'Silent' strokes common after surgery, researchers find

by McMaster University

Dr. PJ Devereaux is a senior scientist at the Population Health Research Institute of McMaster University and Hamilton Health Sciences. Credit: McMaster University/Hamilton Health Sciences.

Canadian researchers have discovered that covert—or 'silent' - strokes are common in seniors after they have elective, non-cardiac surgery and double their risk of cognitive decline one year later.

25 aug 2019--While an overt stroke causes obvious symptoms, such as weakness in one arm or speech problems that last more than a day, a covert stroke is not obvious except on brain scans, such as MRI. Each year, approximately 0.5 per cent of the 50 million people age 65 years or greater worldwide who have major, non-cardiac surgery will suffer an overt stroke, but until now little was known about the incidence or impacts of silent stroke after surgery.

The results of the NeuroVISION study were published today in The Lancet.

"We've found that 'silent' covert strokes are actually more common than overt strokes in people aged 65 or older who have surgery," said Dr. PJ Devereaux, co-principal investigator of the NeuroVISION study. Dr. Devereaux is a cardiologist at Hamilton Health Sciences (HHS), professor in the departments of health research methods, evidence, and impact, and medicine at McMaster University, and a senior scientist at the Population Health Research Institute of McMaster University and HHS.

Dr. Devereaux and his team found that one in 14 people over age 65 who had elective, non-cardiac surgery had a silent stroke, suggesting that as many as three million people in this age category globally suffer a covert stroke after surgery each year.

NeuroVISION involved 1,114 patients aged 65 years and older from 12 centres in North and South America, Asia, New Zealand, and Europe. All patients received an MRI within nine days of their surgery to look for imaging evidence of silent stroke. The research team followed patients for one year after their surgery to assess their cognitive capabilities. They found that people who had a silent stroke after surgery were more likely to experience cognitive decline, perioperative delirium, overt stroke or transient ischaemic attack within one year, compared to patients who did not have a silent stroke.

"Over the last century, surgery has greatly improved the health and the quality of life of patients around the world," said Dr. Marko Mrkobrada, an associate professor of medicine at University of Western Ontario and co-principal investigator for the NeuroVISION study. "Surgeons are now able to operate on older and sicker patients thanks to improvements in surgical and anesthetic techniques. Despite the benefits of surgery, we also need to understand the risks."

"Vascular brain injuries, both overt and covert, are more frequently being detected, recognized and prevented through research funded by our Institute and CIHR," says Dr. Brian Rowe, scientific director of the Institute of Circulatory and Respiratory Health, Canadian Institutes of Health Research (CIHR). "The NeuroVISION Study provides important insights into the development of vascular brain injury after surgery, and adds to the mounting evidence of the importance of vascular health on cognitive decline. The results of NeuroVISION are important and represent a meaningful discovery that will facilitate tackling the issue of cognitive decline after surgery."

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More information: The Lancet (2019). www.thelancet.com/journals/lan … (19)31795-7/fulltext

Journal information: The Lancet 

Provided by McMaster University 

Overtreating patients for hypothyroidism could raise their risk of stroke, study finds

For patients who take medication to treat hypothyroidism, being treated with too much medication can lead to an increased risk of atrial fibrillation, a common heart rhythm disorder associated with stroke, a new study of more than 174,000 patients has found. Credit: Intermountain Medical Center Heart Institute

14 nov 2018--For patients who take medication to treat hypothyroidism, being treated with too much medication can lead to an increased risk of atrial fibrillation, a common heart rhythm disorder associated with stroke, a new study of more than 174,000 patients has found.
The findings were presented by researchers from the Intermountain Medical Center Heart Institute in Salt Lake City at the American Heart Association Scientific Session conference in Chicago.
"We know patients with hypothyroidism have a higher risk of atrial fibrillation, but we didn't consider increased risk within what's considered the normal range of thyroid hormones," said lead researcher Jeffrey L. Anderson, MD, Distinguished Clinical and Research Physician at the Intermountain Medical Center Heart Institute, which is part of the Intermountain Healthcare system. "These findings show we might want to re-consider what we call normal."
In the new study, researchers surveyed the electronic medical records of 174,914 patients treated at Intermountain Healthcare facilities whose free thyroxine (fT4) levels were recorded and who were not on thyroid replacement medication. Researchers then took what's considered a normal range of fT4 levels, divided it into four quartiles, then looked at those patients' records for a current or future diagnosis of atrial fibrillation.
They found a 40 percent increase in existing atrial fibrillation for patients in the highest quartile of fT4 levels compared to patients in the lowest, and a 16 percent increase in newly developing atrial fibrillation during 3-years of follow up.
These findings, said Dr. Anderson, suggest that the optimal healthy range of fT4 should be reconsidered and redefined.
"Thyroid hormones are associated with losing weight and having more energy, which may lead to people being treated at the high end of the normal range," said Dr. Anderson. "Are we harming people by putting them at a higher risk of atrial fibrillation, and therefore stroke?"
The study also showed that fT4 should be measured, along with thyroid-stimulating hormone (TSH), which is more commonly tested for in patients with irregular thyroid hormone levels but was not helpful within the normal range in refining risk.
The link between fT4 and atrial fibrillation was recently recognized in the Rotterdam Study, a population-based cohort study first started in 1990. However, with any new and unexpected report requires replication and independent confirmation. The new study by Intermountain Medical Center Heart Institute researchers establishes the link between fT4 level and atrial fibrillation in patients treated in the United States.
"The next step for researchers is to conduct a randomized trial to see if targeting a lower versus a higher upper range of fT4 in patients receiving thyroid hormone replacement therapy leads to a lower risk of atrial fibrillation and stroke along with other possible heart-related issues, like atherosclerosis," Dr. Anderson said.


Provided by Intermountain Medical Center

AHA names top heart disease and stroke research advances of 2017

New medicines to fight heart disease, updated guidelines for strokes and high blood pressure, and research into genome editing are among the top heart disease and stroke advances in 2017, according to the American Heart Association and American Stroke Association.

08 feb 2018--The AHA, one of the top funders of heart- and stroke-related research worldwide, has been compiling an annual top 10 list of major advances in heart disease and stroke science since 1996. Here, in no particular order, are the organization's picks for leading research accomplishments published in 2017.

