In-Stent CTO Percutaneous Coronary Intervention: Individual Patient Data Pooled Analysis of 4 Multicenter Registries

OBJECTIVES: The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs). BACKGROUND: The outcomes of PCI for ISR CTOs have received limited study. METHODS: The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. RESULTS: ISR represented 15% of the CTOs (n = 1,755). Patients with ISR CTOs had higher prevalence of diabetes (44% vs. 38%; p \u3c 0.0001) and prior coronary artery bypass graft surgery (27% vs. 24%; p = 0.03). Mean J-CTO (Multicenter CTO Registry in Japan) score was 2.32 ± 1.27 in the ISR group and 2.22 ± 1.27 in the de novo group (p = 0.01). Technical (85% vs. 85%; p = 0.75) and procedural (84% vs. 84%; p = 0.82) success was similar for ISR and de novo CTOs, as was the incidence of in-hospital MACE (1.7% vs. 2.2%; p = 0.25). Antegrade wiring was the most common successful strategy, in 70% of ISR and 60% of de novo CTOs, followed by retrograde crossing (16% vs. 23%) and antegrade dissection and re-entry (15% vs. 16%; p \u3c 0.0001). At 12 months, patients with ISR CTOs had a higher incidence of MACE (hazard ratio: 1.31; 95% confidence intervals: 1.01 to 1.70; p = 0.04). CONCLUSIONS: ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospital MACE as de novo CTOs

Long-term prognosis of combined chronic heart failure and chronic renal dysfunction after acute stroke

Aims To assess the prevalence of combined chronic heart failure and chronic renal dysfunction (CHF-CRD) in acute stroke patients and to investigate any prognostic significance on long-term outcome.Methods and resultsFirst-ever acute stroke patients (n = 831) were divided into four groups based on the presence of heart failure (HF, NYHA II-IV with or without left ventricular ejection fraction <40) and/or renal dysfunction (RD, estimated glomerular filtration rate <60 mL/min/1.73 m 2). Patients with acute kidney injury and/or acute decompensated HF were excluded. Group 1 comprised patients without HF or RD (nHF + nRD), Group 2 patients with RD but no HF (nHF + RD), Group 3 those with HF and no RD (HF + nRD), whereas Group 4 included patients with both HF and RD (HF + RD). HF and RD were independent predictors of mortality at 10 years. Patients in Groups 2, 3, and 4 had an increased probability of death during follow-up compared with Group 1: HR 1.34 (95 CI 1.02-1.77, P < 0.05) for group 2; HR 2.24 (95 CI 1.50-3.36, P < 0.001) for group 3; and HR 3.42 (95 CI 2.36-4.95, P < 0.001) for group 4. Age, history of transient ischaemic attacks and combined HF and RD were independent predictors of new cardiovascular events. When compared with Group 1, patients in Group 2 had an HR of 1.48 (95 CI 1.11-1.98, P < 0.01), those in Group 3 an HR of 2.21 (95 CI 1.48-3.29, P < 0.001), and those in Group 4 an HR of 3.59 (95 CI 2.40-5.39, P < 0.001).ConclusionThe combination of CHF-CRD after acute stroke is an independent predictor for mortality and new cardiovascular morbidity over 10 years. © 2010 The Author

The Pathophysiological Mechanism Is an Independent Predictor of Long-Term Outcome in Stroke Patients with Large Vessel Atherosclerosis

Background: Etiopathological mechanisms underlying ischemic stroke play a crucial role in long-term prognosis. We aimed to investigate the association between the mechanism of stroke due to large vessel disease, and long-term outcome. Methods: All consecutive patients registered in the Athens Stroke Registry with atherosclerotic stroke between 1993 and 2010 were included in the analysis. The patients were subdivided into 3 groups according to the presumed underlying mechanism: low-flow infarcts, artery-to-artery embolism, and intrinsic atherosclerosis. They were followed up for up to 10 years or until death. The end points of the study were 10-year all-cause mortality, stroke recurrence, and composite cardiovascular events. Results: Five hundred two patients were classified as follows: 156 (31%) as low-flow (watershed) strokes, 256 (51%) as artery-to-artery embolic strokes, and 90 (18%) as intrinsic atherosclerotic strokes. The cumulative probability of 10-year mortality rate was similar between groups of patients with different stroke mechanisms: 49.9% (95% confidence interval [CI], 38.5-61.3) for patients with low-flow mechanism, 47.6% (95% CI, 39.4-55.8) for patients with artery-to-artery embolism, and 48.5% (95% CI, 34.0-63.0) for patients with intrinsic atherosclerosis. Patients in the intrinsic atherosclerosis group had significantly higher risks of recurrence (adjusted hazard ratio [HR]=2.1; 95% CI, 1.19-3.73) compared with those in the artery-to-artery embolism group. Moreover, patients in the intrinsic atherosclerosis and low-flow groups had significantly higher risks of composite cardiovascular events compared with those in the artery-to-artery embolism group (adjusted HR=1.94; 95% CI, 1.26-3.00; and adjusted HR=1.64; 95% CI, 1.13-2.38, respectively). Conclusion: Low-flow and intrinsic atherosclerosis strokes are associated with a high risk for future cardiovascular events and stroke recurrence. However, long-term mortality is similar across different subgroups. © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved

The type of atrial fibrillation is associated with long-term outcome in patients with acute ischemic stroke

Background/objectives: We aimed to investigate the association between the type of atrial fibrillation (AF) and long-term outcome in terms of mortality and stroke recurrence in patients with ischemic stroke and non-valvular AF. Methods: All consecutive patients admitted with acute ischemic stroke to Alexandra Hospital between 1993 and 2010 were included in the analysis. Patients were categorized in 3 groups according to the type of AF (paroxysmal, persistent, and permanent) and were followed up for up to 10 years after the index stroke or until death. The endpoints were inhospital, 30-day and 10-year stroke recurrence, and 30-day and 10-year all-cause mortality. The Kaplan-Meier product limit method was used to estimate the probability of 10-year stroke recurrence and survival. Multivariate Cox proportional hazard models were used to identify significant predictors of stroke recurrence and all-cause mortality. Results: There were 811 patients (419 females, 392 males) with non-valvular AF and mean age of 75.8 +/- 9.4 years. 277 (34.2%) patients had paroxysmal AF, 165 (20.3%) persistent and 369 (45.5%) permanent. Inhospital stroke recurrence rate was low (1.8%) and similar among the 3 patient groups; on the contrary, the probability of 10-year stroke recurrence was significantly higher in patients with permanent AF (p<0.01 by log-rank test). The probability of 10-year survival was significantly higher in patients with paroxysmal AF (p<0.001 by log-rank test). The type of AF was a significant predictor of 10-year stroke recurrence and mortality. Patients with permanent AF had higher risk of stroke recurrence (HR: 1.78, 95%CI: 1.21-2.61) and mortality (HR: 1.55, 95%CI: 1.20-1.99) compared to patients with paroxysmal AF. Conclusions: Long-term outcome in stroke patients with AF is associated with the type of AF; patients with paroxysmal AF have lower rates of stroke recurrence and mortality. (C) 2012 Elsevier Ireland Ltd. All rights reserved

Clopidogrel vs. Aspirin Treatment on Admission Improves 5-Year Survival After a First-ever Acute Ischemic Stroke. Data from the Athens Stroke Outcome Project

Background and Aims: We undertook this study to compare the impact of aspirin vs. clopidogrel treatment on 5-year survival of patients experiencing a first-ever acute ischemic noncardioembolic stroke. Methods: This was a retrospective study involving patients with an acute ischemic stroke who had an indication for antiplatelet therapy (atherothrombotic, lacunar and cryptogenic stroke subtype). A total of 1228 (383 women) hospitalized due to an acute first-ever stroke and receiving aspirin (n = 880) or clopidogrel (n = 348) were finally involved. To determine the factors that independently predict 5-year survival statistical analysis including the Kaplan-Meier survival curve and multifactorial analysis (Cox regression) was performed. Results: Subjects treated with clopidogrel had improved 5-year survival compared with those receiving aspirin (log rank test: 16.4, p &lt;0.0001). The difference in survival was evident as early as 6 months from index stroke: cumulative survival 93.8% for aspirin vs. 97% for clopidogrel (log rank test: 4.01, p = 0.045). The composite cardiovascular event (including stroke recurrence, myocardial infarction, unstable angina, coronary revascularization, aortic aneurysm rupture, peripheral atherosclerotic artery diseases, and sudden death) rates were lower in the clopidogrel group (n = 60, 17.2%) compared with the aspirin (n = 249, 28.3%) group (log rank test: 12.4, p &lt;0.0001). This preferential effect of clopidogrel over aspirin was independent of age, gender, presence of cardiovascular disease other than stroke or cardiovascular risk factors as well as irrespective of the severity of stroke and days of hospitalization. Conclusions: This study supports that clopidogrel is superior to aspirin in preventing death and cardiovascular events after an acute noncardioembolic ischemic stroke. © 2011 IMSS

