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1.
Anticoagulants for stroke prevention in heart failure with reduced ejection fraction.
Schäfer, A, Flierl, U, Bauersachs, J
Clinical research in cardiology : official journal of the German Cardiac Society. 2022;(1):1-13
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Abstract
Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the absence of atrial fibrillation. While stroke risk is inversely correlated with LV-EF in HF patients with sinus rhythm, strategies using anticoagulation with Vitamin-K antagonists (VKA) were futile as the increase in major bleedings outweighed the potential benefit in stroke reduction. Non-Vitamin K oral anticoagulants (NOACs) proved to be an effective and in general safer approach for stroke prevention in patients with atrial fibrillation and may also have a favourable risk-benefit profile in HF patients. In HF patients with sinus rhythm, the COMPASS trial suggested a potential benefit for rivaroxaban, whereas the more dedicated COMMANDER-HF trial remained neutral on overall ischemic benefit owed to a higher mortality which was not influenced by anticoagulation. More recent data from subgroups in the COMMANDER-HF trial, however, suggest that there might be a benefit of rivaroxaban regarding stroke prevention under certain circumstances. In this article, we review the existing evidence for NOACs in HF patients with atrial fibrillation, elaborate the rationale for stroke prevention in HF patients with sinus rhythm, summarise the available data from anticoagulation trials in HF with sinus rhythm, and describe the patient who might eventually profit from an individualised strategy aiming to reduce stroke risk.
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Non-pharmacological interventions for bone health after stroke: A systematic review.
Sallehuddin, H, Ong, T, Md Said, S, Ahmad Tarmizi, NA, Loh, SP, Lim, WC, Nadarajah, R, Lim, HT, Mohd Zambri, NH, Ho, YY, et al
PloS one. 2022;(2):e0263935
Abstract
OBJECTIVE To examine the effectiveness and safety of non-pharmacological interventions to reduce bone loss among post-stroke adult patients. DATA SOURCES Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database for Systematic Reviews, MEDLINE, CINAHL, ScienceDirect, Scopus, PubMed and PeDRO databases were searched from inception up to 31st August 2021. METHODS A systematic review of randomized controlled trials, experimental studies without randomization and prospective cohort studies with concurrent control of non-pharmacological interventions for adult stroke patients compared with placebo or other stroke care. The review outcomes were bone loss, fall and fracture. The Cochrane Risk of Bias Tools were used to assess methodological quality, and Grading of Recommendations, Assessment, Development and Evaluations Framework to assess outcome quality. Synthesis Without Meta-Analysis (SWiM) was used for result synthesis. RESULTS Seven studies (n = 453) were included. The methodological and outcome qualities varied from low to moderate. There were statistically significant changes between the intervention and parallel/placebo group in bone mineral density, bone mineral content, cortical thickness and bone turnover markers with specific physical and vibration therapies (p<0.05). Falls were higher in the intervention group, but no fracture was reported. CONCLUSION There was low to moderate evidence that physical and vibration therapies significantly reduced bone loss in post-stroke patients at the expense of a higher falls rate. The sample size was small, and the interventions were highly heterogeneous with different duration, intensities and frequencies. Despite osteoporosis occurring with ageing and accelerated by stroke, there were no studies on vitamin D or protein supplementation to curb the ongoing loss. Effective, high-quality non-pharmacological intervention to improve post-stroke bone health is required.
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Tongqiao Huoxue Decoction for the treatment of acute ischemic stroke: A Systematic Review and meta-analysis.
Zhou, X, Shao, T, Xie, X, Ding, M, Jiang, X, Su, P, Jin, Z
Journal of ethnopharmacology. 2022;:114693
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The aim of this study was to evaluate the efficacy and safety of Tongqiao Huoxue Decoction (TQHXT) in the treatment of acute ischemic stroke (AIS); Study Design: A total of 17 randomized controlled trials, involving 1489 AIS patients, were included for data analyses. MATERIALS AND METHODS All randomized controlled trials (RCTs) of TQHXT in the treatment of acute ischemic stroke before September 2020 were retrieved from seven electronic databases, including PubMed, Web of Science, Central, CNKI, CBM, Wanfang, and VIP. Data were analyzed by RevMan 5.3 software, and quality was evaluated by GRADEpro; Results: Results showed that, while TQHXT demonstrated undeniable positive effects in clinical effective rate, neurological deficit scores, activities of daily living (ADL) scores, and hemorheology (including HCT; fibrinogen; plasma viscosity and platelet adherence rate), adverse events (AE) require further study; and Conclusions: This study provides evidence that TQHXT is an effective treatment for acute ischemic stroke. However, due to the limited quality of the included studies, the above conclusion needs to be further verified by stricter randomized controlled, double-blind, large-sample, high-quality trials.