Advancing the treatment of strokes

Following publication in 2017 of the DAWN study in The New England Journal of Medicine showing benefits of mechanical clot removal for longer periods after a stroke starts, the AHA/ASA released new guidelines for treating acute ischemic stroke. The guidelines were released at the International Stroke Conference in January 2018 and included additional data from DEFUSE 3, also presented at the meeting.
The new guidelines, published in the journal Stroke, say the clot-removal treatment window may be increased from six hours to up to 24 hours for specific patients who have clots in large vessels in the brain. The guidelines also increase the number of patients who will have access to a clot-dissolving drug proven to lower the chances for disability. The guidelines reiterated the need for fast action when a person shows the symptoms of a stroke, the second-leading cause of death in the world and a leading cause of disability.

Fixing a gene mutation in human embryos

A study in Nature suggests genome editing could be used to correct disease-causing mutations in the heart muscle of human embryos. Researchers focused on the MYBPC3 gene – which provides instructions for making a protein found in heart muscle cells and causes a form of inherited hypertrophic cardiomyopathy – and used new approaches to allow safe and accurate correction of the abnormal gene.
While early, this research furthers the potential for genome editing to correct mutations that pass from parent to child.

A deeper understanding of heart health for those living in food deserts

Health researchers have focused a lot in recent years on so-called food deserts: low-income neighborhoods with low access to healthy food. But a new study found that it's not so much the "desert" itself as it is low income in general that is linked to poor heart health.
The study, in Circulation: Cardiovascular Quality and Outcomes, studied food deserts in metro Atlanta and found people who live there have higher rates of cardiovascular risk factors such as oxidative stress, inflammation and arterial stiffness. However, researchers concluded these associations are mostly due to low income of the area and its residents rather than proximity to a grocery store – a finding which could impact the future use of public health resources in poor neighborhoods.

Cholesterol-lowering drug cuts risk of heart attacks and strokes

A study in The New England Journal of Medicine found that the new injectable cholesterol-lowering drug evolocumab can reduce heart attacks and strokes among high-risk patients. The FOURIER study – paid for by Amgen, which makes and sells the PCSK9 inhibitor evolocumab under the brand name Repatha – showed that the drug cut the risk of having a heart attack, stroke or dying from a cardiovascular cause by 20 percent when added to intensive statin therapy.
The study reported that Repatha lowered "bad" LDL cholesterol by about 60 percent, to a median of 30.

SGLT2 inhibitors may lower rates of death and heart failure for people with diabetes

A large international study in Circulation showed lower rates of death and heart failure for diabetes patients treated with the SGLT2 inhibitors canagliflozin, dapagliflozin or empagliflozin, compared with other glucose-lowering drugs. The CVD-REAL study – paid for by AstraZeneca, which markets dapagliflozin under the brand name Farxiga – looked at more than 300,000 patients with Type 2 diabetes in the U.S., the U.K., Denmark, Norway and Sweden. The results suggest SGLT2 inhibitors may benefit a broad population of patients with Type 2 diabetes.

Improved therapy for treating patients with peripheral artery disease

According to a study in The Lancet, combining low doses of the blood thinner rivaroxaban and aspirin is more effective than aspirin alone in preventing cardiovascular deaths, heart attacks, strokes and major amputations for people with peripheral artery disease, or PAD.
The 33-country COMPASS study looked at 7,470 patients with PAD, a narrowing of the peripheral arteries to the legs, arms, stomach and head. Although major bleeding increased with the combination therapy, fatal or critical organ bleeding did not. Researchers said the new approach is a major advance in treating patients with peripheral artery disease.

A new treatment for fighting inflammation and reducing cardiovascular events

Scientists have long believed that reducing inflammation may reduce the risk of heart disease. The CANTOS study published in The New England Journal of Medicine looked at more than 10,000 high-risk patients who previously had heart attacks and found that canakinumab, a monoclonal antibody that targets interleukin-1 beta and blocks inflammation, significantly lowered their rate of having or dying from a heart attack, stroke or other cardiovascular cause. Although the drug did not reduce overall deaths from any cause and was associated with significant side effects, the principle underlying the use of a specific anti-inflammatory antibody is important.

Catheter-based procedure extended for more patients with aortic stenosis

Aortic stenosis – a narrowing of the aortic valve opening – is a common and serious valve disease problem. For patients with severe aortic stenosis at high risk for surgical complications, a procedure called transcatheter aortic-valve replacement, or TAVR, that can be done through a catheter rather than with open-heart surgery, is already an accepted alternative.
The SURTAVI study in The New England Journal of Medicine looked at severe aortic stenosis patients at intermediate risk for complications from surgery and found TAVR to be a viable alternative for them as well.


Provided by American Heart Association

Landmark study may impact standard stroke treatment guidelines

A blood clot forming in the carotid artery. 

Standard guidelines for stroke treatment currently recommend clot removal only within six hours of stroke onset. But a milestone study with results published today in the New England Journal of Medicine shows that clot removal up to 24 hours after stroke led to significantly reduced disability for properly selected patients.

16 nov 2017--The international multi-center clinical study, known as the DAWN trial, randomly assigned 206 stroke victims who arrived at the hospital within six to 24 hours to either endovascular clot removal therapy, known as thrombectomy, or to standard medical therapy.
Thrombectomy involves a catheter placed in the femoral artery and snaked up the aorta and into the cerebral arteries where the clot that is blocking the artery, and causing the neurological symptoms, is retrieved.
Almost half of the patients (48.6 percent) who had clot removal showed a considerable decrease in disability, meaning they were independent in activities of daily living 90 days after treatment. Only 13.1 percent of the medication group had a similar decrease. There was no difference in mortality or other safety end-points between the two groups.
"These findings could impact countless stroke patients all over the world who often arrive at the hospital after the current six-hour treatment window has closed," says co-principal investigator Raul Nogueira, MD, professor of neurology, neurosurgery and radiology at Emory University School of Medicine and director of neuroendovascular service at the Marcus Stroke & Neuroscience Center at Grady Memorial Hospital.
"When the irreversibly damaged brain area affected by the stroke is small, we see that clot removal can make a significant positive difference, even if performed outside the six-hour window," says co-principal investigator Tudor Jovin, MD, director of the University of Pittsburgh Medical Center Stroke Institute. "However, this does not diminish urgency with which patients must be rushed to the ER in the event of a stroke. The mantra 'time is brain' still holds true."
To select patients for the trial, the researchers used a new approach which used brain imaging and clinical criteria as opposed to just time alone.
"Looking at the physiological state of the brain and evaluating the extent of tissue damage and other clinical factors seems to be a better way to decide if thrombectomy will benefit patients as opposed to adhering to a rigid time window," says Nogueira.
The researchers planned to enroll a maximum of 500 patients over the course of the study period. However, a pre-planned interim review of the treatment effectiveness after 200 patients were enrolled in the trial led the independent Data Safety Monitoring Board overseeing the study to recommend early termination of the trial, based on pre-defined criteria demonstrating that clot removal provided significant clinical benefit in the studied patients.
"Our research and clinical teams are immensely proud of these breakthrough findings, which are so profound they will likely result in a paradigm shift that will not be seen again for many years in the field of stroke therapeutics," says Michael Frankel, MD, professor of neurology, Emory University School of Medicine, chief of neurology and director of the Marcus Stroke and Neuroscience Center for the Grady Health System.
According to Frankel, the Emory neuroscience team was a major contributor to the DAWN trial, working at Grady Memorial Hospital, the second leading site of the trial's enrollment.
The DAWN trial included trial locations in the United States, Spain, France, Australia and Canada. The trial was sponsored by Stryker Corporation, a medical technology company that manufactures the clot removal devices used in the study.
The DAWN trial results were presented at the European Stroke Organization Conference in May.


