Lesly A Pearce

McMaster University, Hamilton, Ontario, Canada

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Publications (108)845.46 Total impact

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    ABSTRACT: Background Cognitive impairment is frequent in lacunar stroke patients. The prevalence and pattern among Spanish-speaking patients are unknown and have not been compared across regions or with English-speaking patients.AimsThe aim of this study was to characterize cognitive impairment in Spanish-speaking patients and compare it with English-speaking patients.Methods The baseline neuropsychological test performance and the prevalence of mild cognitive impairment, defined as a z-score ≤ −1·5 on memory and/or non-memory tests, were evaluated in Spanish-speaking patients in the Secondary Prevention of Small Subcortical Strokes trial.ResultsOut of 3020 participants, 1177 were Spanish-speaking patients residing in Latin America (n = 693), the United States (n = 121), and Spain (n = 363). Low education (zero- to eight-years) was frequent in Spanish-speaking patients (49–57%). Latin American Spanish-speaking patients had frequent post-stroke upper extremity motor impairment (83%). Compared with English-speaking patients, all Spanish-speaking patient groups had smaller memory deficits and larger non-memory/motor deficits, with Latin American Spanish-speaking patients showing the largest deficits median z-score −1·3 to −0·6 non-memory tests; ≤5·0 for Grooved Pegboard; −0·7 to −0·3 for memory tests). The prevalence of mild cognitive impairment was high and comparable with English-speaking patients in the United States and Latin American Spanish-speaking patients but not the Spanish group: English-speaking patients = 47%, Latin American Spanish-speaking patients = 51%, US Spanish-speaking patients = 40%, Spanish Spanish-speaking patients = 29%, with >50% characterized as non-amnestic in Spanish-speaking patient groups. Older age [odds ratio per 10 years = 1·52, confidence interval = 1·35–1·71), lower education (odds ratio 0–4 years = 1·23, confidence interval = 0·90–1·67), being a Latin American resident (odds ratio = 1·31, confidence interval = 0·87–1·98), and post-stroke disability (odds ratio Barthel Index <95 = 1·89, confidence interval = 1·43–2·50) were independently associated with mild cognitive impairment.Conclusions Mild cognitive impairment in Secondary Prevention of Small Subcortical Strokes Spanish-speaking patients with recent lacunar stroke is highly prevalent but has a different pattern to that observed in English-speaking patients. A combination of socio-demographics, stroke biology, and stroke care may account for these differences.
    International Journal of Stroke 06/2015; 10(4). DOI:10.1111/ijs.12511 · 4.03 Impact Factor
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    ABSTRACT: The spectrum, prevalence, and prognostic implications of abnormal left ventricular geometry (LVG) in patients with lacunar stroke are unknown. We examined the spectrum of LVG and its relationship with vascular risk factors and outcomes after lacunar stroke. LVG was determined with transthoracic echocardiography for 1961 patients with magnetic resonance imaging-verified recent lacunar stroke participating in the Secondary Prevention of Small Subcortical Strokes trial. Multivariable logistic regression and Cox proportional hazards models were used to identify characteristics independently associated with LVG and to estimate risk from abnormal LVG for recurrent stroke and death. Abnormal LVG was present in 77%. Hispanic (odds ratio [OR], 1.4; 95% confidence interval, 1.1-1.8) or black (OR, 2.0; 1.3-2.9) race-ethnicity, diabetes (OR, 1.3; 1.0-1.7), hypertension, impaired renal function (OR, 1.8; 1.2-2.5), intracranial stenosis (OR, 1.5; 1.1-2.1), and abnormal left ventricular function (OR, 2.0; 1.4-3.0) were independently associated with abnormal LVG. Subjects with abnormal LVG also more frequently had advanced manifestations of small-vessel disease specifically previous subcortical infarcts and white matter hyperintensities. After adjusting for assigned treatments, clinical risk factors, and advanced manifestations of small-vessel disease, subjects with abnormal LVG remained at increased risk of stroke recurrence (hazard ratio, 1.5; confidence interval, 1.0-2.4). There was no interaction between LVG and assigned antiplatelet or blood pressure target. Abnormal LVG was not associated with mortality. LVG consistent with chronic hypertensive changes was highly prevalent and correlated with neuroradiologic manifestations of small-vessel disease in lacunar stroke patients. These results support the constructs that both cerebral small-vessel disease and LVG represent end-organ consequences of chronic hypertension. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.
