Factors influencing employment after minor stroke and NSTEMI

Aim: To study the effect of cognitive function, fatigue and emotional symptoms on employment after a minor ischemic stroke compared to non-ST-elevation myocardial infarction (NSTEMI). Material and methods: We included 217 patients with minor ischemic stroke and 133 NSTEMI patients employed at baseline aged 18–70 years. Minor stroke was defined as modified Rankin scale (mRS) 0–2 at day seven or at discharge if before. Included NSTEMI patients had the same functional mRS. We applied a selection of cognitive tests and the patients completed questionnaires measuring symptoms of anxiety, depression and fatigue at follow up. Stroke patients were tested at three and 12 months and NSTEMI at 12 months. Results: The patients still employed at 12 monthswere significantly younger than the unemployed patients and the NSTEMI patients employed were significantly older than the stroke patients (59 vs 55 years, p < .001). In total, 82 % of stroke patients and 90 % of the NSTEMI patients employed at baseline were still employed at 12 months (p = 06). Stroke patients at work after 12 months had higher education than unemployed patients. There were no difference between employed and unemployed patients in risk factors or location of cerebral ischemic lesions. Cognitive function did not change significantly in the stroke patients from three to 12 months. For stroke patients, we found a significant association between HADS-depression and unemployment at 12 months (p = 04), although this association was not present at three months. Lower age and higher educational level were associated with employment at 12 months for all patients. Discussion and conclusion: Age and education are the main factors influencing the ability to stay in work after a minor stroke. Employed stroke patients were younger than the NSTEMI patients, but there was no difference in the frequencies in remaining employed. The employment rate at 12 months was high despite the relatively high prevalence of cognitive impairment in both groups.publishedVersio

Use of lipid-lowering therapy after ischaemic stroke and expected benefit from intensification of treatment

Objectives Elevated low-density lipoprotein cholesterol (LDL-C) increases the risk of recurrent cardiovascular disease (CVD) events. We examined use of lipid-lowering therapy (LLT) following ischaemic stroke, and estimated benefits from guideline-based up-titration of LLT. Methods The Norwegian COgnitive Impairment After STroke (Nor-COAST) study, a multicentre prospective cohort study, collected data on LLT use, dose intensity and LDL-C levels for 462 home-dwelling patients with ischaemic stroke. We used the Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health (SMART-REACH) model to estimate the expected benefit of up-titrating LLT. Results At discharge, 92% received LLT (97% statin monotherapy). Patients with prestroke dementia and cardioembolic stroke aetiology were less likely to receive LLT. Older patients (coefficient -3 mg atorvastatin per 10 years, 95% CI -6 to -0.5) and women (coefficient -5.1 mg atorvastatin, 95% CI -9.2 to -0.9) received lower doses, while individuals with higher baseline LDL-C, ischaemic heart disease and large artery stroke aetiology received higher dose intensity. At 3 months, 45% reached LDL-C ≤1.8 mmol/L, and we estimated that 81% could potentially reach the target with statin and ezetimibe, resulting in median 5 (IQR 0-12) months of CVD-free life gain and median 2% 10-year absolute risk reduction (IQR 0-4) with large interindividual variation. Conclusion Potential for optimisation of conventional LLT use exists in patients with ischaemic stroke. Awareness of groups at risk of undertreatment and objective estimates of the individual patient's benefit of intensification can help personalise treatment decisions and reduce residual cholesterol risk. Trial registration number NCT02650531