Provided by Emory University

Telestroke guidelines from American Telemedicine Association in Telemedicine and e-Health

Credit: Mary Ann Liebert, Inc., publishers

New guidelines to help clinicians use the latest telemedicine communication technologies to provide remote care for patients with symptoms of acute stroke are published in Telemedicine and e-Health.
Bart Demaerschalk, MD, Mayo Clinic College of Medicine, Phoenix, AZ, and a team of authors contributed to the article entitled "American Telemedicine Association: Telestroke Guidelines."

19 aril 2017-- The guidelines describe the network of audio-visual communication technologies and computer systems available to link an expert stroke team with a stroke physician at a distant site and the clinicians caring for a remote stroke patient, and to deliver telestroke clinical services.
Rapid diagnosis and treatment with a clot-disrupting drug in appropriate patients following ischemic stroke can improve outcomes. The timing of treatment delivery is a critical factor in ischemic stroke.
The coauthors of the new Telestroke Guidelines are from Mayo Clinic College of Medicine (Phoenix), Ascension Health and Columbia College of Nursing (Milwaukee, WI), Medical College of Georgia at Georgia Health Sciences University (Augusta), Yale School of Medicine (New Haven, CT), University of Cincinnati (OH), Massachusetts General Hospital (Boston, MA), University of Pittsburgh (PA), and InTouch Health (Santa Barbara, CA).
"The authors are to be commended for this outstanding work. These guidelines will be of great value to clinicians and the patients they treat," says Charles R. Doarn, MBA, Co-Editor-in-Chief of the Journal and Research Professor of Family and Community Medicine, University of Cincinnati, Ohio.

More information: Bart M. Demaerschalk et al, American Telemedicine Association: Telestroke Guidelines, Telemedicine and e-Health (2017). DOI: 10.1089/tmj.2017.0006


Provided by Mary Ann Liebert, Inc

Most atrial fibrillation patients don't get preventive drug before stroke

A 12 lead ECG showing atrial fibrillation at approximately 150 beats per minute.

More than 80 percent of stroke patients with a history of atrial fibrillation either received not enough or no anticoagulation therapy prior to having a stroke, despite the drugs' proven record of reducing stroke risk, according to a Duke Clinical Research Institute study.

14 mar 2017--Reporting in the March 14 issue of the Journal of the American Medical Association, the researchers also found that when patients did receive recommended anticoagulation drugs, they had less severe stroke outcomes and less risk of dying.
"Atrial fibrillation is very common, and people with the condition are at a much higher risk of having stroke," said lead author Ying Xian, M.D., Ph.D., assistant professor of neurology at Duke and member of the Duke Clinical Research Institute. "Treatment guidelines call for these patients to receive an anticoagulant such as warfarin at a therapeutic dose or a non-vitamin K antagonist oral anticoagulant (NOAC), so it's surprising that this is not occurring in the vast majority of cases that occur in community settings."
The study included more than 94,000 patients with atrial fibrillation from the American Heart Association's "Get With The Guidelines-Stroke" registry who had had an acute ischemic stroke. The analysis was sponsored by the Patient-Centered Outcomes Research Institute to inform patients, physicians and others about optimal stroke care.
The researchers found that only 16 percent of patients with atrial fibrillation had received the recommended anticoagulation medication prior to having a stroke. These medications include therapeutic levels of warfarin or NOAC.
A total of 84 percent of patients were not treated according to the guidelines prior to stroke:

• 30 percent were not taking any antithrombotic treatment at all;
• 40 percent were taking an antiplatelet drug such as baby aspirin or clopidogrel;
• and 13.5 percent were on warfarin, but at a level that was not considered therapeutic at the time of their stroke.

"While some of these patients may have had reasons for not being anticoagulated, such as high bleeding or fall risk, more than two-thirds had no documented reason for receiving inadequate stroke prevention therapy," Xian said.
Xian added that in those rare cases where anticoagulation failed to prevent a stroke, patients who were taking the therapy showed a tendency to have less severe strokes, with less disability and death.
"These findings highlight the human costs of atrial fibrillation and the importance of appropriate anticoagulation, Xian said. "Broader adherence to these atrial fibrillation treatment guidelines could substantially reduce both the number and severity of strokes in the U.S. We estimate that between 58,000 to 88,000 strokes might be preventable per year if the treatment guidelines are followed appropriately."

More information: Journal of the American Medical Association, doi:10.1001/jama.2017.1371


Provided by Duke University Medical Center

Strokes steal eight years' worth of brain function, new study suggests

The new study shows that having a stroke robbed older adults of about eight years' worth of brain function. Credit: University of Michigan

Having a stroke ages a person's brain function by almost eight years, new research finds - robbing them of memory and thinking speed as measured on cognitive tests.

07 JUN 2015--In both black and white patients, having had a stroke meant that their score on a 27-item test of memory and thinking speed had dropped as much as it would have if they had aged 7.9 years overnight.

For the study, data from more than 4,900 black and white seniors over the age of 65 was analyzed by a team from the University of Michigan U-M Medical School and School of Public Health and the VA Center for Clinical Management Research. The results will be published in the July issue of Stroke.

Researchers married two sources of information for their analysis: detailed surveys and tests of memory and thinking speed over multiple years from participants in a large, national study of older Americans, and Medicare data from the same individuals.

They zeroed in on the 7.5 percent of black study participants, and the 6.7 percent of white participants, who had no recent history of stroke, dementia or other cognitive issues, but who suffered a documented stroke within 12 years of their first survey and cognitive test in 1998.

By measuring participants' changes in cognitive test scores over time from 1998 to 2012, the researchers could see that both blacks and whites did significantly worse on the test after their stroke than they had before.

