Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN

Chronic bronchitis and acute infections as new risk factors for ischemic stroke and the lack of protection offered by the influenza vaccination.

Cerebrovasc Dis. 2008;26(4):339-47

Authors: Piñol-Ripoll G, de la Puerta I, Santos S, Purroy F, Mostacero E

BACKGROUND AND PURPOSE: Acute and chronic infections may play a role in promoting complications of atherosclerotic disease. We evaluated the importance of acute infections and chronic bronchitis (CB; as a chronic inflammatory state) in several subtypes of ischemic stroke, and we investigated whether the influenza vaccination was independently associated with a reduced likelihood of stroke. METHODS: A case-control study was performed on 393 consecutive ischemic stroke patients and 393 control subjects matched for age, sex and time of year. Data were collected by a structured interview that assessed risk factors, acute infections within the preceding 2 months, CB and whether they had received the influenza vaccination. RESULTS: Infections within the 2 months before stroke onset and CB were more common among patients than control subjects [23.3 vs. 16.3% (p = 0.014) and 17.2 vs. 8.5% (p = 0.001), respectively]. After adjustment for traditional risk factors, the risk of stroke was increased in the subjects with CB (OR = 1.83, 95% CI = 1.35-2.48, p = 0.016), but not with acute infection (OR = 1.32, 95% CI = 0.98-1.78, p = 0.16). Acute infections and CB increased the risk of ischemic events in all age groups; this reached significance for patients older than 60 years. The profile of vascular risk factors was similar in patients with and without previous infections. The influenza vaccination did not prevent ischemic stroke, and it did not reduce the rate of acute previous infections in stroke patients. CONCLUSIONS: CB and infections over the previous 2 months predicted the risk of ischemic stroke. The influenza vaccination was not associated with a reduction in the incidence of stroke in our group of patients.

PMID: 18728360 [PubMed - indexed for MEDLINE]

Role of real-time three-dimensional transoesophageal echocardiography for guiding transcatheter patent foramen ovale closure.

Eur J Echocardiogr. 2009 Jan;10(1):148-50

Authors: Martin-Reyes R, López-Fernández T, Moreno-Yangüela M, Moreno R, Navas-Lobato MA, Refoyo E, Guzmán G, Domínguez-Melcón F, López-Sendón JL

Patent foramen ovale (PFO) is a relatively common congenital condition which has been implicated in cryptogenic stroke as a result of paradoxical thromboembolism by right-to-left shunting. Many studies have demonstrated that transcatheter PFO closure significantly reduced the incidence of recurrent strokes in a small group of high-risk patients with PFO and atrial septal aneurysm compared with antithrombotic drugs. Two-dimensional transoesophageal echocardiography (2D TEE) has become the election technique for guiding patent foramen ovale closure. Real-time Three-dimensional transoesophageal echocardiography (3D TEE) may be potentially superior to 2D TEE in the accurate assessment of the morphology and efficacy of transcatheter closure devices because of a better spacial orientation.

PMID: 18728098 [PubMed - indexed for MEDLINE]

A systematic review of kidney transplantation from expanded criteria donors.

Am J Kidney Dis. 2008 Sep;52(3):553-86

Authors: Pascual J, Zamora J, Pirsch JD

BACKGROUND: During the past few years, there has been renewed interest in the use of expanded criteria donors (ECD) for kidney transplantation to increase the numbers of deceased donor kidneys available. More kidney transplants would result in shorter waiting times and limit the morbidity and mortality associated with long-term dialysis therapy. STUDY DESIGN: Systematic review of the literature. SETTING & POPULATION: Kidney transplantation population. SELECTION CRITERIA FOR STUDIES: Studies were identified by using a comprehensive search through MEDLINE and EMBASE databases. Inclusion criteria were case series, cohort studies, and randomized controlled trials assessing kidney transplantation in adult recipients using ECDs. PREDICTOR: A special focus was given to studies comparing the evolution of kidney transplantation between standard criteria donors (defined as a donor who does not meet criteria for donation after cardiac death or ECD) and ECDs (defined as any brain-dead donor aged > 60 years or a donor aged > 50 years with 2 of the following conditions: history of hypertension, terminal serum creatinine level >or= 1.5 mg/dL, or death resulting from a cerebrovascular accident). OUTCOMES: Criteria used to define and select ECDs, practice patterns, long-term outcomes, early complications, and some patient issues, such as selection criteria and immunosuppressive management. RESULTS: ECD kidneys have worse long-term survival than standard criteria donor kidneys. The optimal ECD kidney for donation depends on adequate glomerular filtration rate and acceptable donor kidney histological characteristics, albeit the usefulness of biopsy is debated. LIMITATIONS: This review is based mainly on data from observational studies, and varying amounts of bias could be present. We did not attempt to quantitatively analyze the effect of ECD kidneys on kidney transplantation because of the huge heterogeneity found in study designs and definitions of ECD. CONCLUSIONS: Based on the available evidence, we conclude that patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy.