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Diet-Derived Circulating Antioxidants and Risk of Stroke: A Mendelian Randomization Study.
Miao, R, Li, J, Meng, C, Li, Y, Tang, H, Wang, J, Deng, P, Lu, Y
Oxidative medicine and cellular longevity. 2022;:6457318
Abstract
BACKGROUND Oxidative stress is crucial in stroke pathogenesis. Many cohort-based studies suggested that the intake of exogenous antioxidants originated from food may prevent stroke. However, the corresponding randomized controlled trials did not show diet-derived antioxidants have a protective effect on stroke. OBJECTIVES To examine the association of genetically proxied diet-derived antioxidants with stroke risk using Mendelian randomization. METHODS We performed a two-sample Mendelian randomization (MR) analysis to evaluate the causal effect of diet-derived antioxidants on stroke risk. For exposure data, we extracted genetic variants as instrumental variables (IVs) that are strongly associated with frequently used diet-derived antioxidants, including vitamin C, vitamin E (α-tocopherol, γ-tocopherol), carotene, retinol, zinc, and selenium, from a large-scale genome-wide association study (GWAS). We obtained IVs' corresponding effect estimates on the risk of total stroke and ischemic stroke from a GWAS meta-analysis with 40,585 cases and 406,111 controls. Finally, we applied five types of Mendelian randomization analysis to obtain preliminary MR results and performed four three kinds of sensitivity analysis to verify them. RESULTS According to the primary MR estimations and further sensitivity analyses, we established two robust associations after Bonferroni correction: genetically proxied circulating γ-tocopherol was causally associated with total stroke [odds ratio (OR) = 0.68, 95% confidence interval (CI) (0.52-0.88), p = 3.78E - 03] and ischemic stroke [OR = 0.66, 95% CI (0.51-0.86), p = 2.34E - 03]. There was no evidence to support the causal effect of other diet-derived antioxidants on the risk of total stroke and ischemic stroke. CONCLUSION Our study revealed a protective impact of genetic susceptibility to high circulating γ-tocopherol levels on stroke risk, providing new information on the potential therapeutic targets for primary stroke prevention.
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Gliflozins for the prevention of stroke in diabetes and cardiorenal diseases: A meta-analysis of cardiovascular outcome trials.
Zhao, LM, Huang, JN, Qiu, M, Ding, LL, Zhan, ZL, Ning, J
Medicine. 2021;(39):e27362
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Abstract
BACKGROUND Individual randomized trials are not powered to assess the relationship between use of sodium-glucose transporter 2 inhibitors and risk of stroke. We sought to explore this issue by a meta-analysis incorporating relevant trials including several latest trials. METHODS Cardiovascular outcome trials of gliflozins were included. Primary outcome was stroke, while secondary outcome was major adverse cardiovascular events (MACE), which was a composite of stroke, myocardial infarction, or cardiovascular death. Meta-analysis was conducted stratified by with/without chronic kidney disease (CKD), with/without heart failure (HF), and with/without atherosclerotic cardiovascular disease (ASCVD), and stratified by different gliflozins. RESULTS We included 9 trials in this meta-analysis. Compared with placebo, gliflozins significantly lowered stroke (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.55-0.84) and MACE (HR 0.77, 95% CI 0.69-0.86) in type 2 diabetes (T2D) patients with CKD, but did not significantly affect stroke (HR 1.00, 95% CI 0.86-1.16) and MACE (HR 0.94, 95% CI 0.86-1.02) in T2D patients without CKD. Gliflozins had no significant effects on the stroke risk (HR 0.94, 95% CI 0.82-1.07) in T2D patients regardless of HF status (Psubgroup = .684) and ASCVD status (Psubgroup = .915), but significantly lowered MACE (HR 0.89, 95% CI 0.83-0.96) in T2D patients regardless of HF status (Psubgroup = .428) and ASCVD status (Psubgroup = .423). Canagliflozin (HR 0.84, 95% CI 0.69-1.01) showed the trend of a reduction in the stroke risk versus placebo, and sotagliflozin (HR 0.73, 95% CI 0.54-0.98) significantly lowered the stroke risk; whereas the other 3 gliflozins did not significantly affect that risk. Ertugliflozin (HR 0.97, 95% CI 0.85-1.11) had no significant effects on the MACE risk, whereas the other 4 gliflozins significantly lowered that risk. CONCLUSIONS Gliflozins, especially canagliflozin and sotagliflozin, should be recommended in T2D patients with CKD to prevent stroke. Most gliflozins lower the risk of MACE in T2D patients regardless of HF status and ASCVD status, whereas ertugliflozin is not observed to lower that risk.
