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

Prevention remains a major therapeutic approach of stroke. Inhibitors of platelet aggregation are the treatment of choice in the secondary prevention of an arterial embolism stroke. Aspirin (200-300 mg/d) is the most commonly used drug, ticlopidine (500 mg/d) is advised if aspirin is contraindicated or if a recurrent stroke of arterial embolism origin occurs in spite of treatment with aspirin. We are waiting with interest for the results of the clinical trial of clopidogrel, a derivative of ticlopidine. Till now, no studies have proved the benefit of antiplatelet treatment in the primary prevention of stroke. In non rheumatic atrial fibrillation, the unanimous results of recent studies confirmed the benefit of oral anticoagulation in the primary and secondary prevention of stroke. Although coumadin is superior to aspirin in non rheumatic atrial fibrillation, aspirin is an efficient alternative when anticoagulation is contraindicated.
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PMID:[Antithrombotic agents and prevention of cerebrovascular accidents]. 884 86

The limitations of current therapies for atrial fibrillation are forcing a rethinking of how they should be used. Questions are being raised about the use of antiarrhythmic drugs, and new nonpharmacologic procedures are promising alternatives. Most patients with atrial fibrillation still require warfarin therapy, but some low-risk patients can forego it. Sinus rhythm spontaneously returns within the first 24 hours in almost half of cases of new atrial fibrillation. Patients with hemodynamic instability due to new-onset atrial fibrillation should proceed directly to electrical cardioversion. Warfarin therapy to maintain an International Normalized Ratio (INR) of 2.0 to 3.0 is currently recommended for all patients with atrial fibrillation with no contraindications to it, except for patients younger than 60 years with lone atrial fibrillation, in whom the risk of stroke is low. Certain antiarrhythmic drugs should be avoided in patients with congestive heart failure, in whom the risks may exceed the benefits. The maze procedure is emerging as an option to restore and maintain sinus rhythm. Radiofrequency atrioventricular node ablation and modification hold promise as options to control the ventricular rate without drugs.
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PMID:Strategies for managing atrial fibrillation. 887 Mar 39

Warfarin can strikingly prevent stroke in patients with NRAF with or without a history of stroke or TIA. The target degree of anticoagulation is an INR between 2.0 and 3.0. Any degree of anticoagulation with less than an INR of 2.0 will not provide full protection, any greater anticoagulation is no more effective, and an INR greater than 4.0 increases the risk of hemorrhage. Patients 65 years or younger without any risk factor do no better with warfarin than with aspirin or placebo, and should not be anticoagulated. All older patients or those with risk factors but without contraindications gain significant stroke prevention with warfarin anticoagulation as recommended above.
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PMID:Stroke prevention in non-rheumatic atrial fibrillation. 899 57

Deep venous thrombosis and subsequent pulmonary embolism due to venous pooling/stasis commonly occur in patients during hip and/or knee arthroplasty (i.e., replacement). This problem may be alleviated by using techniques to promote lower limb blood flow. Electrical stimulation-induced contractions have been shown to activate the skeletal muscle pump, promote limb blood flow, and may be effective for reducing venous pooling/stasis and edema. Therefore, electrical stimulation may reduce the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) during and following surgery. The overall goal of this project was to evaluate the clinical efficacy of sequential electrical stimulation-induced leg muscle contractions on the venous blood flow during surgery. The degree of venous pooling/stasis was monitored via electrical impedance changes in the thorax. The changes in the patient's central hemodynamics were then calculated. Thirty patients were recruited and randomly assigned to either a control group (n = 15, mean age = 66.4 +/- 7.3) or experimental group (n = 15, age = 60.7 +/- 9.7). Both groups received the standard medical treatment for prevention of DVT (i.e., coumadin, heparin, etc.) and compression stockings (TED, Kendall). The control group used the sequential compression device (SCD + TED) and the experimental group used electrical stimulation (ES + TED). Electrical stimulation was applied via surface electrodes to the lower-limb muscles (tibialis anterior and gastrocnemius) and upper limb muscles (quadriceps femoris and hamstrings). These muscles contracted sequentially, using an eight-channel electrical stimulator. Four seconds of calf (contraction/compression) were followed by 7-s of calf and thigh (contraction/compression) interspersed by 60-s rest period during both electrical stimulation or sequential compression device. This cycle continued throughout the surgery (60-75 min) for both groups. At 15 min intervals, venous return was monitored by impedance cardiograph. Physiologic responses including ventricular stroke volume (SV), cardiac output (CO), heart rate (HR), total peripheral resistance (TPR), as well as mean arterial pressure (MAP) were monitored. These responses were statistically analyzed and compared throughout the surgery within each group and between the two groups. The results show stroke volume and cardiac output to be higher throughout surgery in the electrical stimulation group as compared with the sequential compression device group. The heart rate was consistently lower during electrical stimulation for both groups. Total peripheral resistance did not change in the electrical stimulation group; but increased in the sequential compression device group. The data suggest that continuous electrical stimulation-induced contractions could improve lower leg circulation by eliciting the physiologic muscle pump. This will lead to improved venous circulation and reduction of blood stasis during total hip and/or knee surgery. This technique may offer greater protection against DVT and PE during surgery than the commonly used sequential compression device.
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PMID:Electrical stimulation-induced contraction to reduce blood stasis during arthroplasty. 908 86

