Inpatient and Outpatient Infection as a Trigger of Cardiovascular Disease: The ARIC Study

Background Acute infections are known cardiovascular disease (CVD) triggers, but little is known regarding how CVD risk varies following inpatient versus outpatient infections. We hypothesized that in‐ and outpatient infections are associated with CVD risk and that the association is stronger for inpatient infections. Methods and Results Coronary heart disease (CHD) and ischemic stroke cases were identified and adjudicated in the ARIC (Atherosclerosis Risk in Communities Study). Hospital discharge diagnosis codes and Medicare claims data were used to identify infections diagnosed in in‐ and outpatient settings. A case‐crossover design and conditional logistic regression were used to compare in‐ and outpatient infections among CHD and ischemic stroke cases (14, 30, 42, and 90 days before the event) with corresponding control periods 1 and 2 years previously. A total of 1312 incident CHD cases and 727 incident stroke cases were analyzed. Inpatient infections (14‐day odds ratio [OR]=12.83 [5.74, 28.68], 30‐day OR=8.39 [4.92, 14.31], 42‐day OR=6.24 [4.02, 9.67], and 90‐day OR=4.48 [3.18, 6.33]) and outpatient infections (14‐day OR=3.29 [2.50, 4.32], 30‐day OR=2.69 [2.14, 3.37], 42‐day OR=2.45 [1.97, 3.05], and 90‐day OR=1.99 [1.64, 2.42]) were more common in all CHD case periods compared with control periods and inpatient infection was a stronger CHD trigger for all time periods (P Conclusions In‐ and outpatient infections are associated with CVD risk. Patients with an inpatient infection may be at particularly elevated CVD risk and should be considered potential candidates for CVD prophylaxis

Hospitalized Infection as a Trigger for Acute Ischemic Stroke

Acute triggers for ischemic stroke, which may include infection, are understudied, as is whether background cardiovascular disease (CVD) risk modifies such triggering. We hypothesized that infection increases acute stroke risk, especially among those with low CVD risk

Outcome of the ‘Drip-and-Ship’ Paradigm among Patients with Acute Ischemic Stroke: Results of a Statewide Study

www.karger.com/cee This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable to the online version of the article only. Distribution for non-commercial purposes only.

Comparison of Cardiovascular Risk Factors for Coronary Heart Disease and Stroke Type in Women

Background Cardiovascular risk factors have differential effects on various manifestations of cardiovascular disease, but to date direct formal comparisons are scarce, have been conducted primarily in men, and include only traditional risk factors. Methods and Results Using data from the multi-ethnic Women's Health Initiative Observational Study, we used a case-cohort design to compare 1731 women with incident cardiovascular disease during follow-up to a cohort of 1914 women. The direction of effect of all 24 risk factors (including various apolipoproteins, hemoglobin A1c, high-sensitivity C-reactive protein, N-terminal pro-brain natriuretic peptide, and tissue plasminogen activator antigen) was concordant for coronary heart disease (CHD, defined as myocardial infarction and CHD death) and ischemic stroke; however, associations were generally stronger with CHD. Significant differences for multiple risk factors, including blood pressure, lipid levels, and measures of inflammation, were observed when comparing the effects on hemorrhagic stroke with those on ischemic outcomes. For instance, multivariable adjusted hazard ratios per standard deviation increase in non-high-density lipoprotein cholesterol were 1.16 (95% confidence interval, 1.06-1.28) for CHD, 0.97 (0.88-1.07) for ischemic stroke, and 0.76 (0.63-0.91) for hemorrhagic stroke ( P<0.05 for equal association). Model discrimination was better for models predicting CHD or ischemic stroke than for models predicting hemorrhagic stroke or a combined end point. Conclusions Cardiovascular risk factors have largely similar effects on incidence of CHD and ischemic stroke in women, although the magnitude of association varies. Determinants of ischemic and hemorrhagic stroke substantially differ, underscoring their distinct biology. Cardiovascular disease risk may be more accurately reflected when combined cardiovascular disease or cerebrovascular outcomes are broken down into different first manifestations, or when restricted to ischemic outcomes

Rare and Coding Region Genetic Variants Associated With Risk of Ischemic Stroke: The NHLBI Exome Sequence Project