    Journal of Stroke and Cerebrovascular Diseases 03/2015; 24(6). DOI:10.1016/j.jstrokecerebrovasdis.2015.03.005 · 1.99 Impact Factor
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    ABSTRACT: The clinical implications of vertebrobasilar ectasia (VBE) in patients with cerebral small-artery disease are not well defined. We investigated whether VBE is associated with recurrent stroke, major hemorrhage, and death in a large cohort of patients with recent lacunar stroke. Maximum diameters of the vertebral and basilar arteries were measured by magnetic resonance angiography and computed tomographic angiography in 2621 participants in the Secondary Prevention of Small Subcortical Strokes trial. VBE was defined a priori as basilar artery greater than 4.5 mm and/or vertebral artery greater than 4.0 mm. Patient characteristics and risks of stroke recurrence and mortality during follow-up (median, 3.5 years) were compared between patients with and without VBE. VBE affecting 1 or more arteries was present in 200 (7.6%) patients. Patient features independently associated with VBE were increasing age, male sex, white race ethnicity, hypertension, and higher baseline diastolic blood pressure. Baseline systolic blood pressure was inversely associated with VBE. After adjustment for other risk factors, VBE was not predictive of recurrent stroke (hazard ratio [HR], 1.3; 95% confidence interval [CI], .85-1.9) or major hemorrhage (HR, 1.5; CI, .94-2.6), but was of death (HR, 1.7; CI, 1.1-2.7). In this large well-characterized cohort of patients with recent lacunar stroke, VBE was predictive of death but not of recurrent stroke or major hemorrhage. In these exploratory analyses, the frequency of VBE was directly related to diastolic blood pressure but inversely related to systolic blood pressure. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 03/2015; 24(5). DOI:10.1016/j.jstrokecerebrovasdis.2014.12.039 · 1.99 Impact Factor
  • Majid F Bakheet · Lesly A Pearce · Robert G Hart
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    ABSTRACT: Clopidogrel combined with aspirin is routinely prescribed after coronary artery stenting, in patients with acute coronary syndromes, and recently to prevent stroke in patients with acute minor ischemic stroke and TIA. Subdural hematomas are an important complication of antithrombotic treatment, but the risk associated with clopidogrel plus aspirin has not been previously defined. To quantify the risk of subdural hematoma associated with dual antiplatelet therapy with clopidogrel plus aspirin. Randomized clinical trials comparing clopidogrel plus aspirin with aspirin alone were identified by searching the Cochrane Central Register of Controlled Trials from 1990 to 2014, and restricted to those with more than 7 days of treatment. Two reviewers independently extracted data about subdural hematomas. Of 24 randomized trials testing clopidogrel added to aspirin, results for subdural hematoma were available for 11 trials, of which eight did not identify any subdural hematomas. The three trials reporting subdural hematomas were double-blind and included patients with recent lacunar stroke, acute coronary syndromes or atrial fibrillation with a total of 23,136 patients (mean age 66 years) and reported 39 subdural hematomas during a mean follow-up 2·1 years per patient. Clopidogrel plus aspirin was associated with a significantly increased risk of subdural hematoma compared with aspirin alone (risk ratio 2·0, 95% CI 1·0, 3·8; P = 0·04; fixed effects model; I(2) for heterogeneity of 0%, P = 0·51). The average absolute incidence of subdural hematoma averaged 1·1 (95%CI 0·7,1·6) per 1000 patient - years among those assigned clopidogrel plus aspirin in 11 randomized trials. The absolute rate of subdural hematoma during dual antiplatelet therapy is low, averaging 1·1 per 1000 patient-years. Chronic treatment with clopidogrel plus aspirin significantly increases the risk of subdural hematoma compared with aspirin alone. © 2014 World Stroke Organization.
    International Journal of Stroke 12/2014; 10(4). DOI:10.1111/ijs.12419 · 4.03 Impact Factor
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    ABSTRACT: The primary outcome results for the SPS3 trial suggested that a lower systolic target blood pressure (<130 mm Hg) might be beneficial for reducing the risk of recurrent stroke compared with a higher target (130–149 mm Hg), but that the addition of clopidogrel to aspirin was not beneficial compared with aspirin plus placebo. In this prespecified secondary outcome analysis of the SPS3 trial, we aimed to assess whether blood pressure reduction and dual antiplatelet treatment affect changes in cognitive function over time in patients with cerebral small vessel disease.
