Publications by authors named "Giosue Gulli"

26 Publications

  • Page 1 of 1

Predicting Stroke Complications in Hospital and Functional Status at Discharge by Clustering of Cardiovascular Diseases a Multi-Centre Registry-Based Study of Acute Stroke.

J Stroke Cerebrovasc Dis 2021 Oct 21;31(1):106162. Epub 2021 Oct 21.

Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX, UK; Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London W6 8RF, UK. Electronic address:

Objective: Indicators for outcomes following acute stroke are lacking. We have developed novel evidence-based criteria for identifying outcomes of acute stroke using the presence of clusters of coexisting cardiovascular disease (CVD).

Materials And Methods: Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme (SSNAP). A total of 1656 men (mean age ±SD=73.1yrs±13.2) and 1653 women (79.3yrs±13.0) were admitted with acute stroke (83.3% ischaemic, 15.7% intracranial haemorrhagic), 1.0% unspecified) in four major UK hyperacute stroke units (HASU) between 2014 and 2016. Four categories from cardiovascular disease Congestive heart failure, Atrial fibrillation, pre-existing Stroke and Hypertension (CASH).were constructed: CASH-0 (no coexisting CVD); CASH-1 (any one coexisting CVD); CASH-2 (any two coexisting CVD); CASH-3 (any three or all four coexisting CVD). These were tested against outcomes, adjusted for age and sex.

Results: Compared to CASH-0, individuals with CASH-3 had greatest risks of in-hospital mortality (11.1% vs 24.5%, OR=1.8, 95%CI=1.3-2.7) and disability (modified Rankin Scale score ≥4) at discharge (24.2% vs 46.2%, OR=1.9, 95%CI=1.4-2.7), urinary tract infection (3.8% vs 14.6%, OR= 3.3, 95%CI= 1.9-5.5), and pneumonia (7.1% vs 20.6%, OR= 2.6, 95%CI= 1.7-4.0); length of stay on HASU >14 days (29.8% vs 39.3%, OR=1.8, 95%CI=1.3-2.6); and joint-care planning (20.9% vs 29.8%, OR=1.4, 95%CI=1.0-2.0).

Conclusions: We present a simple tool for estimating the risk of adverse outcomes of acute stroke including death, disability at discharge, nosocomial infections, prolonged length of stay, as well as any joint care planning. CASH-0 indicates a low level and CASH-3 indicates a high level of risk of such complications after stroke.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106162DOI Listing
October 2021

Association of risk of malnutrition with adverse outcomes and early support on discharge in acute stroke patients without prestroke disability: A multicenter, registry-based cohort study.

Nutr Clin Pract 2021 Oct 19. Epub 2021 Oct 19.

Institute of Cardiovascular Research, Royal Holloway University of London, Egham, UK.

Background: Malnutrition in hospitals remains highly prevalent. As part of quality improvement initiatives, the Royal College of Physicians recommends nutrition screening for all patients admitted with acute stroke. We aimed to examine the associations of patients at risk of malnutrition with poststroke outcomes.

Methods: We analyzed prospectively collected data from four hyperacute stroke units (HASUs) (2014-2016). Nutrition status was screened in 2962 acute stroke patients without prestroke disability (1515 men, [mean ± SD] 73.5 years ± 13.1; 1447 women, 79.2 ± 13.0 years). The risk of malnutrition was tested against stroke outcomes and adjusted for age, sex, and comorbidities.

Results: Risk of malnutrition was identified in 25.8% of patients). Compared with well-nourished patients, those at risk of malnutrition had, within 7 days of admission, increased risk of stay on the HASU of >14 days (odds ratio [OR]: 9.9 [7.3-11.5]), disability on discharge (OR: 8.1 [6.6-10.0]), worst level of consciousness in the first 7 days (score ≥ 1) (OR: 7.5 [6.1-9.3]), mortality (OR: 5.2 [4.0-6.6], pneumonia (OR: 5.1 [3.9-6.7]), and urinary tract infection (OR: 1.5 [1.1-2.0]). They also required palliative care (OR: 12.3 [8.5-17.8]), discharge to new care home (OR: 3.07 [2.18-4.3]), activities of daily living support (OR: 1.8 [1.5-2.3]), planned joint care (OR: 1.5 [1.2-1.8]), and weekly visits (OR: 1.4 [1.1-1.8]).

Conclusion: Patients at risk of malnutrition more commonly have multiple adverse outcomes after acute stroke and greater need for early support on discharge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ncp.10790DOI Listing
October 2021

Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia.

JAMA Neurol 2021 11;78(11):1314-1323

Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia.

Importance: Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson).

Objective: To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS.

Design, Setting, And Participants: This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination.

Exposures: Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria.

Main Outcomes And Measures: Clinical characteristics and mortality rate.

Results: Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later.

Conclusions And Relevance: In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaneurol.2021.3619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8479648PMC
November 2021

COVID-19-associated ischaemic stroke despite use of anticoagulation.

BMJ Case Rep 2021 Jul 29;14(7). Epub 2021 Jul 29.

Stroke Unit, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK.

A 64-year-old female nurse was admitted to hospital following fever, cough, shortness of breath and low blood pressure. She tested positive for COVID-19 and was treated on a high-dependency unit and prescribed enoxaparin, a prophylactic anticoagulant. Eight days later, she suffered a left middle cerebral artery ischaemic stroke. Over the next 2 weeks, her condition fluctuated, eventually leading to her death. We report her case from clinical history to investigations and outcomes, and explore the potential link between coronavirus, the use of anticoagulation and ischaemic stroke.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bcr-2021-243741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323371PMC
July 2021

Adverse consequences of immediate thrombolysis-related complications: a multi-centre registry-based cohort study of acute stroke.

J Thromb Thrombolysis 2021 Jul 13. Epub 2021 Jul 13.

Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX, UK.