PMID: 18725015 [PubMed - indexed for MEDLINE]

Association of blood pressure and its evolving changes with the survival of patients with heart failure.

J Card Fail. 2008 Sep;14(7):561-8

Authors: Grigorian-Shamagian L, Gonzalez-JuAnatey JR, Vazquez R, Cinca J, Bayes-Genis A, Pascual D, Fernandez-Palomeque C, Bardaji A, Almendral J, Nieto V, Macaya C, Jimenez RP, de Luna AB,

OBJECTIVE: The association between low blood pressure (BP) levels and increased mortality has been established in several studies of heart failure (HF). Although many drugs administered to these patients decrease BP, the relationship between changes in BP and survival has not been investigated. Nor have previous analyses distinguished among different forms of death. We investigated the influence of baseline BP and changes in BP during a 1-year period on the survival of patients with HF, distinguishing among sudden cardiac death, nonsudden cardiac death, and noncardiac death. We also identified the possible relationship with the baseline values of and changes in other clinical and treatment variables, including pharmacologic treatments. METHOD AND RESULTS: A total of 1062 patients with chronic HF included in the Spanish National Registry of Sudden Death (mean age of 64.5 +/- 11.8 years, 72% were men, and 21% were in New York Heart Association class III with a mean left ventricular ejection fraction of 36.7% +/- 14.2%) were prospectively investigated for a mean of 1.9 +/- 0.6 years. A multivariable Cox proportional hazards model adjusting for clinical and therapeutic variables showed an independent association between low baseline systolic blood pressure (SBP) and nonsudden cardiac death (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.93-0.98), but changes in SBP during the following year did not influence survival, regardless of the baseline SBP level (P = .55). Contrariwise, baseline diastolic BP was not associated with mortality, but an increase in diastolic BP during the following year showed a borderline independent significant association with lower nonsudden cardiac death (HR 0.90, 95% CI 0.82-1.00). Treatment with angiotensin-converting enzyme inhibitors or beta-blockers at baseline was also associated with lower nonsudden cardiac mortality, as was an increase in left ventricular ejection fraction during the following year (HR 0.69, 95% CI 0.51-0.93; P = .015). CONCLUSION: Among patients with stable HF, low SBP is associated with a greater risk of nonsudden cardiac death. The change in SBP during a 1-year period has no prognostic value. Because the beneficial effects of drugs associated with increased survival (in this study, angiotensin-converting enzyme inhibitors and beta-blockers) thus seem to be independent of their effects on BP, changes in BP should probably not influence the decision to use such drugs or continue their administration.

PMID: 18722321 [PubMed - indexed for MEDLINE]

Morbidity and mortality in the catastrophic antiphospholipid syndrome: pathophysiology, causes of death, and prognostic factors.

Semin Thromb Hemost. 2008 Apr;34(3):290-4

Authors: Espinosa G, Bucciarelli S, Asherson RA, Cervera R

The catastrophic variant of the antiphospholipid syndrome (APS) is a condition characterized by multiple vascular occlusive events, usually affecting small vessels and evolving over a short period of time, together with laboratory confirmation of the presence of antiphospholipid antibodies. The pathogenesis of catastrophic APS is not completely understood. The mortality rate was ~50% in the earliest published series, but recently it has clearly fallen by some 20% due to the use, as first-line therapies, of full anticoagulation, corticosteroids, plasma exchanges, and intravenous immunoglobulins. Cerebral involvement has been identified as the main cause of death, being present in one third of patients, and consisting mainly of stroke, cerebral hemorrhage and encephalopathy, followed by cardiac involvement and infection. The only identified prognostic factor for a higher mortality rate is the presence of systemic lupus erythematosus.