    The Lancet Neurology 12/2014; 13(12):1177-85. DOI:10.1016/S1474-4422(14)70224-8 · 21.82 Impact Factor
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    ABSTRACT: Background and Purpose-Infarct size and location are thought to correlate with different mechanisms of lacunar infarcts. We examined the relationship between the size and shape of lacunar infarcts and vascular risk factors and outcomes. Methods-We studied 1679 participants in the Secondary Prevention of Small Subcortical Stroke trial with a lacunar infarct visualized on diffusion-weighted imaging. Infarct volume was measured planimetrically, and shape was classified based on visual analysis after 3-dimensional reconstruction of axial MRI slices. Results-Infarct shape was ovoid/spheroid in 63%, slab in 12%, stick in 7%, and multicomponent in 17%. Median infarct volume was smallest in ovoid/spheroid relative to other shapes: 0.46, 0.65, 0.54, and 0.90 mL, respectively (P<0.001). Distributions of vascular risk factors were similar across the 4 groups except that patients in the ovoid/spheroid and stick groups were more often diabetic and those with multicomponent had significantly higher blood pressure at study entry. Intracranial stenosis did not differ among groups (P=0.2). Infarct volume was not associated with vascular risk factors. Increased volume was associated with worse functional status at baseline and 3 months. Overall, 162 recurrent strokes occurred during an average of 3.4 years of follow-up with no difference in recurrent ischemic stroke rate by shape or volume. Conclusions-In patients with recent lacunar stroke, vascular risk factor profile was similar among the different infarct shapes and sizes. Infarct size correlated with worse short-term functional outcome. Neither shape nor volume was predictive of stroke recurrence.
    Stroke 09/2014; 45(10). DOI:10.1161/STROKEAHA.114.005211 · 6.02 Impact Factor
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    ABSTRACT: Background and Purpose-The Secondary Prevention of Small Subcortical Stroke trial (SPS3) recruited participants meeting clinical and radiological criteria for symptomatic lacunes. Individuals randomized to dual antiplatelet therapy with clopidogrel and aspirin had an unanticipated increase in all-cause mortality compared with those assigned to aspirin. We investigated the factors associated with mortality in this well-characterized population. Methods-We identified independent predictors of mortality among baseline demographic and clinical factors by Cox regression analysis in participants of the SPS3 trial. Separately, we examined the effect on mortality of nonfatal bleeding during the trial. Results-During a mean follow-up of 3.6 years, the mortality rate was 1.78% per year for the 3020 participants (mean age, 63 years). Significant independent predictors of mortality at study entry were age, diabetes mellitus, history of hypertension, systolic blood pressure (hazard ratio [HR], 1.3 per 20 mm Hg increase), serum hemoglobin <13 g/dL (HR, 1.6), renal function (HR, 1.3 per estimated glomerular filtration rate decrease of 20 mL/min), and body mass index (HR, 1.8 per 10 kg/m(2) decrease). Participants with ischemic heart disease (P=0.01 for interaction) and normotensive/prehypertensive participants (P=0.03 for interaction) were at increased risk if assigned to dual antiplatelet therapy. Nonfatal major hemorrhage increased mortality in both treatment arms (HR, 4.5; 95% confidence interval, 3.1-6.6; P<0.001). Conclusions-Unexpected interactions between assigned antiplatelet therapy and each of ischemic heart disease and normal/prehypertensive status accounted for increased mortality among patients with recent lacunar stroke given dual antiplatelet therapy. Despite extensive exploratory analyses, the mechanisms underlying these interactions are uncertain.
    Stroke 08/2014; 45(10). DOI:10.1161/STROKEAHA.114.005789 · 6.02 Impact Factor
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    ABSTRACT: To determine the ability of serial cardiac troponin (cTnI) changes (delta) to distinguish type 1 and type 2 myocardial infarction (MI) (excluding all ST-segment elevation MIs (STEMIs)) and describe the diagnostic accuracy and 180-day mortality in MI versus no-MI patients.
