Category: Cardiovascular Disease

Categories : Cardiovascular Disease GenderTags :

Hypertension Risk for Women After Sexual Assault or Harassment

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Photo by Sydney Sims on Unsplash

A new study has found that women who have experienced sexual assault or harassment are at higher long-term risk of developing hypertension than women who have not.

The study appears in the Journal of the American Heart Association.

In the US, nearly 43% of women aged 20 and older have hypertension. Defined as a blood pressure of 130/80mmHg or higher, hypertension is a major risk factor for cardiovascular disease – the number one killer of women, causing one in three deaths each year.

“We know that experiences of sexual violence in the form of sexual assault and workplace sexual harassment are common, and that women are disproportionately victims of such violence, with 13–44% of women reporting sexual assault and up to 80% of women reporting workplace sexual harassment,” said study author Rebecca B. Lawn, PhD. “However, exposure to sexual violence is not widely recognized as a contributor to women’s cardiovascular health. We felt it was important to investigate the relationship among common forms of sexual violence with the risk of developing hypertension. These links could help in the early identification of factors that influence women’s long-term cardiovascular health.”

In this study, researchers analysed data over the course of seven years beginning with a 2008 follow-up of the Nurses’ Health Study II, an ongoing cohort study of US women. The 2008 follow-up measured the incidence of sexual violence and other trauma exposure, as well as post-traumatic stress disorder (PTSD) and symptoms of depression, among a subset of 54 703 of the study’s original participants.

From that subset, Lawn and colleagues analysed data for 33 127 women (95% non-Hispanic white women; average age of 53 years at the beginning of the 2008 follow-up) who had no history of hypertension or had not taken medication for high blood pressure as of the start of the 2008 follow-up.

The analyses found:

  • At the seven-year follow-up in 2015, about 1 in 5 (nearly 7100) of the women self-reported they had developed hypertension, validated with medical records.
  • Sexual assault and workplace sexual harassment were common, with lifetime prevalence of 23% for sexual assault and 12% for workplace sexual harassment; 6% of women reported experiencing both.

Compared to women with no history of sexual assault or harassment, women who reported having experienced both had the greatest increased hypertension risk (21%), followed women who reported experiencing workplace sexual harassment (15%) and an women who reported experiencing sexual assault (11%).

“We did not find any association of increased risk for hypertension among women who had a history of other types of trauma and who did not experience sexual violence, suggesting that increased hypertension risk does not appear to be associated with all trauma exposure,” Dr Lawn said. “Our finding that experiencing both sexual assault and workplace sexual harassment had the highest risk of hypertension underscores the potential compounding effects of multiple sexual violence exposures on women’s long-term cardiovascular health.”

Dr Lawn observed screening for partner violence by primary care clinicians is becoming more common, sexual violence overall is not recognised as a risk factor among women for developing cardiovascular disease.

“These results suggest that screening for a broader range of experiences of sexual violence in routine health care, including sexual harassment in the workplace, as well as verbal harassment or assault, and being aware of and treating potential cardiovascular health consequences may be beneficial for women’s long-term health,” she said. “Reducing sexual violence against women, which is important in its own right, may also provide a strategy for improving women’s lifetime cardiovascular health.”

There are several limitations to the study, including memory biases in recall of sexual violence. The sexual assault and harassment had no measures of severity or timing. Most of the women in the study were white women in the nursing field, limiting generalisability.

“We hope future studies will examine these questions with more detailed information on sexual and other forms of violence. These questions need to be investigated in more diverse groups of people of various ages, races and ethnic backgrounds and gender,” Dr Lawn said. “Although women are disproportionately victims of sexual violence, men are also victims and the physical health implications of experiences of sexual violence against men warrants further investigation.”

Source: American Heart Association

Categories : Cardiovascular Disease Neurodegenerative DiseasesTags :

Heart Attack Survivors at Lower Risk of Parkinson’s

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Credit: American Heart Association

Heart attack survivors may be slightly less likely to develop Parkinson’s disease later in life, according to new research published in the Journal of the American Heart Association.

