Real World Studies Compares Dabigatran with Rivaroxaban or Apixaban in Nonvalvular AFib

MedicalResearch.com Interview with:

Todd C. Villines, M.D. FSCCT Professor of Medicine Uniformed Services University School of Medicine Director of Cardiovascular Research and Cardiac CT Cardiology Fellowship Program Director Walter Reed National Military Medical Center Bethesda, Maryland Assistant Professor of Medicine Georgetown School of Medicine

Dr. Villines

Todd C. Villines, M.D. FSCCT
Professor of Medicine
Uniformed Services University School of Medicine
Director of Cardiovascular Research and Cardiac CT
Cardiology Fellowship Program Director
Walter Reed National Military Medical Center
Bethesda, Maryland
Assistant Professor of Medicine
Georgetown School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: This study was a retrospective, observational real-world analysis assessing the safety and effectiveness of novel oral anticoagulants (NOACs) among patients with non-valvular atrial fibrillation (NVAF) treated through the U.S. Department of Defense Military Health System. The study examined major bleeding and stroke rates in NVAF patients who had initiated treatment with dabigatran compared to those treated with rivaroxaban or apixaban.

The study examined two cohorts: one that resulted in 12,763 propensity score matched dabigatran (150 mg bid) and rivaroxaban (20 mg daily) patients, and another that resulted in 4,802 propensity score matched dabigatran (150 mg bid) and apixaban (5 mg bid) patients. Dabigatran patients demonstrated lower rates of major bleeding compared to rivaroxaban patients (2.08 percent vs 2.53) percent and similar rates of stroke (0.60 percent vs 0.78 percent). In the exploratory analysis, dabigatran and apixaban patients showed similar rates of major bleeding (1.60 percent vs 1.21 percent) and stroke (0.44 percent vs 0.35 percent). Continue reading

Migraine Linked To Increased Risk of Stroke, AFib, PE and Cardiovascular Disease

MedicalResearch.com Interview with:
“Headache.” by Avenue G is licensed under CC BY 2.0
Kasper Adelborg, MD, PhD
Postdoctoral Fellow
Department of Clinical Epidemiology
Aarhus University Hospital 

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Around one billion people worldwide are affected by migraine. Migraine has considerable impact on quality of life and imposes a substantial burden on society. Migraine is primarily a headache disorder, but previous studies have suggested a link between migraine and stroke and myocardial infarction, particularly among women, while the link between migraine and other heart problems are less well known.

In this large register-based Danish study published in the BMJ, we confirmed that migraine is associated with increased risks of stroke and myocardial infarction, but we also found that migraine was associated with increased risks of other cardiovascular diseases (specifically, venous thromboembolism and atrial fibrillation). Migraine was not associated with increased risks of heart failure or peripheral artery disease.

In contrast to most previous studies, our study had a very large sample size and an age- and sex- matched comparison cohort from the general population, which allowed us to put migraine in a population context and to perform several subgroup analyses. Here, we found several interesting findings.

  • In general, the associations were strongest in the first year after diagnosis but persisted in the long term (up to 19 years after diagnosis).
  • Most associations applied to both migraine patients with aura (warning signs before a migraine, such as seeing flashing lights) and in those without aura, and in both women and in men. 

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Could NOACs Be Better Option Than Warfarin To Prevent Ischemic Stroke?

MedicalResearch.com Interview with:

Taku Inohara MD Department of Cardiology, Keio University School of Medicine Tokyo, Japan Duke Clinical Research Institute, Duke University Medical Center Durham, NC 

Dr. Taku Inohara

Taku Inohara MD
Department of Cardiology, Keio University School of Medicine
Tokyo, Japan
Duke Clinical Research Institute, Duke University Medical Center
Durham, NC 

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly prescribed for high-risk patients with atrial fibrillation because they have fewer bleeding complications than warfarin. However, they still pose a risk of intracerebral hemorrhage (ICH). It was unclear if patients with preceding use of NOACs who experienced an ICH were at greater risk of death than patients with no oral anticoagulant (OAC)  or patients who received warfarin.