PMID: 18720310 [PubMed - indexed for MEDLINE]

Acute stroke unit care and early neurological deterioration in ischemic stroke.

J Neurol. 2008 Jul;255(7):1012-7

Authors: Roquer J, Rodríguez-Campello A, Gomis M, Jiménez-Conde J, Cuadrado-Godia E, Vivanco R, Giralt E, Sepúlveda M, Pont-Sunyer C, Cucurella G, Ois A

OBJECTIVE: To evaluate the impact that monitored acute stroke unit care may have on the risk of early neurological deterioration (END), and 90-day mortality and mortality-disability. METHODS: Non-randomized prospective study with consecutive patients with acute ischemic stroke (AIS) admitted to a conventional care stroke unit (CCSU), from May 2003 to April 2005, or to a monitored acute stroke unit (ASU) from May 2005 to April 2006. END was defined as an increase in the NIHSS score >or= 4 points in the first 72 hours after admission. RESULTS: END was detected in 19.6% of patients (11.2% of patients admitted to the ASU and 23.8% to the CCSU; p<0.0001). Patients admitted to the ASU received more treatment with intravenous rtPa (13.5% versus 4.2%; p<0.0001), had a shorter length of stay (9.1 [11.0] d versus 13.1 [10.4] d; p<0.0001), lower 90-day mortality (10.2% versus 17.3%; p=0.02), and lower mortality-disability at 90-days (28.4% versus 40.2%; p=0.004) than those admitted to the CCSU. Multivariable analysis showed that ASU admission was a protector for END (OR: 0.37; 95% CI: 0.23-0.62). On admission, higher NIHSS (OR: 1.06; 95% CI: 1.03-1.10), higher glycaemia (OR: 1.003; 95% CI: 1.001-1.006), and higher systolic pressure (OR: 1.01; 95% CI: 1.002-1.017) were independent predictors of END. CONCLUSIONS: END prevention by ASU care might be a key factor contributing to better outcome and decrease of length of stay in patients admitted to monitored stroke units.

PMID: 18712428 [PubMed - indexed for MEDLINE]

Withdrawal from statins: implications for secondary stroke prevention and acute treatment.

Int J Stroke. 2008 May;3(2):85-7

Authors: Rodríguez-Yáñez M, Dávalos A, Castillo J

PMID: 18706000 [PubMed - indexed for MEDLINE]

Relationship of urinary incontinence and late-life disability: implications for clinical work and research in geriatrics.

Z Gerontol Geriatr. 2008 Aug;41(4):283-90

Authors: Coll-Planas L, Denkinger MD, Nikolaus T

The role of urinary incontinence (UI) in the disablement process model has been mainly defined according to its impact on quality of life, global wellbeing, life satisfaction, institutionalization and death, which are global outcomes of disability. Recent research focused on the "active" role of UI in the main pathway of the disablement process model, i.e. actively involved in the causes of disability. The aim of this paper is to review the complex current scientific evidence on this second active role and to define the implications for further research and for clinical work in geriatrics. The relationship between UI and disability can be classified in the following five pathways:1) UI as risk factor for functional decline and reduced physical activity through the increased risk of falls and fractures.2) Functional decline and reduced physical activity as risk factors for the onset of UI.3) Shared risk factors for UI and functional decline: white matter changes, stroke and other neurological conditions.4) UI in a unifying conceptual framework: the multifactorial etiology of geriatric syndromes.5) UI as an indicator of frailty.Understanding these pathways could improve insight into clinical, pharmacological, environmental, behavioral and rehabilitative mechanisms to define measures for the prevention and treatment of the geriatric syndromes cascade. However, research on effective interventions on these overlapping areas is still quite rare. Additionally there is an urgent need to use the standardized terminology of lower urinary tract symptoms (LUTS), established by the International Continence Society (ICS) to find a common language in disability research. To conclude, the relationship of UI and disability is evident in different pathways. Understanding these associations can have substantial implications for both clinical work and research in this area.

