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

Cat carotid arteries measuring 1.8 to 2 mm in diameter were endarterectomized under the operating microscope over a 1-cm segment and the arteriotomy was closed with a 9-0 monofilament nylon suture. Vessels exhibiting significant narrowing of the lumen due to faulty closure of the arteriotomy were excluded from the study. The vessels were divided into six groups according to the method of treatment of the animals: control, aspirin, Coumadin, Coumadin plus aspirin, heparin for less than four hours, and heparin for four to eight hours. All vessels in the untreated group subjected to simple arteriotomy and closure remained patent. Only heparin demonstrated an apparent beneficial effect after endarterectomy with 100% of the vessels treated more than four hours and 30% of those treated less than four hours remaining patent. This is contrasted to a 0% patency in other endarterectomized vessels.
Stroke
PMID:Effect of anticoagulants and inhibitors of platelet aggregation on thrombotic occlusion of endarterectomized cat carotid arteries. 127 1

Treatment after an ischemic stroke or transient ischemic attack (TIA) should target the presumed cause of the initial episode to facilitate focused prophylaxis. In the majority of ischemic strokes, degenerative large- and small-vessel disease is the cause. In these patients, attention to modifiable risk factors is an important priority. However, uncertainty and controversy remain regarding therapy, although issues are gradually being settled. There are now strong scientific data to support the use of carotid endarterectomy in patients with 70% to 99% stenosis and an ipsilateral TIA or nondisabling stroke. Aspirin is accepted as standard preventive therapy and should be used in all patients with a TIA or stroke, including those who undergo endarterectomy. Although the dose most commonly used in clinical trials is 1,300 mg/day, a daily dose of 325 mg is probably equally effective with less gastrotoxicity. Given present evidence, use of dipyridamole (Persantine) is not warranted. The role of ticlopidine hydrochloride (Ticlid) in stroke prophylaxis is not well defined. Its superiority over aspirin demonstrated in one study may make it the drug of first choice despite its expense and side effects. The efficacy of warfarin sodium (Coumadin, Panwarfin, Sofarin) or heparin in ischemic stroke caused by degenerative cerebrovascular disease is not supported by scientific data, but no prospective controlled studies have demonstrated that these agents are ineffective. Therefore, it seems prudent to reserve anticoagulant therapy for situations in which an ongoing thrombotic process is likely (eg, progressing stroke). Heparin therapy in the immediate post-TIA period is not warranted on the basis of current scientific evidence.
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PMID:Prevention of recurrent ischemic stroke. 174 41

A hemiplegic patient with severe upper extremity spasticity 2 years after a cerebrovascular accident received a diagnostic median nerve block below the elbow with bupivacaine. He had been placed on Coumadin as prophylaxis for cerebrovascular arteriosclerotic disease, and prothrombin time was kept at twice the control value. Less than 48 hours after the procedure, a compartment syndrome developed in the volar forearm. Compartment syndrome has not previously been reported as a complication resulting from a nerve block procedure. We conclude that (1) compartment syndrome may develop after a peripheral nerve block procedure for spasticity, (2) prophylactic anticoagulation may increase the risk for hemorrhagic events resulting from percutaneous injection and (3) early recognition is essential and appropriate decompressive fasciotomy may be indicated if a compartment syndrome develops after a nerve block procedure.
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PMID:Diagnostic peripheral nerve block resulting in compartment syndrome. Case report. 335 80

In a number of cardiac conditions (acute myocardial infarction, chronic left ventricular aneurysm, dilated cardiomyopathy, infective endocarditis and atrial fibrillation in the absence of valvular disease), the risk of embolism gives cause for concern. Although anticoagulation with warfarin (Coumadin)-derivatives has been shown to be effective in some of these situations, there is no evidence regarding the role of antiplatelet agents. The common factor in the thromboembolic potential of acute myocardial infarction, chronic left ventricular aneurysm and dilated cardiomyopathy is mural thrombus. This can be detected by two-dimensional echocardiography and indium-111 platelet scintigraphy. Although of value in elucidating the natural history of mural thrombus, in most cases, management is not substantially aided by these investigations. In patients with extensive myocardial infarction, particularly anterior infarction, moderate intensity anticoagulation started soon after hospital admission reduces the rate of embolism. After 8 to 12 weeks, embolic risk is low so that anticoagulants can usually be discontinued. Patients with chronic left ventricular aneurysm have a low incidence of embolism; anticoagulation is, therefore, inappropriate. Dilated cardiomyopathy is associated with a high risk of embolism; moderate intensity anticoagulation may be advisable in many such cases. Little information is available regarding the incidence of thromboembolism or the role of antithrombotic therapy in the patient with a diffusely dilated left ventricle due to ischemic heart disease. In native valve infective endocarditis, the risk of hemorrhage is high, and the efficacy of conventional anticoagulants unclear; thus, anticoagulation should not be instituted for the cardiac condition as such. However, in prosthetic valve endocarditis, the risk of embolism seems to be very high, and anticoagulant therapy should be continued, but with great care because there is a substantial risk of cerebral hemorrhage. Atrial fibrillation in patients with valvular heart disease is dealt with in a previous review. Patients with nonvalvular atrial fibrillation are at varying risk of embolism, depending on the etiology of the arrhythmia; trials of antithrombotic therapy are needed for the various subsets of patients. In most elderly patients, the etiology is not known, and their stroke risk is high. The risk of embolism in younger patients with idiopathic atrial fibrillation is so low as to make any antithrombotic therapy unnecessary.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Thrombosis and embolism from cardiac chambers and infected valves. 353 72