Complications following thrombolysis for stroke are well documented, and mostly concentrated on haemorrhage. However, the consequences of patients who experience any immediate thrombolysis-related complications (TRC) compared to patients without immediate TRC have not been examined. Prospectively collected data from the Sentinel Stroke National Audit Programme were analysed. Thrombolysis was performed in 451 patients (52.1% men; 75.3 years ± 13.2) admitted with acute ischaemic stroke (AIS) in four UK centres between 2014 and 2016. Adverse consequences following immediate TRC were assessed using logistic regression, adjusted for age, sex and co-morbidities. Twenty-nine patients (6.4%) acquired immediate TRC. Compared to patients without, individuals with immediate TRC had greater adjusted risks of: moderately-severe or severe stroke (National Institutes of Health for Stroke Scale score ≥ 16) at 24-h (5.7% vs 24.7%, OR 3.9, 95% CI 1.4-11.1); worst level of consciousness (LOC) in the first 7 days (score ≥ 1; 25.0 vs 60.7, OR 4.6, 95% CI 2.1-10.2); urinary tract infection or pneumonia within 7-days of admission (13.5% vs 39.3%, OR 3.2, 95% CI 1.3-7.7); length of stay (LOS) on hyperacute stroke unit (HASU) ≥ 2 weeks (34.7% vs 66.7%, OR 5.2, 95% CI 1.5-18.4); mortality (13.0% vs 41.4%, OR 3.7, 95% CI 1.6-8.4); moderately-severe or severe disability (modified Rankin Scale  score ≥ 4) at discharge (26.8% vs 65.5%, OR 4.7, 95% CI 2.1-10.9); palliative care by discharge date (5.1% vs 24.1%, OR 5.1, 95% CI 1.7-15.7). The median LOS on the HASU was longer (7 days vs 30 days, Kruskal-Wallis test: χ = 8.9, p = 0.003) while stroke severity did not improve (NIHSS score at 24-h post-thrombolysis minus NIHSS score at arrival = - 4 vs 0, χ = 24.3, p < 0.001). In conclusion, the risk of nosocomial infections, worsening of stroke severity, longer HASU stay, disability and death is increased following immediate TRC. The management of patients following immediate TRC is more complex than previously thought and such complexity needs to be considered when planning an increased thrombolysis service.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11239-021-02523-2DOI Listing
July 2021

Prestroke Disability Predicts Adverse Poststroke Outcome: A Registry-Based Prospective Cohort Study of Acute Stroke.

Stroke 2020 02 17;51(2):594-600. Epub 2019 Dec 17.

From the Institute of Cardiovascular Research, Royal Holloway University of London, Egham, United Kingdom (T.S.H., S.S., P.S.).

Background and Purpose- Information on what effect disability before stroke can have on stroke outcome is lacking. We assessed prestroke disability in relation to poststroke hospital outcome. Methods- Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme. A total of 1656 men (mean age ±SD =73.1±13.2 years) and 1653 women (79.3±13.0 years) were admitted to hyperacute stroke units with acute stroke in 4 major UK between 2014 and 2016. Prestroke disability, assessed by modified Rankin Scale (mRS), was tested against poststroke adverse outcomes, adjusted for age, sex, and coexisting morbidities. Results- Compared with patients with prestroke mRS score =0, individuals with prestroke mRS scores =3, 4, or 5 had greater adjusted risks of moderately severe or severe stroke on arrival (4.4% versus 16.7%; odds ratio [OR], 3.2 [95% CI, 2.3-4.6] <0.001); urinary tract infection or pneumonia within 7 days of admission (9.6% versus 35.9%; OR, 3.7 [95% CI, 2.8-4.8] <0.001); mortality (7.2% versus 37.1%; OR, 4.9 [95% CI, 3.7-6.5] <0.001); requiring help with activities of daily living on discharge (12.3% versus 26.7%; OR, 3.1 [95% CI, 2.3-4.1] <0.001); and transferred to new care home (2.4% versus 9.4%; OR, 2.1 [95% CI, 1.3-3.3] =0.002). Patients with mRS scores =1 or 2 had intermediate risk of adverse outcomes. Overall, those with a mRS score =1 or 2 had length of stay on hyperacute stroke units extended by 5.3 days (95% CI, 2.8-7.7; <0.001) and mRS score =3, 4 or 5 by 7.2 days (95% CI, 4.0-10.5; <0.001). Conclusions- Individuals with evidence of prestroke disability, assessed by mRS, had significantly increased risk of poststroke adverse outcomes and longer length of stay on hyperacute stroke units and higher level of care on discharge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.119.027740DOI Listing
February 2020

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative: study protocol and rationale of a multicentre retrospective individual patient data meta-analysis.

BMJ Open 2019 11 14;9(11):e031144. Epub 2019 Nov 14.

Neurology Department, University of Maryland School of Medicine, Baltimore, Maryland, USA.

Introduction: Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients.

Methods And Analysis: The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.

Ethics And Dissemination: Ethical approval for the GOAL study has already been obtained from the Medical Review Ethics Committee region Arnhem-Nijmegen. Additionally and when necessary, approval will also be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of worldwide differences in risk factors, causes and outcome of young stroke patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2019-031144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887075PMC
November 2019

New evidence-based A1, A2, A3 alarm time zones for transferring thrombolysed patients to hyper-acute stroke units: faster is better.

Neurol Sci 2019 Aug 27;40(8):1659-1665. Epub 2019 Apr 27.

Institute of Cardiovascular Research, Royal Holloway, University of London, TW20 0EX, Egham, UK.

Objectives: The National Institute of Health and Clinical Excellence and The Royal College of Physicians recommend transferring thrombolysed patients with stroke to a hyperacute stroke unit (HASU) within 4 h from hospital arrival (T), but there is paucity of evidence to support this cut-off. We assessed if a shorter interval within this target threshold conferred a significant improvement in patient mortality.

