Showing papers by "Luciano A. Sposato published in 2015"

Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis

Abstract: Summary Background Among patients with atrial fibrillation, the risk of stroke is highest for those with a history of stroke; however, oral anticoagulants can lower the risk of recurrent stroke by two-thirds. No consensus has been reached about how atrial fibrillation should be investigated in patients with stroke, and its prevalence after a stroke remains uncertain. We did a systematic review and meta-analysis to estimate the proportion of patients newly diagnosed with atrial fibrillation after four sequential phases of cardiac monitoring after a stroke or transient ischaemic attack. Methods We searched PubMed, Embase, and Scopus from 1980 to June 30, 2014. We included studies that provided the number of patients with ischaemic stroke or transient ischaemic attack who were newly diagnosed with atrial fibrillation. We stratified cardiac monitoring methods into four sequential phases of screening: phase 1 (emergency room) consisted of admission electrocardiogram (ECG); phase 2 (in hospital) comprised serial ECG, continuous inpatient ECG monitoring, continuous inpatient cardiac telemetry, and in-hospital Holter monitoring; phase 3 (first ambulatory period) consisted of ambulatory Holter; and phase 4 (second ambulatory period) consisted of mobile cardiac outpatient telemetry, external loop recording, and implantable loop recording. The primary endpoint was the proportion of patients newly diagnosed with atrial fibrillation for each method and each phase, and for the sequential combination of phases. For each method and each phase, we estimated the summary proportion of patients diagnosed with post-stroke atrial fibrillation using random-effects meta-analyses. Findings Our systematic review returned 28 290 studies, of which 50 studies (comprising 11 658 patients) met the criteria for inclusion in the meta-analyses. The summary proportion of patients diagnosed with post-stroke atrial fibrillation was 7·7% (95% CI 5·0–10·8) in phase 1, 5·1% (3·8–6·5) in phase 2, 10·7% (5·6–17·2) in phase 3, and 16·9% (13·0–21·2) in phase 4. The overall atrial fibrillation detection yield after all phases of sequential cardiac monitoring was 23·7% (95% CI 17·2–31·0). Interpretation By sequentially combining cardiac monitoring methods, atrial fibrillation might be newly detected in nearly a quarter of patients with stroke or transient ischaemic attack. The overall proportion of patients with stroke who are known to have atrial fibrillation seems to be higher than previously estimated. Accordingly, more patients could be treated with oral anticoagulants and more stroke recurrences prevented. Funding Heart and Stroke Foundation of Canada, and Natural Science and Engineering Research Council of Canada.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition

Abstract: Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Declining Incidence of Stroke and Dementia: Coincidence or Prevention Opportunity?

Abstract: Declining Incidence of Stroke and Dementia: Coincidence or Prevention Opportunity? Stroke and dementia pose significant threats to the adult brain and share the same treatable risk factors.1 Stroke incidence in high-income countries has been declining,2 coinciding with better risk-factor control. However, hitherto there have been encouraging trends, but no proof, of declining dementia incidence.3 To address this, we analyzed health care administrative data from the Canadian Institute for Health Information for the province of Ontario, Canada.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Abstract: Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Very short paroxysms account for more than half of the cases of atrial fibrillation detected after stroke and TIA: a systematic review and meta‐analysis

Abstract: BackgroundGuidelines suggest that only poststroke atrial fibrillation episodes lasting 30 s or longer should be considered for anticoagulation. However, little evidence supports this recommendation.AimsWe performed a systematic review and meta-analysis to investigate the frequency of poststroke atrial fibrillation lasting less than 30 s in stroke and transient ischemic attack patients.MethodsWe searched PubMed, Embase, and Scopus from 1980 to June 30, 2014 for studies reporting the detection of poststroke atrial fibrillation of less than 30 s and of 30 s or longer. The primary endpoint was the proportion of screened patients diagnosed with poststroke atrial fibrillation lasting less than 30 s. The secondary endpoint was the proportion of patients diagnosed with poststroke atrial fibrillation shorter than 30 s among the overall number of patients in whom a poststroke atrial fibrillation was detected after stroke or transient ischemic attack.ResultsFrom 28 290 titles, we included nine studies in the random-...

Stroke and Neurodegeneration Induce Different Connectivity Aberrations in the Insula

Abstract: Background and Purpose—Stroke and neurodegeneration cause significant brain damage and cognitive impairment, especially if the insular cortex is compromised. This study explores for the first time whether these 2 causes differentially alter connectivity patterns in the insular cortex. Methods—Resting state–functional magnetic resonance imaging data were collected from patients with insular stroke, patients with behavioral variant frontotemporal dementia, and healthy controls. Data from the 3 groups were assessed through a correlation function analysis. Specifically, we compared decreases in connectivity as a function of voxel Euclidean distance within the insular cortex. Results—Relative to controls, patients with stroke showed faster connectivity decays as a function of distance (hypoconnectivity). In contrast, the behavioral variant frontotemporal dementia group exhibited significant hyperconnectivity between neighboring voxels. Both patient groups evinced global hypoconnectivity. No between-group diffe...