    European Heart Journal: Acute Cardiovascular Care 06/2014; 3(4). DOI:10.1177/2048872614538411
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    ABSTRACT: Background Neuroimaging manifestations of small vessel disease are heterogeneous, and correlation with patient features has not been adequately characterized.AimOur goal was to correlate magnetic resonance imaging findings with clinical features in a large multiethnic cohort with recent lacunar stroke.Methods Patient characteristics were correlated with neuroimaging results in the Secondary Prevention of Small Subcortical Stroke study participants.ResultsAmong 3005 patients, mean age was 63 years; 62% were men; and 51%, 30%, and 16% were non-Hispanic White, Hispanic, and Black, respectively. Recent lacunar infarcts were distributed between the subcortical hemisphere (31%), thalamus (26%), brainstem/cerebellum (26%), and basal ganglia/internal capsule (16%). Multiple lacunar infarcts (i.e., acute and remote) were present in 40% and associated with increased age (OR 1·3 per 20 years, 95% CI 1·1, 1·5), male gender (OR 1·5, CI 1·3, 1·7), hypertension (OR 1·5, CI 1·2, 1·8), increased systolic blood pressure (OR 1·2 per 20 mmHg, CI 1·1, 1·3), and prior stroke (OR 3·8, CI 2·9, 5·0). Moderate-severe white matter hyperintensities were present in 50% and associated with increased age (OR 4·3 per 20 years, CI 3·4, 5·4), hypertension (OR 1·8, CI 1·4, 2·3), increased systolic blood pressure (OR 1·3 per 20 mmHg, CI 1·1, 1·5), increased diastolic blood pressure (OR 1·2 per 10 mm, CI 1·0, 1·3), and prior stroke (OR 3·3, CI 2·3, 4·5). Infarct location varied significantly by race-ethnicity (P < 0·001), with Blacks and Hispanics having more infarcts in the brainstem/cerebellum than non-Hispanic Whites, and by gender with women more often having thalamic lacunes than men (P ≤ 0·001).Conclusions In patients with recent lacunar stroke, infarct location and number have distinctie associations with gender, vascular risk factors, and race-ethnicity, demonstrating the complex pathogenesis of lacunar stroke and cerebral small artery disease.
    International Journal of Stroke 06/2014; 9(8). DOI:10.1111/ijs.12282 · 4.03 Impact Factor
  • Ben J Connolly · Lesly A Pearce · Robert G Hart
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    ABSTRACT: Background and Purpose-Subdural hematomas are an important bleeding complication of anticoagulation. We quantify the risk of subdural hematoma associated with anticoagulation with vitamin K antagonists (VKAs) compared with other oral antithrombotic therapies. Methods-Randomized trials were identified from the Cochrane Central Register of Controlled Trials and were included if published since 1980 and compared oral VKAs with antiplatelet therapy or with direct-acting oral anticoagulants. Two reviewers independently extracted data with differences resolved by joint review. Results-Nineteen randomized trials were included that involved 92 156 patients and 275 subdural hematomas. By meta-analysis, VKAs were associated with a significantly increased risk of subdural hematoma (odds ratios, 3.0; 95% confidence interval, 1.5-6.1) compared with antiplatelet therapy (9 trials, 11 603 participants). The risk of subdural hematoma was also significantly higher with VKAs versus factor Xa inhibitors (meta-analysis odds ratios, 2.9; 95% confidence interval, 2.1-4.1; 5 trials, 49 687 patients) and direct thrombin inhibitors (meta-analysis odds ratios, 1.8; 95% confidence interval, 1.2-2.7; 5 trials, 30 866 patients) versus VKAs. The absolute rate of subdural hematoma among 24 485 patients with atrial fibrillation treated with VKAs pooled from 6 trials testing direct-acting oral anticoagulants was 2.9 (95% confidence interval, 2.5-3.5) per 1000 patient-years. Conclusions-VKA use significantly increases the risk of subdural hematoma by approximate to 3-fold relative to antiplatelet therapy. Direct-acting oral anticoagulants are associated with a significantly reduced risk of subdural hematomas versus VKAs. Based on indirect comparisons to VKAs, the risks of subdural hematoma are similar with antiplatelet monotherapies and factor Xa inhibitors.
