplatelet agents had no benefit on the 1-year incidence of composite outcomes and recurrent stroke, although it caused a higher rate of bleeding events in acute non-cardioembolic ischemic stroke patients who were already on SAPT.

Background and Aims

Stroke care in Brazil has improved with the organization of acute stroke care. But it was not enough to reduce the 400,000 cases that occur each year. We present a strategy of modifying the primary prevention for stroke in Brazil with the restructuring of primary care.

Methods

The strategy is a task force, uniting the Pan American Health Organization, the Brazilian Ministry of Health, the Medical Societies acting to plan, train and implement the restructuring of primary care, based on the HEARTS program of the World Health Organization and Cut Stroke in Half of the World Stroke Organization. It is a gradual and monitored change in the way of care in primary care, adapting the programs through flowcharts and simplification of processes through protocols.

Results

The steps for implementation: 1)Organization of a committee with neurologists, cardiologists and family doctors; 2)Choice of 8 health units to implement a pilot; 3)Preparation and adaptation of technical protocols for screening and treatment of hypertension and diabetes (based on the HEARTS program); 4)Implementation of a protocol for atrial fibrilation screening with a point-of-care mobile ECG recording; 5)Preparation of printed material for lifestyle modification; 6)Implementation of Stroke Riskometer App; 6)Preparation of an educacion course for primary care professionals including community health works; 7)Implementation of decision, data collection and monitoring software enriched with artificial intelligence.

The implementation starts on June 2021 and will be expanded to 60 Units of Health in the whole country in 2022.

Conclusions

The success of implementation in the country has potential to decrease in 50% the incidence of stroke.

Background and Aims

The increase burden of stroke and dementia provides strong evidence that currently used primary prevention strategies are not enough and 80% of strokes occur in people with low to moderate risk. The purpose is to test whether a polypill used alone or in combination with lifestyle modification will reduce the incidence of stroke and cognitive impairment in a population of individuals with low to moderate risk of stroke.

Methods

Phase III Randomized Clinical Trial, prospective, factorial 2x2, of 12,268 subjects followed by 3 years. 60 Health Units will be randomized (clusters) to use or not the approach of community health workers with the Stroke Riskometer. After a run-in phase (30 days, all participants with active drug), patients will be randomized to receive the polypill (valsartan 80 mg, anlodipina 5 mg e rosuvastatina 10 mg) or placebo (dose adjustment of amlodipine 2,5 for patients with adverse events). It will be included: (1)adults aged 50-75 years; (2) no previous history of stroke, TIA or cardiovascular disease; (3)systolic blood pressure (BP) 120-139 mmHg; (4) one or more lifestyle risk factors (smoking, overweight, physical inactivity or inadequate diet. It will be excluded patients with hypercholesterolemia or diabetes or take other antihypertensive drugs or open label statins. Subjects will be randomized under a minimization process using age, sex, BP, education level, total cholesterol.

Results

We expect to reduce in 50% the risk of stroke and cognitive decline in 3 years.

Conclusions

With the trial results we expect to change the public prevention policies in primary care.