Parkinson’s disease (PD) is a common neurodegenerative disorder. While a number of non-motor manifestations arise, the typical clinical features involve a movement disorder consisting of bradykinesia, resting tremor, and rigidity, with postural instability occurring at a later stage. The cause of PD is not known, but a number of genetic risk factors have now been characterised, as well as several genes which cause rare familial forms of PD. Secondary parkinsonism, which has symptoms similar to Parkinson’s disease, may be caused by stroke, psychiatric or cardiovascular medications, or other illness.

“We have previously found that following a heart attack, the risk of neurovascular complications such as ischaemic stroke or vascular dementia is markedly increased, so the finding of a lower risk of Parkinson’s disease was somewhat surprising,” said lead study author Jens Sundbøll, MD, PhD. “These findings indicate that the risk of Parkinson’s disease is at least not increased following a heart attack and should not be a worry for patients or a preventive focus for clinicians at follow-up.

“It is not known whether this inverse relationship with risk of Parkinson’s disease extends to people who have had a heart attack. Therefore, we examined the long-term risk of Parkinson’s disease and secondary parkinsonism among heart attack survivors,” Dr Sundbøll said.

Drawing on Danish National Health Service data, the researchers compared the risk of PD and secondary parkinsonism among roughly 182 000 patients who had a first-time heart attack between 1995 and 2016 (average age 71 years old; 62% male) and more than 909 000 matched controls. 

Over a maximum continual follow-up of 21 years, after adjusting for a wide range of potential confounding factors, the analysis found that, when compared to the control group:

  • there was a 20% lower risk of PD among people who had a heart attack; and
  • a 28% lower risk of secondary parkinsonism among those who had a heart attack.

“For physicians treating patients following a heart attack, these results indicate that cardiac rehabilitation should be focused on preventing ischaemic stroke, vascular dementia and other cardiovascular diseases such as a new heart attack and heart failure, since the risk of Parkinson’s appears to be decreased in these patients, in comparison to the general population,” Dr Sundbøll said.

Certain risk factors are common to both heart attack and PD, with higher risk found among elderly men and lower risk among people who drink more coffee and are more physically active. Interestingly, however, some classic heart attack risk factors – such as smoking, high cholesterol, hypertension and Type 2 diabetes – are associated with a reduced risk of PD.

In general, more heart attack patients smoke and have high cholesterol, either of which may explain the slightly reduced risk of PD among heart attack survivors.

“There are very few diseases in this world in which smoking decreases risk: Parkinson’s disease is one, and ulcerative colitis is another. Smoking increases the risk of the most common diseases including cancer, cardiovascular disease and pulmonary disease and is definitely not good for your health,” Dr Sundbøll noted.

One limitation of the study is that there was not enough information about smoking and high cholesterol levels among the participants, which may have influenced the findings. The study participants were almost entirely white, limiting the generalisability to other ethnic groups.

Source: American Heart Association

Categories : Cardiovascular Disease Diet and NutritionTags :

Vegetable Intake Does Not Reduce Cardiovascular Risk, Study Finds

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Photo by Daria Shevtsova from Pexels

A long-term study on almost 400 000 people in the UK finds little or no evidence that differences in the amount of vegetables consumed affects the risk of cardiovascular disease. 

When known socio-economic and lifestyle confounding factors are corrected for, the small apparent positive effect that remains could likely also be explained away by further confounders.

Getting enough vegetables is important for maintaining a balanced diet and avoiding a wide range of diseases. But might a diet rich in vegetables also lower the risk of cardiovascular disease (CVD)? Unfortunately, new results from a powerful, large-scale new study study in Frontiers in Nutrition found no evidence for this.

The notion of CVD risk being lowered by vegetable consumption might seem plausible at first, as their ingredients such as carotenoids and alpha-tocopherol (vitamin E) have properties that could protect against CVD. But so far, prior evidence for an overall effect of vegetable consumption on CVD has been inconsistent.

