[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to explore the prevalence of acute cerebrovascular symptoms temporally related to carotid Doppler examination (DEx), in order to increase the awareness and recording of such events and to discuss possible mechanisms. All adult patients who complained of acute onset neurologic symptoms during or shortly after a carotid DEx, between 01/2003 and 12/2011 in the University Hospital of Lausanne were prospectively collected. We identified four consecutive patients with acute onset neurologic symptoms during or shortly after a carotid DEx among approximately 13,500 patients who underwent carotid DEx in our facility during the nine-year period (0.015% of all examined carotids). Clinical data, imaging reports and CTA (CT angiography) or/and ultrasound images are presented for each patient. Ischemic cerebrovascular events during or immediately after cervical Doppler could be due to chance or to several physical factors. They should be promptly recognized by Doppler personnel and properly treated, but do not put into question the overwhelming benefits of Doppler in cerebrovascular patients.
Ultrasound in Medicine & Biology 12/2014; 41(2). · 2.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction: Statins reduce low-density lipoprotein cholesterol (LDL-C) and are currently the mainstay in the treatment of hyperlipidaemia and subsequently the prevention of atherosclerotic cardiovascular disease (CVD). Nevertheless, there is a need to further lower LDL-C, especially in subjects with severe forms of hypercholesterolaemia despite maximum doses of conventional drugs and/or in those intolerant to existing therapies. Areas covered: Emerging therapeutic approaches to lowering LDL-C involve blocking LDL-receptor degradation by serum proprotein convertase subtilisin kexin 9 (PCSK9). Human monoclonal antibodies that target PCSK9 and its interaction with the LDL-receptor (AMG145, REGN727 and RN316) have been tested in Phase I - III clinical trials for the treatment of hyperlipidaemia in patients at high CVD risk. Expert opinion: These new agents are administered subcutaneously and have been shown to have major LDL-C and apoB lowering effects either alone or in combination with statins. These novel agents are generally well tolerated and once long-term safety data are available they appear promising therapeutic platforms for the treatment of patients with hypercholesterolaemia at risk for or with CVD not controlled by conventional therapies.
[Show abstract][Hide abstract] ABSTRACT: Background
It is still debatable whether anemia predicts stroke outcome.AimTo describe the characteristics of patients with acute ischemic stroke (AIS) and anemia and identify whether hemoglobin status on admission is a prognostic factor of AIS outcome.Methods
All 2439 patients of the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) between January 2003 and June 2011 were selected. Demographics, risk factors, prestroke treatment, clinical, radiological and metabolic variables in patients with and without anemia according to the definition of the World Health Organization were compared. Functional disability and mortality were recorded up to 12 months from admission.ResultsAnemic patients (17·5%) were older, had lower body mass index, higher rates of coronary artery disease (CAD), atrial fibrillation, diabetes mellitus and peripheral artery disease. Anemia was associated with more severe stroke manifestations, lower systolic and diastolic blood pressure measurements, worse estimated glomerular filtration rate and elevated C-reactive protein concentrations upon admission and with increased modified Rankin scores during the follow-up. Anemic patients had higher 7-day, 3-month and 12-month mortality, which was associated with hemoglobin status and other factors, including age, CAD, stroke severity, and baseline C-reactive levels. Hemoglobin levels were inversely associated with recurrent stroke and mortality throughout the 12-month follow-up.Conclusion
Anemia is common among AIS patients and is associated with cardiovascular comorbidities. Low hemoglobin status independently predicts short and long-term mortality.
