Stroke Risk

ALCOHOL CONSUMPTION AND STROKE RISK IN MIDLIFE
Jones SB, Loehr L, Avery CL, et al. Midlife alcohol consumption and the risk of stroke in the Atherosclerosis Risk in Communities study. Stroke. 2015;46(11):3124-3130.

Light-to-moderate alcohol consumption at midlife was not associated with reduced stroke risk compared with abstention over 20 years of follow-up in a study of 12,433 never and current drinkers ages 45 to 65. An increased risk for both stroke and intracerebral hemorrhage (ICH) was observed with heavier consumption, as well as moderate intake for ICH. There were 773 ischemic strokes and 81 ICH incidents over follow-up. Study details included
• For ICH, light and moderate alcohol consumption was not associated with incidence (hazard ratios [HRs], 0.98, 1.06, 0.84).
• Heavier drinking was associated with a 31% increased rate relative to abstention (HR, 1.31).
• For ICH, moderate to heavy (HR, 1.99), but not light, consumption increased incidence.

Continue for spicy foods and mortality >>

SPICY FOODS AND MORTALITY
Lv J, Qi L, Yu C, et al. Consumption of spicy foods and total and cause specific mortality: population based cohort study. BMJ. 2015;351:h3942.

Consumption of spicy foods was inversely associated with total and certain cause-specific mortality, independent of other risk factors for death (eg, cancer, heart disease, and stroke), according to a population-based cohort study of 199,293 men and 288,082 women ages 30 to 79 in China. Specifically:
• Spicy food consumption showed highly consistent inverse associations with total mortality among both men and women.
• Compared with those who ate spicy foods less than once per week, adjusted hazard ratios for death were 0.90, 0.86, and 0.86 for those who ate spicy food on one or two; three to five; or six or seven days per week.
• A 14% relative risk reduction in total mortality was shown among those who consumed spicy foods on six or seven days per week.

COMMENTARY 
This is the type of study that I look forward to and use as an argument to defend my eating habits. Previous studies have shown that chocolate consumption decreases blood pressure and mortality.^1-3 Pistachio consumption has been associated with beneficial effects on glucose metabolism and insulin resistance.⁴ This study makes me think of suggesting to a local restaurant a new health food, based on the evidence, that I would suggest they call the “Skolnik Meal”: a spicy, chocolate pistachio taco.

1. Taubert D, Roesen R, Lehmann C, et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. JAMA. 2007;298(1):49-60.
2. Taubert D, Roesen R, Schomig E. Effect of cocoa and tea intake on blood pressure: a meta-analysis. Arch Intern Med. 2007;167(7):626-634.
3. Buijsse B, Feskens EJM, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study. Arch Intern Med. 2006;166:411-417.
4. Hernandez-Alonso P, Salas-Salvado J, Baldrich-Mora M, et al. Beneficial effect of pistachio consumption on glucose metabolism, insulin resistance, inflammation, and related metabolic risk markers: a randomized clinical trial. Diabetes Care. 2014;37:1–8.

Continue for FDA warns of heart attack and stroke risk of NSAIDs >>

FDA WARNS OF HEART ATTACK AND STROKE RISK OF NSAIDs
FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. www.fda.gov/Drugs/DrugSafety/ucm451800.htm. Accessed November 19, 2015.

The FDA has added heart attack and stroke warnings to OTC nonaspirin NSAIDs. The warning is similar to that added to prescription NSAIDs in 2005.

People who have cardiovascular disease, particularly those who recently had a heart attack or cardiac bypass surgery, are at the greatest risk for cardiovascular adverse events associated with NSAIDs, according to the FDA announcement.

While people who have already had a heart attack are most vulnerable for having another or for dying of heart attack–related causes if treated with NSAIDs, everyone may be at risk—even those without an underlying risk for CVD.