PMID: 18685805 [PubMed - indexed for MEDLINE]

Comparison of benefits and mortality in cardiac resynchronization therapy in patients with atrial fibrillation versus patients in sinus rhythm (Results of the Spanish Atrial Fibrillation and Resynchronization [SPARE] Study).

Am J Cardiol. 2008 Aug 15;102(4):444-9

Authors: Tolosana JM, Hernandez Madrid A, Brugada J, Sitges M, Garcia Bolao I, Fernandez Lozano I, Martinez Ferrer J, Quesada A, Macias A, Marin W, Escudier JM, Gomez AA, Gimenez Alcala M, Tamborero D, Berruezo A, Mont L,

The efficacy of cardiac resynchronization therapy (CRT) in patients with atrial fibrillation (AF) and the need for atrioventricular junction ablation in these patients is controversial. The aim of the study was to analyze CRT results in patients with permanent AF. A total of 470 consecutive patients who underwent CRT in 6 centers were included in this study. Of these patients, 126 (27%) had permanent AF. Patients were evaluated at baseline and 12 months. No difference was found in the magnitude of improvement experienced by patients with AF compared with those in sinus rhythm (SR) with respect to quality of life, distance in 6-minute walking test, and left ventricular reverse remodeling. Despite the beneficial effects of CRT, death from refractory heart failure at 12 months was higher in patients with AF (17 of 126; 13.5%) than those in SR (14/344; 4.1%; p <0,001). Furthermore, permanent AF was an independent predictive factor for mortality from refractory heart failure (hazard ratio 5.4, 95% confidence interval 1.9 to 15.1). In conclusion, patients with AF treated with CRT who survived at the 12-month follow-up had the same functional improvement and remodeling as those in SR. However, AF was an independent risk factor for mortality from heart failure after CRT implantation.

PMID: 18678303 [PubMed - indexed for MEDLINE]

European experience with Relay: a new stent graft and delivery system for thoracic and arch lesions.

J Cardiovasc Surg (Torino). 2008 Aug;49(4):407-15

Authors: Riambau V,

AIM: Thoracic endografting is a very attractive therapeutic approach for thoracic aorta pathologies. Still some technological limitations need to be solved. Relay represents a new endograft specifically designed for thoracic aorta. The two-year clinical outcomes are presented. METHODS: RESTORE is a multicenter, European, prospective and monitored clinical registry. Patients with thoracic pathologies (acute or elective) suitable to be treated with Relay stent-graft were consecutively enrolled. Preoperative demographic data, procedure details, in hospital assessment and two year-follow-up outcomes were registered and analyzed. RESULTS: A cohort of 150 patients (125 males and 25 females) was included. Aneurysm was the most common pathology treated (64.7%) followed by dissections (19.3%). Overall technical success rate was 97.33%. Paraplegia rate was 3.3%, recovered paraparesis in 3.3% of the cases and stroke rate was only 0.6%. Successful reinterventions were necessary in 8.7% of the cases; one trans-thoracic intervention due to a retrograde type A dissection. The 30-day mortality rate was 10%. Four non-related mortality were recorded during surveillance. Reintervention rate during two year-follow-up was 8.9% due to two stent graft migrations, three proximal type I endoleak, four type III endoleak and five distal type I endoleaks. No open conversion was needed during follow-up. No wire form ruptures were observed during the follow-up period. CONCLUSION: Relay provides a safe and accurate thoracic stent grafting for different aortic pathologies with acceptable mortality and morbidity. Associated stroke rate was clearly inferior to the expected.

PMID: 18665104 [PubMed - indexed for MEDLINE]

Hypertension and sleep apnea-hypopnea syndrome: changes in echocardiographic abnormalities depending on the presence of hypertension and treatment with CPAP.