International Journal of Stroke 12/2014; · 4.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: There is a paucity of data regarding the attainment of lipid-lowering treatment goals according to the recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines. The aim of the present study was to assess how applicable these 2013 recommendations are in the setting of an Outpatient University Hospital Lipid Clinic. Methods: This was a retrospective (from 1999 to 2013) observational study including 1000 consecutive adults treated for hyperlipidemia and followed up for ≥3 years. Comparisons for the applicability of current European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) and recent ACC/AHA guidelines were performed. Results: Achievement rates of low density lipoprotein cholesterol (LDL-C) targets set by ESC/EAS were 21%, 44% and 62% among patients at very high, high and moderate cardiovascular risk, respectively, receiving statin monotherapy. Among individuals on high-intensity statins only 47% achieved the anticipated ≥50% LDL-C reduction, i.e. the ACC/AHA target. The corresponding rate was significantly greater among those on statin + ezetimibe (76%, p < 0.05). Likewise, higher rates of LDL-C target attainment according to ESC/EAS guidelines were observed in patients on statin + ezetimibe compared with statin monotherapy (37, 50 and 71% for the three risk groups, p < 0.05 for the very high risk group). Conclusion: The application of the ACC/AHA guidelines may be associated with undertreatment of high risk patients due to suboptimal LDL-C response to high-intensity statins in clinical practice. Adding ezetimibe substantially increases the rate of the ESC/EAS LDL-C target achievement together with the rate of LDL-C lowering response suggested by the ACC/AHA.
Current Medical Research and Opinion 11/2014; · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/objectives
The most recent ACC/AHA guidelines recommend high-intensity statin therapy in ischemic stroke patients of presumably atherosclerotic origin. On the contrary, there is no specific recommendation for the use of statin in patients with non-atherosclerotic stroke, e.g. strokes related to atrial fibrillation (AF). We investigated whether statin treatment in patients with AF-related stroke is associated with improved survival and reduced risk for stroke recurrence and future cardiovascular events.
All consecutive patients registered in the Athens Stroke Registry with AF-related stroke and no history of coronary artery disease nor clinically manifest peripheral artery disease were included in the analysis and categorized in two groups depending on whether statin was prescribed at discharge. The primary outcome was overall mortality; the secondary outcomes were stroke recurrence and a composite cardiovascular endpoint comprising of recurrent stroke, myocardial infarction, aortic aneurysm rupture or sudden cardiac death during the 5-year follow-up.
Among 1602 stroke patients, 404 (25.2%) with AF-related stroke were included in the analysis, of whom 102 (25.2%) were discharged on statin. On multivariate Cox-proportional-hazards model, statin treatment was independently associated with a lower mortality (hazard-ratio (HR): 0.49, 95%CI:0.26–0.92) and lower risk for the composite cardiovascular endpoint during the median 22 months follow-up (HR: 0.44, 95%CI:0.22–0.88), but not with stroke recurrence (HR: 0.47, 95%CI:0.22–1.01, p: 0.053).
In this long-term registry of patients with AF-related stroke, statin treatment was associated with improved survival and reduced risk for future cardiovascular events.
International Journal of Cardiology 11/2014; 177(1):129–133. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: The aim of the present work was to evaluate the combined role of eating behaviors and to investigate their effect on the likelihood of developing an acute coronary syndrome (ACS) or an ischemic stroke. Methodology: During 2009-2010, 1000 participants were enrolled; 250 consecutive patients with a first ACS (83% males, 60±12 years) and 250 control subjects, as well as 250 consecutive patients with a first ischemic stroke (56% males, 77±9 years) and 250 controls. The controls were population-based and age-sex matched with the patients. Detailed information regarding their anthropometric data, medical records and lifestyle characteristics (dietary and smoking habits, physical activity, psychological state and eating practices -using a special questionnaire-) were recorded. Five eating behaviors were selected to compose an eating behavior score for the purposes of this work: adherence to the Mediterranean diet (using the MedDietScore), frequency of breakfast consumption, eating while being stressed, eating while working and skipping meals. Eating behaviors with beneficial health effects were scored with 0, while those with negative effects were assigned score 1. The total range of the score was between 0 and 5. Higher scores reveal "unhealthier" eating practices. Results: After controlling for potential confounding factors, each unit increase of the eating behavior score was associated with 70% (95%CI: 1.29 - 2.22) higher likelihood of developing an ACS. Insignificant associations were observed regarding ischemic stroke. Conclusion: The overall adoption of specific "unhealthy" eating practices seems to have a detrimental effect on cardiovascular health, and especially coronary heart disease.