COMMENTARY
This new statement was based on a comprehensive review of observational studies and clinical trials published since the FDA boxed warning appeared in 2005. The primary changes reflect that the risk for heart attack or stroke can occur as early as the first few weeks of using an NSAID, and the risk increases with longer use and higher doses. The estimates of the level of increased risk range from 10% to more than 50%, depending on the medication and the doses studied. The relative increase in risk is similar for patients with and without heart disease, but of course the likelihood of an adverse event is higher in patients with existent heart disease because of the increased prevalence of cardiovascular outcomes. NSAIDs also increase the risk for congestive heart failure.

Continue for childhood arterial ischemic stroke triggers >>

CHILDHOOD ARTERIAL ISCHEMIC STROKE TRIGGERS
Fullerton HJ, Hills NK, Elkind MS, et al. Infection, vaccination, and childhood arterial ischemic stroke: Results of the VIPS study. Neurology. 2015; 85(17):1459-1466.

Infection may act as a trigger for childhood arterial ischemic stroke (AIS), while routine vaccinations appear protective, according to a study of 355 patients (ages 29 days to 18 years) with AIS and 354 controls. Researchers found:
• Infection in the week prior to stroke was reported in 18% of cases versus 3% of controls, conferring a 6.3-fold increased risk for AIS.
• Upper respiratory infections were the most ­common.
• Prevalence of preceding infection was similar across arteriopathic, cardioembolic, and idiopathic stroke types.
• Use of vasoactive cold medications was similarly low in both groups.
• Children with some/few/no vaccinations were at higher stroke risk than those receiving all or most immunizations.
• In an age-adjusted model, independent risk factors for AIS included infection in the prior week, undervaccination, black race (compared to white), and rural residence.

Continue for comparing stroke risk scores for patients with AF >>

COMPARING STROKE RISK SCORES FOR PATIENTS WITH AF
van den Ham HA, Klungel OH, Singer DE, et al. Comparative performance of ATRIA, CHADS2, and CHA2DS2-VASc risk scores predicting stroke in patients with atrial fibrillation: results from a national primary care database. J Am Coll Cardiol. 2015;66(17):1851-1859.

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk score more accurately identified patients with atrial fibrillation (AF) who were at low risk for stroke than did the CHA2DS2-VASc score, which assigned the same patients to higher-risk categories, in a study of 60,594 patients with AF. Researchers found:
• Event rates for moderate- and high-risk categories for CHA2DS2-VASc were lower than those of the ATRIA and CHADS2.
• Age and previous stroke most strongly predicted ischemic stroke.
• C statistics for the full point scores were 0.70 for the ATRIA risk score, 0.68 for CHADS2, and 0.68 for CHA2DS2-VASc risk score.
• Net reclassification improvement was 0.23 for the ATRIA compared with CHA2DS2-VASc.
• Reclassifying patients with very low stroke risk and AF could prevent overuse of anticoagulants.

Continue for risk of thromboembolism after ICH: Is resumption of warfarin therapy safe? >>

RISK OF THROMBOEMBOLISM AFTER ICH: IS RESUMPTION OF WARFARIN THERAPY SAFE?
Witt DM, Clark NP, Martinez K, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for intracranial hemorrhage. Thromb Res. 2015;136(5):1040-1044.

Patients resuming warfarin therapy following warfarin-associated intracranial hemorrhage (ICH) appeared not to be at increased risk for recurrent ICH but instead tended toward reduced thrombosis and all-cause mortality in a cohort study of 160 individuals discharged from the hospital following warfarin-related index of ICH. In the study, 33.8% of patients resumed warfarin therapy and 66.2% did not. Researchers found:
• Recurrent ICH occurred in a numerically greater, but statistically nonsignificant, proportion of patients who did not resume warfarin therapy (7.6% vs 3.7%).
• Patients who did not resume warfarin had three-fold higher (12.3% vs 3.7%) and approximately two-fold higher (31.3% vs. 18.5%) rates of thrombosis and all-cause mortality during follow-up.