Sleep Med. 2009 Mar;10(3):344-52

Authors: Moro JA, Almenar L, Fernández-Fabrellas E, Ponce S, Blanquer R, Salvador A

INTRODUCTION: Sleep apnea-hypopnea syndrome (SAHS) is an emerging disease with high prevalence. There is controversy as to whether cardiac abnormalities are due to the disease itself or to the arterial hypertension frequently associated with this disease. OBJECTIVES: To analyze echocardiographic abnormalities in a population of SAHS patients depending on the presence or absence of hypertension at the time of diagnosis and after six months of treatment with continuous positive airway pressure (CPAP). METHODS: We studied 85 consecutive patients diagnosed with SAHS who required treatment with CPAP (Hypertensive: 43, nonhypertensive: 42). We performed a baseline echocardiogram after six months of treatment. We analyzed morphological (wall thickness, diameters, ejection fraction) and functional (peak E- and A-wave velocities, deceleration time, Tei index) parameters of the left and right ventricles. RESULTS: Hypertensive patients were older and had higher blood pressure values, but there were no differences between groups in other clinical parameters. The hypertensive group had greater septal thickness (hypertensive: 12.1+/-2.3; nonhypertensive: 10.8+/-2.1mm; p=0.01). There were also differences in impairment of left (hypertensiveHT: 92.9%, nonhypertensive: 65%, p=0.002) and right (hypertensive: 74.4%, nonhypertensive: 42.1%, p=0.006) ventricular filling. After six months of treatment, an improvement of the myocardial performance index was noted in nonhypertensive patients (baseline Tei: 0.55+/-0.1 vs. 6-month Tei: 0.49+/-0.1; p=0.01), whereas no significant change was observed in hypertensive patients. CONCLUSIONS: Cardiac abnormalities in SAHS patients are increased in the presence of associated hypertension. Treatment with CPAP for six months improves cardiac abnormalities in nonhypertensive patients but not in hypertensive patients.

PMID: 18653380 [PubMed - indexed for MEDLINE]

Neurological picture. Familial Sneddon's syndrome with microbleeds in MRI.

J Neurol Neurosurg Psychiatry. 2008 Aug;79(8):962

Authors: Llufriu S, Cervera A, Capurro S, Chamorro A

PMID: 18645217 [PubMed - indexed for MEDLINE]

Higher severity of frontal periventricular white matter and basal ganglia hyperintensities in first-ever lacunar stroke with multiple silent lacunes.

Eur J Neurol. 2008 Sep;15(9):1002-5

Authors: Grau-Olivares M, Arboix A, Bartrés-Faz D, Junqué C

BACKGROUND AND PURPOSE: We investigated whether patients with a lacunar infarct (LI) syndrome exhibiting unique LI or multiple LI on magnetic resonance imaging (MRI) examinations differed in terms of topography and severity of white matter hyperintensities (WMH) ratings. METHODS: Forty consecutive patients with a first-ever acute LI, who presented a lacunar syndrome according to Miller-Fisher's classification were recruited and were classified into a group presenting isolated LI on MRI (n = 17) or multiple LI (n = 23). RESULTS: Despite equivalent demographic, clinical and cognitive characteristics, patients with multiple LI had increased ratings of WMH in frontal, occipital and subcortical regions. No significant correlations could be evidenced between the number of LI and WMH ratings. CONCLUSIONS: Present findings provide support to previous hypothesis considering single and multiple LI MRI presentations of lacunar infarct patients as distinct entities.

PMID: 18637825 [PubMed - indexed for MEDLINE]

In-hospital stroke treated with intravenous tissue plasminogen activator.

Stroke. 2008 Sep;39(9):2614-6

Authors: Masjuan J, Simal P, Fuentes B, Egido JA, Díaz-Otero F, Gil-Núñez A, Novillo-López ME, Díez-Tejedor E, Alonso de Leciñana M