Design: We conducted a retrospective analysis of prospectively collected data from the Sentinel Stroke National Audit Programme.

Setting: Four major UK hyperacute stroke centres between 2014 and 2016.

Participants: A total of 183 men (median age = 75 years, IQR = 66-83) and 169 women (median age = 81 years, IQR = 72.5-88) admitted with acute ischaemic stroke.

Main Outcome Measures: We evaluated T in relation to inpatient mortality, adjusted for age, sex, co-morbidities, stroke severity, time between procedures, time and day on arrival.

Results: There were 51 (14.5%) inpatient deaths. On ROC analysis, the AUC (area under the curve) was 61.1% (52.9-69.4%, p = 0.01) and the cut-off of T where sensitivity equalled specificity was 2 h/15 min (intermediate range = 30 min to 3 h/15 min) for predicting mortality. On logistic regression, compared with the fastest T group within 2 h/15 min, the slowest T group beyond upper limit of intermediate range (≥ 3 h/15 min) had an increased risk of mortality: 5.6% vs. 19.6%, adjusted OR = 5.6 (95%CI:1.5-20.6, p = 0.010).

Conclusions: We propose three new alarm time zones (A1, A2 and A3) to improve stroke survival: "A1 Zone" (T < 2 h/15 min) indicates that a desirable target, "A2 Zone" (T = 2 h/15 min to 3 h/15 min), indicates increasing risk and should not delay any further, and "A3 Zone" (T ≥ 3 h/15 min) indicates high risk and should be avoided.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10072-019-03901-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647361PMC
August 2019

Anticoagulation therapy in patients with stroke and atrial fibrillation: a registry-based study of acute stroke care in Surrey, UK.

BMJ Open 2018 07 11;8(7):e022558. Epub 2018 Jul 11.

Institute of Cardiovascular Research, Royal Holloway, University of London, London, UK.

Introduction: Because of their high risk of stroke, anticoagulation therapy is recommended for most patients with atrial fibrillation (AF). The present study evaluated the use of anticoagulants in the community and in a hospital setting for patients with AF and its associations with stroke.

Methods: Patients admitted with stroke to four major hospitals in County of Surrey, England were surveyed in the 2014-2016 Sentinel Stroke National Audit Programme. Descriptive statistics was used to summarise subject characteristics and χ² test to assess differences between categorical variables.

Results: A total of 3309 patients, 1656 men (mean age: 73.1 years±SD 13.2) and 1653 women (79.3 years±13.0) were admitted with stroke (83.3% with ischaemic, 15.7% haemorrhagic stroke and 1% unspecified). AF occurred more frequently (χ=62.4; p<0.001) among patients admitted with recurrent (30.2%) rather than with first stroke (17.1%). There were 666 (20.1%) patients admitted with a history of AF, among whom 304 (45.3%) were anticoagulated, 279 (41.9%) were untreated and 85 (12.8%) deemed unsuitable for anticoagulation. Of the 453 patients with history of AF admitted with a first ischaemic stroke, 138 (37.2%) were on anticoagulation and 41 (49.6%) were not (χ = 6.3; p<0.043) and thrombolysis was given more frequently for those without prior anticoagulation treatment (16.1%) or unsuitable for anticoagulation (23.6%) compared with those already on anticoagulation treatment (8.3%; χ=10.0; p=0.007). Of 2643 patients without a previous history of AF, 171 (6.5%) were identified with AF during hospitalisation. Of patients with AF who presented with ischaemic stroke who were not anticoagulated or deemed unsuitable for anticoagulation prior to admission, 91.8% and 75.0%, respectively, were anticoagulated on discharge.

Conclusions: The study highlights an existing burden for patients with stroke and reflects inadequate treatment of AF which results in an increased stroke burden. There is significant scope to improve the rates of anticoagulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2018-022558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089275PMC
July 2018

Impact of delay in early swallow screening on pneumonia, length of stay in hospital, disability and mortality in acute stroke patients.

Eur J Clin Nutr 2018 11 27;72(11):1548-1554. Epub 2018 Mar 27.

Institute of Cardiovascular Research, Royal Holloway, University of London, London, UK.

Background/objectives: Early swallow screening, within 4 h of admission, is required for all acute stroke patients to commence nutritional support, as recommended. We evaluated the impact of delay in early swallow screening on outcomes in patients admitted with acute stroke.

Subjects/methods: Prospective cohort study of 1656 men (mean ± SD age = 73.1y ± 13.2) and 1653 women (79.3y ± 13.0) admitted with stroke to hyperacute stroke units (HASUs) in Surrey. Logistic regression was used to assess the risk (adjusted for age, stroke severity and co-morbidities) of delay in swallow screening on pneumonia, length of stay (LOS) > 3 weeks in HASU or hospital, moderately severe to severe disability on discharge (modified Rankin scale score = 4-5) and mortality during admission.

Results: Compared with those who received swallow screening within 4 h of admission, a delay between 4 and 72 h was associated with greater risks of pneumonia: OR = 1.4 (95%CI:1.1-1.9, P = 0.022), moderately severe to severe disability on discharge: OR = 1.4 (1.1-1.7, P = 0.007) and a delay beyond 72 h was associated with even greater risks of pneumonia: OR = 2.3 (1.4-3.6, P < 0.001), prolonged LOS in HASU: OR = 1.7 (1.0-3.0, P = 0.047, median LOS = 6.2 vs. 14.7 days) and hospital: OR = 2.1-fold (1.3-3.4, P = 0.007, median LOS = 6.8 vs. 14.9 days), moderately severe to severe disability on discharge: OR = 2.5 (1.7-3.7, P < 0.001) and mortality: OR = 3.8 (2.5-5.6, P < 0.001). These risks persisted after excluding 103 patients who died within 72 h.