Continue for lipid lowering drugs and stroke risk >>

LIPID LOWERING DRUGS AND STROKE RISK
Alpérovitch A, Kurth T, Bertrand M, et al. Primary prevention with lipid lowering drugs and long term risk of vascular events in older people: population based cohort study. BMJ. 2015;350:h2335.

Statins and fibrates may reduce stroke risk by 30% in older adults with no history of vascular events, according to a population-based cohort study of 7,484 patients.

In a random sample of community-dwelling adults ages 65 and older, investigators calculated hazard ratios for use of any lipid-lowering drug, and for statin and fibrates separately, and found:
• Users of lipid-lowering drugs were at decreased risk for stroke compared with nonusers (hazard ratio [HR], 0.66).
• Statin users were at similarly decreased risk (HR, 0.68).
• Fibrate users were also at decreased risk (HR, 0.66).
• There was no association between lipid-lowering drug use and coronary heart disease (HR, 1.12).

COMMENTARY 
This study supports the use of LDL cholesterol–lowering medication as primary prevention in older individuals to reduce the risk for stroke. The mean age in this study was 74. Previously, the PROSPER study—the only randomized study of older individuals with high vascular risk—showed that pravastatin reduced the risk for coronary disease but not for stroke.¹ This study gives support that lowering cholesterol in older patients with elevated cholesterol can decrease their risk for stroke.

1. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk for vascular disease (PROSPER). Lancet. 2002;360;1623-1630.

Continue for metabolic syndrome and diabetes in stroke recurrence >>

METABOLIC SYNDROME AND DIABETES IN STROKE RECURRENCE
Zhu S, McClure LA, Lau H, et al. Recurrent vascular events in lacunar stroke patients with metabolic syndrome and/or diabetes. Neurology. 2015 Aug 21. [Epub ahead of print]

Metabolic syndrome (METS) and diabetes mellitus (DM) were significant comorbid conditions in lacunar stroke patients, and they were associated with stroke recurrence, according to a study of 3,020 patients with lacunar strokes. Researchers found:
• 25% of patients had METS only, 6% had DM only, 32% had both conditions, and 37% had neither.
• Over a median 3.8 years of follow-up, there were 274 recurrent strokes and 74 myocardial infarctions (MIs).
• Among 240 recurrent ischemic strokes, 56% were lacunar.
• The hazard ratios for any recurrent stroke (HR, 1.7) or lacunar stroke (HR, 2.4) were significantly higher for those with concurrent METS and DM than for those who had neither.
• Risk for incident MI was higher in patients with DM (HR, 2.8) or concurrent DM and METS (HR, 2.6).

ALCOHOL CONSUMPTION AND STROKE RISK IN MIDLIFE
Jones SB, Loehr L, Avery CL, et al. Midlife alcohol consumption and the risk of stroke in the Atherosclerosis Risk in Communities study. Stroke. 2015;46(11):3124-3130.

Light-to-moderate alcohol consumption at midlife was not associated with reduced stroke risk compared with abstention over 20 years of follow-up in a study of 12,433 never and current drinkers ages 45 to 65. An increased risk for both stroke and intracerebral hemorrhage (ICH) was observed with heavier consumption, as well as moderate intake for ICH. There were 773 ischemic strokes and 81 ICH incidents over follow-up. Study details included
• For ICH, light and moderate alcohol consumption was not associated with incidence (hazard ratios [HRs], 0.98, 1.06, 0.84).
• Heavier drinking was associated with a 31% increased rate relative to abstention (HR, 1.31).
• For ICH, moderate to heavy (HR, 1.99), but not light, consumption increased incidence.

Continue for spicy foods and mortality >>

SPICY FOODS AND MORTALITY
Lv J, Qi L, Yu C, et al. Consumption of spicy foods and total and cause specific mortality: population based cohort study. BMJ. 2015;351:h3942.