BACKGROUND AND PURPOSE: In-hospital strokes (IHSs) are potential candidates for thrombolysis. We analyzed the treatment procedures, safety, and efficacy of intravenous tissue plasminogen activator (IV-tPA) in IHSs compared with out-of-hospital strokes (OHSs). METHODS: This study was based on a multicenter prospective registry of patients treated with IV-tPA divided into IHSs and OHSs. We recorded intrahospital delays and stroke outcomes. RESULTS: Among 367 patients treated with IV-tPA, 30 were IHSs. Baseline characteristics were similar except for a greater proportion of diabetes (36.7% vs 17.5%, P=0.01), cardiac failure (16.7% vs 5.3%, P=0.014), and atrial fibrillation (33.3% vs 17.5%, P=0.034) in IHSs than OHSs. In-hospital delays were significantly longer in IHSs for door-to-computed tomography time (39.5+/-18.7 vs 22.6+/-19.7 minutes, P<0.0001) and computed tomography-to-treatment time (92.0+/-26.1 vs 65.4+/-25.8 minutes, P<0.0001). No differences were observed in safety or efficacy. CONCLUSIONS: In-hospital procedures for thrombolysis proceed more slowly in IHSs than in OHSs. Thrombolysis is safe and efficient in IHS.

PMID: 18635852 [PubMed - indexed for MEDLINE]

Metabolic syndrome and resistance to IV thrombolysis in middle cerebral artery ischemic stroke.

Neurology. 2008 Jul 15;71(3):190-5

Authors: Arenillas JF, Ispierto L, Millán M, Escudero D, Pérez de la Ossa N, Dorado L, Guerrero C, Serena J, Castillo J, Dávalos A

OBJECTIVE: The metabolic syndrome (MetS) is a cluster of vascular risk factors associated with a prothrombotic state. We aimed to evaluate the impact of MetS on the response to systemic tPA treatment in patients with acute middle cerebral artery (MCA) ischemic stroke. METHODS: We studied 100 consecutive patients with ischemic stroke with MCA occlusions on prebolus transcranial Doppler (TCD) examination treated with tPA following SITS-MOST criteria. MetS was diagnosed following AHA/NHLBI-2005 criteria. Resistance to thrombolysis was defined as the absence of TCD-assessed complete MCA recanalization 24 hours after tPA infusion. Infarct volume was measured on CT scans. Long-term clinical outcome was evaluated by the modified Rankin scale (mRS) score at day 90. RESULTS: Fifty-eight (58%) patients fulfilled MetS criteria. Median prebolus NIH Stroke Scale score was 17. Forty (42%) patients showed resistance to clot dissolution, and 53 (53%) had poor clinical outcomes (mRS > 2). A multivariable-adjusted logistic regression model identified MetS as independently associated with resistance to thrombolysis (OR 4.7, 95% CI [1.7-13.6], p = 0.004). In the whole sample, MetS was associated with mRS > 2 (OR 2.4 [1.1-5.4], p = 0.03), although this association was no longer significant after multivariable adjustment. However, in patients with atherothrombotic stroke, MetS emerged as an independent predictor of poor long-term outcome (adjusted OR 13.9 [1.3-148.7], p = 0.02). CONCLUSION: In our series, the metabolic syndrome was associated with a poor response to thrombolysis in patients with acute middle cerebral artery occlusions, as reflected by a higher resistance to clot dissolution.

PMID: 18625965 [PubMed - indexed for MEDLINE]

Risk of cardiovascular and cerebrovascular events after atrial fibrillation diagnosis.

Int J Cardiol. 2009 Aug 14;136(2):186-92

Authors: Ruigómez A, Johansson S, Wallander MA, Edvardsson N, García Rodríguez LA

BACKGROUND: Atrial fibrillation (AF) is associated with subsequent cardiovascular events including ischemic stroke, transient ischemic events, and coronary events. This study aimed to evaluate the risk of ischemic cerebrovascular events (ICVE), coronary events (CE) or heart failure (HF) following a diagnosis of AF. METHODS: Patients were selected from the UK General Practice Research Database. The incidence of ICVE, CE and HF was determined during a 6-year follow-up period for patients with a first diagnosis of AF (n=831) and a control group without AF (n=8226). Relative risk of developing a cardiovascular event associated with prior AF and other potential risk factors was estimated using Cox regression analysis. RESULTS: A first diagnosis of ICVE, CE or HF was made in 261 patients in the AF group and 622 in the control group. The relative risks associated with AF were 2.1 for CE (95% CI: 1.6-2.9), 3.0 for ICVE (95% CI: 2.3-4.0) and 6.4 for HF (95% CI: 5.0-8.3). The risks of CE, HF and ICVE were higher in patients with chronic AF than paroxysmal AF (odds ratio: 1.5, 95% CI: 1.0-2.2) and in patients aged at least 60 years or with diabetes. Lifestyle factors did not significantly affect the risk of cardiovascular events in patients with AF. CONCLUSIONS: After a first episode of AF there is an increased risk of ICVE, CE and HF. Patients initially diagnosed with chronic AF have a higher risk than those with paroxysmal AF.

