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Intra-arterial Thrombolysis to Target Occlusions in Distal Arteries and the Microcirculation
Acute ischemic stroke remains a leading cause of disability in the United States and worldwide despite substantially improved treatments for the most severe strokes over the last 5 years. Treatment of severe ischemic strokes, specifically those due to occlusion of large intracranial arteries, has been transformed by endovascular removal of the thrombus using stent retrievers or aspiration catheters. Treatment with mechanical thrombectomy is associated with a 20% to 27% absolute increase in the rate of functional independence compared with patients not treated with thrombectomy. Despite highly efficacious treatment, approxi...
Source: JAMA - March 1, 2022 Category: General Medicine Source Type: research

Deprescribing Antihypertensive Medications for Patients Aged 80 or Older
The treatment of hypertension in older adults is a major public health concern. Among the nearly 13 million persons in the United States aged 80 years or older, approximately 80% have high blood pressure (BP). Hypertension is the most potent modifiable risk factor for cardiovascular disease in older adults and has been strongly associated with stroke, myocardial infarction, heart failure, peripheral artery disease, kidney failure, and dementia. Thus, defining optimal strategies for managing elevated BP in older individuals is a high priority.
Source: JAMA - May 26, 2020 Category: General Medicine Source Type: research

Trends in Cardiometabolic Mortality in the United States, 1999-2017
This study evaluates the Centers for Disease Control and Prevention ’s Wide-Ranging Online Data for Epidemiologic Research to compare trends in heart disease, stroke, diabetes, and hypertension mortality rates by race and sex from 1999 to 2017.
Source: JAMA - August 27, 2019 Category: General Medicine Source Type: research

Effect of Intensive vs Standard Treatment of Hyperglycemia on Functional Outcome in Stroke
This randomized clinical trial compares the effects of continuous intravenous vs subcutaneous sliding scale insulin for treatment of hyperglycemia during acute ischemic stroke on functional outcome in adult patients in the United States.
Source: JAMA - July 23, 2019 Category: General Medicine Source Type: research

Endovascular Therapy for Acute Ischemic Stroke Treated in Clinical Practice
Five randomized clinical trials, published in 2015, demonstrated the benefit of endovascular therapy in appropriately selected patients with acute ischemic stroke due to large vessel occlusion, and a subsequent individual patient data meta-analysis of these trials indicated that the benefit associated with endovascular therapy was greater the earlier that endovascular reperfusion was achieved. Since publication of these important trials, the use of endovascular therapy in the United States has significantly increased, and efforts are ongoing to maximize the potential benefits of endovascular therapy for the greatest number...
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Stroke After Transcatheter Aortic Valve Replacement
This study reported about a 7% risk of stroke, which was not surprising given the patient population and the likelihood of particulate embolization when expanding a new valve within the annulus of the stenosed and calcified native valve. Nevertheless, even with this stroke risk, there was a clear mortality benefit and quality of life was improved as well. After the PARTNER 1A high-risk cohort demonstrated similar or improved outcomes relative to open surgical aortic valve replacement (SAVR) in patients at high (but not inoperable) surgical risk, the US Food and Drug Administration (FDA) approved TAVR in 2011 and the proced...
Source: JAMA - June 18, 2019 Category: General Medicine Source Type: research

Ankle Brachial Index Screening and Improving Peripheral Artery Disease Detection and Outcomes
Lower extremity peripheral artery disease (PAD) affects an estimated 8.5 million adults in the United States and 202 million adults worldwide. PAD consists of atherosclerosis of the lower extremity arteries, resulting in inadequate oxygen supply to lower extremity muscles during walking activity. People with PAD typically walk only 1 to 3 blocks before having to stop and rest because of ischemic leg symptoms. PAD is also a marker for the presence of atherosclerotic disease in the coronary and cerebrovascular arteries. Consistent with this phenomenon, people with PAD have higher rates of acute coronary events, ischemic stro...
Source: JAMA - July 10, 2018 Category: General Medicine Source Type: research

Is Patent Foramen Ovale a Risk Factor for Perioperative Stroke?
Perioperative stroke is one of the most feared complications of any surgery or invasive medical procedure. Perioperative stroke occurs in less than 1% of patients undergoing general surgery, but the risk is several fold higher with cardiac surgery, carotid revascularization, other cerebrovascular procedures, and thoracic aortic repair. Given the volume of these interventions, perioperative and periprocedural stroke likely account for at least 5% of the approximately 800  000 strokes that occur each year in the United States, yet stroke in this setting remains understudied.
Source: JAMA - February 6, 2018 Category: General Medicine Source Type: research

Left Atrial Appendage Occlusion for Prevention of Thromboembolic Events
More than 600  000 patients in the United States undergo cardiac operations each year, including coronary artery bypass graft operations, valve repair or replacement procedures, or other more complex operations. Patients with atrial fibrillation (AF) who undergo these procedures are at risk for postoperative th romboembolic complications, with the left atrial appendage being a common site of thrombus formation. Occlusion of the left atrial appendage may reduce the risk of thromboembolic stroke and can be performed intraoperatively at the time of cardiac operations. The most common surgical approaches to ac hieve left atr...
Source: JAMA - January 23, 2018 Category: General Medicine Source Type: research

Trends in Carotid Revascularization Procedures —Reply
In Reply Dr Hussain and colleagues point out interesting comparisons in carotid revascularization trends in Ontario, Canada, and in the US Medicare population, including similar 30-day stroke or death outcomes after carotid endarterectomy and stenting. We agree that differing reimbursement policies in the United States and Canada may account for differing patterns of carotid stenting after 2006. A noted difference is the lower receipt of procedures among symptomatic patients in the United States vs Ontario. However, such variation is expected because the approach to asymptomatic treatment has been shown to vary among Western countries.
Source: JAMA - January 16, 2018 Category: General Medicine Source Type: research