Although the size of the effect was the same among blacks and whites, past research has shown that the rates of cognitive problems in older blacks are generally twice that of non-Hispanic whites. So the new results mean that stroke doesn't account for the mysterious differences in memory and cognition that grow along racial lines as people age.

The researchers say the findings underscore the importance of stroke prevention.

"As we search for the key drivers of the known disparities in cognitive decline between blacks and whites, we focus here on the role of 'health shocks' such as stroke," says lead author and U-M Medical School assistant professor Deborah Levine, M.D., MPH. "Although we found that stroke does not explain the difference, these results show the amount of cognitive aging that stroke brings on, and therefore the importance of stroke prevention to reduce the risk of cognitive decline."

Other research on disparities in cognitive decline has focused on racial differences in socioeconomic status, education, and vascular risk factors such as diabetes, high blood pressure and smoking that can all contribute to stroke risk. These factors may explain some but not all of the racial differences in cognitive decline.

Levine and her colleagues note that certain factors - such as how many years a person has vascular risk factors, and the quality of his or her education, as well as genetic and biological factors - might play a role in racial differences in long-term cognitive performance.

But one thing is clear: strokes have serious consequences for brain function. On average, they rob the brain of eight years of cognitive health. Therefore, people of all racial and ethnic backgrounds can benefit from taking steps to reduce their risk of a stroke. That includes controlling blood pressure and cholesterol, stopping or avoiding smoking, controlling blood sugar in diabetes, and being active even in older age.

More information: Stroke, DOI: 10.1161/STROKEAHA.114.008156

Provided by University of Michigan Health System

Sleeping over 8 hours a day associated with greater risk of stroke

People who sleep for more than eight hours a day have an increased risk of stroke, according to a study by the University of Cambridge - and this risk doubles for older people who persistently sleep longer than average. However, the researchers say it is unclear why this association exists and call for further research to explore the link.

26 feb 2015--Previous studies have already suggested a possible association between sleep and risk of stroke, but today's study, published in the journal Neurology, is the first to provide detailed information about the British population and to examine the relationship between a change in sleep duration over time and subsequent stroke risk.

Researchers from the Department of Public Health and Primary Care at the University of Cambridge followed just under 10,000 people aged 42-81 years of age from the European Prospective Investigation into Cancer (EPIC)-Norfolk cohort over 9.5 years. During 1998-2000 and then again four years later, they asked the cohort how many hours on average they slept in a day and whether they generally slept well.

Almost seven out of ten participants reported sleeping between six and eight hours a day, whilst one in ten reported sleeping for over eight hours a day. Participants who slept for less than six hours or more than eight hours were more likely to be older, women and less active.

Over the almost ten year period of the study, 346 participants suffered a stroke, either non-fatal or fatal stroke. After adjusting for various factors including age and sex, the researchers found that people who slept longer than eight hours a day were at a 46% greater risk of stroke than average. People who slept less than six hours a day were at an 18% increased risk, but the small number of people falling in this category meant the association was not statistically significant.

Participants who reported persistently long sleep - in other words, they reported sleeping over eight hours when asked at both points of the study - were at double the risk of stroke compared to those with persistently average sleep duration (between six and eight hours a day). This risk was even greater for those whose reported sleep increased from short to long over the four years - their risk was close to four times that of people who maintained an average sleep duration.

In addition to studying the EPIC-Norfolk cohort, the researchers carried out a study of combined data from 11 other studies related to identify the association between sleep duration and patterns of stroke risk. Their final analysis, including 560,000 participants from seven countries, supported the findings from the EPIC-Norfolk cohort study.

Yue Leng, PhD candidate at the University of Cambridge, says: "It's apparent both from our own participants and the wealth of international data that there's a link between sleeping longer than average and a greater risk of stroke. What is far less clear, however, is the direction of this link, whether longer sleep is a symptom, an early marker or a cause of cardiovascular problems."

While older people have less work and fewer social demands and therefore often have the option of sleeping longer, previous research has shown that in fact, they tend to sleep on average for shorter periods.

The researchers say it is unclear yet why the link between sleep and stroke risk should exist. Lack of sleep has been linked with factors such as disrupted metabolism and raised levels of the 'stress hormone' cortisol, all of which may lead to higher blood pressure and increased stroke risk. However, the current study suggests that the association between longer sleep duration and higher risk of stroke was independent of normal risk factors for cardiovascular disease.

Professor Kay-Tee Khaw, senior author on the study, adds: "We need to understand the reasons behind the link between sleep and stroke risk. What is happening in the body that causes this link? With further research, we may find that excessive sleep proves to be an early indicator of increased stroke risk, particularly among older people."

More information: Leng, Y et al. Sleep duration and risk of fatal and nonfatal stroke: A prospective study and meta-analysis. Neurology; 25 Feb 2015

Provided by University of Cambridge

Potassium-rich foods cut stroke, death risks among older women

Postmenopausal women who eat foods higher in potassium are less likely to have strokes and die than women who eat less potassium-rich foods, according to new research in the American Heart Association's journal Stroke.

08 sept 2014--"Previous studies have shown that potassium consumption may lower blood pressure. But whether potassium intake could prevent stroke or death wasn't clear," said Sylvia Wassertheil-Smoller, Ph.D., study senior author and distinguished university professor emerita, department of epidemiology and population health at Albert Einstein College of Medicine, Bronx, NY.

"Our findings give women another reason to eat their fruits and vegetables. Fruits and vegetables are good sources of potassium, and potassium not only lowers postmenopausal women's risk of stroke, but also death."

Researchers studied 90,137 postmenopausal women, ages 50 to 79, for an average 11 years. They looked at how much potassium the women consumed, as well as if they had strokes, including ischemic and hemorrhagic strokes, or died during the study period. Women in the study were stroke-free at the start and their average dietary potassium intake was 2,611 mg/day. Results of this study are based on potassium from food, not supplements.

The researchers found:

• Women who ate the most potassium were 12 percent less likely to suffer stroke in general and 16 percent less likely to suffer an ischemic stroke than women who ate the least.
• Women who ate the most potassium were 10 percent less likely to die than those who ate the least.
• Among women who did not have hypertension (whose blood pressure was normal and they were not on any medications for high blood pressure), those who ate the most potassium had a 27 percent lower ischemic stroke risk and 21 percent reduced risk for all stroke types, compared to women who ate the least potassium in their daily diets.
• Among women with hypertension (whose blood pressure was high or they were taking drugs for high blood pressure), those who ate the most potassium had a lower risk of death, but potassium intake did not lower their stroke risk.

