Cerebral Small Vessel Disease and Risk of Death, Ischemic Stroke, and Cardiac Complications in Patients With Atherosclerotic Disease: The Second Manifestations of ARTerial disease-Magnetic Resonance (SMART-MR) Study
Cerebral small vessel disease has been associated with increased risk of stroke, cognitive decline, dementia, systemic disease (such as nephropathy), and death. The common denominator of these conditions may be vascular pathology related to comorbid conditions such as hypertension, diabetes, and dyslipidemia. Conjin and colleagues investigated whether cerebral white matter lesions and lacunar infarctions were associated with risk of vascular and nonvascular death using data from the Second Manifestations of ARTerial disease-Magnetic Resonance (SMART-MR) study. A total of 1228 patients had completed MRI, which was used to identify lacunar versus nonlacunar ischemic lesions and to quantify white matter lesion burden. The authors noted that ≥1 lacunar infarcts increased the risk of all-cause, vascular, and nonvascular death. White matter lesion volume correlated with the risk of all-cause and vascular death only. There were also associations between lacunar infarcts and white matter lesion volume with risk for ischemic stroke but not ischemic cardiac complications. The authors suggest that lacunar infarcts and white matter lesions lead to an increased risk for all-cause vascular death. However, no information regarding large arterial atherosclerosis, severity of comorbid states, serum markers (eg, C-reactive protein, creatinine), or specific interventions in the studied patients is provided limiting the interpretation of the presented data. Thus, white matter lesions are markers of overall vascular morbidity rather than the causative problem. As such, this study highlights the importance of comprehensive medical care beyond assessment and treatment of the “usual suspects” for ischemic stroke in patients with symptomatic as well as asymptomatic ischemic cerebral small vessel disease.
See p 3105.
Organized Outpatient Care: Stroke Prevention Clinic Referrals Are Associated With Reduced Mortality After Transient Ischemic Attack and Ischemic Stroke
Organized inpatient care and rapid outpatient stroke assessment are increasingly recognized to improve outcomes. Webster and colleagues evaluated the effect of secondary prevention clinic referral on mortality and readmissions after an initial stroke admission from the retrospective Registry of the Canadian Stroke Network (RCSN). The primary outcome was all-cause mortality at 1 year after the index hospital visit for stroke/transient ischemic attack. A total of 16 468 patients with ischemic stroke or transient ischemic attack were identified of whom 7700 (47%) were referred for follow-up at a secondary prevention clinic. Most importantly, 1-year mortality rates were lower in those referred to stroke prevention clinics compared with those who were not (adjusted hazard ratio, 0.67; 95% CI, 0.60–0.75). Secondary analyses demonstrated that 1-year readmission and emergency room visit rates as well as CT imaging, antihypertensive therapy, or anticoagulation for atrial fibrillation were similar between patient subgroups. Length of stay was lower in patients followed in stroke prevention clinics (11.6 versus 5.7 days, P<0.001). Patients followed in stroke prevention clinics had more physician visits, MRI, carotid imaging, echocardiography, Holter monitoring, and were more frequently prescribed antiplatelet and lipid-lowering therapies (all P<0.001). Conversely, they were less likely to have carotid revascularization procedures. This study suggests that timely and more comprehensive stroke/transient ischemic attack workup combined with early risk factor control appear to be critical factors that help decrease mortality in patients followed in stroke clinics. Looking forward, the authors highlight the need to identify the specific clinic interventions that optimize outcome, patient satisfaction, and compliance as well as to assure their cost-effectiveness.
See p 3176.
Outcomes in Mild or Rapidly Improving Stroke Not Treated With Intravenous Recombinant Tissue-Type Plasminogen Activator: Findings From Get With The Guidelines–Stroke
Current acute ischemic stroke treatment guidelines indicate that patients with “minor and isolated or spontaneously clearing neurological signs” may not be treated with intravenous tissue plasminogen activator. This operationally defined criterion is frequently cited as a reason for not using tissue plasminogen activator in otherwise eligible patients. Limited data have emerged that nontreated patients may have a worse outcome than expected. Smith et al analyzed 29 200 patients (31.2% of all eligible patients) with a final discharge diagnosis of ischemic stroke who were not deemed tissue plasminogen activator candidates solely for the documented reason of having “mild or rapidly improving stroke” from the nationwide “Get With The Guidelines–Stroke” study. The median admission National Institutes of Health Stroke Scale score was 2 in patients not receiving tissue plasminogen activator. A staggering 28.3% and 28.5% of these patients were not discharged home or could not ambulate independently by hospital discharge, respectively. By comparison, only respective 8.0% and 12.5% of patients with transient ischemic attack (n=54 551) were not discharged home or were unable to ambulate independently. Not surprising, the likelihood of being discharged home or independent ambulation decreased with presenting National Institutes of Health Stroke Scale score (because no National Institutes of Health Stroke Scale score was documented in 38.1% of patients statistical models were used that included or excluded the National Institutes of Health Stroke Scale). Several shortcomings impair the interpretation of the presented results as highlighted by the authors, for example, pre-existing disability and place of residence were unknown and some patients may have not been eligible for discharge home regardless of their stroke outcomes. Regardless, these data are very concerning and warrant further investigation into the reasons for this unfavorable outcome. They remind clinicians to use their own best judgment instead of “blindly” following the tissue plasminogen activator treatment guidelines. After all, these guidelines are meant to advise clinicians in their decision-making and allow for discretion in their interpretation and implementation depending on the individual situation.
See p 3110.
- © 2011 American Heart Association, Inc.
- Cerebral Small Vessel Disease and Risk of Death, Ischemic Stroke, and Cardiac Complications in Patients With Atherosclerotic Disease: The Second Manifestations of ARTerial disease-Magnetic Resonance (SMART-MR) Study
- Organized Outpatient Care: Stroke Prevention Clinic Referrals Are Associated With Reduced Mortality After Transient Ischemic Attack and Ischemic Stroke
- Outcomes in Mild or Rapidly Improving Stroke Not Treated With Intravenous Recombinant Tissue-Type Plasminogen Activator: Findings From Get With The Guidelines–Stroke
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