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Buyang huanwu decoction combined with probiotics or prebiotics for functional recovery from stroke: A meta-analysis protocol for systematic review.
Liang, R, Tang, Q, Wang, L, Yue, P, Zhu, L
Medicine. 2021;(51):e28371
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Abstract
BACKGROUND Stroke is a global disease that compromises human health. Considering the side effects of Western medicine, alternative medicine, such as Chinese medicine, is widely used. Concurrently, the research and development on the microbiota-gut-brain axis in recent years have made intestinal microflora the new target of treatment. We aim to scientifically evaluate the advantages and clinical guidance of using Buyang-Huanwu (BYHW) decoction combined with probiotics in the intestinal microflora. METHODS The search will focus on published Randomized Controlled Trial (RCTs) that used BYHW decoction, probiotics, prebiotics, synbiotics, or similar microecological preparations to treat stroke. We will search for relevant studies in six databases: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and Chongqing VIP Information. The retrieval date will be limited to the period from inception to June 2021 and will not be restricted by language. The extracted data will be subjected to systematic review and meta-analysis to evaluate its clinical advantages and efficacy. Patient-centred and most responsive outcomes will be selected as major outcomes, including the Fugl-Meyer (FMA) and Barthel scales. Secondary outcomes will be clinically assessed factors, including inflammatory factors in serum, platelet aggregation, other laboratory parameters, and the number and distribution of flora in the gut. We will evaluate the bias of each included study using the latest version of the Cochrane Handbook and the RoB tool. The analysis of all data and the drawing of forest maps will be performed using STAT 15.1 SE software. Regardless of the I2 values generated between the studies, we will perform a subgroup analysis. The grouping method will be based on all included research characteristics and factors that may cause heterogeneity, and may depend on differences in intervention methods, sources of subjects, and other relevant factors. RESULTS We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences, and popular press. CONCLUSION The efficacy and safety of Buyang-Huanwu decoction combined with probiotics for the treatment of stroke will be evaluated, and the conclusion will be published to provide medical evidence for a better clinical decision of patients with stroke.
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Ischaemic heart disease, stroke, and their cardiometabolic risk factors in Africa: current challenges and outlook for the future.
Peer, N, Baatiema, L, Kengne, AP
Expert review of cardiovascular therapy. 2021;(2):129-140
Abstract
INTRODUCTION Although cardiovascular diseases (CVDs) are among the leading causes of death in Sub-Saharan Africa (SSA), prevention is not a priority and effective treatments are not widely available. This perspective discusses the burden, challenges, and potential opportunities for improvement of CVD prevention and control efforts in SSA. AREAS COVERED This paper focuses on ischemic heart disease and stroke, and their key contributors of obesity, hypertension, diabetes and dyslipidaemia which are well-established, rapidly rising, and significant contributors to disease burden in SSA. However, their prevention, detection, treatment and control of are currently disorganized, inconsistent, unreliable, and insufficient with most SSA countries not geared to respond to this growing problem. National policies are frequently lacking or, if available, remain poorly implemented, for the control of these conditions. Primary healthcare systems have not adapted to cope with these rising CVD burdens and remain weak, underfunded and under resourced. Numerous barriers at the healthcare service, healthcare provider, and patient levels prevent optimal CVD risk factor care. EXPERT OPINION Innovative approaches such as task-shifting with the reallocation of care to lower-level healthcare workers and the potential use of inexpensive technological options should be encouraged to provide equitable CVD preventive and curative solutions to SSA's poor.