[Show abstract][Hide abstract] ABSTRACT: Background and purposeThere is no strong evidence that all ischaemic stroke types are associated with high cardiovascular risk. Our aim was to investigate whether all ischaemic stroke types are associated with high cardiovascular risk.Methods
All consecutive patients with ischaemic stroke registered in the Athens Stroke Registry between 1 January 1993 and 31 December 2010 were categorized according to the TOAST classification and were followed up for up to 10 years. Outcomes assessed were cardiovascular and all-cause mortality, myocardial infarction, stroke recurrence, and a composite cardiovascular outcome consisting of myocardial infarction, angina pectoris, acute heart failure, sudden cardiac death, stroke recurrence and aortic aneurysm rupture. The Kaplan–Meier product limit method was used to estimate the probability of each end-point in each patient group. Cox proportional hazards models were used to determine the independent covariates of each end-point.ResultsTwo thousand seven hundred and thirty patients were followed up for 48.1 ± 41.9 months. The cumulative probabilities of 10-year cardiovascular mortality in patients with cardioembolic stroke [46.6%, 95% confidence interval (CI) 40.6–52.8], lacunar stroke (22.1%, 95% CI 16.2–28.0) or undetermined stroke (35.2%, 95% CI 27.8–42.6) were either similar to or higher than those of patients with large-artery atherosclerotic stroke (LAA) (28.7%, 95% CI 22.4–35.0). Compared with LAA, all other TOAST types had a higher probability of 10-year stroke recurrence. In Cox proportional hazards analysis, compared with patients with LAA, patients with any other stroke type were associated with similar or higher risk for the outcomes of overall mortality, cardiovascular mortality, stroke recurrence and composite cardiovascular outcome.Conclusions
Large-artery atherosclerotic stroke and cardioembolic stroke are associated with the highest risk for future cardiovascular events, with the latter carrying at least as high a risk as LAA stroke.
European Journal of Neurology 04/2014; · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Statins (hydroxy-methyl-glutaryl-coenzyme reductase inhibitors) remain the cornerstone of lipid-lowering therapy based on the evidence of clinical outcome trials. However, management of dyslipidemia in clinical practice may require the use of other hypolipidemic agents in combination with statins. Fibrate (agonist of peroxisome proliferator-activated receptor-α, PPR-α) monotherapy is effective for the treatment of hypertriglyceridemia, while the combination of a fibrate with a statin is an option in the management of patients with combined dyslipidemia and diabetes mellitus who present with atherogenic dyslipidemia (low high-density lipoprotein (HDL) cholesterol and elevated triglyceride levels). There is evidence that the combination treatment is efficacious towards a global improvement of the lipid abnormalities with a safety profile similar to that of fibrate monotherapy with regard to liver and muscle toxicity. Nevertheless, renal function may be more commonly affected in those treated with a 'fibrate plus statin'. This concern has been raised with fibrate use either alone or in combination with a statin and should be taken into consideration when starting fibrate treatment while the pathophysiological basis and clinical implications of this drug-related effect need further investigation.
Expert Opinion on Drug Safety 02/2014; · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We compared the effects of lipid lowering with rosuvastatin (RSV) monotherapy versus intensified treatment by combining RSV with ezetimibe (EZT) on kidney function in patients undergoing vascular surgery. Patients were randomly assigned to either 10 mg/d RSV (n = 136) or RSV 10 mg/d plus EZT 10 mg/d (RSV/EZT, n = 126). At 12 months, a similar decrease in estimated glomerular filtration rate (eGFR) was noted. Patients who achieved a low-density lipoprotein cholesterol (LDL-C) of <100 mg/dL had less eGFR decrease than those patients having an LDL-C limit of more than 100 mg/dL. There were no significant changes in the urinary total protein to creatinine ratio in either group. Significant microalbuminuria was evident in both the groups. Patients undergoing vascular surgery show deterioration in their renal function during the first year, despite statin therapy. Intensified lipid-lowering therapy by adding EZT does not appear to have any renoprotective effect.