Researchers suggested that higher dietary potassium intake may be more beneficial before high blood pressure develops. They also said there was no evidence of any association between potassium intake and hemorrhagic stroke, which could be related to the low number of hemorrhagic strokes in the study.

The U.S. Department of Agriculture recommends that women eat at least 4,700 mg of potassium daily. "Only 2.8 percent of women in our study met or exceeded this level. The World Health Organization's daily potassium recommendation for women is lower, at 3,510 mg or more. Still, only 16.6 percent of women we studied met or exceeded that," said Wassertheil-Smoller.

"Our findings suggest that women need to eat more potassium-rich foods. You won't find high potassium in junk food. Some foods high in potassium include white and sweet potatoes, bananas and white beans."

While increasing potassium intake is probably a good idea for most older women, there are some people who have too much potassium in their blood, which can be dangerous to the heart. "People should check with their doctor about how much potassium they should eat," she said.

The study was observational and included only postmenopausal women. Researchers also did not take sodium intake into consideration, so the potential importance of a balance between sodium and potassium is not among the findings. Researchers said more studies are needed to determine whether potassium has the same effects on men and younger people.

Provided by American Heart Association

Incidence of stroke in the elderly has dropped by 40 percent over the last 20 years

A new analysis of data from 1988-2008 has revealed a 40% decrease in the incidence of stroke in Medicare patients 65 years of age and older. This decline is greater than anticipated considering this population's risk factors for stroke, and applies to both ischemic and hemorrhagic strokes. Investigators also found death resulting from stroke declined during the same period. Their findings are published in the July issue of The American Journal of Medicine.

18 july 2014--Preventable but deadly, stroke is the fourth leading cause of mortality in the United States, with approximately 795,000 strokes occurring each year. Beyond the impact on patients, treatment and after care place high demands on doctors and health care facilities. With an aging population reaching Medicare age, deconstructing and studying stroke statistics are important for understanding the causes underlying this downward trend, benefiting both patients and providers.

"Shedding light on trends in the burden of stroke among Medicare beneficiaries may provide important information for policy purposes, including describing the past and current scope of the condition, assessing the potential effect of stroke prevention interventions on a national level, and identifying areas where resources can be targeted more specifically and effectively," says lead investigator Margaret C. Fang, MD, MPH, an Associate Professor of Medicine at the University of California San Francisco School of Medicine, who also serves as the Medical Director of the UCSF Anticoagulation Clinic.

The study was constructed to analyze stroke cases over the past two decades, not to investigate causation; however, researchers did find evolving patterns in the risk factors associated with strokes. Although the prevalence of diabetes mellitus increased over time, other risk factors, such as cigarette smoking, measured systolic blood pressure, and total cholesterol values, decreased.

The decline in stroke rates paralleled increasing use of antihypertensive and statin medications and might explain the reduction in stroke rates. "Antihypertensive medications reduce the risk of stroke by approximately 32% and statins by approximately 21%. Stroke rates seem to decrease most sharply after year 1998, approximately when statin use became more prevalent," explains Dr. Fang. "If true, then this illustrates how medical interventions have resulted in significant improvements in health on a population level."

Investigators analyzed occurrence data from a sample of Medicare patients diagnosed as having suffered a stroke. Risk factors such as high blood pressure, diabetes, smoking status, and high lipid levels were gathered from the National Health and Nutrition Examination Survey (NHANES). The Medicare Current Beneficiary Survey was used to determine medication use.

The team identified more than one million stroke events from 1988 to 2008, of which 87.3% were ischemic and 12.7% hemorrhagic strokes. The analysis showed a reduction in ischemic strokes from 927 per 100,000 in 1988 to just 545 per 100,000 in 2008. Hemorrhagic strokes decreased from 112 per 100,000 to 94 per 100,000 over the same time period, primarily among men.

Data indicated that stroke mortality also declined. The risk-adjusted 30-day mortality rate for ischemic strokes fell from 15.9% in 1988 to 12.7% in 2008. For hemorrhagic stroke, the mortality rates declined slightly from 44.7% in 1988 to 39.3% in 2008.

Dr. Fang notes that "Our analysis confirms the continuing and devastating effect of hemorrhagic stroke, but was unable to assess for casual factors influencing mortality rates; relatively few interventions have been shown to reduce stroke-related mortality. Timely administration of intravenous thrombolytics is associated with more favorable outcomes from ischemic stroke, but has not been shown to have significant effects on mortality. In addition, the rate of thrombolytic administration continues to be low in the United States."

More information: "Trends in Stroke Rates, Risk, and Outcomes in the United States, 1988 to 2008," by Margaret C. Fang, MD, MPH, Marcelo Coca Perraillon, MA, Kaushik Ghosh, PhD, David M. Cutler, PhD, Allison B. Rosen, MD, MPH, ScD (DOI: dx.doi.org/10.1016/j.amjmed.2014.03.017) appears in The American Journal of Medicine, Volume 127/Issue 7 (July 2014)

Provided by Elsevier

Diet higher in protein may be linked to lower risk of stroke

Micrograph showing cortical pseudolaminar necrosis, a finding seen in strokes on medical imaging and at autopsy. H&E-LFB stain. Credit: Nephron/Wikipedia

13 jun 2014--People with diets higher in protein, especially from fish, may be less likely to have a stroke than those with diets lower in protein, according to a meta-analysis published in the June 11, 2014, online issue of Neurology, the medical journal of the American Academy of Neurology.

"The amount of protein that led to the reduced risk was moderate—equal to 20 grams per day," said study author Xinfeng Liu, MD, PhD, of Nanjing University School of Medicine in Nanjing, China. "Additional, larger studies are needed before definitive recommendations can be made, but the evidence is compelling."

The meta-analysis looked at all of the available research on the relationship between protein in the diet and the risk of stroke. Seven studies with a total of 254,489 participants who were followed for an average of 14 years were included in the analysis.

Overall, the participants with the highest amount of protein in their diets were 20 percent less likely to develop a stroke than those with the lowest amount of protein in their diets. The results accounted for other factors that could affect the risk of stroke, such as smoking and high cholesterol. For every additional 20 grams per day of protein that people ate, their risk of stroke decreased by 26 percent.

"If everyone's protein intake were at this level, that would translate to more than 1.4 million fewer deaths from stroke each year worldwide, plus a decreased level of disability from stroke," said Liu.

Liu noted that the analysis does not support increased consumption of red meat, which has been associated with increased stroke risk. Two of the studies were conducted in Japan, where people eat less red meat than westerners do and more fish, which has been associated with decreased risk of stroke.