The study, which drew on UK Biobank data, found a higher consumption of cooked or uncooked vegetables is unlikely to affect the risk of CVD. The study authors also explained how confounding factors might explain previous spurious, positive findings.

“The UK Biobank is a large-scale prospective study on how genetics and environment contribute to the development of the most common and life-threatening diseases. Here we make use of the UK Biobank’s large sample size, long-term follow-up, and detailed information on social and lifestyle factors, to assess reliably the association of vegetable intake with the risk of subsequent CVD,” said Prof Naomi Allen, UK Biobank’s chief scientist and co-author on the study.

The UK Biobank, follows the health of half a million adults in the UK by linking to their healthcare records. Upon their enrolment in 2006-2010, these volunteers were  interviewed about their diet, lifestyle, medical and reproductive history, and other factors.

The researchers used the responses at enrolment of 399 586 participants (of whom 4.5% went on to develop CVD) to questions about their daily average consumption of uncooked versus cooked vegetables. They analysed the association with the risk of hospitalization or death from myocardial infarction, stroke, or major CVD. They controlled for a wide range of possible confounding factors, including socio-economic status, physical activity, and other dietary factors.

Crucially, the researchers also assessed the potential role of ‘residual confounding’, that is, whether unknown additional factors or inaccurate measurement of known factors might lead to a spurious statistical association between CVD risk and vegetable consumption.

The mean daily intake of total vegetables, raw vegetables, and cooked vegetables was 5.0, 2.3, and 2.8 heaped tablespoons per person. The risk of dying from CVD was about 15% lower for those with the highest intake compared to the lowest vegetable intake. However, this effect was greatly weakened when possible confounding factors were taken into account. Controlling for factors such as socio-economic status reduced the predictive statistical power of vegetable intake on CVD by over 80%, suggesting that more precise measures of these confounders would have explained away any residual effect of vegetable intake.

Dr Qi Feng, the study’s lead author, said: “Our large study did not find evidence for a protective effect of vegetable intake on the occurrence of CVD. Instead, our analyses show that the seemingly protective effect of vegetable intake against CVD risk is very likely to be accounted for by bias from residual confounding factors, related to differences in socioeconomic situation and lifestyle.”

The researchers suggest that subsequent studies should further assess whether particular types of vegetables or their method of preparation might affect the risk of CVD.

Source: Frontiers

Categories : Cardiovascular Disease Emergency MedicineTags :

No Difference Between Paramedics’ Advanced Airway Management Strategies

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Source: Mat Napo on Unsplash

Similar outcomes were seen for patients with out-of-hospital cardiac arrest (OHCA) regardless of the advanced airway management strategy used by paramedics, results from the Taiwanese SAVE trial showed.

There was no generally no difference in clinical outcomes between groups that had the initial strategies of endotracheal intubation or supraglottic airway device insertion:

Sustained return of spontaneous circulation (ROSC) two hours after resuscitation: 26.9% vs 25.8%; survival to hospital discharge: 8.5% vs 8.4%; cerebral performance category score ≤ 2: 3.9% vs 4.8%.

Only prehospital ROSC suggested an advantage to standard endotracheal intubation (10.6% vs 6.4%), according to the researchers, whose study was published in JAMA Network Open.

Endotracheal intubation is a difficult procedure to get right. The SAVE paramedics, all experienced in both methods of advanced airway management, employed direct laryngoscopy and achieved a 77% rate of first-attempt airway success with endotracheal intubation (vs 83% with the supraglottic device). Average scene time (18.4 vs 16.9 minutes) and call-to-airway time (15.9 vs 13.9 minutes) were both longer with endotracheal intubation.

“It is unclear whether a stepwise and algorithmic endotracheal intubation training program could reduce the time in the field and the time for advanced airway insertion, and further research is warranted,” the authors said.

For the SAVE trial conducted from 2016 to 2019, researchers randomly split four EMS teams in Taipei into two clusters, each assigned to initial endotracheal intubation or supraglottic i-gel device insertion when responding to OHCAs over a biweekly period. In case the first advanced airway attempt failed, rescue airway management was allowed using a number of techniques.

