Coronary Calcium Score for the Prediction of Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke

The first question to ask your stroke hospital. Do they have anyone in charge of research analysis and creation of stroke interventions from such research? IF NOT, THEY ARE COMPLETELY INCOMPETENT AND HAVE NO BUSINESS BEING A STROKE HOSPITAL.

Coronary Calcium Score for the Prediction of Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke

Hye-Yeon Choi¹, Soo Jeong Shin², Joonsang Yoo^2,3, Kijeong Lee⁴, Dongbeom Song², Young Dae Kim², Hyo Suk Nam², Kyung Yul Lee², Hye Sun Lee⁵, Dong Joon Kim⁶ and Ji Hoe Heo^2,7*

• ¹Department of Neurology, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
• ²Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
• ³Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
• ⁴Department of Neurology, College of Medicine, Eunpyeong St. Mary Hospital, Catholic University of Korea, Seoul, South Korea
• ⁵Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
• ⁶Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
• ⁷Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea

Purpose: 

Many patients with ischemic stroke have concomitant coronary artery disease (CAD). However, it remains unclear which stroke patients should undergo evaluation for asymptomatic CAD, and which screening tools are appropriate. We investigated the role of coronary artery calcium (CAC) score as a screening tool for asymptomatic but severe CAD in acute stroke patients. We determined the selection criteria for CAC screening based on risk factors and cerebral atherosclerosis.

Materials and Methods: 

The present study included consecutive patients with acute stroke who had undergone cerebral angiography and multi-detector computed tomography coronary angiography. Severe CAD was defined as left main artery disease or three-vessel disease. Enrolled patients were randomly assigned to two sets; a set for developing selection criteria and a set for validation. To develop selection criteria, we identified associated factors with severe CAD regarding clinical factors and cerebral atherosclerosis. CAD predictability of selection criteria with the CAC score was calculated.

Results: 

Overall, 2,658 patients were included. Severe CAD was present in 360 patients (13.5%). CAC score was associated with CAD severity (P < 0.001). In the development set (N = 1,860), severe CAD was associated with age >65 years [odds ratio (95% confidence interval), 2.62 (1.93–3.55)], male sex (1.81 [1.33–2.46]), dyslipidemia (1.77 [1.25–2.61]), peripheral artery disease (2.64 [1.37–5.06]) and stenosis in the cervicocephalic branches, including the internal carotid (2.79 [2.06–3.78]) and vertebrobasilar arteries (2.08 [1.57–2.76]). We determined the combination of clinical and arterial factors as the selection criteria for CAC evaluation. The cut-off criterion was two or more elements of the selection criteria. The area under the curve (AUC) of the selection criteria was 0.701. The AUC significantly improved to 0.836 when the CAC score was added (P < 0.001). In the validation set (N = 798), the AUC of the selection criteria only was 0.661, and that of the CAC score was 0.833. The AUC of the selection criteria + CAC score significantly improved to 0.861(P < 0.001).

Conclusion: 

The necessity for CAC evaluation could be determined based on the presence of risk factors and significant stenosis of the cervicocephalic arteries. CAC evaluation may be useful for screening for severe CAD in stroke patients.

Introduction

Ischemic heart disease is the leading cause of long-term mortality in patients with stroke (1). The annual risk of myocardial infarction in patients with ischemic stroke is ~2.2% (1, 2). The presence and extent of asymptomatic stenosis in coronary angiography is strongly predictive of major cardiovascular events. Previous studies identified significant (≥50%) stenosis of the coronary artery in 20–41% of patients with stroke via autopsy, coronary angiography, or multi-detector computed tomography angiography (MDCTA) (3–7). Therefore, coronary screening may be necessary for stroke patients at high risk of coronary artery disease (CAD). However, it still remains uncertain which group of patients with stroke should undergo evaluation for asymptomatic CAD, and which evaluation tools are most appropriate for coronary screening in such patients.