Prevalence and incidence rates of atrial fibrillation in Norway 2004-2014

Objective: To study time trends in incidence of atrial fibrillation (AF) in the entire Norwegian population from 2004 to 2014, by age and sex, and to estimate the prevalence of AF at the end of the study period. Methods: A national cohort of patients with AF (≥18 years) was identified from inpatient admissions with AF and deaths with AF as underlying cause (1994–2014), and AF outpatient visits (2008–2014) in the Cardiovascular Disease in Norway (CVDNOR) project. AF admissions or out-of-hospital death from AF, with no AF admission the previous 10 years defined incident AF. Age-standardised incidence rates (IR) and incidence rate ratios (IRR) were calculated. All AF cases identified through inpatient admissions and outpatient visits and alive as of 31 December 2014 defined AF prevalence. Results: We identified 175 979 incident AF cases (30% primary diagnosis, 69% secondary diagnosis, 0.6% out-of-hospital deaths). AF IRs (95% confidence intervals) per 100 000 person years were stable from 2004 (433 (426–440)) to 2014 (440 (433–447)). IRs were stable or declining across strata of sex and age with the exception of an average yearly increase of 2.4% in 18–44 year-olds: IRR 1.024 (1.014–1.034). In 2014, the prevalence of AF in the adult population was 3.4%. Conclusions: We found overall stable IRs of AF for the adult Norwegian population from 2004 to 2014. The prevalence of AF was 3.4% at the end of 2014, which is higher than reported in previous studies. Signs of an increasing incidence of early-onset AF (<45 years) are worrying and need further investigation.publishedVersio

Is long-bout sedentary behaviour associated with long-term glucose levels 3 months after acute ischaemic stroke? A prospective observational cohort study

Background and purpose Sedentary behaviour is a risk factor for vascular disease and stroke patients are more sedentary than their age-matched peers. The association with glucose levels, as a potential mediator, is unclear, and we have investigated the association between long-bout sedentary behaviour and long-term glucose levels in stroke survivors. Methods This study uses data from the Norwegian Cognitive Impairment After Stroke study, a multicentre cohort study. The patients were recruited at hospital admission for acute stroke, and the follow-up was done at the outpatient clinic. Sedentary behaviour—being in a sitting or reclining position—was registered 3 months after stroke using position transition data from the body-worn sensor activPAL attached to the unaffected thigh. A MATLAB script was developed to extract activity data from 08:00 to 10:00 for 4 days and to categorise the data into four bout-length categories. The primary outcome was glycated haemoglobin (HbA1c), analysed at 3 months. Regression models were used to analyse the association between HbA1c and sedentary behaviour in the whole population and stratified based on a diagnosis of diabetes mellitus (DM). Age, body mass index and the use of antidiabetic drugs were added as covariates into the models. Results From a total of 815 included patients, 379 patients fulfilled the inclusion criteria for this study. We found no association between time in sedentary behaviour and HbA1c in the whole stroke population. We found time in sedentary behaviour in bouts of ≥90 min to be associated with a higher HbA1c in patients with DM. Conclusion Long-bout sedentary time is associated with a higher HbA1c in patients with DM 3 months after ischaemic stroke. Future research should investigate the benefit of breaking up sedentary time as a secondary preventive measure.publishedVersio

Plasma Inflammatory Biomarkers Are Associated With Poststroke Cognitive Impairment: The Nor-COAST Study

Background: Inflammation is proposed to be involved in the pathogenesis of poststroke cognitive impairment. The aim of this study was to investigate associations between concentrations of systemic inflammatory biomarkers after ischemic stroke and poststroke cognitive impairment. Methods: The Nor-COAST study (Norwegian Cognitive Impairment After Stroke) is a prospective observational multicenter cohort study, including patients hospitalized with acute stroke between 2015 and 2017. Inflammatory biomarkers, including the TCC (terminal C5b-9 complement complex) and 20 cytokines, were analyzed in plasma, collected at baseline, 3-, and 18 months poststroke, using ELISA and a multiplex assay. Global cognitive outcome was assessed with the Montreal Cognitive Assessment (MoCA) scale. We investigated the associations between plasma inflammatory biomarkers at baseline and MoCA score at 3-, 18-, and 36-month follow-ups; the associations between inflammatory biomarkers at 3 months and MoCA score at 18- and 36-month follow-ups; and the association between these biomarkers at 18 months and MoCA score at 36-month follow-up. We used mixed linear regression adjusted for age and sex. Results: We included 455 survivors of ischemic stroke. Higher concentrations of 7 baseline biomarkers were significantly associated with lower MoCA score at 36 months; TCC, IL (interleukin)-6, and MIP (macrophage inflammatory protein)-1α were associated with MoCA at 3, 18, and 36 months (P<0.01). No biomarker at 3 months was significantly associated with MoCA score at either 18 or 36 months, whereas higher concentrations of 3 biomarkers at 18 months were associated with lower MoCA score at 36 months (P<0.01). TCC at baseline and IL-6 and MIP-1α measured both at baseline and 18 months were particularly strongly associated with MoCA (P<0.01). Conclusions: Higher concentrations of plasma inflammatory biomarkers were associated with lower MoCA scores up to 36 months poststroke. This was most pronounced for inflammatory biomarkers measured in the acute phase following stroke.publishedVersio