"Purple toes" syndrome and a generalized skin eruption developed in a 73-year-old woman who was taking warfarin sodium (Coumadin) as well as antiarrhythmic agents after a stroke. Both the rash and the discoloration of her feet were apparently related to use of warfarin and gradually resolved after discontinuation of the drug.
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PMID:"Purple toes" syndrome. 707 Oct 41

Elevation in the plasma concentration of fibrinogen in coronary heart disease (CHD) and in stroke has been found to be due to increased biosynthesis and turnover. The pathway of the increased turnover of fibrinogen is via formation of fibrin. A new method for detecting and measuring intravascular fibrin has shown a highly significant elevation in these patients. These elevated levels of fibrin formation, or intravascular clotting, are associated with depressed fibrinolysis or clot lysis. This increased formation of fibrin in the patient is not responsive to conventional oral anticoagulant therapy with Coumadin (Na Warfarin). Prospective studies on over 1,500 patients have shown elevated plasma fibrinogen to have at least as strong an association with cardiovascular death as raised cholesterol. Increased plasma fibrin is highly susceptive to control with low dose heparin and urokinase. These discoveries should provide the health care field with a new basis for detecting early warning signs of CHD and thrombotic stroke and for more effective preventive therapy.
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PMID:Haemostatic factors and coronary heart disease. 716 89

All patients (285) undergoing mitral valve replacement (MVR) with a Carpentier-Edwards (C-E) bioprosthesis +/- coronary bypass grafts (CABG) were reviewed (109 men and 176 women with a median age of 70 years). Overall, the 5-year survival rate was 58.9%, 62.7% for MVR (199 patients) and 50.1% for MVR+CABG (86 patients). Late survival was adversely affected by the operative time variables of NYHA class IV, older (> or = 70 years) age, low (> or = 56%) ejection fraction (EF), and the additional performance of associated procedures+CABG with MVR (P < or = 0.001). The 5-year freedom from stroke rate was 89.2%, 89.1% for MVR and 90.2% for MVR +/- CABG. Advanced heart class was the only significant variable associated with a greater risk of late stroke (P < or = 0.01). Neither chronic preoperative atrial fibrillation nor operative obliteration of the left atrial appendage increased or decreased the late risk of stroke in patients following MVR. Hazard function for stroke occurring in the first postoperative year (first 48 h excluded to discount intraoperative events) demonstrated the highest rate within the first month (40%), rapidly diminishing thereafter. This pattern was reproduced in the 12-year hazard function in that the rate of stroke occurrence was greatest in the first year (6.7%) following implantation. The mean stroke rate over 12 years was 2.5%. Strokes following MVR +/- CABG are more likely to occur in older and more compromised patients, and the higher early rate is not reflected in the mean rate. A more aggressive approach to early anticoagulation with IV heparin, Coumadin, and possibly antiplatelet therapy is advocated to reduce this complication rate.
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PMID:The risk of stroke in the early postoperative period following mitral valve replacement. 875 Dec 49