Using the GWTG-Stroke registry, we found that, while prior use of both NOACs and warfarin was associated with a greater risk of in-hospital mortality than no OAC, patients with prior use of NOACs were more likely to have favorable outcomes than patients with prior use of warfarin. In addition, the lower mortality in NOACs compared with warfarin was more likely to be prominent in patients with dual antiplatelet agents than those without antiplatelet therapy.

MedicalResearch.com: What should readers take away from your report?

Response: High risk patients with atrial fibrillation have to be taking anticoagulation anyway, even ICH occurs, NOACs could still be a better option than warfarin to prevent ischemic stroke.

Physicians should consider NOACs as a safer anticoagulant strategy than warfarin in terms of the severity of their most devastating complication, despite lack of antidotes for current NOACs. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Our findings have the potential to inform future treatment selection when oral anticoagulation is warranted. Future study needs to clarify the temporal trend of OAC-related ICH in parallel of the implementation of NOACs and focus on how the widespread use of NOACs affect the outcome of patients experiencing OAC-related ICH.  

MedicalResearch.com: Is there anything else you would like to add?

Response: The GWTG-Stroke program is provided by the American Heart Association/American Stroke Association (AHA/ASA). This study is in part supported by the ARAMIS registry with research funding from Daiichi Sankyo, Inc., Genentech, Inc., and Janssen. 

Citations:

Inohara T, Xian Y, Liang L, Matsouaka RA, Saver JL, Smith EE, Schwamm LH, Reeves MJ, Hernandez AF, Bhatt DL, Peterson ED, Fonarow GC. Association of Intracerebral Hemorrhage Among Patients Taking Non–Vitamin K Antagonist vs Vitamin K Antagonist Oral Anticoagulants With In-Hospital Mortality. JAMA. Published online January 25, 2018. doi:10.1001/jama.2017.21917

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Aspiration Therapy Offers Alternative To Stent Retrievers For Large Vessel Stroke

MedicalResearch.com Interview with:

Dr. J. Mocco, MD Professor Neurosurgery Mount Sinai Beth Israel  Mount Sinai St. Luke's and Mount Sinai West The Mount Sinai Hospital

Dr. Mocco

Dr. J. Mocco, MD
Professor Neurosurgery
Mount Sinai Beth Israel
Mount Sinai St. Luke’s and Mount Sinai West
The Mount Sinai Hospital

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Numerous trials have demonstrated that Endovascular therapy is strongly beneficial for emergent large vessel stroke patients.

The majority of patients in those trials were treated with Stent retrievers.  COMPASS was designed to evaluate a different type of Endovascular therapy called aspiration Thrombectomy.  Continue reading

Robotics Can Be Used To Train Brain To Recover Hand Use After Stroke

MedicalResearch.com Interview with:

The Brain-Machine Interface (BMI) setup applied in this study. Participants imagine opening their hand without actually making any movement while their hand is placed in a device that passively opens and closes their fingers as it receives the necessary input from their brain activity.

The Brain-Machine Interface (BMI) setup applied in this study. Participants imagine opening their hand without actually making any movement while their hand is placed in a device that passively opens and closes their fingers as it receives the necessary input from their brain activity.

Professor Alireza Gharabaghi
Univ.-Prof. Dr. med. Alireza Gharabaghi
Ärztlicher Leiter
Sektion Funktionelle und Restaurative Neurochirurgie
Neurochirurgische Universitätsklinik
Eberhard Karls Universität Tübingen 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. Stroke is the leading cause of serious, long-term disability. About half of all stroke survivors will never be able to use their affected hand for activities of daily living again.

The current study investigates a novel technology which may lead to new therapeutic options for these patients. 