The 936 OHCA patients in the study had a median age of 77 years, and 60.8% were men.

However, subgroup analysis showed that prehospital ROSC rates favoured endotracheal intubation in patients with nonshockable rhythm, nonpublic collapse, witnessed arrest, call-to-airway time under 14 minutes, and age 77 years or older.

However, different in-hospital management between groups could have affected the results. The two study arms were unequal in size, and the study could have been underpowered because of inaccurate sample size representation at the study outset. However, the researchers lamented that “even if we had realised that the sample size was inadequate at that time, we would not have been able to recruit more cases because of the outbreak of COVID.”

Source: MedPage Today

Categories : Cardiovascular DiseaseTags :

Cough Suppressant Could Lead to New Arrhythmia Treatment

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Photo by cottonbro from Pexels

An over-the-counter cough suppressant can knock some heart cells out of arrhythmia, a discovery that could lead to a new treatment for long QT syndrome. The finding, which was published in Nature Cardiovascular Research, was made using stem cells from patients with the disorder.

The QT interval on an electrocardiogram (ECG) represents the duration of the ventricular action potential, and this physiologically correlates with the duration of the ventricular depolarisation and repolarisation. Cardiac events and fatal arrhythmias may occur when the QT interval is prolonged either congenitally or through acquired causes. In people with long QT syndrome, cardiac cells are not always ready to produce the next beat, a situation that can knock the heart out of its normal rhythm, which may be life-threatening. For many people with long QT, no treatment can correct the heart cells or prevent arrhythmia.

Using mice to investigate how human heart arrhythmias can be stopped is difficult, so Masayuki Yazawa, PhD at the University of Columbia, turned to patient-derived reprogrammed stem cells, which can be made into heart cells in the lab.

The road to the discovery began several years ago when Dr Yazawa found that heart cells in the lab would resume a normal rhythm when a certain enzyme was inhibited. But the drugs used to inhibit the enzyme also had other unintended effects, such as liver toxicity, so alternatives were needed.

Looking through published research, the team learned that the enzyme could be inhibited through an intermediary molecule inside heart cells called SIGMAR1. Further reading suggested that SIGMAR1 could be targeted by a cough suppressant, dextromethorphan.

Dr Yazawa’s team found that the cough suppressant, when added to heart cells, successfully prepared the heart cells for the next beat and soothed the cells’ irregular rhythm.

The cough suppressant reset heart cells from people with Timothy syndrome, a genetic disorder that also causes other heart abnormalities, and from people with more common forms of long QT syndrome.

Dr Yazawa cautioned that it’s premature to use dextromethorphan to treat long QT patients; the drug has a short half-life and would have to be used long term, which might still have unknown adverse side effects.

“But our study shows that drugs targeting SIGMAR1 have potential to treat a wide array of patients with long QT syndrome,” said Dr Yazawa, “and we will continue to look for better options.”

Source: Columbia University

Categories : Cardiovascular DiseaseTags :

New Blood Thinners from Tick Saliva

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Source: Wikimedia CC0

Researchers looking for new anti-clotting drugs have discovered a unique class of medications that act as blood thinners by inhibiting an enzyme in the genes of tick saliva.

The study, published in Nature Communications, focused on novel direct thrombin inhibitors (DTI) from tick salivary transcriptomes, or messenger RNA molecules expressed by an organism. As a result of  the research, there are now new anticoagulant medications that can be developed for the treatment of patients with a variety of coronary issues, including heart attacks.

“Interest in ticks as a model for developing drugs that prevent blood clotting – [often] the cause of heart attacks and strokes – is firmly rooted in evolutionary biology,” said Professor Richard Becker, a co-author of the study.

“Analysis of backbone structures suggest a novel evolutionary pathway by which different blood clot inhibiting properties evolved through a series of gene duplication events. Comparison of naturally occurring blood clot inhibitors of differing tick species suggests an evolutionary divergence approximately 100 million years ago.”