"These results indicate that stroke risk may be reduced by replacing red meat with other protein sources, such as fish," Liu said.

The reduced risk of stroke was stronger for animal protein than vegetable protein.

Protein has the effect of lowering blood pressure, which may play a role in reducing stroke risk, Liu said.

Provided by American Academy of Neurology

Large rehabilitation study looks at getting stroke patients back on their feet

In the largest stroke rehabilitation study ever conducted in the United States, stroke patients who had physical therapy at home improved their ability to walk just as well as those who were treated in a training program that requires the use of a body-weight supported treadmill device followed by walking practice.

29 may 2011--The study, funded by the National Institutes of Health, also found that patients continued to improve up to one year after stroke, defying conventional wisdom that recovery occurs early and tops out at six months. In fact, even patients who started rehabilitation as late as six months after stroke were able to improve their walking.

The results of the study will be published in the May 26, 2011 edition of the New England Journal of Medicine. NIH's National Institute of Neurological Disorders and Stroke (NINDS) provided primary funding for the study.

"More than 4 million stroke survivors experience difficulty walking. Rigorously comparing available physical therapy treatments is essential to determine which is best,'' said Walter Koroshetz, M.D., NINDS deputy director. "The results of this study show that the more expensive, high tech therapy was not superior to intensive home strength and balance training, but both were better than lower intensity physical therapy."

The walking program involves having a patient walk on a treadmill in a harness that provides partial body weight support. This form of rehabilitation, which is known as locomotor training, has become increasingly popular. After the patients complete their training on the treadmill, they practice walking.

Previous studies suggested that these devices, also called commercial lifts or robot-assisted treadmill steppers, are an effective intervention in helping stroke patients walk. But this walking program had not been tested on a large scale or examined in terms of the most appropriate timing for therapy.

The investigators of the Locomotor Experience Applied Post-Stroke (LEAPS) trial set out to compare the effectiveness of the body-weight supported treadmill training with walking practice started at two different stages--two months post-stroke (early locomotor training) and six months post-stroke (late locomotor training). The locomotor training was also compared against an equivalent schedule of home exercise managed by a physical therapist, aimed at enhancing patients' flexibility, range of motion, strength and balance as a way to improve their walking. The primary measure was each group's improvement in walking at one year after the stroke.

The investigators had hypothesized that the body-weight supported treadmill and walking program, especially early locomotor training, would be superior to a home exercise program. However, they found that all groups did equally well, achieving similar gains in walking speed, motor recovery, balance, social participation and quality of life.

At the end of one year, 52 percent of all the study participants had made significant improvements in their ability to walk. The timing of the locomotor training program did not seem to matter. At one year, no differences were found in the proportion of patients who improved walking with the early or late treadmill training program, nor did the severity of their stroke affect their ability to make progress by the end of the year.

The patients' measure of improvement was based on how well they were able to walk independently by the end of the study period. For example, severely impaired stroke patients were considered improved when they were able to walk around inside the house, whereas the patients who were already mobile at home were considered improved when they could progress to walking independently in the community.

All groups achieved similar gains in the speed and distance of their walking, their physical mobility, motor recovery and social participation, resulting in an improved quality of life.

Simultaneous with intensive therapies, all study participants received usual care, physical therapy consistent with current practice standards, which involved a variable number of sessions of about an hour each. The study found that both the locomotor training and the home physical therapy were superior to usual care. After six months, the patients who were assigned to usual therapy recovered only about half as much as the participants who received one of the two study therapy programs for three months. This finding suggests that either the treadmill training program or the at-home balance and strength training sessions are effective forms of physical therapy, and both are superior to usual care.

Despite reports that most improvement after stroke is complete by six months, the patients assigned to usual care for six months made significant improvements in walking speed after they entered the body-weight supported treadmill and walking program. The researchers said this suggests that recovery beyond six months can be enhanced by further therapy.

Individuals in the locomotor training groups were more likely to feel faint and dizzy during the exercise, and those severely affected patients who received early locomotor training experienced more multiple falls. Fifty-seven percent of participants in the study experienced one fall, 34 percent had multiple falls and 6 percent had a fall resulting in injury. Falls are a common problem among stroke survivors, and the investigators say this study builds on evidence that additional research is needed to prevent falls.

The at-home strength and balance therapy group was the most likely to stick with the program; only 3 percent dropped out of this arm of the study, compared to 13 percent of the locomotor training groups. The authors noted that the home training programs were progressive, intensive, and repetitive, and were highly effective in improving functional status and levels of walking ability, and quality of life at one year post-stroke.

"We were pleased to see that stroke patients who had a home physical therapy exercise program improved just as well as those who did the locomotor training," said Pamela W. Duncan, Ph.D., principal investigator of LEAPS, and professor at Duke University School of Medicine in Durham, N.C. "The home physical therapy program is more convenient and pragmatic. Usual care should incorporate more intensive exercise programs that are easily accessible to patients to improve walking, function and quality of life."

The home exercise programs require less expensive equipment, less training for the therapists and fewer clinical staff members. The LEAPS authors suggest that this intervention may help keep stroke survivors active in their own homes and community environments.

More than 400 patients were randomly assigned into the three study groups and participated in 36 90-minute sessions over 12 to 16 weeks. They had either severe or moderate walking impairments. The average age of the patients was 62 years. Fifty-four percent were men and 22 percent were African American. The trial took place at six inpatient rehabilitation centers in Florida and California.

More information: Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu, SS, Nadeau SE, Dobkin BH, Rose DK, Tilson, JK, Cen S, Hayden SK "Body-Weight-Supported Treadmill Rehabilitation Program After Stroke." New England Journal of Medicine, May 26, 2011, Vol. 364;21, pp. 32-42.

Provided by National Institutes of Health

More Elderly Might Benefit From Stroke Treatment


Elderly under-represented in stroke research; receive less treatment than younger patients

11 oct 2009-- Given an aging population, the prevention and treatment of stroke in the very elderly -- who are under-represented in studies regarding therapy -- will become more important, according to research published online Oct. 2 in The Lancet Neurology.

Nerses Sanossian, M.D., of the University of Southern California and Bruce Ovbiagele, M.D., of the University of California, both in Los Angeles, reviewed data on stroke prevention and treatment in the very elderly against a backdrop of increasing life expectancy and a much higher risk of stroke in older age.

Research has shown that antihypertensive therapy can reduce stroke incidence and mortality in those over 80 years of age, and that statin therapy may benefit elderly people at high risk of stroke. Some data also supports the safety and effectiveness of anticoagulation in individuals over 75 with atrial fibrillation, though this therapy is often not given due to fear of complications. Thrombolysis with alteplase may be helpful for treatment of acute stroke in the very elderly, but should be considered on an individual basis.