[Show abstract][Hide abstract] ABSTRACT: The aim of the present work was to evaluate the combined role of eating behaviors and to investigate their effect on the likelihood of developing an acute coronary syndrome (ACS) or an ischemic stroke. During 2009–2010, 1000 participants were enrolled; 250 consecutive patients with a first ACS (83% males, 60 ± 12 years) and 250 control subjects, as well as 250 consecutive patients with a first ischemic stroke (56% males, 77 ± 9 years) and 250 controls. The controls were population-based and age–sex matched with the patients. Detailed information regarding their anthropometric data, medical records and lifestyle characteristics (dietary and smoking habits, physical activity, psychological state and eating practices -using a special questionnaire-) were recorded. Five eating behaviors were selected to compose an eating behavior score for the purposes of this work: adherence to the Mediterranean diet (using the MedDietScore), frequency of breakfast consumption, eating while being stressed, eating while working and skipping meals. Eating behaviors with beneficial health effects were scored with 0, while those with negative effects were assigned score 1. The total range of the score was between 0 and 5. Higher scores reveal “unhealthier” eating practices. After controlling for potential confounding factors, each unit increase of the eating behavior score was associated with 70% (95%CI: 1.29–2.22) higher likelihood of developing an ACS. Insignificant associations were observed regarding ischemic stroke. The overall adoption of specific “unhealthy” eating practices seems to have a detrimental effect on cardiovascular health, and especially coronary heart disease.
[Show abstract][Hide abstract] ABSTRACT: To compare the accuracy of a-priori and a-posteriori dietary patterns in the prediction of acute coronary syndrome (ACS) and ischemic stroke. This is actually the first study to employ state-of-the-art classification methods for this purpose.
During 2009-2010, 1000 participants were enrolled; 250 consecutive patients with a first ACS and 250 controls (60±12 years, 83% males), as well as 250 consecutive patients with a first stroke and 250 controls (75±9 years, 56% males). The controls were population-based and age-sex matched to the patients. The a-priori dietary patterns were derived from the validated MedDietScore, whereas the a-posteriori ones were extracted from principal components analysis. Both approaches were modeled using six classification algorithms: multiple logistic regression (MLR), naïve Bayes, decision trees, repeated incremental pruning to produce error reduction (RIPPER), artificial neural networks and support vector machines. The classification accuracy of the resulting models was evaluated using the C-statistic.
For the ACS prediction, the C-statistic varied from 0.587 (RIPPER) to 0.807 (MLR) for the a-priori analysis, while for the a-posteriori one, it fluctuated between 0.583 (RIPPER) and 0.827 (MLR). For the stroke prediction, the C-statistic varied from 0.637 (RIPPER) to 0.767 (MLR) for the a-priori analysis, and from 0.617 (decision tree) to 0.780 (MLR) for the a-posteriori.
Both dietary pattern approaches achieved equivalent classification accuracy over most classification algorithms. The choice, therefore, depends on the application at hand.
Artificial intelligence in medicine 09/2013; · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ischemic heart disease and cerebrovascular disease remain major health problems with associated mortality and quality-of-life consequences. Antiplatelet agents, including thienopyridines and the new P2Y12 inhibitors, have been shown to improve survival in the secondary prevention setting. We review the available evidence on the effectiveness and safety of previous established as well as novel antithrombotic agents in the secondary prevention of cardiovascular disease with a special focus on cerebrovascular disease.