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General Anesthesia vs Conscious Sedation for Endovascular Therapy of Stroke

MedicalResearch.com Interview with:

Dr. Claus Z. Simonsen, MD, PhD Department of Neurology Aarhus University Hospital

Dr. Simonsen

Dr. Claus Z. Simonsen, MD, PhD
Department of Neurology
Aarhus University Hospital

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Retrospective studies find worse outcome when performing (Endovascular Therapy) EVT under General Anesthesia (GA).

The main finding is that infarct growth in the Conscious Sedation (CS) and GA are not different. And that patients who had EVT under GA had a better outcome after 90 days. This is probably explained by better reperfusion rates under GA which was another part of the study that was surprising. Our neurointerventionalist are comfortable performing EVT under CS, but our study indicates that maybe it is easier to achieve reperfusion it the patient is anesthesized.

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Feasibility of Anticoagulating Cancer Patients At Increased Risk of Stroke

MedicalResearch.com Interview with:

Babak B. Navi MD, MS

Dr. Navi

Babak B. Navi MD, MS
Department of Neurology
Weill Cornell Medicine
New York, New York

MedicalResearch.com: What is the background for this study?

Response: About 10% of patients with ischemic stroke have comorbid cancer and these patients face an increased risk of stroke recurrence. Many strokes in patients with cancer are attributed to unconventional mechanisms from acquired hypercoagulability. Therefore, many physicians recommend anticoagulation, especially low molecular weight heparins, for the treatment of cancer-associated stroke. However, hypercoagulable stroke mechanisms, such as nonbacterial thrombotic endocarditis, are rarely definitively diagnosed in cancer patients antemortem; while atherosclerosis, which is generally treated with antiplatelet medicines such as aspirin, is common in cancer patients. In addition, many historic indications for anticoagulation in ischemic stroke have been disproven by randomized trials because any reductions in stroke risk were offset by increased risks of bleeding. Given these considerations, we believed that a randomized trial comparing anticoagulation with enoxaparin to antiplatelet therapy with aspirin was necessary to determine the superior strategy, prompting implementation of the TEACH pilot randomized trial. The primary aim of TEACH was to determine whether the random assignment of different antithrombotic strategies to cancer patients with acute ischemic stroke would be sufficiently feasible and safe to proceed with a larger efficacy trial.  Continue reading

Racial Differences in Plasma Biomarker May Partially Explain Stroke Disparities

MedicalResearch.com Interview with:

Pankaj Arora MD, FAHA Assistant Professor, Cardiology Division University of Alabama at Birmingham Section Editor, Circulation: Cardiovascular Genetics American Heart Association

Dr. Arora

Pankaj Arora MD, FAHA
Assistant Professor, Cardiology Division
University of Alabama at Birmingham
Section Editor, Circulation: Cardiovascular Genetics
American Heart Association 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Natriuretic peptides are hormones produced by the heart in response to increased wall stress in the atria and ventricles. It is well known that blacks have increased prevalence of cardiovascular disease which contributes to racial disparities in outcomes.

In the current work, we tested the hypothesis that black race is a natriuretic peptide deficiency state using a stratified random cohort of 4,415 participants selected from the REGARDS study (a national population-based cohort study evaluating racial and geographic disparities in stroke in US adults aged ≥45 years of age or older). Next, we looked for published results on the percentage difference in N-terminal proB-type NP (NTproBNP) levels by race in participants free of cardiovascular disease from other population cohorts. Lastly, we explored whether association of natriuretic peptides with all-cause mortality and CV mortality in apparently healthy individuals from REGARDS differs by race.

We found that in multivariable adjustment, NTproBNP levels were up to 27% lower in black individuals as compared with white individuals in the REGARDS study. We pooled our results and found that in meta-analysis of the 3 cohorts, NTproBNP levels were 35% lower in black individuals than white individuals (more than 13,000 individuals in total). Lastly, we found that the higher NTproBNP levels were associated with higher incidence of all-cause mortality, and cardiovascular mortality in healthy blacks and white individuals, and this association did not differ by race.

