Trending Clinical Topic: Stroke

Ryan Syrek


February 25, 2022

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The results of studies on everything from a new stroke risk scoring system for patients with COVID to the cardioprotective nature of periodontal treatment were presented at the recent International Stroke Conference (ISC) 2022 . The combined influx of significant news resulted in stroke becoming the top trending clinical topic of the week. Arguably 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 at highest 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 the patient will have a stroke," Alexander E. Merkler, MD, lead author of a study of the system, told|Medscape Cardiology. For example, someone with 0-1 points has 0.2% risk for stroke but a patient with 4-6 points has 2%-3% risk, Merkler explained.

Researchers used the American Heart Association (AHA) Get With the Guidelines COVID-19 cardiovascular disease registry and evaluated 21,420 adult patients (mean age 61 years, 54% men) who were hospitalized with COVID-19 at 122 centers from March 2020 to March 2021. That the risk factors include absence of fever and history of pulmonary disease was somewhat surprising, said Merkler. However, he explained that a high fever is an inflammatory response and perhaps patients who aren't responding appropriately "could be sicker in general and have a poor immune system, and thereby be at increased risk for stroke." As for pulmonary disease, patients without a history who are admitted for COVID "may have an extremely high burden of COVID, or are extremely sick, and that's why they're at higher risk for stroke."

In other news presented at ISC 2022, the first randomized trial to determine whether periodontal treatment can reduce risk for cardiovascular events or stroke showed promise. In the PREMIERS study, 280 patients with a recent stroke or transient ischemic attack (TIA) and periodontal disease were randomly assigned to standard or intensive periodontal treatment and followed for 1 year. All patients received comprehensive conventional stroke risk factor treatment. Results after 1 year of follow-up showed that the primary outcome (stroke/myocardial infarction [MI]/death) occurred in 7.7% of the intensive-treatment group compared with 12.3% of the standard-care group, giving a hazard ratio of 0.65 (95% CI, 0.30-1.38; P = .26). Both groups had a lower rate of recurrent events compared with a historical control group, which had a 1-year rate of stroke/MI/death of 24%. Secondary outcomes showed a reduction in 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 focused on intra-arterial thrombolysis after thrombectomy in patients with acute ischemic stroke. The results of the phase 2b CHOICE study were published online in JAMA to coincide with a presentation at ISC 2022. The main findings showed a remarkable and significant 18.4% absolute increase in the number of patients who achieved an excellent neurologic outcome, defined as modified Rankin Scale (mRS) score of 0-1, after treatment with intra-arterial alteplase immediately after thrombectomy. The benefit was achieved without any increase in intracranial hemorrhage. The results were greeted with enthusiasm from commentators. Louise McCullough, MD, chair of the late-breaking science session at which the study was presented and ISC program chair, described the results as "very dramatic and very exciting."

In further promising news, a study examining the use of tenecteplase (TNK) in ischemic stroke found that patients who were treated with the newer agent had an almost 50% lower rate of symptomatic intracranial hemorrhage (sICH) compared with those who received alteplase (ALT). TNK is approved by the US Food and Drug Administration to treat MI but not ischemic stroke; however, clinicians sometimes use it off-label for this purpose. AHA guidelines suggest that TNK may be reasonable to consider for ischemic stroke in certain 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 sICH rate was 3.6% for ALT and 1.8% for TNK (odds ratio [OR] 0.49; P < .001). The adjusted OR was 0.42 (P < .001).

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 large-vessel occlusion stroke who underwent endovascular treatment (EVT) within 24 hours of symptom onset. The randomized, phase 3 trial's primary endpoint was disability level, as measured by overall distribution of the 90-day mRS score. Of more than 900 patients with acute ischemic stroke who underwent EVT that were included, the median mRS score at 90 days was 3 both in patients who received tirofiban and in those who received placebo. The rates of sICH and mortality at 90 days also did not differ significantly between groups.

The combination of significant clinical findings presented at ISC 2022 may have lasting practice implications moving forward. The wealth of new data on stroke captured much attention, resulting in the week's top trending clinical topic.

Learn more about ischemic stroke.


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