[Show abstract][Hide abstract] ABSTRACT: In the August 2013 issue of the Journal of Vascular Surgery, the Letter to the Editor by Arnaoutoglou et al (Regarding "The impact of endograft type on inflammatory response after endovascular treatment of abdominal aortic aneurysm". J Vasc Surg 2013;58:570.) contained the incorrect order for the authors. Prof Miltiadis Matsagkas should be listed as the senior author of this Letter.
[Show abstract][Hide abstract] ABSTRACT: Children with heterozygous familial hypercholesterolemia (heFH) are prone to premature atherosclerosis. Vascular endothelial dysfunction may predict increased cardiovascular risk in children with heFH. The aim of this study was to assess for early functional and structural vascular changes in children with heFH. This cross-sectional study included 30 children with heFH (mean age 12 years) and 30 age- and sex-matched controls. Brachial artery flow-mediated dilation (FMD), carotid intima-media thickness (cIMT), carotid-femoral pulse wave velocity, and large- and small vessel compliance were measured noninvasively. HeFH children exhibited significantly greater total and LDL cholesterol, apolipoprotein B, and lipoprotein (a) levels (p < 0.05 for all) and lower FMD (6.23 ± 3.88 vs. 9.46 ± 4.54 %, p < 0.004) compared with controls. When children were divided in age subgroups, FMD was found to be significantly decreased in heFH compared with control subjects only in ages >10 years (p < 0.05). However, FMD was found to be similarly impaired in heFH children in all age subgroups (two-way analysis of variance, p = 0.39). No differences in other vascular function indices were found. In heFH patients, but not in controls, FMD was inversely correlated with cIMT (r = -0.378, p = 0.036). In conclusion, endothelial dysfunction occurs early in heFH children indicating an increased risk for premature cardiovascular disease and reflecting probably the need for early initiation of anticholesterolemic treatment. Decreased FMD is detected before structural atherosclerotic changes occur.
[Show abstract][Hide abstract] ABSTRACT: ABSTRACT Alzheimer's disease (AD) is the most prevalent type of dementia, involving progressive deterioration of neuronal networks. Although the pathophysiologic mechanism of AD is not fully elucidated, apart from β-amyloid and tau protein, a diverse number of factors such as cardiovascular risk factors, inflammation and lipids metabolism may play a significant role. Numerous epidemiological and laboratory studies support vascular injury and inflammation, as key pathological processes. The present review is focused on cardiovascular risk factors, lipids and circulating biomarkers of inflammation, discussing them as independent mechanisms converging to the same final pathogenetic cascade of AD.
The International journal of neuroscience 07/2013; · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND PURPOSE: Ankle-brachial blood pressure index (ABI) is a clinical tool to identify the presence of peripheral artery disease. There is a scarcity of data associating ABI with long-term outcome in patients with IS. The association between ABI and long-term outcome in patients with first-ever acute IS was assessed. METHODS: Ankle-brachial blood pressure index was assessed in all consecutive patients with a first-ever acute IS admitted at Alexandra University hospital (Athens, Greece) between January 2005 and December 2010. ABI was considered normal when > 0.90 and ≤ 1.30. The Kaplan-Meier product limit method was used to estimate the probability of 5-year composite cardiovascular event-free (defined as recurrent stroke, myocardial infarction or cardiovascular death) and overall survival. A multivariate analysis was performed to assess whether ABI is an independent predictor of 5-year mortality and dependence. RESULTS: Amongst 653 patients, 129 (19.8%) with ABI ≤ 0.9 were identified. Five-year cumulative composite cardiovascular event-free and overall survival rates were better in normal ABI stroke patients (log-rank test: 7.22, P = 0.007 and 23.40, P < 0.001, respectively). There was no difference in 5-year risk of stroke recurrence between low and normal ABI groups (hazard ratio, HR = 1.23, 95%CI 0.68-2.23). In multivariate Cox regression analysis, independent predictors of 5-year mortality included age (HR = 2.55 per 10 years, 95%CI 1.86-3.48, P < 0.001), the National Institutes of Health Stroke Scale (per point increase HR = 1.12, 95%CI 1.08-1.16, P < 0.001), and low ABI (HR = 2.22, 95%CI 1.22-4.03, P = 0.009). Age (HR = 1.21 per 10 years, 95%CI 1.01-1.45, P = 0.04) and low ABI (HR = 1.72, 95%CI 1.11-2.67, P = 0.01) were independent predictors of the composite cardiovascular end-point. CONCLUSIONS: Low ABI in patients with acute IS is associated with increased 5-year cardiovascular event risk and mortality. However, ABI does not appear to predict long-term stroke recurrence.
