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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Initial pharmacologic therapy for hypertension is low-dose thiazide diuretics, beta-blockers, and ACE inhibitors. Increasing data have confirmed that ACE inhibitors have specific benefit in patients with diabetes, atherosclerosis, left ventricular dysfunction, and renal insufficiency. CCBs are alternative agents for ISH in the elderly and appear to decrease stroke with perhaps less protection against progression of renal insufficiency and proteinuria, CAD mortality and new onset heart failure versus other initial agents, especially ACE inhibitors. ARBs are well tolerated and effective blood pressure lowering agents but have not been confirmed as effective as ACE inhibitors for reducing renal progression, clinical events, or mortality from heart failure. Effective pharmacologic antihypertensive therapy may avoid disabling and undetected cerebrovascular disease, cognitive dysfunction, and disturbing symptoms of elevated blood pressure. Vasopeptidase inhibitor, such as omapatrilat, and endothelin-1 antagonist, such as bosentan, may become future agents approved for the reduction of morbidity and mortality with hypertension. The ALLHAT trial continues to examine the potential benefits and harms of amlodipine versus chlorthalidone and lisinopril in a diverse high-risk population. Based on ALLHAT data, however, doxazosin is no longer an acceptable initial pharmacological agent. Intensive pharmacologic treatment with blood pressure lowering to less than 130/85 mm Hg is recommended with diabetes, renal insufficiency, and heart failure with additional goal of less than 125/75 mm Hg with renal failure and proteinuria greater than 1 g/24 h, based on multiple outcome studies.
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PMID:Update in pharmacologic treatment of hypertension. 1140 10

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.
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PMID:Abdominal aortic aneurysm repair. 1156 37

It is well-known that patients with terminal renal insufficiency are at increased risk for a future cardiovascular event. A relevant relationship also appears to apply to the early stages of renal insufficiency. The HOPE study has shown that the incidence of myocardial infarction, apoplexy and cardiovascular mortality in patients with incipient renal insufficiency is significantly raised. The study also found that the incidence of cardiovascular events is in direct proportion to the level of serum creatinine. Against this background, patients at risk can be readily identified. The HOPE study documents a considerable cardiovascular risk for patients with incipient renal insufficiency and concomitant uncomplicated hypertension, atherosclerosis or diabetes. In view of this, the use of ACE inhibitors in patients with moderate renal insufficiency should now be introduced. In the HOPE subjects, ramipril was found not only to lower the cardiovascular risk, but also to improve renal insufficiency.
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PMID:[Renal failure and cardiovascular risk. Increased borderline serum creatinine--a warning sign?]. 1177 Mar 72

Experimental and clinical evidence suggest that angiotensin converting enzyme (ACE) inhibition may reduce cardiovascular (CV) risk by directly affecting endothelial dysfunction, atherosclerosis and thrombus formation. These direct effects are in addition to effects on vascular tone or pressure. The Health Outcomes and Prevention Evaluation (HOPE) study assessed the role of an ACE inhibitor ramipril in reducing CV events in 9297 patients > or = 55 years who were at high risk of CV events but did not have left ventricular dysfunction, heart failure, or high blood pressure at the time of study entry. In the overall HOPE population, the risk of the primary composite outcome (cardiovascular death, myocardial infarction, or stroke) was reduced by 22% (p < 0.001), and in patients with diabetes plus one other CV risk, it was reduced by 25% (p = 0.0004). Ramipril treatment achieved risk reduction in patients with mild renal insufficiency (serum creatinine > or = 1.4 mg/dl). Ramipril treatment did not increase adverse events in patients with renal insufficiency. The Study to Evaluate Carotid Ultrasound changes in patients treated with Ramipril and Vitamin E (SECURE) demonstrated that ramipril 10 mg significantly reduced the rate of carotid intimal medial thickening, suggesting a direct effect on atherosclerotic progression.
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PMID:What should the role of ACE inhibitors be in the treatment of diabetes? Lessons from HOPE and MICRO-HOPE. 1184 51