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AI Study Supports Association of Increased Coffee Consumption With Decreased CVD Risk

MedicalResearch.com Interview with:
Coffee being poured Coffee pot pouring cup of coffee.  copyright American Heart Association
Laura Stevens
University of Colorado
Aurora, CO

MedicalResearch.com: What is the background for this study? What are the main findings?

Response:
We started with asking ourselves how we could better predict cardiovascular and stroke outcomes.  In an ideal world, we would be able to predict cardiovascular disease (CVD) and stroke with 100% accuracy long before the occurrence of the event.  The challenge here is there are so many potential risk factors, and testing each one using traditional methods would be extremely time consuming, and possibly infeasible.

Therefore, we used artificial intelligence to find potential risk factors that could be important for risk of CVD and stroke.  The results of this analysis pointed to consumption of coffee cups per day and the number of times red meat was consumed per week as being potentially important predictors of CVD.

We then looked into these findings further using traditional statistical analyses to determine that increased coffee consumption and red meat consumption appeared to be associated with decreased risk of CVD.  The study initially used data from the Framingham Heart Study (FHS) original cohort.

The findings from this data were then tested using data from 2 independent studies, the Cardiovascular Heart Study (CHS) and the Atherosclerosis Risk in Communities Study (ARIC), which both supported the association of increased coffee consumption with decreased CVD risk.

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Standard or Low Dose Alteplase in Acute Ischemic Stroke–Does It Matter?

MedicalResearch.com Interview with:

Craig Anderson | MD PhD FRACP Executive Director  Professor of Neurology and Epidemiology, Faculty of Medicine, UNSW Sydney Neurologist, Neurology Department, Royal Prince Alfred Hospital The George Institute for Global Health at Peking University Health Science Center Haidian District | Beijing, 100088 P.R. China

Prof. Anderson

Craig Anderson | MD PhD FRACP
Executive Director
Professor of Neurology and Epidemiology, Faculty of Medicine, UNSW Sydney
Neurologist, Neurology Department, Royal Prince Alfred Hospital
The George Institute for Global Health at Peking University Health Science Center
Haidian District | Beijing, 100088 P.R. China

MedicalResearch.com: What is the background for this study? What are the main findings?

Response:  There is much controversy over the benefits of a lower dose of intravenous alteplase, particularly in Asia, after the Japanese regulatory authorities approved a dose of 0.6 mg/kg 10 years ago compared to the US FDA and other regulatory authorities approving 0.9 mg/kg 20 years ago.  The investigator inititiated and conducted ENCHANTED trial aimed to determine the effectiveness and safety of these two doses in an international multicentre pragmatic open design.

The main results did not confirm the low-dose to be statistically ‘non-inferior’ partly due to the primary outcome measure chosen and partly due to the statistical approach, but it did confirm that the lower dose was safer with less risk of the major complication of this treatment, that of major bleeding in the brain.  However, it would appear that this safety effect was offset by some reduce efficacy in terms of functional recovery.

The aim of this secondary analysis of the trial data was to examine in more detail the differences between low and standard dose alteplase according to the participants’ age, ethnicity (Asian vs non-Asian) and severity of neurological deficit at the time of treatment.  We did this because the popular belief is that a lower dose might be preferred in older people, and Asians, because of the potential for more likelihood of bleeding, and preferentially to use the standard dose in those with more severe strokes potentially due to greater ‘clot burden’ from a blocked artery to the brain.

The results showed that the main findings on the outcome of surviving free of disability were the same according to age, ethnicity and stroke severity – that is, there was no preferential dose in any of these groups.  Similarly, the safety benefit of low dose alteplase on brain haemorrhage, did not clearly translate into clinical disability outcomes in any of the patient groups studied.

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