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Comment Learning from TARDIS: time for more focused trials in stroke prevention
Antithrombotic therapy immediately following stroke is important to minimise the risk of recurrence, but the optimum choice and number of drugs to use are unclear, and efficacy in preventing thrombosis needs to be weighed against bleeding risk. In The Lancet, the TARDIS investigators report findings from a randomised trial1 that tested intensive antiplatelet therapy with three agents (aspirin, clopidogrel, and dipyridamole) against therapy based on current UK guidelines2 (either clopidogrel, or aspirin plus dipyridamole) for 30 days in patients with transient ischaemic attack (TIA) or ischaemic stroke.
Source: LANCET - December 20, 2017 Category: General Medicine Authors: Pierre Amarenco Tags: Comment Source Type: research

Comment Secondary prevention shifts into second gear
Aspirin has been a mainstay in the secondary prevention of cardiovascular events since the 1990s.1 In the mid-1990s, the antiplatelet clopidogrel was tested against aspirin in patients with atherosclerotic vascular disease and was found to reduce vascular death, ischaemic stroke, and myocardial infarction by 8 ·7%.2 The combination of clopidogrel and aspirin for secondary prevention to reduce cardiovascular events was tested in patients with symptomatic atherothrombosis; however, no benefit was observed.
Source: LANCET - November 10, 2017 Category: General Medicine Authors: E Magnus Ohman Tags: Comment Source Type: research

Comment Antithrombotic therapy in peripheral artery disease
Peripheral artery disease is a systemic atherothrombotic disease in which plaque builds up in the arteries that carry blood to the limbs. If severe enough, impaired blood flow can cause critical limb ischaemia, which presents as resting pain, ulceration, or gangrene, and might require a limb amputation in the most extreme cases.1 People with peripheral artery disease often have plaque in other arterial beds, and thus are at increased risk for myocardial infarction, ischaemic stroke, and cardiovascular death.
Source: LANCET - November 10, 2017 Category: General Medicine Authors: Jeffrey S Berger Tags: Comment Source Type: research

Comment Circadian rhythm and ischaemia –reperfusion injury
Every day, thousands of patients are exposed to ischaemia-reperfusion injury, either in uncontrolled circumstances (eg, acute myocardial infarction or ischaemic stroke) or under controlled conditions (eg, heart, kidney, or liver surgery, or transplantation). Whatever the clinical setting is, the extent of final tissue damage (ie, infarct size) is mainly determined by the duration of the ischaemic phase and the amount of jeopardised tissue.1 Experimental and proof-of-concept clinical trials have shown that infarct size results from the addition of an ischaemia-induced injury plus a reperfusion-induced injury, and that timel...
Source: LANCET - October 26, 2017 Category: General Medicine Authors: Thomas Bochaton, Michel Ovize Tags: Comment Source Type: research

Comment Cerebral amyloid angiopathy and implications for atrial fibrillation management
Atrial fibrillation, the most common arrhythmia in adults, will increase in prevalence as the population ages.1 The risk of embolic stroke in atrial fibrillation also increases with age. Treatments for the prevention of embolic stroke include warfarin, direct oral anticoagulant agents, and non-anticoagulation strategies such as left atrial appendage occlusion.1 Current scores to estimate the risk of ischaemic stroke (CHA2DS2-VaSc score) or haemorrhage (HAS-BLED score) help guide intervention, but do not account for cerebral amyloid angiopathy (CAA), a prevalent, but overlooked condition.
Source: LANCET - June 29, 2017 Category: General Medicine Authors: Christopher V DeSimone, Jonathan Graff-Radford, Majd A El-Harasis, Alejandro A Rabinstein, Samuel J Asirvatham, David R Holmes Tags: Comment Source Type: research

Comment Preventing major gastrointestinal bleeding in elderly patients
Antiplatelet therapy is the most frequently recommended treatment to prevent recurrent ischaemic events in patients who have had an ischaemic stroke, an acute coronary syndrome, or symptomatic peripheral arterial disease. The most frequently used drugs are aspirin or clopidogrel. Most guidelines recommend lifelong intake of antiplatelet therapy. However, randomised trials that have investigated the benefit of antiplatelet therapy had an observation period of between 2 years and 4 years.1 Therefore, we lack data on the long-term benefit and risk of antiplatelet therapy across long time periods, particularly in elderly patients.
Source: LANCET - June 13, 2017 Category: General Medicine Authors: Hans-Christoph Diener Tags: Comment Source Type: research

Seminar Stroke
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterect...
Source: LANCET - September 12, 2016 Category: Journals (General) Authors: Graeme J Hankey Tags: Seminar Source Type: research

Editorial Atrial fibrillation and stroke: unrecognised and undertreated
When did you or your primary care physician last palpate your wrist to check for a regular heart rate? This simple action, followed by an electrocardiogram if the heart rate is irregular, might be crucial in preventing death and disability from ischaemic stroke, heart failure, or myocardial infarction. In this week's issue, we publish a clinical Series of three papers on atrial fibrillation ahead of the annual European Society of Cardiology (ESC) meeting held in Rome, Italy, Aug 27 –31. Atrial fibrillation is estimated to affect 33 million people worldwide.
Source: LANCET - August 19, 2016 Category: Journals (General) Authors: The Lancet Tags: Editorial Source Type: research

