Medical Bulletin 23/ October/ 2024 - Video

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 version and is a resource for clinicians in implementing a variety of prevention strategies for individuals with no prior history of stroke. The new guideline provides evidence-based recommendations for strategies to support brain health and prevent stroke throughout a person's lifespan by improving healthy lifestyle behaviors and getting preventive care.

The new clinical guideline from the American Stroke Association, a division of the American Heart Association was published in the Association's journal Stroke.

TOP 10 TAKE-HOME MESSAGES

1. From birth to old age, every person should have access to and regular visits with a primary care health professional to identify and achieve opportunities to promote brain health.

2. Screening for and addressing adverse social determinants of health are important in the approach to prevention of incident stroke. This updated guideline includes an orientation to social determinants of health, acknowledging its impact on access to care and treatment of stroke risk factors. Therefore, screening for social determinants of health is recommended in care settings where at-risk stroke patients may be evaluated, with the acknowledgment that evidence-based interventions to address adverse social determinants of health are evolving.

3. The Mediterranean diet is a dietary pattern that has been shown to reduce the risk of stroke, especially when supplemented with nuts and olive oil. However, low-fat diets have had little impact on reducing the risk. This guideline recommends that adults with no prior cardiovascular disease and those with high or intermediate risk adhere to the Mediterranean diet.

4. Physical activity is essential for cardiovascular health and stroke risk reduction. This guideline includes a summary of high-quality data showing that prolonged sedentary behavior during waking hours is associated with an increased risk of stroke. Therefore, we provide a new recommendation for screening for sedentary behavior and counseling patients to avoid being sedentary, as well as a call for new studies of interventions to disrupt sedentary behavior. This is in addition to the recommendation to engage in regular moderate to vigorous physical activity.

5. Glucagon-like protein-1 receptor agonists have been shown to be effective not only for improving management of type 2 diabetes but also for weight loss and lowering the risk of cardiovascular disease and stroke. On the basis of these robust data, we provide a new recommendation for the use of these drugs in patients with diabetes and high cardiovascular risk or established cardiovascular disease.

6. Blood pressure management is critical for stroke prevention. Randomized controlled trials have demonstrated that treatment with 1 antihypertensive medication is effective for reaching the blood pressure goal in only ≈30% of participants and that the majority of participants achieved the goal with 2 or 3 medications. Therefore, ≥2 antihypertensive medications are recommended for primary stroke prevention in most patients who require pharmacological treatment of hypertension.

7. Antiplatelet therapy is recommended for patients with antiphospholipid syndrome or systemic lupus erythematosus without a history of stroke or unprovoked venous thromboembolism to prevent stroke. Patients with antiphospholipid syndrome who have had a prior unprovoked venous thrombosis likely benefit from vitamin K antagonist therapy over direct oral anticoagulants.

8. Prevention of pregnancy-related stroke can be achieved primarily through management of hypertension. Treatment of verified systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg during pregnancy and within 6 weeks postpartum is recommended to reduce the risk of fatal maternal intracerebral hemorrhage. In addition, adverse pregnancy outcomes are common and are associated with chronic hypertension and an elevated stroke risk later in life. Therefore, screening for these pregnancy outcomes is recommended to evaluate for and manage vascular risk factors, and a screening tool is included to assist with screening in clinical practice.

9. Endometriosis, premature ovarian failure (before 40 years of age), and early-onset menopause (before 45 years of age) are all associated with an increased risk for stroke. Therefore, screening for all 3 of these conditions is a reasonable step in the evaluation and management of vascular risk factors in these individuals to reduce stroke risk.

10. Understanding transgender health is essential to truly inclusive clinical practice. Transgender women taking estrogens for gender affirmation have been identified as having an increased risk of stroke. Therefore, evaluation and modification of risk factors could be beneficial for stroke risk reduction in this population.

The SOUL cardiovascular outcomes trial was a double-blinded, randomised trial that compared oral semaglutide to placebo as an adjunct to standard of care for the prevention of major adverse cardiovascular events (MACE). The trial enrolled 9,650 people with type 2 diabetes and established cardiovascular disease (CVD) and/or chronic kidney disease (CKD). As part of standard of care, 49% of patients received SGLT2i at some point during the trial.

The trial achieved its primary objective by demonstrating a statistically significant and superior reduction in major adverse cardiovascular events of 14% for people treated with oral semaglutide compared to placebo. The primary endpoint of the study was defined as the composite outcome of the first occurrence of major adverse cardiovascular events defined as cardiovascular death, non-fatal myocardial infarction or non-fatal stroke. All three components of the primary endpoint contributed to the superior major adverse cardiovascular events reduction demonstrated by oral semaglutide.

In the trial, oral semaglutide appeared to have a safe and well-tolerated profile in line with previous oral semaglutide trials.

