Guidelines for the Early Management of Patients With Ischemic Stroke

Adams, Harold P.; Adams, Robert J.; Brott, Thomas G.; Zoppo, Gregory J. del; Furlan, Anthony J.; Goldstein, Larry B.; Grubb, Robert L.; Higashida, Randall T.; Kidwell, Chelsea S.; Kwiatkowski, Thomas; Marler, John R.; Hádemenos, George J.

doi:10.1161/01.str.0000064841.47697.22

Cited by 976 publications

(350 citation statements)

References 365 publications

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“…and treatment. 26 We assumed that 10% of patients would receive tissue plasminogen activator. Patients having a major thrombotic event were expected to stay in hospital an average of 15.3 days.…”

Section: Model Inputsmentioning

confidence: 99%

Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy

Regier

Sunderji²,

Lynd³

et al. 2006

Canadian Medical Association Journal

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ResearchL ong-term oral anticoagulation therapy with vitamin K antagonists is prescribed as prophylaxis against strokes and other embolic events in patients with atrial fibrillation or a mechanical heart valve. 1,2 Warfarin therapy, however, is complicated by the variability of its biologic effect, its narrow therapeutic index, and the associated thrombotic or hemorrhagic events in the event of over-or underanticoagulation. 2 It has been shown that improved anticoagulant control can be achieved through frequent monitoring of the international normalized ratio (INR), resulting in improved health outcomes. 3 Monitoring the INR and managing warfarin dosing by a primary care physician is the current clinical standard of practice in Canada. 4 Physician management requires patients to visit a laboratory regularly for INR testing. The laboratory reports the INR to the physician, who subsequently contacts the patient with any required change in dosage. An alternative strategy is patient self-management. Self-management entails the measurement of the INR by the patient using a pointof-care device and, when necessary, self-adjustment of the warfarin dose using a nomogram. 4 Several published trials have compared self-management with physician management or management in an anticoagulation clinic. 4-13 It has been found that patients who self-manage check their INR more frequently and are able to maintain a greater proportion of INRs within the therapeutic range compared with those whose therapy is monitored by a physician or in an anticoagulation clinic. [11][12][13] The results of a recent meta-analysis showed a significant reduction in thromboembolic events (odds ratio [OR] 0.45), major hemorrhagic events (OR 0.65) and all-cause mortality (OR 0.61) for those using a self-management or self-test strategy. 14 The results also showed that self-management compared with self-testing alone reduces the occurrence of thromboembolic events (OR 0.27) and death (OR 0.37). 14 These results, together with the greater initial costs of educating patients to self-manage and of the pointof-care device itself, provide the impetus for a formal costeffectiveness analysis.The objective of this study was to evaluate the incremental cost and health benefits of self-managed versus physicianmanaged chronic oral anticoagulation therapy from the perspective of the Canadian health care payer. A Bayesian approach was adopted to facilitate the incorporation of prior knowledge of transition probabilities and for probabilistic sensitivity analysis. Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy Background: Patient self-management of long-term oral anticoagulation therapy is an effective strategy in a number of clinical situations, but it is currently not a funded option in the Canadian health care system. We sought to compare the incremental cost and health benefits of self-management with those of physician management from the perspective of the Canadian health care payer over a 5-year period.

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Section: Model Inputsmentioning

confidence: 99%

Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy

Regier

Sunderji²,

Lynd³

et al. 2006

Canadian Medical Association Journal

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“…Combination therapy may circumvent some limitations of singleagent therapy by boosting efficacy, by limiting side effects, or by extending the time window for treatment (Cheng et al, 2004;Danton, 2004;Adams et al, 2003;Rogalewski et al, 2006;Fisher, 2003). Nevertheless, combining therapies increases the complexity of experimental design (Saver and Kalafut, 2001); hence, a framework is required for drug selection and prioritising experiments.…”