Consumption of spicy foods was inversely associated with total and certain cause-specific mortality, independent of other risk factors for death (eg, cancer, heart disease, and stroke), according to a population-based cohort study of 199,293 men and 288,082 women ages 30 to 79 in China. Specifically:
• Spicy food consumption showed highly consistent inverse associations with total mortality among both men and women.
• Compared with those who ate spicy foods less than once per week, adjusted hazard ratios for death were 0.90, 0.86, and 0.86 for those who ate spicy food on one or two; three to five; or six or seven days per week.
• A 14% relative risk reduction in total mortality was shown among those who consumed spicy foods on six or seven days per week.

COMMENTARY 
This is the type of study that I look forward to and use as an argument to defend my eating habits. Previous studies have shown that chocolate consumption decreases blood pressure and mortality.^1-3 Pistachio consumption has been associated with beneficial effects on glucose metabolism and insulin resistance.⁴ This study makes me think of suggesting to a local restaurant a new health food, based on the evidence, that I would suggest they call the “Skolnik Meal”: a spicy, chocolate pistachio taco.

1. Taubert D, Roesen R, Lehmann C, et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. JAMA. 2007;298(1):49-60.
2. Taubert D, Roesen R, Schomig E. Effect of cocoa and tea intake on blood pressure: a meta-analysis. Arch Intern Med. 2007;167(7):626-634.
3. Buijsse B, Feskens EJM, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study. Arch Intern Med. 2006;166:411-417.
4. Hernandez-Alonso P, Salas-Salvado J, Baldrich-Mora M, et al. Beneficial effect of pistachio consumption on glucose metabolism, insulin resistance, inflammation, and related metabolic risk markers: a randomized clinical trial. Diabetes Care. 2014;37:1–8.

Continue for FDA warns of heart attack and stroke risk of NSAIDs >>

FDA WARNS OF HEART ATTACK AND STROKE RISK OF NSAIDs
FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. www.fda.gov/Drugs/DrugSafety/ucm451800.htm. Accessed November 19, 2015.

The FDA has added heart attack and stroke warnings to OTC nonaspirin NSAIDs. The warning is similar to that added to prescription NSAIDs in 2005.

People who have cardiovascular disease, particularly those who recently had a heart attack or cardiac bypass surgery, are at the greatest risk for cardiovascular adverse events associated with NSAIDs, according to the FDA announcement.

While people who have already had a heart attack are most vulnerable for having another or for dying of heart attack–related causes if treated with NSAIDs, everyone may be at risk—even those without an underlying risk for CVD.

COMMENTARY
This new statement was based on a comprehensive review of observational studies and clinical trials published since the FDA boxed warning appeared in 2005. The primary changes reflect that the risk for heart attack or stroke can occur as early as the first few weeks of using an NSAID, and the risk increases with longer use and higher doses. The estimates of the level of increased risk range from 10% to more than 50%, depending on the medication and the doses studied. The relative increase in risk is similar for patients with and without heart disease, but of course the likelihood of an adverse event is higher in patients with existent heart disease because of the increased prevalence of cardiovascular outcomes. NSAIDs also increase the risk for congestive heart failure.

Continue for childhood arterial ischemic stroke triggers >>

CHILDHOOD ARTERIAL ISCHEMIC STROKE TRIGGERS
Fullerton HJ, Hills NK, Elkind MS, et al. Infection, vaccination, and childhood arterial ischemic stroke: Results of the VIPS study. Neurology. 2015; 85(17):1459-1466.

Infection may act as a trigger for childhood arterial ischemic stroke (AIS), while routine vaccinations appear protective, according to a study of 355 patients (ages 29 days to 18 years) with AIS and 354 controls. Researchers found:
• Infection in the week prior to stroke was reported in 18% of cases versus 3% of controls, conferring a 6.3-fold increased risk for AIS.
• Upper respiratory infections were the most ­common.
• Prevalence of preceding infection was similar across arteriopathic, cardioembolic, and idiopathic stroke types.
• Use of vasoactive cold medications was similarly low in both groups.
• Children with some/few/no vaccinations were at higher stroke risk than those receiving all or most immunizations.
• In an age-adjusted model, independent risk factors for AIS included infection in the prior week, undervaccination, black race (compared to white), and rural residence.

