Trending Clinical Topic: Stroke

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Findings from studies on everything from a new stroke risk scoring system for COVID patients to the cardioprotective nature of periodontal therapy were presented at the recent International Conference on Stroke (ISC ) 2022 . The combined influx of important news has made stroke the hottest trending clinical topic of the week. Arguably the most important of all the findings presented at ISC 2022, researchers announced the development of a quick and easy scoring system to predict which hospitalized patients with COVID-19 are most at risk for stroke ( see infographic).

The scoring system assigns points for each factor; the higher the score, the higher the risk. “The system is simple. You can calculate the points in 5 seconds and then predict the chances of the patient having a stroke,” Alexander E. Merkler, MD, lead author of a study on the system, told | Medscape Cardiology. For example, a person with 0-1 points has a 0.2% risk of stroke but a patient with 4-6 points has a 2%-3% risk, Merkler explained.

Researchers used the American Heart Association’s (AHA) Get With the Guidelines COVID-19 Cardiovascular Disease Registry and evaluated 21,420 adult patients (mean age 61, 54% male) who were hospitalized with COVID -19 in 122 centers from March 2020 to March 2021 That risk factors include no fever and a history of lung disease was somewhat surprising, Merkler said. However, he explained that a high fever is an inflammatory response and perhaps patients who do not react appropriately “could be sicker in general and have a weakened immune system, and therefore be at increased risk of cerebrovascular accident”. Regarding lung disease, patients with no history who are admitted for COVID “may have an extremely high burden of COVID, or are extremely ill, and that is why they are at higher risk for stroke.”

In other news presented at ISC 2022, the first randomized trial to investigate whether periodontal treatment can reduce the risk of cardiovascular events or stroke has shown promise. In the PREMIERS study, 280 patients with recent stroke or transient ischemic attack (TIA) and periodontal disease were randomly assigned to standard or intensive periodontal therapy and followed for 1 year. All patients received full conventional therapy for stroke risk factors. The results after 1 year of follow-up showed that the primary endpoint (stroke/myocardial infarction [MI]/death) occurred in 7.7% of the intensive treatment group versus 12.3% of the standard care group, giving a relative risk of 0.65 (95% CI, 0.30-1.38; P = 0.26). Both groups had a lower rate of recurrent events than a historical control group, which had a 1-year stroke/MI/death rate of 24%. Secondary outcomes showed reduced blood pressure, A1c levels, carotid intima-media thickness, and better lipid profiles in all patients who underwent periodontal treatment.

Remarkable benefit was also seen in a separate study of intra-arterial thrombolysis after thrombectomy in patients with acute ischemic stroke. The results of the phase 2b CHOICE study have been published online in JAMA to coincide with a presentation at ISC 2022. The main results showed a remarkable and significant absolute increase of 18.4% in the number of patients who achieved an excellent neurological outcome, defined as a score on the modified Rankin scale ( mRS) of 0-1, after treatment with intra-arterial alteplase immediately after thrombectomy. The benefit was obtained without any increase in intracranial haemorrhages. The results were enthusiastically received by commentators. Louise McCullough, MD, chair of the late-breaking scientific session at which the study was presented and chair of the ISC program, described the results as “very dramatic and very exciting.”

In other promising news, a study examining the use of tenecteplase (TNK) in ischemic stroke found that patients treated with the new agent had an almost 50% lower rate of symptomatic intracranial hemorrhage (HICs) than those who were receiving alteplase (ALT ). TNK is approved by the US Food and Drug Administration to treat myocardial infarction but not ischemic stroke; however, clinicians sometimes use it off-label for this purpose. AHA guidelines suggest that TNK may be reasonably considered for ischemic stroke in some patients. The current standard of care is ALT, which has been approved for this indication since 1996. In an analysis that included 9238 patients (7313 who received ALT and 1925 who received TNK), the rate of sICH was 3.6% for ALT and 1.8% for TNK (odds ratio [OR] 0.49; P P

Not all news was positive at ISC 2022. A study found that adjunctive treatment with intravenous tirofiban did not improve clinical outcomes in patients with stroke with great vessel occlusion who had undergone endovascular therapy (EVT) within 24 hours of onset of symptoms. The primary endpoint of the phase 3 randomized trial was the level of disability, as measured by the global distribution of the mRS score at 90 days. Of over 900 patients with acute ischemic stroke who experienced VTE who were included, the median mRS score at 90 days was 3 in both patients who received tirofiban and those who received placebo. The sICH and 90-day mortality rates also did not differ significantly between the groups.

The combination of important clinical findings presented at ISC 2022 could have lasting implications for practice in the future. The wealth of new stroke data has garnered a lot of attention, resulting in the hottest clinical topic of the week.

Learn more about ischemic stroke.

Jessica C. Bell