Nishant K Mishra

Publications (21) View all

• Article: Postthrombolysis outcomes in acute ischemic stroke patients of Asian race-ethnicity.

  Nishant K Mishra, Bernard P L Chan, Hock-Luen Teoh, Chang-Hui Meng, Kennedy R Lees, Christopher Chen, Vijay K Sharma
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  ABSTRACT: BACKGROUND: Race-ethnic differences may influence postthrombolysis outcomes in acute ischemic stroke patients. Guidelines for thrombolytic therapy to treat Asian stroke patients are based mostly on extrapolated western data. AIMS: We undertook to examine outcomes among Asians by comparing a propensity-matched cohort of thrombolyzed patients from a tertiary center in Singapore with nonthrombolyzed Asian comparators collated from Virtual International Stroke Trials Archives (control). METHODS: We identified propensity scores-matched patients between thrombolyzed and control Asian patients lodged in the Virtual International Stroke Trials Archives by employing propensity scores method. We compared matched patients for their distributions of three-month functional (modified Rankin scores) and neurological outcomes (National Institute of Health Stroke Scale) by employing Cochran-Mantel-Haenszel test and proportional odds logistic regression analysis. We report odds ratio and 95% confidence interval for improved outcomes on day 90. RESULTS: Virtual International Stroke Trials Archives and National University Hospital, Singapore, contributed 517 and 133 patients of Asian race-ethnicity (n = 650), respectively. After propensity matching, sample size reduced to 237 patients; 104 were from Virtual International Stroke Trials Archives. Age (59·7 vs. 61·5 years, P = 0·2) and mean baseline National Institute of Health Stroke Scale scores were similar (14) between thrombolyzed and control. The odds ratio for shift toward improved modified Rankin scores and National Institute of Health Stroke Scale distributions after tissue plasminogen activator therapy were 2·8 (95% confidence interval 1·8-4·5, P < 0·0001, n = 233; Cochran-Mantel-Haenszel P < 0·0001) and 2·8 (95% confidence interval 1·7-4·7, P = 0·0008, n = 201; Cochran-Mantel-Haenszel P = 0·0001). CONCLUSIONS: Our data indicate that Asian patients derive benefit from thrombolytic therapy.
  International Journal of Stroke 03/2013; · 2.38 Impact Factor
• Article: Thrombolysis in very elderly people: controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive.

  Mishra NK, Ahmed N, Andersen G, Egido JA, Lindsberg PJ, Ringleb PA, Wahlgren NG, Lees KR, VISTA collaborators, SITS collaborators
  BMJ 01/2011; BMJ:C6046. · 14.09 Impact Factor
• Article: Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus

  N.K. Mishra, N. Ahmed, A. Davalos, H.K. Iversen, T. Melo, L. Soinne, N. Wahlgren, K.R. Lees For the SITS, VISTA collaborators
  Neurology 01/2011; · 8.31 Impact Factor
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  Available from: Nishant K Mishra

  Article: Comparison of outcomes following thrombolytic therapy among patients with prior stroke and diabetes in the Virtual International Stroke Trials Archive (VISTA).

  Nishant Kumar Mishra, Stephen M Davis, Markku Kaste, Kennedy R Lees
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  ABSTRACT: The use of alteplase in patients who have had a prior stroke and concomitant diabetes is not approved in Europe. To examine the influence of diabetes and prior stroke on outcomes, we compared data on thrombolysed patients with nonthrombolysed comparators. We selected patients with ischemic stroke on whom we had data on age, pretreatment baseline National Institutes of Health Stroke Scale (b-NIHSS), and 90-day outcome measures (functional modified Rankin score [mRS]) and neurological measures [NIHSS]) in the Virtual International Stroke Trials Archive. We compared outcomes between thrombolysed patients and nonthrombolysed comparators in those with and without diabetes, those who have had a prior stroke, or both and report findings using the Cochran-Mantel-Haenszel (CMH) test and proportional odds logistic regression analyses. We report an age-adjusted and b-NIHSS-adjusted CMH P value and odds ratio (OR). Rankin data were available for 5,817 patients: 1,585 thrombolysed patients and 4,232 nonthrombolysed comparators. A total 1,334 (24.1%) patients had diabetes, 1,898 (33.7%) patients have had a prior stroke, and 491 (8%) patients had both. Diabetes and nondiabetes had equal b-NIHSS (median 13; P = 0.3), but patients who have had a prior stroke had higher b-NIHSS than patients who have not had a prior stroke (median 13 vs. 12; P < 0.0001). Functional outcomes were better for thrombolysed patients versus nonthrombolysed comparators among both nondiabetic (P < 0.0001; OR 1.4 [95% CI 1.3-1.6]) and diabetic (P = 0.1; 1.3 [1.05-1.6 ]) subjects. Similarly, outcomes were better for thrombolysed patients versus nonthrombolysed comparators among who have not had a prior stroke (P < 0.0001; 1.4 [1.2-1.6 ]) and those who have (P = 0.02; 1.3 [1.04-1.6 ]). There was no interaction of diabetes and prior stroke with treatment (P = 0.8). Neurological outcomes were consistent with the mRS. Outcomes from thrombolysis are better among patients with diabetes and/or those who have had a prior stroke than in control subjects. Withholding thrombolytic treatment from otherwise-eligible patients may not be justified.
  Diabetes care 12/2010; 33(12):2531-7. · 8.09 Impact Factor
• Article: Influence of age on outcome from thrombolysis in acute stroke: a controlled comparison in patients from the Virtual International Stroke Trials Archive (VISTA).

  Nishant Kumar Mishra, Hans-Christoph Diener, Patrick D Lyden, Erich Bluhmki, Kennedy R Lees
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  ABSTRACT: Thrombolysis for acute ischemic stroke in patients aged > 80 years is not approved in some countries due to limited trial data in the very elderly. We compared outcomes between thrombolysed and nonthrombolysed (control) patients from neuroprotection trials to assess any influence of age on response. Method-Among patients with ischemic stroke of known age, pretreatment severity (baseline National Institutes of Health Scale Score), and 90-day outcome (modified Rankin Scale score; National Institutes of Health Scale score), we compared the distribution of modified Rankin score in thrombolysed patients with control subjects by Cochran-Mantel-Haenszel test and then logistic regression after adjustment for age and baseline National Institutes of Health Scale score. We examined patients ≤ 80 and ≥ 81 years separately and then each age decile. Rankin data were available for 5817 patients, 1585 thrombolysed and 4232 control subjects; 20.5% were aged > 80 years (mean ± SD, 85.1 ± 3.4 years). Baseline severity was higher among thrombolysed than control subjects (median National Institutes of Health Scale score 14 versus 13, P < 0.05). The distribution of modified Rankin Scale scores was better among thrombolysed patients (P < 0.0001; OR, 1.39; 95% CI, 1.26 to 1.54). The association occurred independently with similar magnitude among young (P < 0.0001; OR, 1.42; 95% CI, 1.26 to 1.59) and elderly (P = 0.002; OR, 1.34; 95% CI, 1.05 to 1.70) patients. ORs were consistent across all age deciles > 30 years; outcomes assessed by National Institutes of Health Scale score gave supporting significant findings, and dichotomized modified Rankin Scale score outcomes were also consistent. Outcome after thrombolysis for acute ischemic stroke was significantly better than in control subjects. Despite the expected poorer outcomes among elderly compared with young patients that is independent of any treatment effect, the association between thrombolysis treatment and improved outcome is maintained in the very elderly. Age alone should not be a barrier to treatment.
  Stroke 10/2010; 41(12):2840-8. · 5.73 Impact Factor