Prof Becker and his international colleagues discovered DTIs from tick salivary transcriptomes and optimised their use as a pharmaceutical. The most potent is a key regulating enzyme in blood clot formation with very high specificity and binding capacity that is almost 500 times that of bivalirudin, a drug used during a typical nonsurgical procedure used to treat narrowing of the coronary arteries. Those minimally invasive procedures are performed in roughly 1 million persons yearly in the United States.

“Despite their greater ability to reduce the incidence of the formation of blood clots, the drugs demonstrated less bleeding, achieving a wider therapeutic index in nonhuman models,” Becker says. “The higher potency of the drug means it’s not necessary to use a lot of it in treating patients, which holds the cost of goods and manufacturing down.”

According to Prof Becker, tick saliva, as in other blood-feeding such as mosquitoes, contains pharmacological and immunological active compounds, which modulate immune responses and induce antibody production. This research leveraged an understanding of tick-host interactions and antibody formation.

“The holy grail of anticoagulant therapy has always been specificity, selectivity, efficacy and safety,” said Prof Becker. “Clinician-scientists must have the training and an environment that embraces asking questions and finding solutions, including those potential found deep within nature. An ability to both measure and adjust the drug dose and rapidly reverse its effects is particularly important for safety purposes. The next step is to complete pharmacology, toxicology, drug stability and other important regulatory steps before conducting clinical trials in humans.”

Source: University of Cincinnati

Categories : Cardiovascular DiseaseTags :

Taking Healthcare to SASSA Queues: Pensioners Screened for Hypertension

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Hundreds of pensioners queuing for their old age grants are being screened and tested for hypertension at paypoints in Mpumalanga. In this way, care is provided where and to whom it’s needed most.

In total, more than 4.2 million people in South Africa aged 60 and older currently receive the Older Persons Grant. For many of them, particularly in rural areas, grant collection days often involve standing in queues for hours.

In a pilot project in Bushbuckridge, Mpumalanga, the South African Medical Research Council (SAMRC) and SAMRC/WITS’s Rural Public Health and Health Transitions Research Unit. are using these queues as an opportunity to take screening for hypertension to some of the most vulnerable and often neglected people in the country.

The study is being conducted in collaboration with local communities, the South African Social Security Agency (SASSA), the South African Post Office (SAPO) in Ximhungwe and Boxer Superstores in Thulamahashe.

The project called “Know Your Numbers” was launched in April 2021 with 20 fieldworkers from local communities at six sites where hundreds of pensioners gather each month to collect their grants. The teams take people’s blood pressure using mobile Omron machines.

“Screening about 100 people per queue, we are picking up high blood pressure in about 60% of the participants. These people are all referred to their closest local clinic for further assessment, treatment and care as required. About 30% of the participants are male and about 70% female and that’s because there are sadly less men alive to collect social grants,” said Jane Simmonds, Know Your Numbers project manager at SAMRC/WITS’s Rural Public Health and Health Transitions Research Unit.

Silent killer
Hypertension is known as the ‘silent killer’ because there are no exclusive symptoms that point directly to the disease. A 2021 study by the SAMRC found that the prevalence of hypertension rose between 1998 and 2016, from 27% to 45% in men and 31% to 48% in women. This has a significant impact on the health of older persons. “Older adults contribute critical support to local households, fostering orphans, enabling schooling and countering food insecurity. We can ill afford a rising toll of deaths from stroke and heart failure, or greater vulnerability to Covid-19,” said Steve Tollman, Unit Director.

“Many people don’t have money to travel to the doctor or clinic before they’re already very sick,” said Simmonds. Measuring blood pressure in people standing in the queue could help them manage and improve their health and save them the costs and time involved in visiting a clinic for a simple monthly health check.

“People will not go to town or clinics for treatment or vaccines if they have to choose between spending their R1800 grant on food or for transport,” said Simmonds, who lobbied for what became a successful project to offer the Covid vaccine directly to pensioners while they were queuing.

