Circadian Variation in the Timing of Stroke Onset

Elliott, W.J.

doi:10.1161/01.str.29.5.992

Cited by 583 publications

(465 citation statements)

References 34 publications

(17 reference statements)

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“…However, with the advancement and popularity of hospital-based, 24-hour, ambulatory BP monitoring devices as well as homebased self-monitoring devices, the importance of the use of ambulatory BP, especially those measurements taken at home have gained attention (1)(2)(3)(4)(5)(6)(7)(8). HBP obtained early in the morning at home by self-measurement is specifically highlighted as having a substantial impact on cardiovascular risk.…”

Section: State Of Bp Controlmentioning

confidence: 99%

“…HBP obtained early in the morning at home by self-measurement is specifically highlighted as having a substantial impact on cardiovascular risk. Indeed, many reports indicate a close association between HBP early in the morning and occurrence of cardiovascular events (6)(7)(8)10). In addition, cardiovascular risk is greater in patients with masked hypertension and/or those with poorcontrolled than in those with a well-controlled BP (18).…”

Section: State Of Bp Controlmentioning

confidence: 99%

“…This type of hypertension has a strong association with a morning rise in BP (sustained type morning hypertension) (21). In addition, cerebral stroke, coronary ischemia and sudden death are more likely to occur in the morning (6)(7)(8). GFR normally declines with age, at an estimated rate of 1 ml/min/year (22).…”

Section: Morning Hypertension and Organ Damagementioning

confidence: 99%

“…Indeed, HBP obtained early in the morning has been shown to have a substantial impact on the awareness of cardiovascular risks (1)(2)(3)(4)(5). In addition, many clinical reports indicate a close association between BP in the early morning and the occurrence of cardiovascular events such as myocardial infarction, cerebral apoplexy or sudden death (6)(7)(8). Recent investigations on the adequacy of BP control using HBP and office/clinic BP (OBP) performed in Japan clearly demonstrate that current antihypertensive therapy is inadequate to achieve the target goals (9,10).…”

Section: Introductionmentioning

confidence: 99%

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Morning Blood Pressure Predicts Hypertensive Organ Damage in Patients with Renal Diseases: Effect of Intensive Antihypertensive Therapy in Patients with Diabetic Nephropathy

et al. 2005

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Blood pressure (BP) measured at home early in the morning (HBP) has been recognized as a useful predictor for organ damage and has been viewed as an important therapeutic target in patients with hypertension. The present study was aimed to determine whether this notion holds true in patients with progressive renal disease.The study enrolled patients with mild to moderate renal impairment. They were all directed to record selfmeasured HBP to evaluate the adequacy of BP control. In addition to the conventional antihypertensive therapy, intensive treatment to more efficiently reduce elevated morning HBP was applied, especially in patients with diabetic nephropathy. The results were as follows:1) The status of BP control assessed using HBP and office/clinic BP (OBP) shows predominance of morning hypertension. The prevalence of patients with well-controlled systolic HBP was 38%, those with poorly-controlled HBP 30%, masked hypertension 20% and white coat hypertension 12%. 2) Early morning systolic HBP in diabetics was significantly higher than that in non-diabetics. However, when evaluated on systolic OBP, both groups were comparable. 3) Logistic regression analysis showed that the predictive variables to explain morning hypertension (more than 130 mmHg and increased systolic HBP) were age, amount of daily urinary protein excretion and left ventricular mass index (LVMI). 4) Following conventional therapy, intensive antihypertensive therapy consisting of calcium channel blockers (CCB) and/or diuretics given in the morning, and angiotensin receptor blockers (ARB) given in the evening, together with 1-blockers given at bedtime, efficaciously reduced elevated HBP in the morning. This result was associated with significant reduction in daily urinary protein excretion and in serum plasminogen-activator inhibitor (PAI-1) concentration. The present study indicates that, regardless of ongoing conventional antihypertensive therapy, the majority of patients with renal disease had morning hypertension, suggesting that these patients are at a higher risk for cardiovascular disease. For the purpose of improving morning hypertension, intensive treatments with combined CCB, ARB and 1-blockers could have substantial benefit on the morbidity and prognosis in patients with diabetic nephropathy. (Internal Medicine 44: 1239-1246, 2005)

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Section: State Of Bp Controlmentioning

confidence: 99%

Section: State Of Bp Controlmentioning

confidence: 99%

Section: Morning Hypertension and Organ Damagementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Morning Blood Pressure Predicts Hypertensive Organ Damage in Patients with Renal Diseases: Effect of Intensive Antihypertensive Therapy in Patients with Diabetic Nephropathy

et al. 2005

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“…ischemic strokes likely follow the same diurnal pattern. 2 Several studies compared the clinical and radiological features between patients with wake-up stroke and patients with strokes that occurred within the therapeutic windows of alteplase. the two groups of patients were essentially identical in these studies.…”

mentioning

confidence: 99%

Wake-Up to Wake-Up Stroke!