Continue for comparing stroke risk scores for patients with AF >>

COMPARING STROKE RISK SCORES FOR PATIENTS WITH AF
van den Ham HA, Klungel OH, Singer DE, et al. Comparative performance of ATRIA, CHADS2, and CHA2DS2-VASc risk scores predicting stroke in patients with atrial fibrillation: results from a national primary care database. J Am Coll Cardiol. 2015;66(17):1851-1859.

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk score more accurately identified patients with atrial fibrillation (AF) who were at low risk for stroke than did the CHA2DS2-VASc score, which assigned the same patients to higher-risk categories, in a study of 60,594 patients with AF. Researchers found:
• Event rates for moderate- and high-risk categories for CHA2DS2-VASc were lower than those of the ATRIA and CHADS2.
• Age and previous stroke most strongly predicted ischemic stroke.
• C statistics for the full point scores were 0.70 for the ATRIA risk score, 0.68 for CHADS2, and 0.68 for CHA2DS2-VASc risk score.
• Net reclassification improvement was 0.23 for the ATRIA compared with CHA2DS2-VASc.
• Reclassifying patients with very low stroke risk and AF could prevent overuse of anticoagulants.

Continue for risk of thromboembolism after ICH: Is resumption of warfarin therapy safe? >>

RISK OF THROMBOEMBOLISM AFTER ICH: IS RESUMPTION OF WARFARIN THERAPY SAFE?
Witt DM, Clark NP, Martinez K, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for intracranial hemorrhage. Thromb Res. 2015;136(5):1040-1044.

Patients resuming warfarin therapy following warfarin-associated intracranial hemorrhage (ICH) appeared not to be at increased risk for recurrent ICH but instead tended toward reduced thrombosis and all-cause mortality in a cohort study of 160 individuals discharged from the hospital following warfarin-related index of ICH. In the study, 33.8% of patients resumed warfarin therapy and 66.2% did not. Researchers found:
• Recurrent ICH occurred in a numerically greater, but statistically nonsignificant, proportion of patients who did not resume warfarin therapy (7.6% vs 3.7%).
• Patients who did not resume warfarin had three-fold higher (12.3% vs 3.7%) and approximately two-fold higher (31.3% vs. 18.5%) rates of thrombosis and all-cause mortality during follow-up.

Continue for lipid lowering drugs and stroke risk >>

LIPID LOWERING DRUGS AND STROKE RISK
Alpérovitch A, Kurth T, Bertrand M, et al. Primary prevention with lipid lowering drugs and long term risk of vascular events in older people: population based cohort study. BMJ. 2015;350:h2335.

Statins and fibrates may reduce stroke risk by 30% in older adults with no history of vascular events, according to a population-based cohort study of 7,484 patients.

In a random sample of community-dwelling adults ages 65 and older, investigators calculated hazard ratios for use of any lipid-lowering drug, and for statin and fibrates separately, and found:
• Users of lipid-lowering drugs were at decreased risk for stroke compared with nonusers (hazard ratio [HR], 0.66).
• Statin users were at similarly decreased risk (HR, 0.68).
• Fibrate users were also at decreased risk (HR, 0.66).
• There was no association between lipid-lowering drug use and coronary heart disease (HR, 1.12).

COMMENTARY 
This study supports the use of LDL cholesterol–lowering medication as primary prevention in older individuals to reduce the risk for stroke. The mean age in this study was 74. Previously, the PROSPER study—the only randomized study of older individuals with high vascular risk—showed that pravastatin reduced the risk for coronary disease but not for stroke.¹ This study gives support that lowering cholesterol in older patients with elevated cholesterol can decrease their risk for stroke.

1. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk for vascular disease (PROSPER). Lancet. 2002;360;1623-1630.

Continue for metabolic syndrome and diabetes in stroke recurrence >>

METABOLIC SYNDROME AND DIABETES IN STROKE RECURRENCE
Zhu S, McClure LA, Lau H, et al. Recurrent vascular events in lacunar stroke patients with metabolic syndrome and/or diabetes. Neurology. 2015 Aug 21. [Epub ahead of print]

Metabolic syndrome (METS) and diabetes mellitus (DM) were significant comorbid conditions in lacunar stroke patients, and they were associated with stroke recurrence, according to a study of 3,020 patients with lacunar strokes. Researchers found:
• 25% of patients had METS only, 6% had DM only, 32% had both conditions, and 37% had neither.
• Over a median 3.8 years of follow-up, there were 274 recurrent strokes and 74 myocardial infarctions (MIs).
• Among 240 recurrent ischemic strokes, 56% were lacunar.
• The hazard ratios for any recurrent stroke (HR, 1.7) or lacunar stroke (HR, 2.4) were significantly higher for those with concurrent METS and DM than for those who had neither.
• Risk for incident MI was higher in patients with DM (HR, 2.8) or concurrent DM and METS (HR, 2.6).

ALCOHOL CONSUMPTION AND STROKE RISK IN MIDLIFE
Jones SB, Loehr L, Avery CL, et al. Midlife alcohol consumption and the risk of stroke in the Atherosclerosis Risk in Communities study. Stroke. 2015;46(11):3124-3130.

Light-to-moderate alcohol consumption at midlife was not associated with reduced stroke risk compared with abstention over 20 years of follow-up in a study of 12,433 never and current drinkers ages 45 to 65. An increased risk for both stroke and intracerebral hemorrhage (ICH) was observed with heavier consumption, as well as moderate intake for ICH. There were 773 ischemic strokes and 81 ICH incidents over follow-up. Study details included
• For ICH, light and moderate alcohol consumption was not associated with incidence (hazard ratios [HRs], 0.98, 1.06, 0.84).
• Heavier drinking was associated with a 31% increased rate relative to abstention (HR, 1.31).
• For ICH, moderate to heavy (HR, 1.99), but not light, consumption increased incidence.

Continue for spicy foods and mortality >>

SPICY FOODS AND MORTALITY
Lv J, Qi L, Yu C, et al. Consumption of spicy foods and total and cause specific mortality: population based cohort study. BMJ. 2015;351:h3942.

Consumption of spicy foods was inversely associated with total and certain cause-specific mortality, independent of other risk factors for death (eg, cancer, heart disease, and stroke), according to a population-based cohort study of 199,293 men and 288,082 women ages 30 to 79 in China. Specifically:
• Spicy food consumption showed highly consistent inverse associations with total mortality among both men and women.
• Compared with those who ate spicy foods less than once per week, adjusted hazard ratios for death were 0.90, 0.86, and 0.86 for those who ate spicy food on one or two; three to five; or six or seven days per week.
• A 14% relative risk reduction in total mortality was shown among those who consumed spicy foods on six or seven days per week.

COMMENTARY 
This is the type of study that I look forward to and use as an argument to defend my eating habits. Previous studies have shown that chocolate consumption decreases blood pressure and mortality.^1-3 Pistachio consumption has been associated with beneficial effects on glucose metabolism and insulin resistance.⁴ This study makes me think of suggesting to a local restaurant a new health food, based on the evidence, that I would suggest they call the “Skolnik Meal”: a spicy, chocolate pistachio taco.