PMID: 18625526 [PubMed - indexed for MEDLINE]

Harms and benefits of lymphocyte subpopulations in patients with acute stroke.

Neuroscience. 2009 Feb 6;158(3):1174-83

Authors: Urra X, Cervera A, Villamor N, Planas AM, Chamorro A

Lymphocytes are major players in the development of innate and adaptive immune responses but their behavior in patients with acute stroke has received little attention. EXPERIMENTAL PROCEDURES: Using flow cytometry we identified total lymphocytes, T cells, helper T (Th) cells, cytotoxic T lymphocytes (CTL), natural killer (NK) cells, B cells, and regulatory T (Treg) cells in 46 consecutive patients with acute stroke within a median of 180 min of clinical onset, and at days 2, 7, and 90. Daily neurological score (National Institutes of Health Stroke Scale), diffusion-weighted imaging on brain magnetic resonance imaging, functional impairment, and stroke-associated infection (SAI) at day 7 were assessed. Apoptosis in lymphocyte subsets, tumor necrosis factor (TNF) -alpha/interleukin (IL) -4 production in stimulated Th and CTL, cluster of differentiation 86 (CD86) (B7-2) expression in B cells, cortisol and metanephrine in serum were measured. Multivariate analyses were used to evaluate SAI, and stroke outcome. RESULTS: Increased apoptosis and a fall of T, Th, CTL, B, and Treg cells were observed after stroke. Severer stroke on admission and SAI disclosed a greater decline of T, Th, and CTL cells. Increased cortisol and metanephrine was associated with severe stroke and SAI, and inversely correlated with T, and CTL. T cells, and CTL were correlated with infarct growth. Stroke but not SAI resulted in lower TNF-alpha production in Th cells. SAI showed the greatest fall of lymphocytes, T, Th, and CTL, but not B cells, or Treg. Poor outcome was associated with reduced levels of B cells, and increased expression of CD86 in B cells, but not with SAI. CONCLUSION: Lymphopenia and increased apoptosis of T, Th, CTL, Treg and B cells are early signatures after human stroke. A decreased cellular response after stroke is a marker of ongoing brain damage, the stress response, and a higher risk of infection. A lower humoral response is predictor of poorer long-term outcome.

PMID: 18619524 [PubMed - indexed for MEDLINE]

Morbidity and mortality among heart failure patients in Galicia, N.W. Spain: the GALICAP Study.

Int J Cardiol. 2009 Jul 24;136(1):56-63

Authors: Otero-Raviña F, Grigorian-Shamagian L, Fransi-Galiana L, Názara-Otero C, Fernández-Villaverde JM, del Alamo-Alonso A, Nieto-Pol E, de Santiago-Boullón M, López-Rodríguez I, Cardona-Vidal JM, Varela-Román A, González-Juanatey JR,

OBJECTIVE: Characterization of current morbidity and mortality among heart failure (HF) outpatients in Galicia (N.W. Spain), together with their main determinants. DESIGN: Prospective multicentre study involving 149 primary care physicians. SETTING: Primary care physicians selected randomly from among all (1959) primary care physicians in Galicia. PATIENTS: Clinical and epidemiological information for 1195 outpatients with HF were collected in 2006, with a mean follow-up of 6.5+/-1.5 months. MAIN OUTCOME MEASURES: Survival rates were calculated by Cox's proportional hazard model. RESULTS: Mean patient age was 76 years, 48% were male, 82% had a history of arterial hypertension, and 32% ischaemic cardiopathy. Echocardiography had been performed in 67%, showing preserved systolic function in 61%. Ninety-two (8%) died during follow-up [74 (80%) of them from cardiac causes], and 313 (29%) were re-admitted to hospital [230 (73%) of them for cardiac reasons]. Multivariate analysis identified the following independent predictors of cardiovascular death and/or readmission: ischaemic cardiopathy [hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.29-4.40], stroke (HR 1.79, CI 1.18-2.73), oedema (HR 1.49, CI 1.10-2.03), anaemia (HR 1.66, CI 1.21-2.27), deteriorated systolic function (HR 1.62, CI 1.19-2.20), and previous cardiovascular admissions (HR 2.33, CI 1.67-3.24). Residence in the Barbanza district was identified as an independent predictor of survival free from cardiovascular admission (HR 0.56, CI 0.37-0.86). CONCLUSION: Morbidity and mortality are currently high among Galician HF patients, and their best single predictor is previous hospitalization for cardiovascular reasons.