"Perhaps not surprisingly, the use of evidence-based stroke treatments in patients much older than the clinical trial population in which these treatments were initially tested is of great concern to many clinicians. However, a growing body of evidence indicates that these therapies can be feasibly and effectively used in very elderly patients with stroke or at risk of stroke," the authors conclude.

Abstract
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Intervention Found to Improve Depression After Stroke

Psychosocial-behavioral intervention plus antidepressant more effective than usual care

08 aug 2009-- A brief psychosocial-behavioral intervention, when applied in addition to antidepressant treatment, can markedly reduce both short- and long-term depression following stroke, according to research published online Aug. 6 in Stroke.

Pamela H. Mitchell, Ph.D., of the University of Washington in Seattle, and colleagues conducted a randomized study in 101 patients who were identified as clinically depressed after an ischemic stroke. Patients were divided into two groups and treated with either a brief psychosocial-behavioral intervention plus an antidepressant or usual care, including an antidepressant. Treatment was continued over eight weeks.

Compared with the usual-care group, the researchers found that patients in the intervention group had a significantly lower depression score both immediately after treatment and at 12 months. The mean percent decrease in depression score after 12 months was significantly greater in the intervention group compared with the usual-care group (47 versus 32 percent). Additionally, the authors note, significantly more of the patients in the intervention group were in remission both after treatment and at 12 months.

"A brief psychosocial-behavioral intervention adjunctive to antidepressant therapy is highly effective in reducing depression and achieving remission in the short term with the effect sustained for up to two years," the authors write. "Participants in the usual-care control group also reduced their depression over the first year, but more slowly and with a lesser degree of remission."

Abstract
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Functional Status Declines Over Time After First Stroke

Decline independent of stroke severity; seen especially in Medicaid and uninsured groups

27 june 2009-- In the five years following a first stroke, patients have modest declines in functional status, which are more noticeable in those with Medicaid or who are uninsured, according to research published online June 25 in Stroke.

Mandip S. Dhamoon, M.D., of Columbia University in New York City, and colleagues analyzed data from 525 survivors of a first ischemic stroke, all at least 40 years of age. The researchers evaluated subjects at six months and annually for five years, assessing functional status with the Barthel Index, terming it favorable or unfavorable based on the score. Follow-up was censored at death, a recurrent stroke or a heart attack.

The researchers found that the proportion of patients with favorable functional status declined annually after adjusting for demographics, risk factors, and stroke characteristics (odds ratio per year after stroke, 0.91). The functional status of those with Medicaid or no insurance declined, but the status of those with Medicare or private insurance did not.

"Functional decline in our study was seen particularly among those who were uninsured or insured with Medicaid. This decline began to be apparent at approximately three years," the authors write. "Over time after stroke, however, functional status among those with private insurance and Medicare and those with Medicaid or no insurance may diverge due to disparities in care and more limited access to rehabilitative services, information about health, and ongoing management of risk factors and chronic conditions that are known to have an impact on functional status."

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Older Adults Often Inaccurately Report Their Own Stroke History

25 may 2009--The responses of older adults who are asked whether they had a stroke frequently do not agree with diagnoses obtained by magnetic resonance imaging (MRI) of the brain, according to a report posted online today that will appear in the July print issue of Archives of Neurology, one of the JAMA/Archives journals.

Self-administered questionnaires are frequently used to obtain information about an individual's history of stroke, according to background information in the article. "In general, self-reports on medical conditions that are well defined and relatively easy to diagnose often have a high positive predictive value, in contrast to conditions characterized by complex symptoms," the authors write. "Stroke is associated with motor impairment but can also be accompanied by impairments in memory, sensation and speech or language, diminishing the ability of an individual to accurately report a history of stroke."

Christiane Reitz, M.D., Ph.D., of Columbia University Medical Center, New York, and colleagues acquired MRIs for 717 Medicare recipients 65 years and older (average age 80.1) living in northern Manhattan. Participants underwent an in-person interview about general health and functioning, medical history, a physical and neurological examination and psychological testing. They or their caregivers also completed an eight-question survey about stroke history, including whether they had ever had symptoms of or been told by a physician they had a stroke.

A total of 85 individuals (11.9 percent) reported a history of stroke. On the MRI, evidence of a stroke was observed in 225 participants (31.4 percent). The sensitivity of self-reported stroke-meaning number of individuals who reported having had a stroke divided by the total number of individuals with stroke detected on MRI-was 32.4 percent. The specificity, or the number of individuals who reported having no history of stroke divided by the total number of individuals who had no evidence of stroke on MRI, was 78.9 percent.

"Lower-functioning memory, cognitive or language ability or presence of hypertension [high blood pressure] or myocardial infarction [heart attack] were associated with an increased frequency of false-negative reports," the authors write.

In addition, younger individuals were more likely to accurately report their stroke history than older adults, and sensitivity was higher among African American than white or Hispanic individuals. Older adults may have more difficulty recalling prior events, contributing to lower sensitivity, the authors note. Rates of cerebrovascular disease are higher among African Americans, so individuals in this population may have an increased awareness of stroke signs and symptoms due to previous discussions with clinicians or contact with individuals who have had strokes.

"Our results indicate that sensitivity and specificity of stroke self-report are low when using MRI scans as validation," the authors conclude. "In stroke research, sensitive neuroimaging techniques rather than stroke self-report should be used to determine stroke history."

Arch Neurol. 2009;66[7]:(doi:10.1001/archneurol.2009.83

Source
Archives of Neurology

Had a stroke? The elderly may not know, or remember

CHICAGO,22 may 2009– Older adults often do not realize or may even forget they have had a stroke and may not be a reliable source of medical information, U.S. researchers said on Monday.

Brain scans showed that while just 12 percent of seniors asked about strokes remembered having had one, nearly a third had brain damage showing they had.

The stroke itself could damage memory, and many people may also have so-called silent strokes that are never diagnosed at the time, Dr. Christiane Reitz of Columbia University Medical Center in New York and colleagues wrote in the Archives of Neurology.

"Stroke is associated with motor impairment but can also be accompanied by impairments in memory, sensation and speech or language, diminishing the ability of an individual to accurately report a history of stroke," they wrote.

The team studied magnetic resonance imaging or MRI scans of 717 people 65 or older who were covered by the federal Medicare insurance program for the elderly. "Approximately 75 percent of strokes occur in persons older than 65 years," the researchers wrote.

