WAKE-UP Time for Thrombolysis in Acute Stroke?

By Martina McGrath, MD
October 30, 2018

MRI thrombolysis for stroke of unknown time of onset

Current clinical guidelines recommend thrombolysis in acute stroke where patients present within 4.5 hours of onset of symptoms. However, for up to a quarter of patients, the time of symptom onset is unknown as they wake from sleep with neurological deficits.1 Such patients frequently do not meet criteria for therapies such as thrombolysis or mechanical thrombectomy.

Prior studies have suggested a particular pattern may be seen on an MRI of the brain in the early hours following stroke onset; a visible ischemic lesion on diffusion-weighted imaging along with the lack of a hyperintense signal in the same area on fluid-attenuated inversion recovery (FLAIR). The benefit of aggressive stroke intervention in patients with the combination of unknown time of symptom onset and this particular signal mismatch on MRI brain scans is unknown. Continue reading “WAKE-UP Time for Thrombolysis in Acute Stroke?”

Quality of Life & Cost-Effectiveness of Intensive Blood Pressure Lowering

By Connor Emdin
September 6, 2017

In recent years, there has been considerable shift in treatment targets for blood pressure management. In 2014, the Eighth Joint National Commission (JNC 8) guidelines controversially up-revised blood pressure targets and recommended a target blood pressure of less than 140/80mm Hg in adults less than 60 years of age, increasing to less than 150/90mm Hg in those aged over 60 years. They argued that at the time, no randomized trial had demonstrated that lower blood pressure targets were associated with reduced risk of cardiovascular disease or death.1 These recommendations were a cause of heated debate and were inconsistent with recommendations from several other expert bodies, including American Heart Association and American College of Cardiology. Continue reading “Quality of Life & Cost-Effectiveness of Intensive Blood Pressure Lowering”

Inclisiran: A Novel Therapeutic for Long-Term Lowering of LDL Cholesterol?

By Connor Emdin
May 18, 2017

Elevated low-density lipoprotein cholesterol (LDL cholesterol) is a leading cause of coronary heart disease and death worldwide.1 When LDL cholesterol particles become oxidized, they can invade the endothelium of blood vessels and attract macrophages, forming atherosclerotic plaques. Over a lifetime, high levels of LDL cholesterol can lead to the formation of numerous unstable atherosclerotic plaques, potentially leading to myocardial infarction, stroke, and death from cardiovascular disease (CVD).2 Continue reading “Inclisiran: A Novel Therapeutic for Long-Term Lowering of LDL Cholesterol?”

Syncope—Are We Missing an Important Cause?

By Adam Schaffer, MD
April 19, 2017

As a hospitalist, syncope is an admitting diagnosis that I consider a challenge. Syncope is a presentation that we see frequently, and so can start to seem routine. Though published estimates of the causes of syncope vary, most have shown that the etiologies of syncope that we are most concerned about—such as bradyarrhythmias or ventricular tachyarrhythmias—make up a minority of cases. In one retrospective cohort study of the causes of syncope in 987 patients who were referred for cardiac electrophysiology evaluation, bradyarrhythmias accounted for 13.6% of cases and ventricular tachyarrhythmias accounted for 12.1% of cases.1  Vasovagal syncope, among the more benign etiologies of syncope, accounted for 47.0% of cases. These numbers come from a population of patients who were referred for electrophysiology evaluation, and so it is very possible that cardiac arrhythmias were overrepresented in this population compared to an unselected group of patients. Thus clinicians who evaluate syncope patients need to remain vigilant in order to correctly identify the minority of syncope patients who have a potentially serious cause of their syncopal episode. Continue reading “Syncope—Are We Missing an Important Cause?”

Safety and Efficacy of Prolonged Rivaroxaban to Prevent Recurrent Venous Thromboembolism

By Martina M. McGrath, MD
March 30, 2017

Venous thromboembolism (VTE) remains an important cause of vascular death.1 Treatment options have greatly expanded in recent years with the introduction of Wektnovel oral anticoagulants including apixaban, rivaroxaban and dabigatran and several large clinical trials have demonstrated similar efficacy and safety to warfarin in the initial treatment of VTE.2 Continue reading “Safety and Efficacy of Prolonged Rivaroxaban to Prevent Recurrent Venous Thromboembolism”

Migraine in Women—An aura for cardiovascular disease risk?

By Martina M. McGrath, MD
July 6, 2016

Migraine occurs in up to 20% of the population and disproportionately affects women. Migraine with aura has previously been linked with increased risk of ischemic stroke. Proposed mechanisms include the coexistence of vascular risk factors, underlying endothelial dysfunction or increased thrombogenic potential. Continue reading “Migraine in Women—An aura for cardiovascular disease risk?”

The SPRINT Study: A randomized trial of intensive versus standard blood pressure control

By Martina M. McGrath, MD
July 6, 2016

Published in November 2015, the Systolic Blood Pressure Intervention Trial (SPRINT) study (N Engl J Med 2015;373:2103-2116) sought to address the question of the optimal blood pressure target for patients at risk of cardiovascular disease.

This randomized controlled trial examined intensive versus standard treatment of hypertension in patients aged over 50 years with systolic blood pressure (SBP) of 130-180mmHg and increased cardiovascular risk. Important groups excluded were those with diabetes, difficult-to-control blood pressure, a history of stroke, cardiovascular events or procedures within the prior 3 months, or symptomatic heart failure within the previous six months. Continue reading “The SPRINT Study: A randomized trial of intensive versus standard blood pressure control”