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Advances in the Development of Biomarkers for Poststroke Epilepsy.
Liang, M, Zhang, L, Geng, Z
BioMed research international. 2021;:5567046
Abstract
Stroke is the main cause of acquired epilepsy in elderly people. Poststroke epilepsy (PSE) not only affects functional recovery after stroke but also brings considerable social consequences. While some factors such as cortical involvement, hemorrhagic transformation, and stroke severity are associated with increased seizure risk, so far that remains controversial. In recent years, there are an increasing number of studies on potential biomarkers of PSE as tools for diagnosing and predicting epileptic seizures. Biomarkers such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), glutamate, and S100 calcium-binding protein B (S100B) in blood are associated with the occurrence of PSE. This review is aimed at summarizing the progress on potential biomarkers of PSE.
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Intermittent Theta Burst Stimulation (iTBS) for Treatment of Chronic Post-Stroke Aphasia: Results of a Pilot Randomized, Double-Blind, Sham-Controlled Trial.
Szaflarski, JP, Nenert, R, Allendorfer, JB, Martin, AN, Amara, AW, Griffis, JC, Dietz, A, Mark, VW, Sung, VW, Walker, HC, et al
Medical science monitor : international medical journal of experimental and clinical research. 2021;:e931468
Abstract
BACKGROUND Research indicates intermittent theta burst stimulation (iTBS) is a potential treatment of post-stroke aphasia. MATERIAL AND METHODS In this double-blind, sham-controlled trial (NCT01512264) participants were randomized to receive 3 weeks of sham (G₀), 1 week of iTBS/2 weeks of sham (G₁), 2 weeks of iTBS/1 week of sham (G₂), or 3 weeks of iTBS (G₃). FMRI localized residual language function in the left hemisphere; iTBS was applied to the maximum fMRI activation in the residual language cortex in the left frontal lobe. FMRI and aphasia testing were conducted pre-treatment, at ≤1 week after completing treatment, and at 3 months follow-up. RESULTS 27/36 participants completed the trial. We compared G0 to each of the individual treatment group and to all iTBS treatment groups combined (G₁₋₃). In individual groups, participants gained (of moderate or large effect sizes; some significant at P<0.05) on the Boston Naming Test (BNT), the Semantic Fluency Test (SFT), and the Aphasia Quotient of the Western Aphasia Battery-Revised (WAB-R AQ). In G₁₋₃, BNT, and SFT improved immediately after treatment, while the WAB-R AQ improved at 3 months. Compared to G₀, the other groups showed greater fMRI activation in both hemispheres and non-significant increases in language lateralization to the left hemisphere. Changes in IFG connectivity were noted with iTBS, showing differences between time-points, with some of them correlating with the behavioral measures. CONCLUSIONS The results of this pilot trial support the hypothesis that iTBS applied to the ipsilesional hemisphere can improve aphasia and result in cortical plasticity.
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The role of diet in secondary stroke prevention.
English, C, MacDonald-Wicks, L, Patterson, A, Attia, J, Hankey, GJ
The Lancet. Neurology. 2021;(2):150-160
Abstract
Poor quality diet and nutrition is strongly associated with risk of first stroke, and adherence to a Mediterranean-style diet has been reported to reduce the risk of first stroke. The association between diet quality and the risk of recurrent stroke is less certain and there is no reliable evidence that improving diet quality or dietary supplementation reduces recurrent stroke risk. Current evidence is largely based on epidemiological studies of diverse dietary approaches, ranging from nutritional supplements to specific foods, food groups, and dietary patterns, and is difficult to interpret. In the absence of reliable evidence from randomised clinical trials, the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach can be used to assess the potential causal role of diet quality and interventions in reducing recurrent stroke, and to provide guidance for clinical practice and directions for future research. Further work is needed to identify and develop the most promising dietary interventions for evaluation by large randomised clinical trials.