The purpose of this study was to assess the risk of coronary artery bypass grafting (CABG) in the group of patients (pts) over 70 years of age and to examine results of surgical treatment in these pts. Between January 1993 to December 1999 1276 pts underwent CABG. From this group 114 consecutive pts at the age over 70 were retrospectively studied. The average age of the pts was 71.8 +/- 2.2 years (range, 70 to 79 years). Eighty nine male (78.1%) and 25 female (21.9%) pts were operated. One or more myocardial infarction had occurred in 64.0% of pts preoperatively. All the pts underwent left cardiac catheterization. The indication for surgery was significant stenosis of the left main trunk in 35 (30.7%) pts and three vessels disease in 54 (47.4%) pts. The total number of peripheral anastomoses was 274 (average 2.4 +/- 0.9 grafts per pts). In 29 cases left internal mammary artery (to left anterior descending artery) and in 245 reversed saphenous vein grafts were used. The early postoperative mortality in the group of pts at the age over 70 (10 pts--8.8%) was significantly higher than in the group of younger pts (41 of 1162 pts). The cause of death in septuagenarians was: low cardiac output syndrome (5 pts), respiratory failure (2 pts), renal insufficiency (2 pts) and cerebral stroke (1 pt). In early postoperative course the incidence of any organ insufficiency (cardiac, respiratory, renal and neurological) was higher in the group of pts over 70 years of age than in the younger pts. Seven-year probability of survival calculated from Kaplan-Meier method was 66 +/- 4%. After operation 84.5% of pts were asymptomatic, while only 5 pts were in III and IV CCS functional class. CABG in pts at the age over 70 is associated with higher operative risk and higher rate of perioperative organ failure. After surgery most pts enjoy improvement in life quality.
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PMID:[Coronary artery bypass grafting in patients over 70 years of age]. 1192 50

Recent published data suggest that performing carotid endarterectomy (CEA) in patients with renal dysfunction is associated with a prohibitively high perioperative stroke and death rate. On the basis of our experience, we hypothesized that CEA is a safe procedure in patients with renal insufficiency. A retrospective review of one surgeon's CEA experience from 1988 to 1998 was performed. A total of 398 procedures performed on 370 patients were reviewed for patient demographics and adverse events in the 30-day perioperative period. Risk factors, indications for procedure, and degree of stenosis, as well as intraoperative use of shunts, patch angioplasty, drains, completion angiography, and EEG monitoring were compared. Patients were categorized by preoperative creatinine (Cr) levels as normal (Cr <or= 1.5) or abnormal (Cr > 1.5). All data were subjected to statistical analysis. Our results showed that CEA can be performed safely in patients with renal dysfunction with no increase in perioperative stroke or death rate. Performing CEA in patients with renal insufficiency does require preoperative cardiac evaluation and close cardiac monitoring, as there appears to be an increased rate of myocardial infarction in our series.
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PMID:The safety of carotid endarterectomy in patients with preoperative renal dysfunction. 1197 48

The review covers principles of treatment with statins, their pharmacokinetics, characterizes six most usable in clinical practice statins and one novel drug--rozuvastatin from a "superstatins" group. Statins proved effective in primary and secondary prophylaxis of coronary atherosclerosis, secondary prevention of ischemic stroke and diseases of peripheral arteries with intermittent claudication, prevention of Alzheimer's disease. Statins are indicated in dyslipidemia in diabetes mellitus type 2, nephrotic syndrome and renal insufficiency. Further studies are needed on statins' effects on hypercholesterolemia, their antiinflammatory and immunomodulating properties, the ability to enhance revascularization of ischemic tissue and stimulate proliferation of osteoblasts in osteoporosis.
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PMID:[Statins in clinical practice]. 1208 96