Conclusions: Delay in early screening for swallow capacity in acute stroke patients is detrimental to outcomes, possibly due to delaying nutritional provision or through inappropriate feeding leading to aspiration. Routine early screening needs greater attention in HASUs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41430-018-0148-4DOI Listing
November 2018

Evaluation of anticoagulation status for atrial fibrillation on early ischaemic stroke outcomes: a registry-based, prospective cohort study of acute stroke care in Surrey, UK.

BMJ Open 2017 Dec 14;7(12):e019122. Epub 2017 Dec 14.

Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK.

Objective: The relationship of anticoagulation therapies with stroke severity and outcomes have been well documented in the literature. However, none of the previous research has reported the relationship of atrial fibrillation (AF)/anticoagulation therapies with urinary tract infection (UTI), pneumonia and length of stay in hyperacute stroke units (HASUs). The present study aimed to evaluate AF and anticoagulation status in relation to early outcomes in 1387 men (median age=75 years, IQR=65-83) and 1371 women (median age=83 years, IQR=74-89) admitted with acute ischaemic stroke to HASUs in Surrey between 2014 and 2016.

Methods: We conducted this registry-based, prospective cohort study using data from the Sentinel Stroke National Audit Programme. Association between AF anticoagulation status with severe stroke on arrival (National Institutes of Health Stroke Scale score ≥16), prolonged HASU stay (>3 weeks), UTI and pneumonia within 7 days of admission, severe disability on discharge (modified Rankin Scale score=4 and 5) and inpatient mortality was assessed by logistic regression, adjusted for age, sex, hypertension, congestive heart failure, diabetes and previous stroke.

Results: Compared with patients with stroke who are free from AF, those with AF without anticoagulation had an increased adjusted risk of having more severe stroke: 5.8% versus 14.0%, OR=2.4 (95% CI 1.6 to 3.6, P<0.001), prolonged HASU stay: 21.5% versus 32.0%, OR=1.4 (1.0-2.0, P=0.027), pneumonia: 8.2% versus 19.1%, OR=2.1 (1.4-2.9, P<0.001), more severe disability: 24.2% versus 40.4%, OR=1.6 (1.2-2.1, P=0.004) and mortality: 9.3% versus 21.7%, OR=1.9 (1.4-2.8, P<0.001), and AF patients with anticoagulation also had greater risk for having UTI: 8.6% versus 12.3%, OR=1.9 (1.2-3.0, P=0.004), pneumonia: 8.2% versus 11.5%, OR=1.6 (1.1-2.4, P=0.025) and mortality: 9.7% versus 21.7%, OR=1.9 (1.4-2.8, P<0.001). The median HASU stay for stroke patients with AF without anticoagulation was 10.6 days (IQR=2.8-26.4) compared with 5.8 days (IQR=2.3-17.5) for those free from AF (P<0.001).

Conclusions: Patients with AF, particularly those without anticoagulation, are at increased risk of severe stroke, associated with prolonged HASU stay and increased risk of early infection, disability and mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2017-019122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736041PMC
December 2017

Therapeutic Plasma Exchange in Patients with Neurologic Disorders: Insufficient Evidence to Support the Use of Hydroxyethyl Starch.

Indian J Hematol Blood Transfus 2017 Sep 17;33(3):445-447. Epub 2017 May 17.

Department of Neurology, Ashford and St Peter's Hospital, London Road, Ashford, Surrey TW15 3AA UK.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12288-017-0833-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5544654PMC
September 2017

Differences in the distribution of stroke subtypes in a UK black stroke population - final results from the South London Ethnicity and Stroke Study.

BMC Med 2016 May 20;14:77. Epub 2016 May 20.

Department of Clinical Neurosciences, Stroke Research group, University of Cambridge, Cambridge, UK.

Background: Stroke incidence is increased in Black individuals but the reasons for this are poorly understood. Exploring the differences in aetiological stroke subtypes, and the extent to which they are explained by conventional and novel risk factors, is an important step in elucidating the underlying mechanisms for this increased stroke risk.

Methods: Between 1999 and 2010, 1200 black and 1200 white stroke patients were prospectively recruited from a contiguous geographical area in South London in the UK. The Trial of Org 10172 (TOAST) classification was used to classify stroke subtype. Age- and sex-adjusted comparisons of socio-demographics, traditional vascular risk factors and stroke subtypes were performed between black and white stroke patients and between Black Caribbean and Black African stroke patients using age-, sex-, and social deprivation-adjusted univariable and multivariable logistic regression analyses.

Results: Black stroke patients were younger than white stroke patients (mean (SD) 65.1 (13.7) vs. 74.8 (13.7) years). There were significant differences in the distribution of stroke subtypes. Small vessel disease stroke was increased in black patients versus white patients (27 % vs. 12 %; OR, 2.74; 95 % CI, 2.19-3.44), whereas large vessel and cardioembolic stroke was less frequent in black patients (OR, 0.59; 95 % CI, 0.45-0.78 and OR, 0.61; 95 % CI, 0.50-0.74, respectively). These associations remained after controlling for traditional vascular risk factors and socio-demographics. Black Caribbean patients appeared to have an intermediate risk factor and stroke subtype profile between that found in Black African and white stroke patients. Cardioembolic stroke was more strongly associated with Black Caribbean ethnicity versus Black African ethnicity (OR, 1.48; 95 % CI, 1.04-2.10), whereas intracranial large vessel disease was less frequent in Black Caribbean patients versus Black African subjects (OR, 0.44; 95 % CI, 0.24-0.83).

Conclusions: Clear differences exist in stroke subtype distribution between black and white stroke patients, with a marked increase in small vessel stroke. These could not be explained by differences in the assessed traditional risk factors. Possible explanations for these differences might include variations in genetic susceptibility, differing rates of control of vascular risk factors, or as yet undetermined environmental risk factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12916-016-0618-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4873985PMC
May 2016

Yield of ultra-rapid carotid ultrasound and stroke specialist assessment in patients with TIA and minor stroke: an Italian TIA service audit.