    Stroke 06/2014; 45(6):1672-8. DOI:10.1161/STROKEAHA.114.005430 · 6.02 Impact Factor
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    ABSTRACT: Background While living with others has been associated with improved functional outcome after acute stroke, it is unclear if this affects adherence to stroke prevention measures.AimsWe examined the relationship between living arrangements and adherence to antiplatelet therapy assignment and participation status in an international randomized trial for secondary stroke prevention.Method Antiplatelet therapy adherence, trial retention outcomes, and baseline characteristics for participants enrolled in the Secondary Prevention of Small Subcortical Strokes study were compared between those who lived alone vs. with others (n = 2374). Participant status at end-of-trial was categorized into (1) on assigned antiplatelet, (2) off assigned antiplatelet by participant request, or (3) participant withdrew consent/lost to follow-up. Multivariable multivariate logistic regression was used to identify patient features at entry predictive of participant status at trial end.ResultsLiving arrangement, alone vs. with other(s), was not significantly associated with participant status. Participants enrolled in the United States/Canada (odds ratio 3·1, confidence intervals 2·0–5·0, vs. Latin America), taking more (7+) prescription medications (odds ratio 1·7, confidence intervals 1·1–2·7, vs. 0–2 medications), and scoring lower on the Stroke Specific Quality of Life scale (odds ratio 1·3, confidence intervals 1·1–1·5, per 10 points) were more likely to withdraw or become lost to follow-up in the study vs. completing the study on assigned antiplatelet therapy. Participants enrolled in the United States/Canada (odds ratio 5·0, confidence intervals 2·4–10·0, vs. Latin America) and taking fewer (0–2) medications (odds ratio 1·9, confidence intervals 1·2–3·1 vs. 3–6 medications) were more likely to request discontinuation of assigned antiplatelet medication vs. completing the study.Conclusion Living with others was not independently predictive of protocol adherence in this cohort. Number of medications and Stroke Specific Quality of Life scale score may be more indicative of likelihood of trial participation and acceptance of long-term antiplatelet regimen.
    International Journal of Stroke 04/2014; 9(4). DOI:10.1111/ijs.12267 · 4.03 Impact Factor
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    Journal of the American College of Cardiology 04/2014; 63(12):A1588. DOI:10.1016/S0735-1097(14)61591-6 · 15.34 Impact Factor
  • B. J. Connolly · L. A. Pearce · R. G. Hart
    Canadian Stroke Congress; 12/2013
  • M. F. Bakheet · R. G. Hart · L. A. Pearce · O. Benavente
    Canadian Stroke Congress; 12/2013
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    ABSTRACT: Background Lowering of blood pressure prevents stroke but optimum target levels to prevent recurrent stroke are unknown. We investigated the effects of different blood-pressure targets on the rate of recurrent stroke in patients with recent lacunar stroke. Methods In this randomised open-label trial, eligible patients lived in North America, Latin America, and Spain and had recent, MRI-defined symptomatic lacunar infarctions. Patients were recruited between March, 2003, and April, 2011, and randomly assigned, according to a two-by-two multifactorial design, to a systolic-blood-pressure target of 130-149 mm Hg or less than 130 mm Hg. The primary endpoint was reduction in all stroke (including ischaemic strokes and intracranial haemorrhages). Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00059306. Findings 3020 enrolled patients, 1519 in the higher-target group and 1501 in the lower-target group, were followed up for a mean of 3.7 (SD 2.0) years. Mean age was 63 (SD 11) years. After 1 year, mean systolic blood pressure was 138 mm Hg (95% CI 137-139) in the higher-target group and 127 mm Hg (95% CI 126-128) in the lower-target group. Non-significant rate reductions were seen for all stroke (hazard ratio 0.81, 95% CI 0.64-1.03, p=0.08), disabling or fatal stroke (0.81, 0.53-1.23, p=0.32), and the composite outcome of myocardial infarction or vascular death (0.84, 0.68-1.04, p=0.32) with the lower target. The rate of intracerebral haemorrhage was reduced significantly (0.37, 0.15-0.95, p=0.03). Treatment-related serious adverse events were infrequent. Interpretation Although the reduction in stroke was not significant, our results support that in patients with recent lacunar stroke, the use of a systolic-blood-pressure target of less than 130 mm Hg is likely to be beneficial.
