Search

Background and Purpose— Coronary artery disease is the leading cause of death after TIA. Reliable estimates of the risk of MI after TIA, however, are lacking. Methods— Our purpose was to determine the incidence of and risk factors for MI after TIA. We cross-referenced preexisting incidence cohorts from the Rochester Epidemiology Project for TIA (1985–1994) and MI (1979–2006) to identify all community residents with incident MI after incident TIA. Incidence of MI after TIA was determined using Kaplan–Meier life-table methods. This was compared to the age-, sex-, and period-specific MI incidences in the general population. Proportional hazards regression analysis was used to examine associations between clinical variables and the occurrence of MI after TIA. Results— Average annual incidence of MI after TIA was 0.95%. Relative risk for incident MI in the TIA cohort compared to the general population was 2.09 (95% CI, 1.52–2.81). This was highest in patients younger than 60 years old (relative risk, 15.1; 95% CI, 4.11–38.6). Increasing age (hazard ratio, 1.51 per 10 years; 95% CI, 1.14–2.01), male sex (hazard ratio, 2.19; 95% CI, 1.18–4.06), and the use of lipid-lowering therapy at the time of TIA (hazard ratio, 3.10; 95% CI, 1.20–8.00) were independent risk factors for MI after TIA. Conclusions— Average annual incidence of MI after TIA is ≈1%, approximately double that of the general population. The relative risk increase is especially high in patients younger than 60 years old. These data are useful for identifying subgroups of patients with TIA at highest risk for subsequent MI.

Background— American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) Methods and Results— The Mayo Clinic STEMI protocol was implemented in April 2004 and included activation of the cardiac catheterization laboratory by the emergency medicine physician; a single call system to activate the catheterization laboratory; catheterization laboratory staff arrival within 20 to 30 minutes of activation; and real-time performance feedback within 24 to 48 hours. Data were collected on nontransferred STEMI patients. The preimplementation group (June 2002 to March 2004) comprised 96 patients with a median DTB of 97 (interquartile range, 82, 130) minutes, and 40% had a DTB P P =0.41). Conclusions— The Mayo Clinic STEMI protocol implemented strategies to reduce DTB for nontransferred patients with STEMI. DTB was significantly reduced, and the results were sustained over the 4-year follow-up period. Our experience demonstrates the effectiveness and durability of process changes targeting timeliness of primary percutaneous coronary intervention.

To evaluate the association of diastolic blood pressure (dBP), systolic blood pressure (sBP), and mean arterial pressure (MAP) in the emergency department (ED) with mortality within 90 days in patients with acute ischemic stroke (AIS).This observational study was conducted at an ED with an annual census of 70,000 visits, with approximately 500 for AIS. The cohort consisted of 357 patients who presented to the ED within 24 hours of stroke symptom onset. sBP and dBP were measured at triage by a nurse blinded to the study. The duration of follow-up was limited to the first 90 days following ED presentation. BP levels were categorized as low, normotensive, and high after examining scatter plots of a patient's risk of death adjusted for duration of follow-up vs dBP, sBP, and MAP. These BP categories were evaluated using indicator variables in Cox proportional hazards models, after adjusting for age, sex, and the National Institute of Health Stroke Scale (NIHSS) score.Patients with low BP (dBP70, sBP155, or MAP100 mm Hg) were significantly more likely to die within 90 days than those with BP in the normotensive range (dBP 70 to 105, sBP 155 to 220, MAP 100 to 140 mm Hg). These associations were significant even after adjusting for age, gender, and NIHSS score.There appears to be an optimal acute BP range below which early mortality is greater following AIS, suggesting avoidance of hypotension in the first 24 hours.

Hyperglycemia predicts increased stroke mortality independently of age, stroke severity, or stroke type. The next step is to ascertain whether treating hyperglycemia reduces mortality and improves functional outcome. The objective of this review was to determine whether maintaining serum glucose within a specific normal range (4–7.5 mmol/L or 72–135 mg/dL) in the first 24 hours of acute ischemic stroke influences outcome. We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, Science Citation Index, Web of Science, ongoing trials registers, and SCOPUS. Eligible studies were randomized controlled trials comparing intensively monitored insulin therapy versus usual care in adult patients with acute ischemic stroke. We obtained a total of 191 …