Neurol Sci 2014 Dec 3;35(12):1969-75. Epub 2014 Aug 3.

Department of Neuroscience, Unit of Neurology, UOC Neurologia, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale A.Stefani 1, 37126, Verona, Italy,

In Italy the vast majority of TIA and minor strokes are seen in the A&E. Early diagnosis and management of TIA and minor stroke in this setting is habitually difficult and often lead to cost-ineffective hospital admissions. We set up an ultra-rapid TIA service run by neurovascular physicians based on early specialist assessment and ultrasound vascular imaging. We audit the clinical effectiveness and feasibility of the service and the impact of this service on TIA and minor strokes hospital admissions. We compared the rate of TIA and minor stroke admissions/discharges in the year before (T0) and in the year during which the TIA service was operating (T1). At T1 57 patients had specialist evaluation and 51 (89.5 %) of them were discharged home. Two (3.5 %) patients had recurrent symptoms after discharge. Seven had a pathological carotid Doppler ultrasound. Four of them had hospital admission and subsequent carotid endoarterectomy within a week. Taking the whole neurology department into consideration at T1 there was a 30-41 % reduction in discharges of patients with TIA or minor stroke. Taking the stroke unit section into consideration at T1 there was a 25 % reduction in admissions of patients with NIHSS score <4 and 40 % reduction in admissions of patients with Barthel Index above 80. The model of TIA service we implemented based on ultra-rapid stroke physician assessment and carotid ultrasound investigation is feasible and clinically valid. Indirect evidence suggests that it reduced the rate of expensive TIA/minor stroke hospital admissions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10072-014-1875-5DOI Listing
December 2014

Off-label thrombolysis versus full adherence to the current European Alteplase license: impact on early clinical outcomes after acute ischemic stroke.

J Thromb Thrombolysis 2014 May;37(4):549-56

SSO Stroke Unit, U.O. Neurologia d.O., DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy,

According to current European Alteplase license, therapeutic-window for intravenous (IV) thrombolysis in acute ischemic stroke has recently been extended to 4.5 h after symptoms onset. However, due to numerous contraindications, the portion of patients eligible for treatment still remains limited. Early neurological status after thrombolysis could identify more faithfully the impact of off-label Alteplase use that long-term functional outcome. We aimed to identify the impact of off-label thrombolysis and each off-label criterion on early clinical outcomes compared with the current European Alteplase license. We conducted an analysis on prospectively collected data of 500 consecutive thrombolysed patients. The primary outcome measures included major neurological improvement (NIHSS score decrease of ≤8 points from baseline or NIHSS score of 0) and neurological deterioration (NIHSS score increase of ≥4 points from baseline or death) at 24 h. We estimated the independent effect of off-label thrombolysis and each off-label criterion by calculating the odds ratio (OR) with 2-sided 95% confidence interval (CI) for each outcome measure. As the reference, we used patients fully adhering to the current European Alteplase license. 237 (47.4%) patients were treated with IV thrombolysis beyond the current European Alteplase license. We did not find significant differences between off- and on-label thrombolysis on early clinical outcomes. No off-label criteria were associated with decreased rate of major neurological improvement compared with on-label thrombolysis. History of stroke and concomitant diabetes was the only off-label criterion associated with increased rate of neurological deterioration (OR 5.84, 95% CI 1.61-21.19; p = 0.024). Off-label thrombolysis may be less effective at 24 h than on-label Alteplase use in patients with previous stroke and concomitant diabetes. Instead, the impact of other off-label criteria on early clinical outcomes was not different compared with current European Alteplase license.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11239-013-0980-2DOI Listing
May 2014

Effects of prefrontal repetitive transcranial magnetic stimulation on the autonomic regulation of cardiovascular function.

Exp Brain Res 2013 Apr 2;226(2):265-71. Epub 2013 Mar 2.

Department of Neurology, Clinical Department of Neuroscience, Stroke Unit, Teaching Hospitals of Verona, Piazzale A. Stefani 26, 37126 Verona, Italy.

Several protocols based on repetitive transcranial magnetic stimulation (rTMS) have been proposed for treatment of a variety of neurological disorders. Despite the widespread use, little is known about the effects of rTMS on the autonomic nervous control of the cardiovascular system. Twelve volunteers underwent rTMS sessions consisted in 8-min baseline recording, 8-min 0.7-Hz rTMS stimulation at 100 % of the motor cortex excitability threshold on the prefrontal cortex of one randomly assigned hemisphere. After 8-min recovery, the same procedure was performed on the contra-lateral hemisphere. Non-invasive (Portapres device) beat-by-beat blood pressure and heart period time series were recorded and analyzed by spectral and cross-spectral analysis in the low-frequency (LF ≈ 0.1 Hz) and in the high-frequency (HF = respiratory frequency) range. Repetitive TMS, particularly after stimulation of the right hemisphere, induced a slight increase in the parasympathetic drive and no effects on the sympathetic activity. There was a significant bradycardia after stimulation on the right hemisphere, not significant bradycardia after left stimulation. LF/HF ratio was 3.8 ± 2.1 during baseline and changed to 1.9 ± 0.6 during rTMS on the left and to 1.6 ± 0.6 during rTMS on the right. No significant changes were observed in blood pressure. Low-frequency rTMS of the prefrontal cortex induces a slight parasympathetic activation and no changes in the sympathetic function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00221-013-3431-6DOI Listing
April 2013

Stroke risk after posterior circulation stroke/transient ischemic attack and its relationship to site of vertebrobasilar stenosis: pooled data analysis from prospective studies.

Stroke 2013 Mar 5;44(3):598-604. Epub 2013 Feb 5.

St. George's University of London, London , UK.