Cardiovascular autonomic dysfunction in multiple sclerosis: a meta-analysis.

Abstract: Background and objective: The definition of cardiovascular autonomic dysfunction in patients with multiple sclerosis is controversial Thus, its true prevalence is unknown We performed a systematic review and meta-analysis to compare the proportion of patients with multiple sclerosis that would be diagnosed with cardiovascular dysautonomia using a definition of at least one abnormal cardiac autonomic test vs at least two abnormal studies Methods: We searched PubMed, Embase, and Scopus from 1980 to December 2013 for publications reporting abnormal autonomic tests in patients with multiple sclerosis We performed random-effects meta-analyses for calculating the proportion of patients diagnosed with autonomic dysfunction with both definitions Results: We included 16 studies comprising 611 patients with multiple sclerosis, assessing Z3 cardiovascular autonomic tests The proportion of patients with autonomic dysfunction was two-fold higher (p=0006) when using the definition of only one abnormal autonomic test (421%) compared to that using at least two abnormal results (188%) Conclusions: We found a wide variation in the proportion of patients with multiple sclerosis diagnosed with cardiovascular dysautonomia by using the two definitions Consensus is needed to define autonomic dysfunction in patients with multiple sclerosis In the meantime, we

Causes of Death Data in the Global Burden of Disease Estimates for Ischemic and Hemorrhagic Stroke.

Abstract: Background: Stroke mortality estimates in the Global Burden of Disease (GBD) study are based on routine mortality statistics and redistribution of ill-defined codes that cannot be a cause of death, the so-called ‘garbage codes' (GCs). This study describes the contribution of these codes to stroke mortality estimates. Methods: All available mortality data were compiled and non-specific cause codes were redistributed based on literature review and statistical methods. Ill-defined codes were redistributed to their specific cause of disease by age, sex, country and year. The reassignment was done based on the International Classification of Diseases and the pathology behind each code by checking multiple causes of death and literature review. Results: Unspecified stroke and primary and secondary hypertension are leading contributing ‘GCs' to stroke mortality estimates for hemorrhagic stroke (HS) and ischemic stroke (IS). There were marked differences in the fraction of death assigned to IS and HS for unspecified stroke and hypertension between GBD regions and between age groups. Conclusions: A large proportion of stroke fatalities are derived from the redistribution of ‘unspecified stroke' and ‘hypertension' with marked regional differences. Future advancements in stroke certification, data collections and statistical analyses may improve the estimation of the global stroke burden.

Stroke preparedness in children: translating knowledge into behavioral intent: a systematic review and meta-analysis.

Abstract: Background If translated into behavioral intent, improving stroke knowledge may potentially impact on better outcomes. Children are an attractive target population since they can drive familial behavioral changes. However, the impact of interventions on stroke knowledge among children is unclear. We performed a systematic review and meta-analysis to investigate whether educational interventions targeting children improve stroke knowledge and lead to behavioral changes. Methods We searched Ovid, PubMed, and Embase between January 2000 and December 2014. We included studies written in English reporting the number of children aged 6–15 years undergoing educational interventions on stroke and providing the results for baseline and early and late postintervention tests. We compared the proportion of correct answers between baseline, early, and late responses for two endpoints: knowledge and behavioral intent. Results Of the initial 58 articles found, we included nine that met the inclusion criteria. Compared with baseline tests (51·7%, 95% confidence interval 40·9–62·4), there was improvement in stroke knowledge in early (74·0%, 95% confidence interval 64·4–82·5, P = 0·002) and late (67·3%, 95% confidence interval 55·4–78·2, P = 0·027) responses. There was improvement in the early (92·1%, 95% confidence interval 86·0–96·6, P < 0·001) and late (83·9%, 95% confidence interval 73·5–92·1, P = 0·001) responses for behavioral intent compared with the baseline assessment (63·8%, 95% confidence interval 53·5–73·4). Conclusion Children are a potentially attractive target population for improvement in stroke knowledge and behavioral intent, both in the short and long term. Our findings may support the implementation of large-scale stroke educational initiatives targeting children.

Worsening risk factors and more strokes The dark side of economic growth

Abstract: Stroke incidence has substantially decreased in developed countries.1 Health policies implemented in the 1970s to control hypertension, diabetes mellitus, and dyslipidemia, smoking cessation programs, and the use of oral anticoagulants in patients with atrial fibrillation have likely contributed to the decline in stroke incidence.1 By contrast, the landscape in rural China is rather bleak. In this issue of Neurology ®, Wang et al.2 report increasing prevalence of vascular risk factors and incidence of first-ever stroke in a Chinese low-income rural population. Since China has experienced impressive development and given that socioeconomic status generally correlates with better health outcomes, these findings are somewhat surprising and warrant analysis.