    The Lancet 08/2013; 382(9891):507-515. DOI:10.1016/S0140-6736(13)60852-1 · 45.22 Impact Factor
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    ABSTRACT: http://www.aacc.org/events/Annual_Meeting/abstracts/Documents/AACC_13_AM_B175-B239.pdf Background: The diagnosis of acute myocardial infarction (MI) is based on clinical factors and an increased cardiac troponin (cTn), with a rising and /or falling cTn pattern required. The use of a delta (change) value may play a role in optimizing diagnostic specificity. The goal of this study was to validate the diagnostic accuracy of the Ortho-Clinical Diagnostics (OCD) Vitros ES cTnI assay based on a) 99th percentile and b) the delta values (absolute concentration differences) between 0-3h and 0-6h serial blood draws. Methods: We reviewed 1271 patients presenting with symptoms suggestive of ischemia presenting to the emergency department with serial cTnI concentrations. Plasma (heparin) was obtained at presentation and 3 (n=628), 6 (n =958) and/or 9 (n=951) h. cTnI was measured by the OCD assay (LoD, 12 ng/L; 99th percentile 34 ng/L, 10%CV). Charts with any increased cTnI were adjudicated for MI, predicated on the Universal Definition of MI guidelines. Results: Type 1 MI was diagnosed in 8% (n=33 STEMI; n=69 NSTEMI) and type 2 MI in 17% (total MI rate 25%). At 0h, similar proportions of type 1 STEMI (45%), NSTEMI (55%) and type 2 MI (42%) were increased above the 99th percentile (p=0.2). The table demonstrates diagnostic accuracy findings. Clinical sensitivity improved over serial testing, from 46% at 0h to 96% at 6h. Specificity was 93% at presentation (0h), and the delta change values at 3 and 6h did not improve diagnostic accuracy (specificity 90-91%) compared to the individual timed cTnI finding at baseline. Conclusions: We confirm that the contemporary OCD Vitros ES cTnI assay is an important diagnostic aid in ruling in/out acute MI for both type 1 and 2 MIs using the 99th percentile. The delta change value did not improve diagnostic utility to the assay which already provided a high clinical specificity at baseline.
    2013 American Association for Clinical Chemistry (AACC) Annual Meeting; 07/2013
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    ABSTRACT: Among participants in the Secondary Prevention of Small Subcortical Strokes randomized trial, we sought to identify patients with high versus low rates of recurrent ischemic stroke and to assess effects of aggressive blood pressure control and dual antiplatelet therapy according to risk status. Multivariable analyses of 3020 participants with recent magnetic resonance imaging-defined lacunar strokes followed for a mean of 3.7 years with 243 recurrent ischemic strokes. Prior symptomatic lacunar stroke or transient ischemic attack (TIA) (hazard ratio [HR] 2.2, 95% confidence interval [CI] 1.6, 2.9), diabetes (HR 2.0, 95% CI 1.5, 2.5), black race (HR 1.7, 95% CI 1.3, 2.3), and male sex (HR 1.5, 95% CI 1.1, 1.9) were each independently predictive of recurrent ischemic stroke. Recurrent ischemic stroke occurred at a rate of 4.3% per year (95% CI 3.4, 5.5) in patients with prior symptomatic lacunar stroke or TIA (15% of the cohort), 3.1% per year (95% CI 2.6, 3.9) in those with more than 1 of the other 3 risk factors (27% of the cohort), and 1.3% per year (95% CI 1.0, 1.7) in those with 0-1 risk factors (58% of the cohort). There were no significant interactions between treatment effects and stroke risk status. In this large, carefully followed cohort of patients with recent lacunar stroke and aggressive blood pressure management, prior symptomatic lacunar ischemia, diabetes, black race, and male sex independently predicted ischemic stroke recurrence. The effects of blood pressure targets and dual antiplatelet therapy were similar across the spectrum of independent risk factors and recurrence risk.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 06/2013; 23(4). DOI:10.1016/j.jstrokecerebrovasdis.2013.05.021 · 1.99 Impact Factor
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    ABSTRACT: BACKGROUND: It remains controversial whether dual antiplatelet therapy reduces stroke more than aspirin alone. AIM: We aimed to assess the effects of adding clopidogrel to aspirin on the occurrence of stroke and major haemorrhage in patients with vascular disease. METHODS: Meta-analysis of published randomized trials comparing the combination of clopidogrel and aspirin vs. aspirin alone that reported stroke and major bleeding. RESULTS: Thirteen randomized trials were included with a total of 90 433 participants (mean age 63 years; 63% male) with a mean follow-up of 1·0 years and 2011 strokes. Stroke was reduced 19% by dual antiplatelet therapy (odds ratio = 0·81, 95% confidence interval 0·74-0·89) with no evidence of heterogeneity of effect across different trial populations (I(2) index = 5%, P = 0·4 for heterogeneity). Dual antiplatelet therapy reduced ischemic stroke by 23% (odds ratio = 0·77; 95% confidence interval 0·70-0·85); there was a nonsignificant 12% increase in intracerebral haemorrhage (odds ratio = 1·12, 95% confidence interval 0·86-1·46). Among 1930 participants with recent (<30 days) brain ischemia from four trials, stroke was reduced by 33% (odds ratio = 0·67, 95% confidence interval 0·46-0·97) by dual antiplatelet therapy vs. aspirin alone. The risk of major bleeding was increased by 40% (odds ratio = 1·40, 95% confidence interval 1·26-1·55) by dual antiplatelet therapy. CONCLUSIONS: This meta-analysis demonstrates a substantial relative risk reduction in stroke by clopidogrel plus aspirin vs. aspirin alone that is consistent across different trial cohorts. Major haemorrhage is increased by dual antiplatelet therapy.