Background And Purpose: Recent prospective studies have shown vertebrobasilar (VB) stenosis predicts stroke risk in posterior circulation stroke and transient ischemic attack. It is unclear whether this association is independent of other risk factors, and whether intracranial or extracranial stenosis confers different risks.

Methods: A pooled individual patient analysis of data from 2 prospective studies was performed in 359 patients presenting with VB transient ischemic attack or stroke. Contrast-enhanced magnetic resonance angiography, or computed tomography angiogram, and clinical follow-up were available in 323 patients. Risk of stroke was calculated from any VB transient ischemic attack/stroke in the month before the presenting episode (first event) and from the presenting event. A systematic review of similar prospective studies was performed.

Results: Ninety-day risk of stroke from the first event was 24.6% in patients with VB stenosis versus 7.2% in those without (odds ratio, 4.2; 95% confidence interval, 2.1-8.6; P<0.0001). Risk was higher (33%) with intracranial (odds ratio, 6.5; 2.8-15.0; P<0.0001) than extracranial stenosis (16.2%; odds ratio, 2.5; 0.9-6.8; P=0.06). Risk from the presenting event was 9.6% in patients with stenosis versus 2.8% in those without (odds ratio, 3.7; 1.2-11.0; P=0.012), and again the risk was higher with intracranial stenosis. Cox regression showed the risk associated with VB stenosis was independent of other cardiovascular risk factors. The systematic review identified only 1 other report, which included only 6 patients.

Conclusions: Symptomatic VB stenosis, particularly intracranial stenosis, is a strong independent predictor of stroke recurrence. The high early risk of stroke provides a strong rationale for randomized trials to determine whether stenting can reduce risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.112.669929DOI Listing
March 2013

Chronic fusiform aneurysm evolving into giant aneurysm in the basilar artery.

Neurol Sci 2012 Feb 24;33(1):111-5. Epub 2011 May 24.

Stroke Unit, U.O. Neurologia d.O., DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.

Fusiform basilar aneurysm is a rare condition with elevated mortality within a few days if untreated. On the basis of clinical course, the fusiform aneurysm can be distinguished in an acute type, such as dissecting aneurysm, which usually causes subarachnoid hemorrhage or cerebral ischemia and in a chronic type with a relatively slow growth, which may evolve into a giant aneurysm leading to serious complications. We report a case of an 80-year-old man with a surgically untreated fusiform aneurysm that evolved into a giant aneurysm of the basilar artery within 4 years. The patient presented recurrent ischemic events involving the posterior circulation without aneurysmal rupture or bleeding.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10072-011-0628-yDOI Listing
February 2012

Vertebrobasilar stenosis predicts high early recurrent stroke risk in posterior circulation stroke and TIA.

Stroke 2009 Aug 28;40(8):2732-7. Epub 2009 May 28.

Clinical Neuroscience, St George's University of London, Cranmer Terrace, London, SW17 0RE UK.

Background And Purpose: 20% of ischemic stroke is in the posterior circulation, but there is little prospective data on early recurrent stroke risk and whether vertebrobasilar stenosis predicts a high recurrence risk. This natural history data are important as it is technically possible to stent such lesions. Contrast enhanced MRA (CE-MRA) and CT angiography (CTA) now allow noninvasive identification of vertebrobasilar stenosis.

Methods: 216 consecutive patients presenting with posterior circulation TIA or stroke were recruited and prospectively followed for 90 days. 8 patients with vertebral dissection were excluded. CE-MRA or CTA at presentation and 90-day follow-up was available in 182. Any posterior circulation TIA/stroke in the month before the presenting episode was recorded.

Results: Taking the first event (including TIA/stroke in the previous month) as the index case recurrent stroke risk in patients with stenosis was 30.5% versus 8.9% in those without; RR 3.4 (95% CI 1.7 to 7.0), P<0.001). Taking the presenting episode as the index case the risk was 13.8% versus 4.1%; RR 3.4 (95% CI 1.1 to 10.5) P=0.0274. The probability of recurrence was highest soon after the initial event.

Conclusions: The presence of vertebro-basilar stenosis identifies a group of patients with posterior circulation stroke who have a high early recurrent stroke risk. Early intervention might reduce recurrent stroke risk. Vertebral stenosis can now be treated by stenting, but determining whether this reduces the early stoke risk requires randomized controlled trials.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.109.553859DOI Listing
August 2009

Cerebrovascular responses to hypoxia and hypocapnia in Ethiopian high altitude dwellers.

Stroke 2008 Feb 20;39(2):336-42. Epub 2007 Dec 20.

International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada.

Background And Purpose: Cerebrovascular responses to hypoxia and hypocapnia in Peruvian altitude dwellers are impaired. This could contribute to the high incidence of altitude-related illness in Andeans. Ethiopian high altitude dwellers may show a different pattern of adaptation to high altitude. We aimed to examine cerebral reactivity to hypoxia and hypocapnia in healthy Ethiopian high altitude dwellers. Responses were compared with our previous data from Peruvians.

Methods: We studied 9 Ethiopian men at their permanent residence of 3622 m, and one day after descent to 794 m. We continuously recorded cerebral blood flow velocity (CBFV; transcranial Doppler). End-tidal oxygen (P(ET)o(2)) was decreased from 100 mm Hg to 50 mm Hg with end-tidal carbon dioxide (P(ET)co(2)) clamped at the subject's resting level. P(ET)co(2) was then manipulated by voluntary hyper- and hypoventilation, with P(ET)o(2) clamped at 100 mm Hg (normoxia) and 50 mm Hg (hypoxia).