She explained how transport costs and problems accessing the Electronic Vaccination Data System (EVDS) had become barriers to vaccination for older people when the vaccine was first rolled out.

“When the Covid vaccines became available to people 60 and older in July last year, I thought that if we could meet people in queues for hypertension screening, then why not reach them for vaccines? I spent a lot of time talking to the Minister Of Health, Deputy-Director General or anyone that would listen to me about this concept. Eventually the Solidarity Fund came on board to fund vaccine outreach sites through the national health department. These sites have done over 500 000 vaccines since July 2021,” she said.

SASSA’s Dianne Dunkerley told GroundUp that SASSA had agreed to a pilot project with strict conditions to protect the security of beneficiaries and to avoid prolonging their already lengthy wait in line.

Dunkerley said the project is being welcomed by older people. “Older people who didn’t realise they had hypertension were identified, and could then go to local clinics for treatment and further monitoring,” she said.

“In cases where people did not want to make decisions immediately, they were sent home with information to discuss with family and friends which is great.”

Fieldworkers from the community speaking to pensioners about the health screening outside the SA Post Office where they collect their social grant.

Dunkerly said SASSA “would not be averse to expanding this project to other provinces” and discussions were underway.

“We really have started seeing the benefits and the reduction of costs, both of transport and of time, for older people. We think that because they’re old, they don’t have anything else to do. Well, many pensioners look after entire families and do all kinds of things. Where we can minimise the time they spend looking for services, it really is a good thing,” she said.

Professor Andre Kengne, Director of the Non-Communicable Diseases Research Unit at SAMRC, told GroundUp, “Early lessons from the ‘Know Your Number’ project are strongly suggesting that the reach of prevention and control services for common health conditions including chronic diseases such as hypertension, can be substantially improved by taking some of the essential services such as health screening and health promotion to the most vulnerable people in the community.”

He said older persons are the most affected by chronic non-communicable diseases and that improving the detection, linkage to care and control of those conditions through appropriate community-based approaches, significantly reduces the related harmful health effects.

The researchers hope that lessons from the ongoing and thorough pilot evaluation can be used to lobby the government to include screening and tests for diabetes, HIV, TB, cancers and other health issues which affect older persons.

By Barbara October

Source: GroundUp

Categories : Cardiovascular Disease GeneticsTags :

Prevalence of Cardiac Arrhythmia Risk Genes Greater Than Believed

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Source: Pixabay/CC0

By sequencing genes linked to cardiac arrhythmia risk in more than 20 000 people without an indication for genetic testing, scientists were able to identify possible pathogenic variants in 0.6% of individuals, according to a study published in Circulation.

This rate is higher than those previously reported, according to Carlos G. Vanoye, PhD, research associate professor of Pharmacology and a co-author of the study.

“This study suggests the prevalence of genetic susceptibility to cardiac arrhythmia may be underestimated,” Dr Vanoye said.

The American College of Genetics and Genomics (ACMG) currently recommends that incidentally discovered pathogenic or likely pathogenic variants in 73 Mendelian disease genes be reported back to patients. This includes many genetic variants associated with congenital cardiac arrhythmias, causing irregular heartbeats which can lead to stroke or sudden cardiac death.

However, the pathogenicity of many genetic variants in these known arrhythmia genes is uncertain, and classification of these variants is still in the early stages.

“A person can carry a disease-causing gene variant but exhibit no obvious signs or symptoms of the disease,” Dr Vanoye said. “Because the genes we studied are associated with sudden death, which may have no warning signs, discovery of a potentially life-threatening arrhythmia gene variant can prompt additional clinical work-up to determine risks and guide preventive therapies.”

The current study used data from the Electronic Medical Records and Genomics sequencing (eMERGEIII) study. The eMERGEIII study investigated the feasibility of population genomic screening by sequencing 109 genes implicated across the spectrum of Mendelian (single inherited gene mutation) diseases in over 20 000 individuals, returning variant results to the participants, and using Electronic Health Record (EHR) and follow-up clinical data to ascertain patient phenotypes.

