Objectives We sought to evaluate predictors of stroke on LVAD from data available prior to implantation, and quantify stroke-related morbidity and mortality Background Stroke is a major complication after LVAD. Pre-implant factors that influence stroke are not well understood. Methods We evaluated all patients in the INTERMACS registry who were implanted with continuous-flow LVADs from May 1, 2012 to March 31, 2015. Preoperative risk factors for stroke, and stroke incidence, morbidity, and mortality were analyzed. Results During the study period, 7112 patients underwent CF LVAD placement. Median follow-up was 9.79 months (range 0.02–34.96 months). Of all patients, 752 (10.57%) had at least one stroke, with an incidence rate of 0.123 strokes per patient-year. 447 (51.38%) strokes were ischemic and 423 (48.62%) were hemorrhagic. Patients with hemorrhagic stroke had worse survival than those with ischemic strokes (30-day survival 45.3% vs. 80.7, p <0.001). Of patients with a first stroke, 13% had a second stroke. Pre-implant predictors of stroke were female gender (HR 1.51, 95% CI 1.25–1.82, p <0.001), pre-implant systolic blood pressure (HR 1.01, 95% CI 1.00–1.01, p = 0.002), heparin-induced thrombocytopenia (HIT) (HR 3.68, 95% CI 1.60–8.47, p = 0.002), intra-aortic balloon pump (IABP) (HR 1.21, 95% CI 1.01–1.46, p = 0.043), and primary cardiac diagnosis (ischemic/other/unknown) (p = 0.040). Conclusion Despite improvements in LVAD technology, stroke-related morbidity and mortality is substantial. Further investigation is necessary to decrease the risk of this devastating complication.

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Objectives: To assess whether black race and other cerebrovascular risk factors have a differential effect on first vs recurrent stroke events.Methods: Estimate the differences in the magnitude of the association of demographic (age, back race, sex) or stroke risk factors (hypertension, diabetes, cigarette smoking, atrial fibrillation, left ventricular hypertrophy, or heart disease) for first vs recurrent stroke from a longitudinal cohort study of 29,682 black or white participants aged 45 years and older.Results: Over an average 6.8 years follow-up, 301 of 2,993 participants with a previous stroke at baseline had a recurrent stroke, while 818 of 26,689 participants who were stroke-free at baseline had a first stroke. Among those stroke-free at baseline, there was an age-by-race interaction (p 5 0.0002), with a first stroke risk 2.70 (95% confidence interval: 1.86-3.91) times greater for black than white participants at age 45, but no racial disparity at age 85 (hazard ratio 5 0.91; 95% confidence interval: 0.70-1.18). In contrast, there was no evidence of a higher risk of recurrent stroke at any age for black participants (p . 0.05). The association of traditional stroke risk factors was generally similar for first and recurrent stroke. Conclusion:The association of age and black race differs substantially on first vs recurrent stroke risk, with risk factors playing a similar role. Risk factors for first stroke have been well studied, 1 providing a framework for primary stroke prevention. Multivariable risk functions developed in the Framingham 2 and Cardiovascular Health Study 3 cohorts have identified age, sex, hypertension, diabetes, cigarette smoking, left ventricular hypertrophy, atrial fibrillation, and heart disease as predictors of incident stroke in a stroke-free population. A limitation of those studies was their inability to address the role of race (black race specifically) as a risk factor for stroke; however, there are substantial differences in stroke incidence between black and white persons, with incident stroke in black persons approximately 3 times higher between the ages of 45 and 65 years, but with disparities attenuating by age 85. [4][5][6][7][8] While substantial data document the risk factors for first stroke, there are fewer data establishing the risk factors for recurrent stroke (that is, risk factors for a subsequent stroke in a population with a previous stroke). The

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In this comprehensive contemporary review of acute ischemic stroke management, what is new and different will be highlighted beginning with prehospital stroke systems of care, emergency medical systems, and mobile stroke units, followed by hospital stroke teams, emergency evaluation, telemedicine, and brain and vascular imaging, and finishing with emergency treatments including thrombolysis and mechanical thrombectomy.

Background: There are growing concerns for the side effects of dabigatran etexilate (dabigatran), including higher incidence of dyspepsia and gastrointestinal bleeding. We conducted a multicenter early implementation study to prospectively evaluate the safety, efficacy and adherence to dabigatran for secondary stroke prevention. Methods: Consecutive atrial fibrillation (AF) patients with ischemic stroke (IS) or transient ischemic attack (TIA) received dabigatran for secondary stroke prevention during their hospital stay according to American Heart Association recommendations at five tertiary care stroke centers. The study population was prospectively followed and outcomes were documented. The primary and secondary safety outcomes were major hemorrhage and all other bleeding events respectively defined according to RELY trial methodology. Results: A total of 78 AF patients (mean age 71 ± 9years; 54% men; 81% IS, 19% TIA; median CHADS 2 (Congestive heart failure, Hypertension, diabetes mellitus, age >75 years, prior stroke or TIA); range 2-5) score 4 were treated with dabigatran [(110mg bid (74%); 150mg bid (26%)]. During a mean follow-up period of 7 ± 5 months (range 1-18) we documented no cases of IS, TIA, intracranial hemorrhage, systemic embolism or myocardial infarction in AF patients treated with dabigatran. There were two (2.6%) major bleeding events (lower gastrointestinal bleeding) and two (2.6%) minor bleedings [hematuria (n = 1) and rectal bleeding (n = 1)]. Dabigatran was discontinued in 26% of the study population with high cost being the most common reason for discontinuation (50%). Discussion: Our pilot data indicate that dabigatran appears to be safe for secondary stroke prevention during the first year of implementation of this therapy. However, high cost may limit the long-term treatment of AF patients with dabigatran, leading to early discontinuation.

IntroductionComprehensive stroke centers (CSCs) accept transferred patients from referring hospitals in a given regional area. The transfer process itself has not been studied as a potential factor that may impact outcome. We compared in-hospital mortality and severe disability or death at CSCs between transferred and directly admitted intracerebral hemorrhage (ICH) patients of matched severity.Materials and MethodsWe retrospectively reviewed all primary ICH patients from a prospectively-collected stroke registry and electronic medical records, at two tertiary care sites. Patients meeting inclusion criteria were divided into two groups: patients transferred in for a higher level of care and direct presenters. We used propensity scores (PS) to match 175 transfer patients to 175 direct presenters. These patients were taken from a pool of 530 eligible patients, 291 (54.9%) of whom were transferred in for a higher level of care. Severe disability or death was defined as a modified Rankin Scale (mRS) sore of 4–6. Mortality and morbidity were compared between the 2 groups using Pearson chi-squared test and Student t test. We fit logistic regression models to estimate odds ratios (OR) and 95% confidence intervals (CI) for association between transfer status and in-hospital mortality and severe disability or death in full and PS-matched patients.ResultsThere were no significant differences in the PS-matched transfer and direct presentation groups. Patients transferred to a regional center were not at higher odds of in-hospital mortality (OR: 0.93, 95% CI: 0.50–1.71) and severe disability or death (OR: 0.77, 95% CI: 0.39–1.50), than direct presenters, even after adjustment for PS, age, baseline NIHSS score, and glucose on admission.ConclusionOur observation suggests that transfer patients of similar disease burden are not at higher risk of in-hospital mortality than direct presenters.

Compared to LEV daily, BID dosing achieved significantly higher levels and a better recovery to predialysis levels. Although limited by small numbers, a similar relationship between postdialysis levels was not detected.