Correspondence Telemedicine expedites access to optimal acute stroke care
In their meta-analysis of patient-level data from five randomised trials, Mayank Goyal and colleagues1 (April 23, p 1723) reported that endovascular thrombectomy was effective for patients with acute ischaemic stroke caused by large-vessel occlusions (number needed to treat, 2 ·6). Individuals that will benefit include older patients (age>80 years), those ineligible to receive tissue plasminogen activator (tPA), and those with internal carotid artery or M1 occlusion. We agree with the authors that the findings “have global implications on structuring systems of care”1 to ensure no eligible patient is missed under these expanded criteria.
Source: LANCET - August 19, 2016 Category: Journals (General) Authors: Kathleen L Bagot, Dominique A Cadilhac, Peter J Hand, Michelle Vu, Christopher F Bladin Tags: Correspondence Source Type: research

Series Stroke prevention in atrial fibrillation
Atrial fibrillation is found in a third of all ischaemic strokes, even more after post-stroke atrial fibrillation monitoring. Data from stroke registries show that both unknown and untreated or under treated atrial fibrillation is responsible for most of these strokes, which are often fatal or debilitating. Most could be prevented if efforts were directed towards detection of atrial fibrillation before stroke occurs, through screening or case finding, and treatment of all patients with atrial fibrillation at increased risk of stroke with well-controlled vitamin K antagonists or non-vitamin K antagonist anticoagulants.
Source: LANCET - August 19, 2016 Category: Journals (General) Authors: Ben Freedman, Tatjana S Potpara, Gregory Y H Lip Tags: Series Source Type: research

Comment Age of PISCES: stem-cell clinical trials in stroke
Laboratory studies and limited clinical trials over the past two decades have shown feasibility and safety, and have revealed potential mechanisms of action of stem-cell therapy in ischaemic stroke. Despite consistent efficacy in animal studies, functional benefits after transplantation of stem cells remain to be shown unequivocally in stroke patients.1 Translation of stem-cell therapy from the laboratory to the clinic has been approached with ample caution, in part due to the largely negative outcomes for several stroke therapeutics in human beings compared with those in animals.
Source: LANCET - August 2, 2016 Category: Journals (General) Authors: Cesar V Borlongan Tags: Comment Source Type: research

Articles Human neural stem cells in patients with chronic ischaemic stroke (PISCES): a phase 1, first-in-man study
Single intracerebral doses of CTX-DP up to 20 million cells induced no adverse events and were associated with improved neurological function. Our observations support further investigation of CTX-DP in stroke patients.
Source: LANCET - August 2, 2016 Category: Journals (General) Authors: Dheeraj Kalladka, John Sinden, Kenneth Pollock, Caroline Haig, John McLean, Wilma Smith, Alex McConnachie, Celestine Santosh, Philip M Bath, Laurence Dunn, Keith W Muir Tags: Articles Source Type: research

Comment Stroke is largely preventable across the globe: where to next?
Despite the ever-increasing disease burden of stroke in the world,1 accurate data on stroke risk factors are still scarce. In the first phase of the INTERSTROKE study,2 more than 90% of strokes (ischaemic stroke and intracerebral haemorrhage) were attributed to just ten risk factors. However, the study was restricted to developing countries only, and was not powered to explore age, sex, ethnicity, and regional variations in the effect of risk factors or pathological type of stroke, such as ischaemic stroke and intracerebral haemorrhage.
Source: LANCET - July 14, 2016 Category: Journals (General) Authors: Valery L Feigin, Rita Krishnamurthi Tags: Comment Source Type: research

Comment The benefits of aspirin in early secondary stroke prevention
Aspirin is considered an affordable and widely available, if only modestly effective, thromboprophylactic for secondary stroke prevention. The two large randomised controlled trials of aspirin in acute ischaemic stroke reported that aspirin reduced the odds of early recurrent stroke at 2 –4 weeks by about 12% (odds ratio [OR] 0·88, 95% CI 0·79–0·97) and the odds of death or dependency at the end of follow-up by about 5% (OR 0·95, 0·91–0·99).1 The ten trials of aspirin for long-term secondary prevention in patients with previous transient ischaemic attack (TIA) or ischaem ic stroke reported that aspirin reduced ...
Source: LANCET - May 17, 2016 Category: Journals (General) Authors: Graeme J Hankey Tags: Comment Source Type: research

Articles Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials
Our findings confirm that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key intervention. The considerable early benefit from aspirin warrants public education about self-administration after possible TIA. The previously unrecognised effect of aspirin on severity of early recurrent stroke, the diminishing benefit with longer-term use, and the contrasting time course of effects of dipyridamole have implications for understanding mechanisms of action.
Source: LANCET - May 17, 2016 Category: Journals (General) Authors: Peter M Rothwell, Ale Algra, Zhengming Chen, Hans-Christoph Diener, Bo Norrving, Ziyah Mehta Tags: Articles Source Type: research

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