1. Taubert D, Roesen R, Lehmann C, et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. JAMA. 2007;298(1):49-60.
2. Taubert D, Roesen R, Schomig E. Effect of cocoa and tea intake on blood pressure: a meta-analysis. Arch Intern Med. 2007;167(7):626-634.
3. Buijsse B, Feskens EJM, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study. Arch Intern Med. 2006;166:411-417.
4. Hernandez-Alonso P, Salas-Salvado J, Baldrich-Mora M, et al. Beneficial effect of pistachio consumption on glucose metabolism, insulin resistance, inflammation, and related metabolic risk markers: a randomized clinical trial. Diabetes Care. 2014;37:1–8.

Continue for FDA warns of heart attack and stroke risk of NSAIDs >>

FDA WARNS OF HEART ATTACK AND STROKE RISK OF NSAIDs
FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. www.fda.gov/Drugs/DrugSafety/ucm451800.htm. Accessed November 19, 2015.

The FDA has added heart attack and stroke warnings to OTC nonaspirin NSAIDs. The warning is similar to that added to prescription NSAIDs in 2005.

People who have cardiovascular disease, particularly those who recently had a heart attack or cardiac bypass surgery, are at the greatest risk for cardiovascular adverse events associated with NSAIDs, according to the FDA announcement.

While people who have already had a heart attack are most vulnerable for having another or for dying of heart attack–related causes if treated with NSAIDs, everyone may be at risk—even those without an underlying risk for CVD.

COMMENTARY
This new statement was based on a comprehensive review of observational studies and clinical trials published since the FDA boxed warning appeared in 2005. The primary changes reflect that the risk for heart attack or stroke can occur as early as the first few weeks of using an NSAID, and the risk increases with longer use and higher doses. The estimates of the level of increased risk range from 10% to more than 50%, depending on the medication and the doses studied. The relative increase in risk is similar for patients with and without heart disease, but of course the likelihood of an adverse event is higher in patients with existent heart disease because of the increased prevalence of cardiovascular outcomes. NSAIDs also increase the risk for congestive heart failure.

Continue for childhood arterial ischemic stroke triggers >>

CHILDHOOD ARTERIAL ISCHEMIC STROKE TRIGGERS
Fullerton HJ, Hills NK, Elkind MS, et al. Infection, vaccination, and childhood arterial ischemic stroke: Results of the VIPS study. Neurology. 2015; 85(17):1459-1466.

Infection may act as a trigger for childhood arterial ischemic stroke (AIS), while routine vaccinations appear protective, according to a study of 355 patients (ages 29 days to 18 years) with AIS and 354 controls. Researchers found:
• Infection in the week prior to stroke was reported in 18% of cases versus 3% of controls, conferring a 6.3-fold increased risk for AIS.
• Upper respiratory infections were the most ­common.
• Prevalence of preceding infection was similar across arteriopathic, cardioembolic, and idiopathic stroke types.
• Use of vasoactive cold medications was similarly low in both groups.
• Children with some/few/no vaccinations were at higher stroke risk than those receiving all or most immunizations.
• In an age-adjusted model, independent risk factors for AIS included infection in the prior week, undervaccination, black race (compared to white), and rural residence.

Continue for comparing stroke risk scores for patients with AF >>

COMPARING STROKE RISK SCORES FOR PATIENTS WITH AF
van den Ham HA, Klungel OH, Singer DE, et al. Comparative performance of ATRIA, CHADS2, and CHA2DS2-VASc risk scores predicting stroke in patients with atrial fibrillation: results from a national primary care database. J Am Coll Cardiol. 2015;66(17):1851-1859.

The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk score more accurately identified patients with atrial fibrillation (AF) who were at low risk for stroke than did the CHA2DS2-VASc score, which assigned the same patients to higher-risk categories, in a study of 60,594 patients with AF. Researchers found:
• Event rates for moderate- and high-risk categories for CHA2DS2-VASc were lower than those of the ATRIA and CHADS2.
• Age and previous stroke most strongly predicted ischemic stroke.
• C statistics for the full point scores were 0.70 for the ATRIA risk score, 0.68 for CHADS2, and 0.68 for CHA2DS2-VASc risk score.
• Net reclassification improvement was 0.23 for the ATRIA compared with CHA2DS2-VASc.
• Reclassifying patients with very low stroke risk and AF could prevent overuse of anticoagulants.