In the current study, investigators analysed 10 arrhythmia-associated genes in individuals without an indication for genetic testing.

The researchers determined the functional consequences of these variants of uncertain significance and used the data to refine the assessment of pathogenicity. In the end, they reclassified 11 of these variants: three that were likely benign and eight that were likely pathogenic.

In all, 0.6% of the studied population had a variant that increases risk for potentially life-threatening arrhythmia and there was overrepresentation of arrhythmia phenotypes among these patients. This is a rate higher than previously known for genetic arrhythmia syndromes (approximately 1 in 2000) and illustrates the potential for population genomic screening, Dr Vanoye said.

“Population genomic screening can positively affect public health. Many rare, disease-associated variants can be found this way which can then help determine the disease-risk of the carriers of these variants,” Dr Vanoye said. “Although the costs of genomic screening may be currently high, assessing patient risk followed up by clinical care would reduce the financial and emotional cost of the disease.”

Source: Northwestern Medicine

Categories : Cardiovascular DiseaseTags :

In Severe Stroke, Mechanical Clot Removal Leads to Improved Outcomes

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A clot within a blood vessel interrupting blood flow to the brain.
Copyright American Heart Association

Ischaemic stroke patients previously considered unlikely to survive without severe disability may regain far more function if the blood clots are mechanically removed in addition to standard medical therapy, according to preliminary late-breaking research presented today at the American Stroke Association’s International Stroke Conference 2022.

In 2018, the American Heart Association’s stroke treatment guidelines were updated to recommend endovascular therapy (mechanical clot removal) for select stroke patients to improve the odds of functional recovery. This new study in Japan is the first randomised, controlled trial to demonstrate the effectiveness of endovascular therapy in patients with severe strokes involving clots in one or more large brain arteries, causing a large blood flow interruption in the brain. This approach had worked for patients with fewer areas of the brain disrupted, however, clinical experience was mixed for patients with more severe strokes.

Infarction area, or core area, estimates the volume of brain affected and describes the blockage location as seen on a brain CT. A lower number translates to a stroke affecting more core areas of the brain: 8-10=small core, 6-7=moderate core and 0-5=large core. Current US stroke guidelines recommend endovascular therapy for core areas 6-9. This study examined blockages that scored as 3-5. Strokes with blockages measuring 0-2 core areas are considered too severe and highly unlikely the patient would return to ambulatory independence.

“I have often encountered a dramatic improvement in a patient just after the mechanical clot removal procedure, even when the infarction area was large. Yet, patients sometimes also experienced severe haemorrhagic transformation [a life-threatening complication that occurs when blood from outside the brain crosses the blood-brain barrier and worsens stroke outcome] after the artery was reopened. So, in Japan, our stroke physicians are always cautious about endovascular therapy when the infarction area is large,” said Professor Shinichi Yoshimura, lead author of the study.

This randomised study included 203 stroke patients (average age of 76 years; 44% women). Most (71%) were examined and had MRI or a CT scan of the brain within 6 hours after stroke symptoms were first noticed, when patients are generally considered eligible for endovascular therapy. The other patients were seen between 6-24 hours after symptoms were noticed, and additional imaging showed areas of the brain that might benefit from prompt treatment.

On imaging, all patients were found to have clots blocking a large cerebral artery – either the internal carotid artery, the proximal middle cerebral artery or both. The strokes were rated as severe (median 22 on the National Institutes of Health (NIH) Stroke Scale,) and involved disrupted blood flow to large areas of the brain (about 7 out of 10 regions).

After imaging, the patients were randomly selected to receive either standard medical care for stroke (intravenous fluids, controlling blood pressure and other risk factors, and thrombolytics for lower bleeding risk patients) or standard medical care plus endovascular therapy performed within an hour after imaging to mechanically remove the clots. Due to bleeding concerns, intravenous thrombolytics were sparingly administered to select patients in a similar proportion in both treatment groups (27 of those who received endovascular therapy and 29 who received standard care).