Chan¹

2014

Can. J. Neurol. Sci.

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here is a typical story. a patient arrives at the emergency room. he was well when he went to bed and then he woke up with symptoms suggestive of stroke several hours later. even without further scrutiny, the clinician determines that intravenous thrombolytic therapy is contraindicated. end of story. Such is the plight of patients with wake-up stroke. Can we do more? Can we do better? Wake-up stroke is not rare. about 5 to 30% of patients who presents to the emergency room for presumed acute stroke have wake-up stroke. Because of uncertainty regarding the time of symptoms onset, these patients are routinely excluded from intravenous thrombolytic therapy. in a population-based study, 14% of ischemic strokes presented to an emergency department were wake-up stroke. among these patients, more than one third would have been eligible for thrombolysis if arrival time were not a factor. 1 if the same pattern holds true for Canada, that would translate to thousands of additional patients eligible for thrombolytic therapy. When one deals with wake-up stroke, one needs to re-visit the concept of "last seen well". the time "last seen well" is a good and objective way to time the onset of stroke symptoms. When symptom onset is unwitnessed, such as patients who are aphasic and alone at the time, "last seen well" may become an obstacle to thrombolysis. in the case of wake-up stroke, "last seen well" often puts the patient outside the conventional therapeutic time window. although well-intentioned, we may not be right to assume that the time of symptom onset is close to the time of "last seen well". let us assume that the onset of stroke symptoms occurs in a random fashion during sleep hours. for a patient who was well when he went to bed eight hours earlier, the chances of stroke occurring during the final four hours will be the same as the chance of it starting during the first four hours, or 50%. that means that 50% of these patients are potential candidates for intravenous thrombolytic therapy. of course, the assumption that the chance of stroke occurring equally at every time point during sleep is questionable at best. other vascular events, particularly acute myocardial infarction in which the onset is marked by the development of chest pain, tend to occur in the final hour before arousal. ischemic strokes likely follow the same diurnal pattern. 2 Several studies compared the clinical and radiological features between patients with wake-up stroke and patients with strokes that occurred within the therapeutic windows of alteplase. the two groups of patients were essentially identical in these studies. 3,4 the evidence suggests that wake-up strokes more likely occur in the early morning hours just before arousal. Clinicians involved in thrombolytic therapy for acute stroke know that some patients presenting within 4.5 hours of symptoms onset will show well defined infarct on cranial computed tomogram (Ct) scan. We also have examples of patients who have normal cranial Ct scan even though their symptoms occurred more than 4....

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Ambient Air Pollution and the Risk of Acute Ischemic Stroke

Wellenius

Burger²,

Coull³

et al. 2012

Arch Intern Med

303

245

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Background The link between daily changes in ambient fine particulate matter air pollution (PM2.5) and cardiovascular morbidity and mortality is well established. Whether PM2.5 at levels below current US National Ambient Air Quality Standards also increases the risk of ischemic stroke remains uncertain. Methods We reviewed the medical records of 1705 Boston-area patients hospitalized with neurologist-confirmed ischemic stroke and abstracted data on the time of symptom onset and clinical characteristics. PM2.5 concentrations were measured at a central monitoring station. We used the time-stratified case-crossover study design to assess the association between the risk of ischemic stroke onset and PM2.5 levels in the hours and days preceding each event. We examined whether the association with PM2.5 differed by ischemic stroke etiology and patient characteristics. Results The estimated odds ratio of ischemic stroke onset was 1.34 (95% confidence interval (CI): 1.13, 1.58; p<0.001) following a 24-hour period classified as “moderate” (PM2.5 15–40 μg/m3) by the US Environmental Protection Agency’s (EPA) Air Quality Index compared to a 24-hour period classified as “good” (≤15 μg/m3). Considering PM2.5 as a continuous variable, the estimated odds ratio of ischemic stroke onset was 1.11 (95% CI: 1.03, 1.20; p=0.006) per interquartile range increase in PM2.5 (6.4 μg/m3). The increase in risk was greatest within 12–14 hours of exposure to PM2.5 and was most strongly associated with markers of traffic-related pollution. Conclusion These results suggest that exposure to PM2.5 levels considered generally safe by the US EPA increase the risk of ischemic stroke onset within hours of exposure.

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Circadian Variation in the Timing of Stroke Onset

Cited by 583 publications

References 34 publications

Morning Blood Pressure Predicts Hypertensive Organ Damage in Patients with Renal Diseases: Effect of Intensive Antihypertensive Therapy in Patients with Diabetic Nephropathy

Morning Blood Pressure Predicts Hypertensive Organ Damage in Patients with Renal Diseases: Effect of Intensive Antihypertensive Therapy in Patients with Diabetic Nephropathy

Wake-Up to Wake-Up Stroke!

Ambient Air Pollution and the Risk of Acute Ischemic Stroke

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