Design/Methods: Adult patients presenting to the emergency department who had an ultimate discharge diagnosis of ischemic stroke were included in this cohort. The prehospital GCS was obtained from ambulance records in real time, performed by EMS crew. The outcomes of interest were stroke severity as measured by NIHSS, occurrence of endovascular intervention, functional outcome measured by modified Rankin score, and death within 90 days. Logistic regression analyses using JMP 8.0 for the mac performed to assess for correlation. Results: There were upto 4 pre-hospital GCS collected in the cohort (n=145), depending on transportation times. For this study, the first pre-hospital GCS, obtained at the time of first patient contact, was used. GCS Distribution followed a non parametric pattern; the median GCS was 15, range 3-15, IQR 12.5-15. The median and IQRs were: pulse 78 (70-90), sBP 151 (133-176), dBP 83 (72-97), MAP 106 (95-121). Table 1 depicts the number of patients with each GCS, and their median time of arrival to the ED after symptom onset. On univariate analysis, prehospital GCS was significantly correlated with each of the outcome measures of interest. Patients with lower GCS were significantly more likely to have more severe strokes (P Conclusions: The prehospital GCS appears to be a good predictor of stroke severity, and thus correlates for higher likelihood of endovascular intervention. Similarly, the prehospital GCS also correlates well with functional outcome at hospital discharge and death within 90 days. Disclosure: Dr. Weaver has nothing to disclose. Dr. Nappi has nothing to disclose. Dr. Bodhit has nothing to disclose. Dr. Ju has nothing to disclose. Dr. Applewhite has nothing to disclose. Dr. Hedna has nothing to disclose. Dr. Waters has nothing to disclose. Dr. Stead has nothing to disclose.

Objective: To determine whether prehospital vital signs are correlated with outcome after acute intracerebral hemorrhage. Design/Methods: This analysis included all adult patients who presented with an intracerebral hemorrhage during the study period. Patients with subarachnoid and subdural hemorrhages were not included. Prehospital data were obtained from EMS. Prehospital data collected included GCS, pulse, glucose, systolic and diastolic BP, and mean arterial pressure (MAP). Outcomes included stroke severity and Death. Stroke severity was determined by the NIHSS in the Emergency Department. Death after ICH was ascertained from follow up clinic visits, medical records, and the social security death index. Results: 50% of the cohort arrived by EMS. Table 1 depicts the median and interquartile ranges for the prehospital vitals. The median time from symptom onset to presentation was 103 minutes, with an interquartile range of 82 to 171 minutes. The median NIHSS was 16 (IQR 10-26). A total of 64% of the cohort died. Median days to death was 2, with an interquartile range of 1 to 13, and a total range of 0 to 26. Functional outcome as measured by the modified rankin score demonstrated a median of 5. Patients who has a low GCS in the field were significantly more likely to have more severe stroke (p= 0.0152, and have a worse functional outcome (p=0.0027), and higher risk of death (p=.0095). Similarly, patients with lower mean arterial pressure were also significantly more likely to have a higher risk of death (p=.0219). Elevated prehospital glucose was significantly associated with death (p=0.0336). Indeed hyperglycemia was significantly associated with poor outcome (p=0.0158 for NIHSS; and p= 0.0299 for Rankin) for the entire cohort, regardless of whether they came via EMS. Conclusions: Prehospital parameters appear to be correlated with worse outcomes after acute intracerebral hemorrhage. Disclosure: Dr. Bodhit has nothing to disclose. Dr. Ju has nothing to disclose. Dr. Nappi has nothing to disclose. Dr. Weaver has nothing to disclose. Dr. Applewhite has nothing to disclose. Dr. Hedna has nothing to disclose. Dr. Waters has nothing to disclose. Dr. Stead has nothing to disclose.

Objective: To determine if admission medical research council(MRC) motor strength grade and presence of vascular collateralization are predictors of outcome after endovascular intervention(EI) for acute stroke. Background Large vessel ischemia constitute 30-50% of all cerebrovascular events and EI are gaining importance in the management. There are few clinical indicators of poor outcome like NIH stroke scale, age, extent of territory, infarct volume among others. Design/Methods: Retrospective analysis of 62 patients who underwent EI (MERCI,penumbra,alligator,balloon angioplasty,stents or combination of these procedures) with or without concurrent t-PA for acute stroke from 2007-2011. All patients had head and neck CTA with perfusion and EI. Admission MRC motor grade and collateralization on CTA were independent variables. Modified collateral flow(CS) grading 0-3 for absent, ≤50%,>50% but Results: Median age=75; median motor grade=2,with an interquartile range0-3. 53% were discharged to acute rehab or home(good outcome). SNF placement was 16%(intermediate outcome). Hospice disposition and death was 30%(poor outcome). In the poor outcome category,100% had MRC grade 0-1. The motor grade was significantly associated with death/SNF;as well as worse functional outcome(p Conclusions: This preliminary data suggest Motor grade assessment serve as a robust predictor of outcome after acute stroke intervention. Limitations:Severe neglect,intubated/sedated patients,and previous stroke.Modified collateral flow score grading needs revision as there is a disparity between different grades especially grade 1 & 2. For example person with minimal collaterals (eg: 5%)is in the same category of CS 1 as the person with 49% collaterals, which has a huge bearing on clinical outcome. Disclosure: Dr. Hedna has nothing to disclose. Dr. Favilla has nothing to disclose. Dr. Patel has nothing to disclose. Dr. Khaku has nothing to disclose. Dr. Stead has nothing to disclose. Dr. Gottipati has nothing to disclose. Dr. Gottipati has nothing to disclose. Dr. Waters has nothing to disclose.