Stroke is the second leading cause of death and the third leading cause of years of life lost. Genetic factors contribute to stroke prevalence, and candidate gene and genome-wide association studies (GWAS) have identified variants associated with ischemic stroke risk. These variants often have small effects without obvious biological significance. Exome sequencing may discover predicted protein-altering variants with a potentially large effect on ischemic stroke risk

Recurrent orthostatic numbness with carotid stenosis and beta-blocker use

Results:The episodes began when the patient was placed on twice a day 50 mg dose of Lopresor. The patient presented with stereotypic, recurrent, transient numbness involving his entire right arm. Every such episode occurred on changing from a supine or sitting posture into an upright one, lasted less than a minute in duration, and resolved rapidly when the patient became supine again. They increased in frequency when the dose was increased first to 75 mg twice a day and then to 100 mg twice a day, with the patient having daily episodes on admission. Lopresor was discontinued and the patient\u27s symptoms resolved.AdverseEffects:1 patient had recurrent orthostatic numbness.AuthorsConclusions:Anti-hypertensive medications can uncover otherwise asymptomatic carotid disease and alter the course of patient management by precipitating surgical intervention. Conversely, one could argue that these medications should be used cautiously in patients with known high-grade stenosis even in the absence of significant orthostatic hypotension. The TIA [transient ischemic attack] reported here is a classical example of a perfusion failure TIA. These TIAs are frequently associated with severe carotid stenosis and signify distal insufficiency.FreeText:The patient\u27s admission orthostatic measurements were: supine blood pressure (BP) 117/69, pulse 63; standing BP 108/61, pulse 59. Subsequent orthostatic measurements were: supine BP 142/82, pulse 69; standing BP 139/84, pulse 84. Brain magnetic resonance imaging was unremarkable. Ultrasound showed high-grade stenosis of the left internal carotid artery (ICA). Intracranial magnetic resonance angiogram showed stenosis of the A1 segment of the left anterior cerebral artery (ACA). Cerebral angiogram confirmed severe stenosis of the left ICA with a string sign. The left sided injection filled very few branches of the left middle cerebral artery. The left ACA filled from the right via the anterior communicating artery.Patients:1 patient, a 59 year old man. Dropout due to side effect.TypeofStudy:Recurrent orthostatic numbness associated with Lopresor. A case report.DosageDuration:50 mg bid (=100 mg daily) increased first to 75 mg bid (=150 mg daily) and then to 100 mg bid (=200 mg daily). Duration not stated

Trajectories of Engagement in Leisure-time Physical Activity and Risk of Incident Ischemic Stroke: The Atherosclerosis Risk in Communities Study

Introduction: Engagement in leisure-time physical activity (PA) levels recommended by the American Heart Association (AHA) is inversely associated with ischemic stroke risk. PA level can fluctuate over time but the association between PA fluctuations and ischemic stroke risk is unknown. The extent that ischemic stroke risk could be attenuated by increasing PA among those who are inactive could inform stroke prevention. Hypothesis: We hypothesize that participants who remained active or increased their PA levels will have lower ischemic stroke risk relative to those who were persistently inactive. Methods: We included 12,611participants of the Atherosclerosis Risk in Communities (ARIC) cohort study ages 45-64 at visit 1 (1987-1989) who did not have a history of stroke at visit 3 (1993-1995). Leisure-time PA was assessed using the modified Baecke questionnaire at visits 1 and 3 and categorized according to the AHA guidelines for PA (ideal, intermediate, or poor). All adjudicated definite and probable incident ischemic strokes between visit 3 and end of year 2013 were included. Cox-proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ischemic stroke by cross-categories of PA at visits 1 and 3 using those with poor PA at both visits as the referent group. We adjusted for age, sex, race/center, smoking status, and alcohol intake at visit 3. Results: During a median of 18.6 years of follow-up, 777 incident ischemic stroke events occurred. Compared with those with poor PA at visits 1 and 3, participants with ideal PA at both visits had the lowest ischemic stroke risk (HR=0.64, 0.51, 0.80). Those whose PA increased from poor to ideal also had significantly lower ischemic stroke risk (HR = 0.70, 0.53, 0.94). Conclusion: Sustained ideal PA was associated with the lowest ischemic stroke risk. Increasing PA between visit 1 and visit 3 was also associated with significantly lower ischemic stroke risk. Increasing PA may be an important component of stroke prevention