ObjectiveTo test the hypothesis that markers of coagulation and hemostatic activation (MOCHA) help identify causes of cryptogenic stroke, we obtained serum measurements on 132 patients and followed them up to identify causes of stroke.MethodsConsecutive patients with cryptogenic stroke who met embolic stroke of undetermined source (ESUS) criteria from January 1, 2017, to October 31, 2018, underwent outpatient cardiac monitoring and the MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) obtained ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. Prespecified endpoints monitored during routine clinical visits included new atrial fibrillation (AF), malignancy, venous thromboembolism (VTE), or other defined hypercoagulable states (HS).ResultsOverall, 132 patients with ESUS (mean age 64 ± 15 years, 61% female, 51% nonwhite) met study criteria. During a median follow-up of 10 (interquartile range 7–14) months, AF, malignancy, VTE, or HS was identified in 31 (23%) patients; the 53 (40%) patients with ESUS with abnormal MOCHA were significantly more likely than patients with normal levels to have subsequent new diagnoses of malignancy (21% vs 0%, p < 0.001), VTE (9% vs 0%, p = 0.009), or HS (11% vs 0%, p = 0.004) but not AF (8% vs 9%, p = 0.79). The combination of 4 normal MOCHA and normal left atrial size (n = 30) had 100% sensitivity for ruling out the prespecified endpoints.ConclusionThe MOCHA profile identified patients with cryptogenic stroke more likely to have new malignancy, VTE, or HS during short-term follow-up and may be useful in direct evaluation for underlying causes of cryptogenic stroke.
Background Studies of COVID-19 have shown that African Americans have been affected by the virus at a higher rate compared to other races. This cohort study investigated comorbidities and clinical outcomes by race among COVID-19 patients admitted to the intensive care unit. Methods This is a case series of critically ill patients admitted with COVID-19 to an academic healthcare system in Atlanta, Georgia. The study included all critically ill hospitalized patients between March 6, 2020, and May 5, 2020. Clinical outcomes during hospitalization included mechanical ventilation, renal replacement therapy, and mortality stratified by race. Results Of 288 patients included (mean age, 63 ± 16 years; 45% female), 210 (73%) were African American. African Americans had significantly higher rates of comorbidities compared to other races, including hypertension (80% vs 59%, P = 0.001), diabetes (49% vs 34%, P = 0.026), and mean BMI (33 kg/m 2 vs 28 kg/m 2 , P < 0.001). Despite African Americans requiring continuous renal replacement therapy during hospitalization at higher rates than other races (27% vs 13%, P = 0.011), rates of intubation, intensive care unit length of stay, and overall mortality (30% vs 24%, P = 0.307) were similar. Conclusion This racially diverse series of critically ill COVID-19 patients shows that despite higher rates of comorbidities at hospital admission in African Americans compared with other races, there was no significant difference in mortality.
Introduction: Markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF) or malignancy. The objective of this study was to validate these results in a larger ESUS cohort. Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent outpatient cardiac monitoring and the MOCHA profile including serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. Prespecified endpoints monitored during routine clinical follow-up included diagnosis of AF, malignancy, venous thromboembolism (VTE) or other defined hypercoagulable states. Results: During the study period, 113 ESUS patients (mean age 64 +/- 15 years, 63% female, 54% non-white) underwent prolonged cardiac monitoring (70% MCOT, 42% ILR) and MOCHA profile testing (median days from stroke 33, IQR 15-57). During a mean follow-up of 7 ± 4 months, AF, malignancy, VTE or other defined hypercoagulable state was identified in 30 (27%) patients; the 41 (36%) ESUS patients with an abnormal MOCHA profile were significantly more likely to have an endpoint than patients with a normal profile (59% vs 8%, p<0.0001). The absence of any elevated MOCHA tests (n=41) had 100% sensitivity for the prespecified endpoints. Conclusion: In this validation study, we found that the MOCHA profile identified ESUS patients more likely to have AF, malignancy, VTE or other defined hypercoagulable states during follow-up and may identify a subgroup of ESUS patients who could benefit from early anticoagulation; a normal MOCHA profile identifies ESUS patients who have a low risk of developing these endpoints on antiplatelet therapy.
Introduction: Recent randomized trials have shown that patent foramen ovale (PFO) closure combined with antiplatelet therapy in cryptogenic stroke patients ≤ 60 years of age is associated with a reduced risk of stroke compared to antiplatelet therapy alone, presumably by preventing a paradoxical embolism. The objective of this study was to evaluate the MOCHA profile, a sensitive marker of venous thromboembolism (VTE), in ESUS patients with PFO. Methods: Consecutive ESUS patients ≥ 18 years of age seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent testing of MOCHA including serum d-dimer (DD), prothrombin fragment 1.2 (PTF1.2), thrombin-antithrombin (TAT) complex and fibrin monomer (FM). All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. We compared baseline characteristics and clinical outcomes between patients with and without PFO. Results: During the study period, 113 ESUS patients (mean age 64 +/- 15 years, 63% female, 54% non-white, 20% PFO) underwent MOCHA profile testing; 37 (32.7%) were ≤ 60 years of age. In the subgroup ≤ 60 years of age, the 11 (23%) PFO+ patients were younger (mean age 40 vs 46, p=0.009), more likely to be white (55% vs 35%, p=0.0001) and had higher ROPE score (median 8 vs 6, p=0.06) than PFO- patients. There was no significant difference between PFO+ and PFO- patients in the frequency of abnormal MOCHA (18% vs 19%), mean DD, PTF1.2, TAT, FM and frequency of VTE (1 event in each group). PFO+ and PFO- patients had a high frequency of migraine with aura (64%, 38%, p=0.15) and headache days in the month prior to stroke (mean 11 vs 5, p=0.72). In multivariable analysis of the overall cohort, age (OR 1.14 1.06-1.22 p<0.001) and ROPE score (OR 2.29 1.13-4.65 p=0.02) were significantly associated with abnormal MOCHA while PFO status (p=0.4) and migraine (p=0.23) were not. Conclusion: In ESUS patients ≤ 60 years of age, there was no difference in the MOCHA profile between PFO+ and PFO- patients. The high frequency of migraine with aura and headache days in the month prior to stroke regardless of PFO status needs further study to evaluate its role in young ESUS patients.
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