Nonvalvular atrial fibrillation is associated with an overall risk of stroke of 4.5% per year. Advancing age, prior stroke or transcient cerebral ischemia, diabetes and hypertension are known risk factors. Ischemic stroke in patients with atrial fibrillation are generally more severe than ischemic stroke in patients with sinus rhythm. Warfarin is effective for primary and secondary prevention of ischemic stroke, reducing the risk by 68%. The effect of aspirin is still controversial, reducing the risk by 18-44%. Recent clinical trials have investigated the effect of warfarin given at a very low intensity either alone or combined with aspirin. The results from the SPAF III study demonstrated that a combination of mini-intensity warfarin plus aspirin was insufficient for stroke prevention in atrial fibrillation. Other trials now indicate, that oral anticoagulation at INR-values below 2.0 is not effective for stroke prevention in these patients. It is recommended that patients at high risk of stroke are treated with warfarin at an intensity of INR 2.0-3.0. Patients younger than 65 without other risk factors can be given aspirin 325 mg/day. The present clinical challenge is to ensure effective and safe oral anticoagulation to patients with atrial fibrillation at high risk of stroke.
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PMID:Prevention of thromboembolic events in atrial fibrillation. 919 82

The demand for anticoagulation services is rising. Warfarin anticoagulation has been shown to reduce the risk of stroke in patients with non-valvular atrial fibrillation by 68%. This raises issues about how services are best organized to initiate and monitor anticoagulation in this potentially large group of patients. We report the results of a regional postal survey undertaken to describe the views of general practitioners and consultants regarding warfarin anticoagulation in light of this potentially high increase in demand.
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PMID:Warfarin anticoagulation in primary care: a regional survey of present practice and clinicians' views. 947 38

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

Clinical trials conducted during the past five years have yielded important results that have allowed us to refine our approach to stroke prevention. Treatment of isolated systolic hypertension prevents stroke and is generally well tolerated. New antiplatelet agents (clopidogrel and the combination of aspirin plus high-dose dipyridamole) have been shown to be effective in reducing vascular events in survivors of ischemic stroke, although aspirin remains the mainstay of antiplatelet therapy for stroke prevention. Several clinical trials support the benefit of lipid-lowering agents ("statins") in reducing stroke. Warfarin reduces stroke for high-risk patients with atrial fibrillation. Carotid endarterectomy is highly beneficial in reducing stroke for symptomatic patients with severe carotid stenosis (greater than 70 percent), but the benefit is less for symptomatic patients with a moderate degree of stenosis (50 to 69 percent) and for patients with asymptomatic carotid disease of any severity.
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PMID:Stroke: part I. A clinical update on prevention. 1032 55

Atrial fibrillation is the commonest sustained disorder of cardiac rhythm and is associated with increased risk of stroke and thromboembolic events. Warfarin (dose-adjusted to a target INR of 2.0-3.0) has been well established to reduce this risk of stroke by 68% (95% CI 50-79%), while aspirin provides a risk reduction of 21% (95% CI 0-38%). Nevertheless, warfarin confers a risk of bleeding and the inconvenience of regular monitoring checks, while aspirin seems effective only for certain low-risk subgroups. Thus there have been strenuous efforts to improve thromboprophylaxis in atrial fibrillation, by using low-intensity anticoagulation regimens, combination antiplatelet therapy and refinement of risk stratification strategies. Attempts at using a low-intensity, fixed-dose warfarin regimen have, however, been disappointing. For now, a strategy of risk stratification should be adopted to identify highest risk patients with atrial fibrillation who would benefit from anticoagulation.
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PMID:Atrial fibrillation, thromboembolism and antithrombotic therapy. 1034 46

Atrial fibrillation is associated with a sixfold increased risk for stroke. More than a dozen published randomized trials of anticoagulants or antiplatelet agents for stroke prevention provide solid evidence on which to base antithrombotic prophylaxis. Adjusted-dose warfarin reduces risk for stroke by about 60% compared with placebo, aspirin reduces this risk (primarily for nondisabling stroke) by about 20% compared with placebo, and warfarin reduces it by about 40% compared with aspirin. Warfarin provides maximal protection against stroke at international normalized ratios of 2.0 to 3.0. Risk stratification of patients with atrial fibrillation identifies those who potentially benefit most or least from anticoagulation; this is important because a substantial percentage of patients with atrial fibrillation have relatively low rates of stroke if they are given aspirin. Many elderly patients with recurrent intermittent atrial fibrillation experience high rates of stroke and benefit from anticoagulation. The value of precordial or transesophageal echocardiography in addition to clinical risk stratifiers for stratifying stroke risk is controversial. Altered hemostasis favoring thrombosis may contribute to formation of atrial appendage thrombus, but these conditions remain ill defined. The past decade has brought unprecedented progress toward understanding thromboembolism in patients with atrial fibrillation and has changed the clinical perspective of a prevalent cardiac arrhythmia into an important opportunity for stroke prevention. Making the most of this promise calls for appreciation of the epidemiology of atrial fibrillation and the concept of risk specificity in the face of diverse therapeutic options.
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PMID:Atrial fibrillation and thromboembolism: a decade of progress in stroke prevention. 1057 32


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