ASTRAL Score Predicts 5-Year Dependence and Mortality in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The ASTRAL score was externally validated showing remarkable consistency on 3-month outcome prognosis in patients with acute ischemic stroke. The present study aimed to evaluate ASTRAL score's prognostic accuracy to predict 5-year outcome. METHODS: All consecutive patients with acute ischemic stroke registered in the Athens Stroke Registry between January 1, 1998, and December 31, 2010, were included. Patients were excluded if admitted &gt;24 hours after symptom onset or if any ASTRAL score component was missing. End points were 5-year unfavorable functional outcome, defined as modified Rankin Scale 3 to 6, and 5-year mortality. For each outcome, the area under the receiver operating characteristics curve was calculated; also, a multivariate Cox proportional hazards analysis was performed to investigate whether the ASTRAL score was an independent predictor of outcome. The Kaplan-Meier product limit method was used to estimate the probability of 5-year survival for each ASTRAL score quartile. RESULTS: The area under the receiver operating characteristics curve of the score to predict 5-year unfavorable functional outcome was 0.89, 95% confidence interval 0.88 to 0.91. In multivariate Cox proportional hazards analysis, the ASTRAL score was independently associated with 5-year unfavorable functional outcome (hazard ratio, 1.09; 95% confidence interval, 1.08-1.10). The area under the receiver operating characteristics curve for the ASTRAL score's discriminatory power to predict 5-year mortality was 0.81 (95% confidence interval, 0.78-0.83). In multivariate analysis, the ASTRAL score was independently associated with 5-year mortality (hazard ratio, 1.09, 95% confidence interval, 1.08-1.10). During the 5-year follow-up, the probability of survival was significantly lower with increasing ASTRAL score quartiles (log-rank test &lt;0.001). CONCLUSIONS: The ASTRAL score reliably predicts 5-year functional outcome and mortality in patients with acute ischemic stroke

Prevalence of atrial fibrillation in Greece: The Arcadia Rural Study on Atrial Fibrillation

Introduction Atrial fibrillation (AF) is a major factor for stroke and stroke-associated mortality, and its incidence is increasing during the last decades. There are only scarce data about its prevalence in Greece. We designed an epidemiological cross-sectional study to estimate the prevalence of AF in Greece and evaluate the adequacy of anticoagulant treatment in AF patients. Subjects and methods The Arcadia Rural Study on Atrial Fibrillation (ARSAF) was conducted between 2002-2003 in five rural villages of the Arcadia province (Greece) with a permanent population of 1312 individuals. Patients had a thorough medical examination and electrocardiogram, and information was collected about their medical history and comorbidities. CHADS 2 score was used to determine stroke risk for participants with AF. Results 1155 subjects (88% of the entire population) participated in the study. The overall prevalence of AF was 3.9% showing an increasing trend with increasing age ranging from 0.4% in patients &amp;lt; 55 years to 10.7% in patients &amp;gt; 84 years. Among patients with AF, 14 (32%) had paroxysmal AF. The presence of AF was associated with increasing age (OR: 1.67 for every 10 years increase, 95% CI: 1.26-2.15), hypertension (OR: 2.12, 95% CI: 1.02-4.14), heart failure (OR: 11.85, 95% CI: 4.92-28.56) and prior cerebrovascular disease (OR: 4.17, 95% CI: 1.44-12.06). Among these subjects with AF, 12 (26.6%) were considered as low-risk (CHADS 2 = 0), 18 (40.0%) as intermediate-risk (CHADS 2 = 1), and 15 (33.3%) as high-risk (CHADS 2 &amp;gt; 1) patients for stroke. 25 (55.5%) patients with AF did not receive appropriate antithrombotic treatment. Conclusion The prevalence of AF in Greece is similar to other countries and increases with increasing age

Prediction of long-term outcomes by arterial stiffness and pressure wave reflections in patients with acute stroke: the Athens Stroke Registry

Background and purpose: Stroke patients' management might be improved by addressing the role of aortic stiffness (carotid-femoral pulse wave velocity: cfPWV) and pressure wave reflections (PWRs, augmentation index: AIx) in their pathogenesis and outcome. We tested the hypothesis that cfPWV and AIx, separately and combined, predict long-term outcomes [all-cause mortality, incidence of cardiovascular events, stroke recurrence and disability defined by modified Ranking Scale (mRS) ≥3] in patients with acute stroke, using data from the 'Athens Stroke Registry'. Methods: Data from 552 patients (70% men, age: 66.1 ∓10.4years, 13.4% deaths from any cause, 21.2% cardiovascular events, 14.1% stroke recurrences and 20.1% poor mRS, mean follow-up 68.4∓41.4months) were analyzed. Results: The main findings were that: high aortic stiffness (cfPWV > 13 m/s) alone is an independent predictor of all-cause mortality and cardiovascular (CV) events, but not of stroke recurrence and poor functional outcome; evaluated separately from aortic stiffness, neither low nor high PWRs have any prognostic value; even after multiple adjustments, patients with both high aortic stiffness (cfPWV > 13 m/s) and low PWRs (Aix < 22%) have almost two-fold higher hazard ratio, not only for all-cause mortality and CV events but also for stroke recurrence and poor functional outcome. Conclusions: The present study provides evidence about the role of aortic stiffness, PWRs and their combined incremental value in the long-term survival, morbidity, and functional disability after acute stroke. © 2022 Wolters Kluwer Health, Inc