Hospital readmission within 10 years post stroke: frequency, type and timing

Abstract Background The aim of this study was to examine the hospital readmissions in a 10 year follow-up of a stroke cohort previously studied for acute and subacute complications and to focus on their frequency, their causes and their timing. Methods The hospital records of 243 patients, 50% of a cohort of 489 patients acutely and consecutively admitted to our stroke unit in 2002/3, were subjected to review 10 years after the incidental stroke and all acute admissions were examined. The main admitting diagnoses were attributed to one of 18 predefined categories of illness. Additionally, the occurrence of death was registered. Results After 10 years 68.9% of patients had died and 72.4% had been readmitted to the hospital with a mean number of readmissions of 3.4 (+15.1 SD). 20% of the readmissions were due to a vascular cause, 17.3% were caused by infection, 9.3% by falls with (6.1%) and without fracture, 5.7% by a hemorrhagic event. The readmission rate was highest in the first 6 months post stroke with a rate of 116.2 admissions/100 live patient-years. Falls with fractures occurred maximally 3–5 years post stroke. Conclusions Hospital readmissions over the 10 years following stroke are caused by vascular events, infections, falls and hemorrhagic events, where the first 6 months are a period of particular vulnerability. The magnitude and the spectrum of these long-term complications suggest the need for a more comprehensive approach to post stroke prophylaxis

Mechanisms, predictors and clinical impact of early neurological deterioration: the protocol of the Trondheim early neurological deterioration study

Background: 10-40% of patients with acute ischemic stroke (AIS) suffer an early neurological deterioration (END), which may influence their long term prognosis. Multiple definitions of END exist, even in recently published papers. In the search for causes, various biochemical, clinical, and imaging markers have been found to be associated to END after AIS in some but not in other studies. The primary aim of this study is to assess the contribution of END to functional level at 3 months post stroke measured by modified Rankin Scale (mRS). Secondary aims are to identify factors and mechanisms associated with END and to define the prevalence, degree and timing of END in relation to stroke onset, and to compare Scandinavian Stroke Scale (SSS) and National Institute of Health Stroke Scale (NIHSS) based END-definitions. We hypothesized that END detected by changes in NIHSS and SSS (according to previously published criteria) at a threshold of 2 points indicate worsened prognosis, and that SSS is not inferior to NIHSS in predicting such a change. We further hypothesized that clinical deterioration has several causes, including impaired physiological homeostasis, vascular pathology, local effects and reactions secondary to the ischemic lesion, along with biochemical disturbances. Methods: Single-centre prospective observational study. Participants: Previously at home-dwelling patients admitted to our stroke unit within 24 hours after ictus of AIS are included into the study, and followed for 3 months. They are managed according to current procedures and national guidelines. A total of 368 patients are included by the end of the enrolment period (December 31st 2013), and the material will be opened for analysis by June 30th 2014. Frequent neurological assessments, continuous monitoring, and repeated imaging and blood samples are performed in all patients in order to test the hypotheses. Discussion: Strengths and weaknesses of our approach, along with reasons for the methods chosen in this study are discussed