European Journal of Neurology 06/2013; · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of the present work was to compare the influence of classic cardiovascular disease (CVD) risk factors on the development of acute coronary syndrome (ACS) and ischemic stroke. During 2009-2010, 1,000 participants were enrolled: 250 were consecutive patients with a first ACS, 250 were consecutive patients with a first ischemic stroke, and 500 were population-based, control subjects, 1-for-1 matched to the patients by age and gender. The following CVD risk factors were evaluated: smoking/passive smoking, family history of CVD, physical inactivity, hypertension, hypercholesterolemia, diabetes mellitus, presence of overweight and obesity, trait anxiety (assessed with the Spielberger State-Trait Anxiety Inventory form Y-2), and adherence to the Mediterranean diet (assessed by the MedDietScore). Furthermore, participants graded the perceived significance of the aforementioned factors, using a scale from 1 (not important) to 9 (very important). The risk factors with the highest effect size for ACS, as determined by the Wald criterion, were smoking and hypercholesterolemia; regarding stroke, they were anxiety and family history of CVD (all p <0.01). When the odds ratios of each factor for ACS and stroke were compared, insignificant differences were observed, except for smoking. On the basis of the participants' health beliefs, smoking and stress emerged as the most important risk factors, whereas all subjects graded passive smoking as a least important factor. In conclusion, similarities of the risk factors regarding ACS and ischemic stroke facilitate simultaneous primary prevention measures.
The American journal of cardiology 04/2013; · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND PURPOSE: The ASTRAL score was externally validated showing remarkable consistency on 3-month outcome prognosis in patients with acute ischemic stroke. The present study aimed to evaluate ASTRAL score's prognostic accuracy to predict 5-year outcome. METHODS: All consecutive patients with acute ischemic stroke registered in the Athens Stroke Registry between January 1, 1998, and December 31, 2010, were included. Patients were excluded if admitted >24 hours after symptom onset or if any ASTRAL score component was missing. End points were 5-year unfavorable functional outcome, defined as modified Rankin Scale 3 to 6, and 5-year mortality. For each outcome, the area under the receiver operating characteristics curve was calculated; also, a multivariate Cox proportional hazards analysis was performed to investigate whether the ASTRAL score was an independent predictor of outcome. The Kaplan-Meier product limit method was used to estimate the probability of 5-year survival for each ASTRAL score quartile. RESULTS: The area under the receiver operating characteristics curve of the score to predict 5-year unfavorable functional outcome was 0.89, 95% confidence interval 0.88 to 0.91. In multivariate Cox proportional hazards analysis, the ASTRAL score was independently associated with 5-year unfavorable functional outcome (hazard ratio, 1.09; 95% confidence interval, 1.08-1.10). The area under the receiver operating characteristics curve for the ASTRAL score's discriminatory power to predict 5-year mortality was 0.81 (95% confidence interval, 0.78-0.83). In multivariate analysis, the ASTRAL score was independently associated with 5-year mortality (hazard ratio, 1.09, 95% confidence interval, 1.08-1.10). During the 5-year follow-up, the probability of survival was significantly lower with increasing ASTRAL score quartiles (log-rank test <0.001). CONCLUSIONS: The ASTRAL score reliably predicts 5-year functional outcome and mortality in patients with acute ischemic stroke.