Atherosclerosis is a systemic disease and CAD shares several risk factors with cerebral atherosclerosis (8). In fact, previous studies have demonstrated a significant association between CAD and atherosclerosis of the cervicocephalic arteries including the vertebrobasilar artery (VBA) and carotid arteries (4, 6, 9, 10). These findings suggest that CAD may be predicted to some extent by the presence of cerebral atherosclerosis and vascular risk factors.

Previous studies have indicated that coronary artery calcium (CAC) is superior to risk factor-based prediction of CAD and coronary events (11–14). Additionally, other studies reported that CAC scores are associated with the severity of CAD (15). In a large prospective population cohort registry, the risk of coronary events increased as the CAC score increased (12). This study aimed to investigate the role of the CAC score as a screening tool for the diagnosis of asymptomatic but severe CAD in patients with acute stroke. We also sought to determine the selection criteria for CAC screening in patients with stroke based on the presence of risk factors and cerebral atherosclerosis.

More at link. 

Body Weight Fluctuations Linked to More Deaths in Patients With Coronary Artery Disease

Your doctor, if any good at all, will be telling you this in the next couple of weeks.
http://dgnews.docguide.com/body-weight-fluctuations-linked-more-deaths-patients-coronary-artery-disease?
Repeated cycles of weight loss and gain may be linked to higher risk for stroke, myocardial infarction (MI), and death in people with pre-existing coronary artery disease, according to a study published online in the New England Journal of Medicine.
The study was the first to measure the effect of weight cycling on health outcomes in people with pre-existing heart disease.
People with the largest weight changes were found to experience 136 % more strokes, 117% more MIs, and 124% more deaths than those with the smallest shifts in weight. Those in the high-fluctuation group had weight changes as large as 3.9 kg (~8.6 lbs), while weight varied by around 0.9 kg (~2 lbs) in the group with the smallest shifts in weight.
“Our findings suggest that we need to be concerned about weight fluctuation in this group that is already at high risk due to coronary disease,” said lead author Sripal Bangalore, MD, Cardiovascular Clinical Research Center, NYU Langone Medical Center, New York, New York.
“Even though this analysis was not designed to find out the causes of increased risk with body weight fluctuations, we need to examine how we can help Americans keep weight off, rather than having it go up and down.”
The researchers reviewed data on 9,509 men and women with coronary artery disease who participated in the Treating to New Targets trial, which originally concluded in 2005. Study participants were aged 35 to 75 years and all had coronary artery disease, high cholesterol levels, and some history of heart problems. Half were being treated with cholesterol-lowering drugs in intensive doses to see if this resulted in fewer deaths. All patients were monitored for a median of 4.7 years.
The analysis linked shifts in body weight to statistically significant differences in outcomes only in people who were overweight or obese at the beginning of the study, but not for people who started with normal weight.
Body weight changes were also strongly linked to an increase in newly diagnosed diabetes, and associations persisted regardless of a person’s average body weight and traditional risk factors for heart disease.
The researchers cautioned that their re-analysis does not show a cause-and-effect relationship between weight cycling and poor outcomes, but only an association. The authors also recognise that they were unable to tell if people lost weight intentionally, unintentionally, or due to illness, or if any eventual heart problems resulted directly from the weight loss, change in weight, or illness.
Dr. Bangalore hopes that the current findings will lead to further study of weight fluctuation in people with coronary artery disease and to the development of related practice guidelines once all the evidence is in.
SOURCE: NYU Langone Medical Center

Don't go too low with blood pressure in hypertensive CAD patients

I guess I have mild CAD, two small arteries in the heart are 30% blocked, my blood pressure with drugs is now 140/85. So I think I'm good. The writeup on this is damned hard for a peon like me to understand.
http://www.mdlinx.com/internal-medicine/article/597?