Results: During spontaneous breathing, P(ET)co(2) increased after descent, from 38.2+/-1.0 mm Hg to 49.8+/-0.6 mm Hg (P<0.001). There was no significant response of CBFV to hypoxia at either high (-0.19+/-3.1%) or low (1.1+/-2.9%) altitudes. Cerebrovascular reactivity to normoxic hypocapnia at high and low altitudes was 3.92+/-0.5%.mm Hg(-1) and 3.09+/-0.4%.mm Hg(-1); reactivity to hypoxic hypocapnia was 4.83+/-0.7%.mm Hg(-1) and 2.82+/-0.5%.mm Hg(-1). Responses to hypoxic hypocapnia were significantly smaller at low altitude.

Conclusions: The cerebral circulation of Ethiopian high altitude dwellers is insensitive to hypoxia, unlike Peruvian high altitude dwellers. Cerebrovascular responses to P(ET)co(2) were greater in Ethiopians than Peruvians, particularly at high altitude. This, coupled with their high P(ET)co(2) levels, would lead to high cerebral blood flows, and may be advantageous for altitude living.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.107.491498DOI Listing
February 2008

Autonomic regulation during orthostatic stress in highlanders: comparison with sea-level residents.

Exp Physiol 2007 Mar 30;92(2):427-35. Epub 2006 Nov 30.

Institute for Cardiovascular Research, University of Leeds, Leeds, UK.

This report is a comparison of orthostatic tolerance and autonomic function in three groups of high-altitude dwellers: Andeans with and without chronic mountain sickness (CMS) and healthy Ethiopians. Results are compared with those from healthy sea-level residents. The aim was to determine whether different high-altitude populations adapted differently to the prevailing hypobaric hypoxia. Orthostatic tolerance was assessed using a test involving head-up tilt (HUT) and graded lower body suction. This was performed at the subjects' resident altitude. Blood pressure (Portapres) and R-R interval (ECG) were recorded during the test, and spectral and cross-spectral analyses of heart period and systolic blood pressure time series were performed using data obtained both while supine and during HUT. The transfer function gain in the low-frequency range (LF, approximately 0.1 Hz) at the point of maximal coherence was used as a measure of cardiac baroreflex sensitivity (BRS). As previously reported, Peruvians displayed an unusually good orthostatic tolerance, while Ethiopians showed an orthostatic tolerance comparable to that of healthy sea-level residents. There were no significant differences between groups in the supine values of the spectral analysis results. Head-up tilt induced the expected changes in Ethiopians (an increase in the LF components and a decrease in the respiratory components) but not in Andeans. Cross-spectral analysis showed abnormal results from all groups of high-altitude dwellers. These results indicate that Ethiopians, but not Peruvians, behave similarly to sea-level residents in terms of orthostatic tolerance and autonomic responses to orthostatic stress, as assessed from spectral analyses, and this indicates good adaptation to their environment. However, in all the high-altitude groups the results of cross-spectral analysis were atypical, suggesting some degree of impairment in baroreflex function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1113/expphysiol.2006.035519DOI Listing
March 2007

Cerebral vasodilatation to exogenous NO is a measure of fitness for life at altitude.

Stroke 2006 Jul 8;37(7):1754-8. Epub 2006 Jun 8.

Department of Neurology, New Mexico Health Enhancement and Marathon Clinics (NMHEMC) Research Foundation, Albuquerque, NM 87122-1424, USA.

Background And Purpose: Andean highlanders, unlike Ethiopians, develop chronic mountain sickness (CMS), a maladaptation to their native land. Ambient hypoxia induces NO-mediated vasodilatation. Fitness for life at altitude might be revealed by cerebrovascular responses to NO.

Methods: Nine altitude-native men were examined at 3622 and 794 m in Ethiopia and compared with 9 altitude-native Andean men tested at 4338 and 150 m in Peru. We assessed CMS scores, hematocrits, end-tidal pressure of carbon dioxide (P(ET)co2), oxygen saturations, and cerebral blood flow velocity (CBV). We evaluated fitness for life at altitude from the cerebrovascular response to an exogenous NO donor.

Results: At high altitude, CMS scores and hematocrits were higher in Andeans, and they had lower oxygen saturations. Ethiopians had higher P(ET)co2 at all study sites. At low altitude, saturations were similar in both groups. Responsiveness of the cerebral circulation to NO was minimal in Ethiopians at low altitude, whereas Andeans had a large response. In contrast, at high altitude, Ethiopians showed large responses, and Peruvians had minimal responses.

Conclusions: By our measure, high altitude-native Peruvians were well-adapted lowlanders, whereas Ethiopian highlanders were well adapted to altitude life. Environmental pressures were sufficient for human adaptation to chronic hypoxia in Africa but not South America. The mechanisms underlying these differences are unknown, although studies of neurovascular diseases suggest that this may be related to a NO receptor polymorphism.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/01.STR.0000226973.97858.0bDOI Listing
July 2006

Prolonged latency in the baroreflex mediated vascular resistance response in subjects with postural related syncope.

Clin Auton Res 2005 Jun;15(3):207-12

Institute for Cardiovascular Research, University of Leeds, Leeds LS2 9JT, UK.