    International Journal of Stroke 05/2013; 10(5). DOI:10.1111/ijs.12050 · 4.03 Impact Factor
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    ABSTRACT: Delta calculations were not useful in distinguishing NSTEMI from type 2 MI although cTnI concentrations were higher in NSTEMI patients. Type 2 MI patients experienced increased mortality similar to NSTEMI patients which highlights the need for further investigation into therapy for Type 2 Ml.
    American College of Cardiology - ACC 2013; 03/2013
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    ABSTRACT: BACKGROUND: Subdural hematomas are an important bleeding complication of antithrombotic therapies. We sought to characterize the risk of subdural hematoma associated with antiplatelet therapy. METHODS: Trials were gathered from the Cochrane Central Register of Controlled Trials and from recent meta-analyses of trials regarding antiplatelet therapy for the primary prevention of stroke. Randomized trials published since 1980 comparing antiplatelet therapy with placebo or control and reporting subdural hematoma were included in the analysis. For recent large trials that did not report subdural hematomas, unpublished results were sought. Two reviewers independently extracted data on study design and subdural hematomas, with differences resolved by joint review and consensus. RESULTS: Four published trials were identified that compared aspirin with placebo/control involving 6565 participants (mean age 66 years) with 8 total subdural hematomas. Unpublished data from 5 aspirin trials with 90,689 participants reported 18 total subdural hematomas. The incidence of subdural hematomas varied from 0.02 per 1000 patient-years for primary prevention trials of middle-aged health professionals to 1 to 2 per 1000 patient-years for older patients with atrial fibrillation. Pooled data from all 9 trials revealed an odds ratio of 1.6 (95% confidence interval 0.8-3.5; heterogeneity P = .8; I(2) index 0%) for antiplatelet therapy and risk of subdural hematoma. CONCLUSIONS: Based on the limited available data, it is uncertain whether aspirin therapy increases the risk of subdural hematoma: the observed 1.6-fold increased risk was not statistically significant. The incidence of subdural hematoma during aspirin therapy is low but varies widely depending upon the age of the patient population.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 02/2013; 22(4). DOI:10.1016/j.jstrokecerebrovasdis.2013.01.007 · 1.99 Impact Factor

Publication Stats

6k Citations
845.46 Total Impact Points

Institutions

  • 2014
    • McMaster University
      • Department of Medicine
      Hamilton, Ontario, Canada
  • 1993–2012
    • University of Texas Health Science Center at San Antonio
      • • School of Nursing
      • • Department of Neurology
      • • Division of Hospital Medicine
      San Antonio, TX, United States
  • 2011
    • Town of Bel Air
      Maryland, United States
  • 2000–2011
    • Hennepin County Medical Center
      • Department of Emergency Medicine
      Minneapolis, Minnesota, United States
    • Mount Sinai Medical Center
      New York City, New York, United States
  • 2009
    • University of Minnesota Duluth
      • Laboratory Medicine and Pathology
      Duluth, Minnesota, United States
  • 1999–2006
    • University of Texas at San Antonio
      San Antonio, Texas, United States
    • Mayo Foundation for Medical Education and Research
      Rochester, Michigan, United States
    • Southern Illinois University School of Medicine
      Springfield, Illinois, United States
  • 2005
    • Birmingham City University
      Birmingham, England, United Kingdom