Coronary artery bypass operations are associated with increased morbidity and mortality in the elderly. Similarly, it has been shown that coronary angioplasty is associated with a higher risk of complications in the elderly than in younger patients. The purpose of this study was to evaluate the 1-month outcome of elderly patients (>75 years old) who were included in the Stenting without Coumadin French Registry. From December 1992 to March 1995, 2,900 patients (mean age 61+/-11 years) were included in this registry. All patients were treated with ticlopidine (250 to 500 mg/day) for 1 month from the day of percutaneous transluminal angioplasty, aspirin (100 to 250 mg/day) for >6 months, and low-molecular-weight heparin (antiXa 0.5 to 1 IU/ml) for 1 month in phase II, 15 days in phase III, and 7 days in phase IV. No heparin was given in phase V. The study group included 233 patients (8.0%) > 75 years old (mean age 79+/-4), 44 (18%) of whom were women. All patients underwent dilatation of a native coronary vessel. One hundred seventeen had unstable angina (50.2%), 20 had postmyocardial infarction ischemia (8.6%), and 6 had acute myocardial infarction (2.6%). Indications for stenting were de novo lesion in 63 patients (27.0%), restenosis in 38 (16.3%), suboptimal result in 48 (20.6%), nonocclusive dissection in 56 (24.0%), and occlusive dissection in 28 (12.0%), respectively. Stented coronary arteries were the left anterior descending in 109 (46.8%), the right in 80 (34.3%), the left circumflex in 40 (17.2%), and the left main in 4 (1.7%). Palmaz-Schatz stents were used in 228 patients (82.0%), AVE microstents in 38 (13.7%), and other stents in 12 (4.3%). More than 1 stent was used in 48 patients (17.3%). The mean diameter of the balloon used for stenting was 3.31+/-0.38 mm and maximal inflation pressure was 12.2+/-2.9 atm. At one-month follow-up, vascular complications occurred in 5 patients, requiring surgery in 2 (1.3%), acute closure occurred in 1 (0.4%), subacute closure in 3 (1.3%), emergency or planned coronary artery bypass graft surgery in none, acute myocardial infarction in 4 (1.7%), stroke in 1 (0.4%), and death in 8 (3.4%). The composite end point of a major cardiac event was observed in 13 cases (5.6%). Coronary stenting using ticlopidine and aspirin appears to be a particularly safe approach in this high-risk subset.
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PMID:One-month results of coronary stenting in patients > or = 75 years of age. 967 Oct 2

In the Coumadin Aspirin Reinfarction Study (CARS), the primary (efficacy) endpoint was time to the first occurrence of reinfarction, ischemic stroke, or cardiovascular death. Study events likely to be a component of the primary endpoint were reviewed by a blinded Events Classification Committee (ECC). To accommodate the inherent delay imposed by the adjudication process, we used the results of prior adjudication to predict classifications for selected unadjudicated study events in order to conduct "up-to-date" interim analyses for the Data and Safety Monitoring Committee (DSMC). Rates at which previously adjudicated study events were confirmed as primary event components were used to adjust the Kaplan-Meier estimates of survival and the log-rank statistics. Multiple events for a given subject were weighted according to the probability that prior events would be confirmed. Once all study events were adjudicated, final analyses confirmed the results of the adjusted interim analysis. For monitoring clinical trials with adjudicated endpoint events, models based on prior adjudication histories can be reliably used to predict event classifications for unadjudicated events and support accurate, contemporary interim analyses.
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PMID:Adjusting survival analysis for the presence of unadjudicated study events. 1082 19

The Coumadin Aspirin Reinfarction Study demonstrated that combination treatment with fixed dose warfarin (1 or 3 mg) + aspirin 80 mg was not superior to aspirin 160 mg alone after myocardial infarction for reducing nonfatal reinfarction, nonfatal stroke, and cardiovascular death. In this analysis, we examined the importance of aspirin dose in the protection against the secondary end point of ischemic stroke. The comparison arms for this analysis were warfarin 1 mg + aspirin 80 mg versus aspirin 160 mg. In the Coumadin Aspirin Reinfarction Study, 2,028 patients were randomized to aspirin 80 mg plus warfarin 1 mg, and 3,393 were randomized to aspirin 160 mg alone. A predictive model for ischemic stroke was developed using the Cox proportional-hazards model. A reduced Cox proportional-hazards model was developed to test for the effect of aspirin dose on ischemic stroke in predefined subgroups. The incidence of ischemic stroke was lower in patients treated with aspirin 160 mg than in patients treated with aspirin 80 mg + warfarin 1 mg (0.6% vs 1.1%; p = 0.0534). Age, previous stroke or transient ischemic attack, and aspirin dose were independent predictors of ischemic stroke. In addition, the highest risk patients, those with Q-wave myocardial infarction and male patients, appeared to receive greater benefit from aspirin 160 mg than from aspirin 80 mg + warfarin 1 mg. The results of this secondary analysis suggest that aspirin 160 mg is more effective than aspirin 80 mg + warfarin 1 mg in preventing ischemic stroke in post-myocardial infarction patients.
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PMID:Comparison of two aspirin doses on ischemic stroke in post-myocardial infarction patients in the warfarin (Coumadin) Aspirin Reinfarction Study (CARS). 1152 65


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