PMID: 18617282 [PubMed - indexed for MEDLINE]

Metabolic challenge to glia activates an adenosine-mediated safety mechanism that promotes neuronal survival by delaying the onset of spreading depression waves.

J Cereb Blood Flow Metab. 2008 Nov;28(11):1835-44

Authors: Canals S, Larrosa B, Pintor J, Mena MA, Herreras O

In a model of glial-specific chemical anoxia, we have examined how astrocytes influence both synaptic transmission and the viability of hippocampal pyramidal neurons. This relationship was assessed using electrophysiological, pharmacological, and biochemical techniques in rat slices and cell cultures, and oxidative metabolism was selectively impaired in glial cells by exposure to the mitochondrial gliotoxin, fluoroacetate. We found that synaptic transmission was blocked shortly after inducing glial metabolic stress and peri-infarct-like spreading depression (SD) waves developed within 1 to 2 h of treatment. Neuronal electrogenesis was not affected until SD waves developed, thereafter decaying irreversibly. The blockage of synaptic transmission was totally reversed by A(1) adenosine receptor antagonists, unlike the development of SD waves, which appeared earlier under these conditions. Such blockage led to a marked reduction in the electrical viability of pyramidal neurons 1 h after gliotoxin treatment. Cell culture experiments confirmed that astrocytes indeed release adenosine. We interpret this early glial response as a novel safety mechanism that allocates metabolic resources to vital processes when the glia itself sense an energy shortage, thereby delaying or preventing entry into massive lethal ischemic-like depolarization. The implication of these results on the functional recovery of the penumbra regions after ischemic insults is discussed.

PMID: 18612316 [PubMed - indexed for MEDLINE]

Factor VII -323 decanucleotide D/I polymorphism in atrial fibrillation: implications for the prothrombotic state and stroke risk.

Ann Med. 2008;40(7):553-9

Authors: Roldán V, Marín F, González-Conejero R, García-Honrubia A, Martí S, Alfaro A, Valdés M, Corral J, Lip GY, Vicente V

There are limited data on the influence of genetic polymorphisms in atrial fibrillation (AF) stroke risk. We hypothesized that a functional haemostatic polymorphism, that is, the factor VII -323 Del/Ins polymorphism, would influence the prothrombotic state associated with AF, as well as stroke risk. Other functional polymorphisms were also tested. METHODS: We performed a cross-sectional study of 119 AF patients, who were compared to 96 patients with stroke secondary to AF. In the first patient group, we analysed plasma prothrombin fragment 1+2 levels (F1+2, an index of thrombin generation) to reflect the prothrombotic state of AF. RESULTS: AF patients carrying the -323 Ins allele had lower plasma F1+2 levels (P=0.015). After multivariate analysis adjusted by age, sex and clinical risk factors, advanced age and 807C/T polymorphism of glycoprotein Ia (GPIa) gene were associated with higher risk of ischaemic stroke (OR: 1.06; P=0.003 and OR: 1.91; P=0.025), whilst FVII Ins -323 allele was associated with lower stroke risk (OR: 0.41; P=0.017). CONCLUSION: FVII -323 Ins allele may modulate the prothrombotic state associated with AF. Despite the small sample size, we found that FVII Ins -323 allele could be associated with a lower stroke risk in AF, whereas the 807C/T polymorphism may increase the risk.

PMID: 18608122 [PubMed - indexed for MEDLINE]