SOUL was a multicentre, international, randomised, double-blind, parallel-group, placebo-controlled, phase 3 cardiovascular outcomes trial with 9,650 people enrolled. It was conducted to assess the effect of oral semaglutide vs placebo on cardiovascular outcomes in people with type 2 diabetes and established Cardiovascular disease and/or chronic kidney disease. The SOUL trial was initiated in 2019.

The key objective of SOUL was to demonstrate that oral semaglutide lowers the risk of major adverse cardiovascular events (a composite endpoint consisting of cardiovascular death, non-fatal myocardial infarction and non-fatal stroke) compared to placebo, both added to standard of care in patients with type 2 diabetes and established Cardiovascular disease and/or chronic kidney disease.

Without proper medical invention, injuries sustained from traffic collisions, serious workplace accidents or weapons may result in fatal hemorrhaging. University of Central Florida researchers aim to prevent such bleeding in potentially deadly situations with a new hemostatic spongelike bandage with antimicrobial efficacy that they recently developed and detailed in a newly published study in the journal Biomaterials Science.

The method Kausik Mukhopadhyay assistant professor of materials science and engineering at UCF and study co-author and his team developed is called SilFoam as it's more of a foam than a traditional bandage wrap. SilFoam is a liquid gel comprised of siloxanes (silicon and oxygen) that is delivered via a special two-chamber syringe which rapidly expands into a spongy foam upon exposure to each other within the wound in under one minute. The sponge applies pressure to restrict the hemorrhage at the delivery site while also serving as an antibacterial agent because of the silver oxide in it.

For every five milliliters of gel injected, you can expect an expansion of about 35 milliliters, Mukhopadhyay says.

"Anytime you have a profuse bleeding or bleeding, you want to press on top and stop the bleeding," he says. "So, what we did here is actually the same thing. Instead of putting the hand, we injected it, and it creates a voluminous expansion."

Mukhopadhyay and his collaborators found that their sponge also resulted in a more gentle removal.

"During the reaction, it generates a little bit amount of heat that helps the process very fast," he says. "On top of that, oxygen gas as part of the reaction's byproduct, tries to come out. So instead of making it a cross-linkable rubber, it's a soft sponge with a lot of internal porosity."

They used specially crafted mannequins designed with realistic blood vessels and wounds developed by a local company called SIMETRI to test their foam on in hopes the preliminary results were promising enough to proceed with further testing.

"One of the most important parts of this was that we used non-invasive models," Mukhopadhyay says. "At this phase, we can get approvals and move forward to study the in vivo models. At this stage, there are no psychological effects on vets or surgeons either."

The experimentation showed promise, especially when the researchers compared SilFoam to five other existing treatment methods.

They found that SilFoam had many advantages such as significantly less leakage, room-temperature storage versus requiring cold temperatures, ultimately lower cost of materials, little to no training requirements to use the syringe.

A new, computerized, mental health assessment tool may allow doctors to quickly identify children experiencing anxiety or depression before surgery, suggests new research presented at the ANESTHESIOLOGY® 2024 annual meeting. In the small, single-center study, researchers found more than half of the children screened had anxiety before having surgery and more than one-third had depression.

“The use of the KCAT® tool in pediatric patients in the preoperative setting is very feasible and the results of our pilot study show a substantial prevalence of these mental health conditions in this surgical population,” said Elizabeth Pealy, M.D., lead author of the study and assistant professor of anesthesia and critical care at the University of Chicago Medicine. “Anxiety and depression are caused by many factors. Many kids are anxious before having surgery and the stress of undergoing the actual procedure can accentuate it.”

It is difficult for pediatric anesthesiologists to determine if patients have undiagnosed anxiety or depression, or severe preoperative anxiety, prior to the surgery. Increased anxiety can contribute to the child being uncooperative during the anesthetic induction, as well as prolonged recovery, increased postoperative pain and delirium, and decreased patient satisfaction. With thousands of children undergoing surgery every year, having a comprehensive yet quick method to screen for these conditions is needed.

In the study, researchers tested the feasibility of administering KCAT — a computerized adaptive mental health assessment tool — on pediatric surgical patients in the preoperative holding area and examined the prevalence of anxiety and depression in this group. According to the authors, KCAT allows for quick and accurate assessment of anxiety and depression without the need for a trained clinician interviewer. It is administered on a tablet device and allows for real-time assessment in the perioperative setting.

Sixty-five children scheduled for elective surgery at a large children’s hospital were enrolled. The median age was 13 years old (range 7-18 years). All of the children completed the assessment (taking an average of two minutes and 13 seconds), with 15 receiving parental assistance. The researchers found 57% of patients screened positive for anxiety and 34% of patients screened positive for depression.

“This is the first study to examine the use of this tool on children in this setting,” said Sarah Nizamuddin, M.D., co-author of the study and associate professor of anesthesia and critical care at the University of Chicago Medicine. “The ability to rapidly assess for and capture anxiety and depression levels can allow providers to offer a variety of anxiety-reducing options prior to and after surgery to the patients who would benefit the most. Further studies should aim to determine how to use the information to better cater to the needs of pediatric patients to improve their experience during surgery.”