Section: Introductionmentioning

confidence: 99%

Preclinical Drug Evaluation for Combination Therapy in Acute Stroke Using Systematic Review, Meta-Analysis, and Subsequent Experimental Testing

O’Collins

Macleod

Cox

et al. 2010

J Cereb Blood Flow Metab

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There is some evidence that in animal models of acute ischaemic stroke, combinations of neuroprotective agents might be more efficacious than the same agents administered alone. Hence, we developed pragmatic, empirical criteria based on therapeutic target, cost, availability, efficacy, administration, and safety to select drugs for testing in combination in animal models of acute stroke. Magnesium sulphate, melatonin, and minocycline were chosen from a library of neuroprotective agents, and were tested in a more 'realistic' model favoured by the STAIR (Stroke Therapy Academic Industry Roundtable). Outcome was assessed with infarct volume, neurologic score, and two newly developed scales measuring general health and physiologic homeostasis. Owing to the failure to achieve neuroprotection in aged, hypertensive animals with drug delivery at 3 hours, the bar was lowered in successive experiments to determine whether neuroprotection could be achieved under conditions more conducive to recovery. Testing in younger animals showed more favourable homeostasis and general health scores than did testing in older animals, but infarct volume and neurologic scores did not differ with age, and treatment efficacy was again not shown. Testing with shorter occlusions resulted in smaller infarct volumes; nevertheless, treatment efficacy was still not observed. It was concluded that this combination, in these stroke models, was not effective.

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“…Despite a Class I recommendation from the American Heart Association/American Stroke Association joint guidelines, CBT with intra-arterial lysis is not an FDA-approved therapy [11,12]. The mechanical embolus removal in cerebral ischemia (MERCI) trial led to the FDA approval of the Merci Retrieval System (Concentric Medical, Mountain View, CA) for mechanical thrombectomy of large cerebral vessels [13].…”

Section: Introductionmentioning

confidence: 99%

Acute stroke intervention by interventional cardiologists

DeVries

White

Collins

et al. 2009

Cathet Cardio Intervent

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Objectives: To report the technical success and clinical outcomes of catheter-based therapy (CBT) for acute ischemic stroke in patients ineligible for intravenous thrombolysis. Background: Acute ischemic stroke is common but undertreated. CBT for acute ischemic stroke is a therapeutic option in selected patients who are not candidates for intravenous thrombolysis. Methods: Consecutive stroke patients who were ineligible for intravenous thrombolysis and underwent CBT were identified by retrospective chart review. Demographic information, National Institutes of Health Stroke Scale (NIHSS), procedural characteristics, and clinical outcomes during hospitalization and at 90 days follow up were collected. Experienced interventional cardiologists with the consultative support of stroke neurologists were on call for acute strokes. Results: A total of 33 acute ischemic stroke patients underwent emergency cerebral angiography, with 26 patients undergoing CBT. Successful ' 'culprit' ' artery recanalization was achieved in 23 (88%) of the 26 patients. In-hospital adverse events occurred in 4 (15%) patients, with intracerebral hemorrhage (ICH) (12%) representing the most common adverse event. The baseline NIHSS for patients who underwent intervention was 16.5 6 9.9 (median 16) and improved significantly to 9.9 6 8.7 (median 9) (P < 0.001) at hospital discharge. A modified Rankin score of two or less (indicating mild disability) was achieved in half (n 5 13) of the CBT treated patients. All cause mortality at 90 days was 8% (2/26). Conclusions: In selected patients, CBT provided by qualified interventional cardiologists supported by stroke neurologists, offers a safe and effective option for patients with acute stroke who are not eligible for intravenous thrombolysis. '

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Guidelines for the Early Management of Patients With Ischemic Stroke

Cited by 976 publications

References 365 publications

Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy

Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy

Preclinical Drug Evaluation for Combination Therapy in Acute Stroke Using Systematic Review, Meta-Analysis, and Subsequent Experimental Testing

Acute stroke intervention by interventional cardiologists

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