The volunteers were interviewed about their health and took some basic neurological and psychological tests. Patients and their caregivers also completed a survey about stroke history, including whether they had stroke symptoms or had been told they had a stroke.

Nearly 12 percent, or 85 people, said they had. But MRI scans showed 225 people, or 30 percent, had actually suffered a stroke.

People who got it wrong were more likely to have poorer memory or language ability, or have stroke risk factors such as high blood pressure or a history of a heart attacks. Younger people in the study were more likely to get it right.

"However, it is likely that some of the strokes that were not reported were silent strokes," the researchers wrote.

The team said researchers who want to study stroke in older adults need to rely on MRI scans, and not patients, to get accurate information about stroke history.

Single gene defect can cause stroke, other artery diseases

UT Houston researchers publish study results

HOUSTON, 04 may 2009– For the first time, scientists have discovered a single gene defect that causes thoracic aortic aneurysms and dissections as well as early onset coronary artery disease, ischemic stroke and Moyamoya disease. The research is led by scientists at The University of Texas Health Science Center at Houston.

The study, "Mutations in Smooth Muscle Alpha-Actin (ACTA2) Cause Early Onset Coronary Artery Disease, Stroke and Moyamoya Disease, Along with Thoracic Aortic Aneurysms and Dissections," was published early online April 30 in the American Journal of Human Genetics.

"If someone is found to have an alteration or mutation in this gene, we can do screening for vascular diseases, and if diagnosed with disease, they can take medications and undergo surgical approaches to prevent premature death or disability," said senior author and principal investigator Dianna Milewicz, M.D., Ph.D., professor and director of the Division of Medical Genetics at The University of Texas Medical School at Houston.

The discovery of the causal relationship between the mutated gene ACTA2 and artery diseases has opened the door to a new way of thinking about the vascular system, Milewicz said.

"We need to look at the artery system as a continuous system or organ," said Milewicz, the President George Bush Professor in Cardiovascular Medicine. "We've been looking at it the wrong way. If you have this particular genetic mutation, it can present in several different diseases affecting different arteries."

Milewicz and her team studied 127 members of 20 families from around the world who had ACTA2 mutations. They were phenotyped for premature vascular diseases, defined as an age of onset less than 55 years in men and less than 60 years in women.

Premature thoracic aortic aneurysms and dissections were the main vascular disease for 76 mutation carriers, while 26 had premature coronary artery disease, 15 had ischemic stroke, including Moyamoya disease, and 15 had more than one vascular disease.

In thoracic aortic disease, the wall of the aorta, the main blood vessel leading out of the heart, weakens and forms an aneurysm that can ultimately lead to an aortic dissection and death. Coronary artery disease, the most common type of heart disease, is the leading cause of death for both men and women in the United States. Stroke is the third leading cause of death in the country.

In the study, none of the family members without the ACTA2 defect had any vascular disease, helping to rule out other genetic or environmental causes. In four families, members younger than age 20 suffered a stroke and five strokes resulted from Moyamoya disease, a rare stroke disease in which the internal carotid arteries become occluded.

The main function of smooth muscle cells is to contract in response to the stretching from pulsing blood flow. Vascular pathology from mutant aortas and analysis of smooth muscle cells removed from patients and grown in the laboratory suggest that persons with ACTA2 have increased multiplication of smooth muscle cells that contribute to blocked or enlarged arteries, according to the study.

Milewicz and her team previously discovered the role of the mutated ACTA2; mutations in ACTA2 account for 14 percent of the inherited form of thoracic aortic aneurysms and dissections, making it the major gene identified for the condition.

During the research, Milewicz identified a large family with persistent livedo reticularis, a purplish mesh-like skin discoloration caused by the occlusion of arteries in the skin. This family also had a history of premature onset coronary artery disease and premature stroke without the risk factors know to cause these diseases (smoking, high cholesterol)

"Family members asked if it all could be related and I told them at the time that they just had really bad luck with several mutated genes," Milewicz said. "It didn't occur to me until later that it might be from the same genetic defect."

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The study results from collaborative efforts of physicians and scientists in the Texas Medical Center including surgeons Hazim Safi, M.D., professor and chairman of the Department of Cardiothoracic Vascular Surgery at the UT Houston Medical School; Dong Kim, M.D., chairman of the medical school's Department of Neurosurgery and director of the Mischer Neuroscience Institute at Memorial Hermann—Texas Medical Center; and Anthony Estrera, M.D., associate professor of cardiothoracic vascular surgery.

Secondary Stroke Prevention Lower in Elderly Patients

Study emphasizes need for secondary stroke prevention in patients of all ages

18 APRIL 2009 -- In stroke survivors, secondary prevention is essential regardless of age, according to a study published online April 16 in BMJ.
Rosalind Raine, Ph.D., of the University College London in the United Kingdom, and colleagues studied 12,830 patients aged 50 years and older who had a stroke between 1995 and 2005 and survived the first 30 days afterward.
The researchers found that secondary prevention rates were low in both men and women (25.6 percent and 20.8 percent, respectively). They also found that secondary prevention was significantly lower among patients aged 80 to 89 years than in those aged 50 to 59 years (adjusted odds ratio, 0.53), even though secondary prevention was associated with a 50 percent reduction in mortality risk in all age groups.
"The evidence suggests that concerns about the trade-off between benefits and risks in elderly people may be exaggerated and that one-year survival benefit is not modified by age," the authors write. "Therefore under-treatment of older people cannot be justified, unless it is explained by informed patient choice."
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High-dose paracetamol "may help stroke patients"

LONDON , 15 april 2009- Giving a high dose of paracetamol to stroke patients with raised body temperatures appears to improve their chance of recovering without serious disability, Dutch researchers said on Tuesday.

The finding suggests the common pain reliever, which is known as acetaminophen in the United States, should be considered as a cheap and widespread stroke therapy.

A temperature above 37 degrees Celsius immediately after a stroke is known to worsen the prognosis, with the odds of a poor outcome doubling for every degree increase. About a third of stroke patients have temperatures above 37.5.

Paracetamol at a daily dose of 6 grams reduces body temperature by about 0.3 degrees.

Doctors from the Erasmus MC University Medical Center in Rotterdam carried out a 1,400-patient study comparing outcomes for stroke patients given paracetamol and a placebo.

They found that 40 percent of patients with a baseline body temperature of 37-39 degrees given paracetamol improved beyond expectations.

Writing in the journal Lancet Neurology, Heleen den Hertog and colleagues said the results needed further confirmation in a larger study but that paracetamol could be a simple, safe and cheap treatment for strokes.