This prospective study was focused on the radiological features of stroke and the recent contribution of computerized tomographic scan (CT scan) to diagnosis of hospitalized stroke patients. All patients admitted for stroke to the Neurology Department of the Nouakchott Hospital between January 1, 1996 and June 30, 1997 were enrolled in this study. Patients were divided into two groups, i.e. CT group including patients that underwent CT scan during hospitalization and control group including patients that did not undergo CT scan for financial reasons. The etiology of stroke (35.1% of hospitalizations) was ischemic in 52% of cases and hemorrhagic in 48%. There were more men than women and mean age was 60 years for ischemic stroke versus 56 years for hemorrhagic stroke. Only 8% of patients presented documented diabetes. Deep infarction accounted for 52% of ischemic stroke including large-artery infarction in 61.2% and lacunar infarction in 38.8%. Superficial infarction usually involved the territory supplied by the superficial sylvian artery. Intraparenchymal hematomas accounted for 78% of hemorrhagic strokes in relation with the high incidence of arterial hypertension (65.2%). The most common locations were capsulo-lenticular (55%) and capsulo-thalamic (39%). Stroke-related mortality was high (20.3%) especially in patients presenting prolonged disturbances of consciousness and renal insufficiency. By allowing more accurate assessment of lesions, CT-scan improved patient management and therapeutic outcome.
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PMID:[Contribution of computerized tomography in the diagnosis of cerebrovascular accidents in Nouakchott, Mauritania]. 1219 10

An 18-year-old male patient with MELAS phenotype and 2 previous episodes of cerebral stroke, recurrent seizures and nephropathy, was treated with creatine monohydrate after the acute onset of psychomental regression and changing states of somnolence and aggressive and agitated behaviour. These symptoms disappeared completely after 4 weeks of treatment with creatine after which the patient regained all his previous mental abilites. Brain (white matter) proton magnetic resonance spectroscopy (chemical shift imaging) performed at 6 and 12 months of treatment showed lactic acid (Lac) accumulation and high creatine (Cr) levels in relation to choline-containing compounds (Cho). Urinary creatinine excretion as an indicator of the muscle and brain creatine pool increased upon short-term (12 days) high-dosage creatine supplementation (20 g per day) while plasma creatinine concentrations as possible indicators both of increasing creatine pool and of renal insufficiency increased during the course (28 months) of low-dosage creatine supplementation (5 g per day). Deterioration of renal function was finally indicated by urea retention and by impairment of renal creatinine clearance. These observations suggest that creatine supplementation may have a neuroprotective effect in patients with MELAS and episodes of acute mental deterioration. Adverse effects of creatine supplementation on renal function must be considered especially in patients with preexisting nephropathy.
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PMID:Effects of oral creatine supplementation in a patient with MELAS phenotype and associated nephropathy. 1220 Jul 46

Among the uremia-associated risk factor, which can be influenced today, anemia is considered most relevant because it induces functional and organic alterations of cardiac/circulatory function. Research concerning influence of the anemia on the pulmonary hemodynamic and cardiac output (CO) in pre-uremic patients are not available up to now. Cardiac and circulatory function of 52 patients were examined before initiation of dialysis therapy using a Swan-Ganz thermodilution catheter. After excluding patients with impaired cardiac pump function the results of 31 of the 52 patients could be analyzed. They were divided into two groups (Hb > resp. < 7.0 g/dl): in patients with severe anemia (Hb 5.7 +/- 0.6 g/dl; n = 7) cardiac index was higher (4.8 +/- 0.4 1/min/m2 < 0.01) compared with the other group (Hb 9.8 +/- 1.7 g/dl; n = 24; CI 3.9 +/- 1.1 1min/m2). The increase of cardiac index caused by anemia correlated with increased stroke volume and heart rate and lowered pulmonary and peripheral resistance. Patients with severe anemia showed a tendency to an impaired cardiac index below Hb < 5-6 g/dl. The hypercirculation did not cause an increase of the pulmonary arterial and pulmonary wedge pressure. Particularly in the case of already existing myocardial damage and coronary arteriosclerosis the presence of anemia and renal insufficiency leads to a highly increased morbidity and mortality. This "cardio-renal anemia-syndrom" is responsible for frequent refractory heart failure. Disturbances of cardiac/circulatory function are observed in pre-uremic patients three times more frequently than in patients after myocardial infarction. Early correction of anemia seems to reduce the risk of fatal cardial complications and to improve the quality of life and the prognosis of pre-uremic patients.
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PMID:Renal anemia and its hemodynamic response--findings invasively determined over a period of 20 years. 1222 27


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