Atrial Fibrillation in Patients with Neuropathological Diagnosis of Primary Alzheimer’s Disease (I9-5A)

Abstract: OBJECTIVE: To characterize the clinical, neuropsychological and neuropathological profile of Alzheimer’s disease (AD) patients with and without atrial fibrillation(AF). BACKGROUND: The prevalence of dementia and AF increase with age. Recent evidence shows that AF patients are at a higher risk of developing cognitive impairment and dementia, irrespective of their stroke history. Thus, AF constitutes a promising target for the prevention of dementia. DESIGN/METHODS: We compared demographic data, vascular risk factors, functional status (clinical dementia rating), and neuropsychological functioning of neuropathologically confirmed cases of AD from the National Alzheimer9s Coordinating Center database with (AF-AD) and without (nAF-AD) AF diagnosis. We also used neural network analyses to identify neuropathology findings related with AF. RESULTS: We included 1686 patients with pathological diagnosis of AD. Patients with AF-AD were older at the time of onset of cognitive decline (77.1±9.2 vs. 71.5±11.2 years, p<0.001) and at death (85.6.5±7.7 vs. 79.8±10.4, p<0.001), and were more likely to be hypertensive (66.3 vs. 56.1[percnt], p=0.002) than those with nAF-AD. Comorbidities were also more frequent in AF-AD patients compared to nAF-AD: coronary artery disease (27.3 vs. 26.6[percnt], p<0.001), congestive heart failure (21.5 vs. 6.0[percnt], p<0.001), stroke (19.2 vs. 11.7[percnt], p<0.001), and transient ischemic attack (15.9 vs. 10.7[percnt], p=0.014). Accordingly, large infarcts (14.4 vs. 8.5[percnt], p=0.002) and the overall ischemic vascular component (large infarcts, lacunar infarcts, or microinfarcts) were more frequently among AF-AD patients than nAF-subjects (37.5 vs. 30.6[percnt], p=0.023). AF-AD patients had better performances than nAF-AD subjects in cognitive functioning (general cognitive functioning, executive function, memory, language, attention) and functional status. In the neural network analysis, AF was only related with vascular brain lesions, showing no association with neurodegenerative changes. CONCLUSIONS: AF-AD has a more "vascular" and “benign” profile than nAF-AD. Dementia seems to be mediated by brain infarcts rather than by neurodegeneration. FUNDING: National Institute on Aging (UO1 AG016976). Disclosure: Dr. Riccio has nothing to disclose. Dr. Sposato has nothing to disclose. Dr. Ruiz Vargas has nothing to disclose. Dr. Toledo has nothing to disclose. Dr. Trojanowski has received personal compensation for activities with Johnson & Johnson. Dr. Hachinski has nothing to disclose.

bias when assessing the usefulness of different screening methods.

Abstract: 1. Joseph LG, Gyorkos TW, Coupal L. Bayesian estimation of disease prevalence and the parameters of diagnostic tests in the absence of a gold standard. Am J Epidemiol 1995;141: 263e272. 2. Sposato LA, Cipriano LE, Saposnik G, Ruíz Vargas E, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and metaanalysis. Lancet Neurol 2015;14:377e387. 3. Choe WC, Passman RS, Brachmann J, Morillo CA, Sanna T, Bernstein RA, Di Lazzaro V, Diener HC, Rymer MM, Beckers F, Koehler J, Ziegler PD. A comparison of atrial fibrillation monitoring strategies after cryptogenic stroke (from the Cryptogenic Stroke and Underlying AF Trial). Am J Cardiol 2015;116:889e893. 4. Boriani G, Glotzer TV, Santini M, West TM, De Melis M, Sepsi M, Gasparini M, Lewalter T, Camm JA, Singer DE. Device-detected atrial fibrillation and risk for stroke: an analysis of >10,000 patients from the SOS AF project (Stroke preventiOn Strategies based on Atrial Fibrillation information from implanted devices). Eur Heart J 2014;35:508e516. 5. Sposato LA, Cipriano LE, Riccio PM, Hachinski V, Saposnik G. Very short paroxysms account for more than half of the cases of atrial fibrillation detected after stroke and TIA: a systematic review and meta-analysis. Int J Stroke 2015;10:801e807. 6. Rankin AJ, Tran RT, Abdul-Rahim AH, Rankin AC, Lees KR. Clinically important atrial arrhythmia and stroke risk: a UK-wide online survey among stroke physicians and cardiologists. QJM 2014;107:895e902. 7. Hindricks G, Pokushalov E, Urban L, Taborsky M, Kuck KH, Lebedev D, Rieger G, Pürerfellner H; XPECT Trial Investigators. Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: results of the XPECT trial. Circ Arrhythm Electrophysiol 2010;3:141e147. 8. Sposato LA, Riccio PM, Hachinski V. Poststroke atrial fibrillation: cause or consequence? Critical review of current views. Neurology 2014;82:1180e1186.