Liz Meszaros, MDLinx, 08/31/2016

Contrary to popular belief, blood pressure that is too low may be associated with worse outcomes in hypertensive patients with coronary artery disease (CAD), according to CLARIFY researchers, who presented their results at the European Society of Cardiology Congress 2016, in Rome, Italy.

BP in hyptensive CAD patients

Low BP was associated with worse outcomes, according to CLARIFY researchers.

“The optimal blood pressure target in patients with hypertension continues to be debated, especially in those with coronary artery disease (CAD). ESC guidelines recommend lowering blood pressure to values within the range 130–139/80–85 mmHg for patients with CAD to reduce the risk of further cardiovascular events,” said principal investigator Philippe Gabriel Steg, MD, professor, cardiology, Universite Paris-Diderot, and director, Coronary Care Unit, Hopital Bichat, Paris, France.
“Some argue ‘the lower, the better’ but there is a concern that patients with CAD may have insufficient blood flow to the heart if their blood pressure is too low,” he added.
Dr. Steg, who is also a professor at the National Heart and Lung Institute, Imperial College, London, United Kingdom, and colleagues conducted an analysis of the CLARIFY registry to determine the relationship between blood pressure achieved with treatment and cardiovascular outcomes in patients with CAD.
For their analysis, they included 22,672 subjects with stable CAD enrolled in the CLARIFY registry and treated for hypertension between November 2009 and June 2010, from 45 countries. They averaged systolic/diastolic BPs before each cardiovascular event, and estimated hazard ratios (HRs) with multivariable adjusted Cox proportional hazards models, using the 120–129 mmHg systolic BP and 70–79 mmHg diastolic BP subgroups as reference.
In these patients, they found that after a median follow-up of 5 years, a systolic BP of 140 mmHg or higher, and a diastolic BP of 80 mmHg or higher were both associated with an increased risk of cardiovascular events.
They also found that a systolic BP of less than 120 mmHg was associated with an increased risk for the primary outcome—which was the composite of cardiovascular death, myocardial infarction, or stroke—(adjusted HR: 1.56; 95% CI: 1.36-1.81), and all secondary outcomes except stroke, including primary outcome, all-cause death, and hospitalization for heart failure.
Furthermore, a diastolic BP less than 70 mmHg was associated with an increased risk of the primary outcome (adjusted HR: 1.41; 95% CI: 1.24-1.61 for diastolic BP from 60-69 mmHg; and HR: 2.01; 95% CI: 1.50-2.70 for less than 60 mmHg) and in all secondary outcomes except stroke.
“We found that systolic blood pressure less than 120 mmHg was associated with a 56% greater risk of the composite primary outcome of cardiovascular death, myocardial infarction, or stroke. Diastolic blood pressure between 60 and 69 mmHg was associated with a 41% increased risk of the primary outcome, with risk rising to 2-fold when diastolic blood pressure fell below 60 mmHg,” said Dr. Steg.
“This large study of hypertensive CAD patients from routine clinical practice found that systolic BP less than 120 mmHg and diastolic BP less than 70 mmHg are each associated with adverse cardiovascular outcomes, including mortality. The findings support the existence of a J-curve phenomenon, where the initial lowering of BP is beneficial but further lowering is harmful,” he explained.
“Our results suggest that the ESC recommendation remains valid and physicians should exercise caution when using BP-lowering treatment in patients with CAD. This should however not detract from our efforts to diagnose and treat hypertension which remains massively underdiagnosed and undertreated worldwide,” Dr. Steg concluded.

AristaCare Takes Rehabilitation to the Next Level - SOUTH PLAINFIELD, NJ

This sounds so upbeat that I would be a cad to criticize it. But there are absolutely no statistics in here to compare them to any other place. I'm a f*cking cad and this article is pandering to the worst degree.
http://thealternativepress.com/articles/aristacare-takes-rehabilitation-to-the-next-level
If YOU don't start holding hospitals, care centers and neurologists to any sort of standard, this is exactly what you get. Meaningless press releases that help no one recover.