In addition to the gain, the delay of the baroreflex response plays an important role in the maintenance of cardiovascular system stability. Additionally when postural changes induce sudden drops in blood pressure, a delayed response may fail to maintain sufficient cerebral perfusion pressure. We tested the hypothesis that the delay of the carotid baroreceptor reflex is impaired in subjects with poor orthostatic tolerance. An orthostatic test with 60 degrees head-up tilt, and progressive lower-body negative pressure was performed on 27 patients with histories of unexplained syncope and 13 control subjects. The test was stopped at the onset of presyncope and time to presyncope was taken as a measure of orthostatic tolerance. Twelve patients had normal tolerance and thirteen patients had low tolerance. We measured beat-to-beat blood pressure (Finapres) and brachial artery blood flow velocity (Doppler ultrasonography). Before the test, we determined the response of forearm vascular resistance (mean arterial pressure/mean brachial artery velocity) to loading/unloading of carotid baroreceptors by the application of neck suction/pressure (-/+30 mmHg) to a chamber fitted overlying the carotid sinus. We measured the gain in the response (maximum percentage change from baseline value in vascular resistance divided by the neck collar pressure) and the latency in the response (delay of the maximum change in vascular resistance after neck-collar stimulation). Results are reported as means +/- SEM. In the three groups, there were no differences in the sensitivity of the vascular resistance response after baroreceptor loading/unloading. Following baroreceptor unloading, the latency of the response was 14.0+/-1.3 seconds in early fainters, 9.3+/-0.7 seconds in normal patients and 10.1+/-1.2 seconds in controls. The latency in blood pressure rise was 11.1+/-1.3 seconds in early fainters, 7.9+/-0.9 seconds in normal patients and 7.2+/-1.0 seconds in controls. The results following baroreceptor loading were more scattered. The early fainters still had a tendency to show prolonged latency. These results suggest that the delay in the baroreflex response plays an important role in postural related syncope.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10286-005-0273-8DOI Listing
June 2005

R-R interval-blood pressure interaction in subjects with different tolerances to orthostatic stress.

Exp Physiol 2005 May 21;90(3):367-75. Epub 2005 Jan 21.

Institute for Cardiovascular Research, University of Leeds, Leeds LS2 9JT.

In addition to the gain, the time delay in the input-output response in a feedback system is crucial for the maintenance of its stability. Patients with posturally related (vasovagal) syncope have inadequate control of blood pressure and one possible explanation for this could be prolonged latency of the baroreflex. We studied 14 patients with histories of syncope and poor orthostatic tolerance (assessed by a progressive orthostatic stress test) and 16 healthy controls. We performed spontaneous sequence analysis of the fluctuations of R-R period (ECG) and systolic arterial pressure (SAP, Finapres) recorded during a 20 min supine period and during 20 min 60 deg head-up tilt (HUT). The baroreflex latency was determined by identifying the lag between the changes in SAP and in R-R interval from which the highest correlation coefficient was obtained. During the supine period, 74% of sequences in control subjects and 54% in patients occurred with zero beats of delay (i.e. R-R interval changed within the same R-R interval). The remaining sequences occurred with delays of up to four beats. HUT shifted the baroreflex delay to be approximately one heartbeat slower and again patients showed more sequences with prolonged response. The delay in heartbeats was transformed into delay in time. In control subjects, 75% of baroreflex responses occurred within 1 s. In patients, 75% of baroreflex responses took more than 2 s to occur. The results showed that syncopal patients with poor orthostatic tolerance have increased baroreflex latency. This may lead to instability and inadequate blood pressure control and may predispose to vasovagal syncope.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1113/expphysiol.2004.029496DOI Listing
May 2005

Moderate aerobic training improves autonomic cardiovascular control in older women.

Clin Auton Res 2003 Jun;13(3):196-202

Dept. of Neurological Science and Vision, Section of Physiology, University of Verona, Verona, Italy.

The decline in the cardiovascular autonomic regulation in advanced age is considered a risk factor for several cardiovascular diseases. We tested, on eleven healthy untreated women aged 60-70 years, whether a six-month period of group-based training exerts positive effects on this age-associated decline. Before and after training, ECG and arterial pressure (Finapres) were recorded in supine position. We calculated mean values +/- SEM of R-R period (RR), systolic (SAP) and diastolic (DAP) arterial pressure, as well as, by autoregressive spectral analysis methods, low (approximately 0.1 Hz) and high (respiratory) frequency oscillations of RR (LF(RR), HF(RR)) and SAP (LF(SAP), HF(SAP)), and the baroreflex sensitivity (BRS). Training induced statistically significant changes (p < 0.05 by paired t-test): increase in RR (mean +/- SEM) from 894 +/- 41 to 947 +/- 31 ms and in heart rate variability (HRV) by 25 %, decrease in DAP from 75.8 +/- 3.0 to 70.8 +/- 2.2 mmHg, no change in SAP. LF(RR) and LF(SAP) increased by more than 100%, while BRS by 32%. We suggest that the increase in BRS might be responsible for the observed bradycardia and higher LF(RR). An improved modulation, rather than an increase, in tonic sympathetic activity, is also suggested. A specific program of moderate aerobic training is adequate to increase the BRS and the HRV in older women.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10286-003-0090-xDOI Listing
June 2003

Cross-spectral analysis of cardiovascular parameters whilst supine may identify subjects with poor orthostatic tolerance.

Clin Sci (Lond) 2003 Jul;105(1):119-26

Institute for Cardiovascular Research, University of Leeds, Leeds LS2 9JT, UK.

An easy and low-cost method for identification of subjects prone to orthostatic vasovagal syncope would be of clinical benefit. An orthostatic test with 60 degrees head-up tilt and progressive lower-body negative pressure was performed on 79 patients with histories of unexplained syncope and 26 control subjects. The test was stopped at the onset of presyncope and time to presyncope was taken as a measure of orthostatic tolerance. Spectral and cross-spectral analysis was performed on the supine time series of the R-R interval (ECG) and systolic pressure (Finapres) recorded before the beginning of the test. According to reference values, 38 patients and 11 controls were classified as having poor orthostatic tolerance (PPT and CPT respectively), whereas 41 patients and 15 controls displayed normal orthostatic tolerance (PNT and CNT respectively). The central frequency of the low-frequency (LF approximately equal to 0.1 Hz.) oscillations in PNT and CNT was significantly higher than that in PPT and CPT. In addition, it was significantly linearly correlated with the time of presyncope. Using our test of orthostatic tolerance as a comparison, the LF central frequency allows the classification of subjects with poor or normal tolerance with 80% sensitivity and 82% specificity. These results suggest that the LF central frequency in the supine position may provide a useful index in the diagnosis of orthostatic intolerance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1042/CS20020322DOI Listing
July 2003
-->