Comparing the 100 patients who received endovascular therapy with 102 on standard therapy alone, the analysis found:

  • Patients who received endovascular therapy were 2.43 times more likely (31% vs 13%) to be able to walk unassisted and to have a residual disability rated as none to moderate 90 days later.
  • After 90 days, more of the patients (14% vs. 6.9%) who received endovascular therapy were considered functionally independent, meaning they were either able to carry out all their pre-stroke activities or to have a slight disability that did not require daily assistance.
  • At 48 hours after treatment, more of the patients (31% vs. 8.8%) who received endovascular therapy had major early neurological improvement.

“Our findings confirm that anyone who suffers from stroke should be transferred to a medical facility capable of endovascular therapy as soon as possible. The benefit of endovascular therapy is not limited by the severity or region of a stroke. These patients may have the chance to more fully recover from stroke and go back to their previous lives and activity levels,” said Professor Takeshi Morimoto, senior author of the study.

Several outcomes were compared to evaluate the safety of adding endovascular therapy to medical treatment, with researchers reporting:

  • Within 48 hours, scans revealed that more of the patients who received endovascular therapy had experienced some bleeding within the brain (with or without symptoms), 58% vs. 31%, respectively.
  • However, the number of patients who experienced other adverse outcomes was similar in the two treatment groups. The adverse events included brain bleeding within 48 hours that caused a worsening of neurological status (4 points or greater worsening on the NIH Stroke Scale); the need for surgery to relieve pressure on the brain in the first week; death within 90 days; or the recurrence of ischaemic stroke within 90 days.

“The finding of more intracranial bleeding in the patients who received endovascular therapy is very important. However, there were haemorrhages with symptoms and some that caused no symptoms. The haemorrhages with no symptoms were detected on imaging conducted for this study in the endovascular treatment group, not in the standard practice group. Symptomatic intracranial haemorrhage still occurred more commonly among patients in the endovascular group, however, it was not a statistically significant difference from the standard care group,” Morimoto said.

Due to different treatment protocols in Japan, where there is less use of intravenous thrombolysis than in the US and other western countries, and where more strokes are imaged with MRI than CT, this study’s results may over- or underestimate the effectiveness of endovascular therapy.

The researchers are currently performing sub-analyses to help identify factors that might signal which patients are more likely to have a greater return of function after the treatment. “In addition, tools, devices or rehabilitation methods that could potentially improve the likelihood for similar patients to recover with less disability should be investigated,” Morimoto said.

Source: American Heart Association

Categories : Cardiovascular DiseaseTags :

Micronutrients Could Replenish Mitochondria in Cardiac Cells

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There is convincing evidence that micronutrients, such as iron, selenium, zinc, copper, and coenzyme Q10, can impact the function of cardiac cells’ energy-producing mitochondria to contribute to heart failure according to a review published in the Journal of Internal Medicine.

Research has established a relationship between poor cardiac performance and metabolic perturbations, including deficits in substrate uptake and utilisation, reduction in mitochondrial oxidative phosphorylation and excessive reactive oxygen species production. Together, these disturbances result in depletion of cardiac adenosine triphosphate (ATP) and loss of cardiac energy. Delivering more energy substrates such as fatty acids to the mitochondria will be worthless if the mitochondria can’t turn them into fuel. 

Micronutrients are required to efficiently convert macronutrients to ATP. However, studies have shown that up to 50% of patients with heart failure have deficiencies in one or more micronutrients. “Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation,” the authors argued. Their findings suggest that micronutrient supplementation could represent an effective treatment for heart failure.

“Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation, moving our view of the failing heart away from ‘an engine out of fuel’ to ‘a defective engine on a path to self-destruction’,” said co–lead author Nils Bomer, PhD, of the University Medical Center Groningen, in The Netherlands.

An accompanying editorial suggests a large trial to see if there is indeed a clinical benefit.

Source: Wiley