Continue for risk of thromboembolism after ICH: Is resumption of warfarin therapy safe? >>

RISK OF THROMBOEMBOLISM AFTER ICH: IS RESUMPTION OF WARFARIN THERAPY SAFE?
Witt DM, Clark NP, Martinez K, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for intracranial hemorrhage. Thromb Res. 2015;136(5):1040-1044.

Patients resuming warfarin therapy following warfarin-associated intracranial hemorrhage (ICH) appeared not to be at increased risk for recurrent ICH but instead tended toward reduced thrombosis and all-cause mortality in a cohort study of 160 individuals discharged from the hospital following warfarin-related index of ICH. In the study, 33.8% of patients resumed warfarin therapy and 66.2% did not. Researchers found:
• Recurrent ICH occurred in a numerically greater, but statistically nonsignificant, proportion of patients who did not resume warfarin therapy (7.6% vs 3.7%).
• Patients who did not resume warfarin had three-fold higher (12.3% vs 3.7%) and approximately two-fold higher (31.3% vs. 18.5%) rates of thrombosis and all-cause mortality during follow-up.

Continue for lipid lowering drugs and stroke risk >>

LIPID LOWERING DRUGS AND STROKE RISK
Alpérovitch A, Kurth T, Bertrand M, et al. Primary prevention with lipid lowering drugs and long term risk of vascular events in older people: population based cohort study. BMJ. 2015;350:h2335.

Statins and fibrates may reduce stroke risk by 30% in older adults with no history of vascular events, according to a population-based cohort study of 7,484 patients.

In a random sample of community-dwelling adults ages 65 and older, investigators calculated hazard ratios for use of any lipid-lowering drug, and for statin and fibrates separately, and found:
• Users of lipid-lowering drugs were at decreased risk for stroke compared with nonusers (hazard ratio [HR], 0.66).
• Statin users were at similarly decreased risk (HR, 0.68).
• Fibrate users were also at decreased risk (HR, 0.66).
• There was no association between lipid-lowering drug use and coronary heart disease (HR, 1.12).

COMMENTARY 
This study supports the use of LDL cholesterol–lowering medication as primary prevention in older individuals to reduce the risk for stroke. The mean age in this study was 74. Previously, the PROSPER study—the only randomized study of older individuals with high vascular risk—showed that pravastatin reduced the risk for coronary disease but not for stroke.¹ This study gives support that lowering cholesterol in older patients with elevated cholesterol can decrease their risk for stroke.

1. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk for vascular disease (PROSPER). Lancet. 2002;360;1623-1630.

Continue for metabolic syndrome and diabetes in stroke recurrence >>

METABOLIC SYNDROME AND DIABETES IN STROKE RECURRENCE
Zhu S, McClure LA, Lau H, et al. Recurrent vascular events in lacunar stroke patients with metabolic syndrome and/or diabetes. Neurology. 2015 Aug 21. [Epub ahead of print]

Metabolic syndrome (METS) and diabetes mellitus (DM) were significant comorbid conditions in lacunar stroke patients, and they were associated with stroke recurrence, according to a study of 3,020 patients with lacunar strokes. Researchers found:
• 25% of patients had METS only, 6% had DM only, 32% had both conditions, and 37% had neither.
• Over a median 3.8 years of follow-up, there were 274 recurrent strokes and 74 myocardial infarctions (MIs).
• Among 240 recurrent ischemic strokes, 56% were lacunar.
• The hazard ratios for any recurrent stroke (HR, 1.7) or lacunar stroke (HR, 2.4) were significantly higher for those with concurrent METS and DM than for those who had neither.
• Risk for incident MI was higher in patients with DM (HR, 2.8) or concurrent DM and METS (HR, 2.6).