Impacto del control de los distintos Factores de Riesgo en la fase aguda del AVC: Objetivos. Vicente Giner Galvañ. Unidad de HTA y Riesgo Cardiometabólico. Servicio de Medicina Interna. Hospital Verge dels Lliris. Alcoi. Alacant. Valencia, 8 y 9 de Junio de 2012

Isquémico Hemorrágico Idiopático Lacunar Cardioembólico Arterio-arterial Trombótico Pequeño vaso Gran vaso

Isquémico Hemorrágico Idiopático Lacunar Cardioembólico Arterio-arterial Trombótico Pequeño vaso Gran vaso HTA Disglucemia Dislipidemia Arritmias (FA) SAHS

Introducción Ictus: entidad vascular altamente heterogénea Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Al contrario de lo que ocurre en otras enfermedades vasculares, el ictus es una entidad heterogénea tanto en sus diferentes formas de presentación clínica como en su etiopatogenia diversa. Sus factores de riesgo y su pronóstico a corto y largo plazo también varían según el subtipo de ictus.

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es

Introducción Ictus: entidad vascular altamente heterogénea Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es La mortalidad intrahospitalaria fue del 12,9%, dentro de los márgenes de la mayoría de las series publicadas. La hipertensión arterial (HTA) se presentó en el 55,5%, seguida por la fibrilación auricular (FA) (29,8%) y la diabetes mellitus (DM) (23,4%). Arboix A. Rev Esp Cardiol. 2008;61:

Introducción Ictus: entidad potencialmente curable Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es El tratamiento agudo del ictus se puede subclasificar en 2 partes: 1.- Medidas generales y de control de complicaciones (Control PA, glucemia, infecciones/temperatura, arritmias…). 2.- Tratamiento recanalizador.

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es  En el paciente no subsidiario de trombolisis  En el paciente subsidiario de trombolisis Introducción Ictus: entidad potencialmente curable

Presión arterial

Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Por cada 10 mmHg de incremento de PAS por encima de 180 mmHg el riesgo de deterioro neurológico se incrementa un 40% y de mal pronóstico global un 23%. Robinson T. Cerebrovasc Dis. 1997;7:

Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Es común la detección de elevación de la PA en las primeras horas de evolución del ictus, de tal forma que valores de PAS>160 mmHg son detectables en el 60% y atribuibles a estrés, dolor, retención urinaria… (HTA reactiva). Robinson T. Cerebrovasc Dis. 1997;7:

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Toyoda K. Stroke 2006;37:

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Toyoda K. Stroke 2009;40: Acute SBP values between 12 and 36 hours postadmission, but not those on admission or at 6 hours, were predictive of neurological deterioration within the initial 3 weeks of ischemic stroke, particularly for cardioembolic stroke patients.

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Toyoda K. Stroke 2009;40:

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Vemmos KN. J Hum Hypertens. 2004;18:253-9.

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Dawson S. Stroke 2000;31: Registro FINAPRES

Toyoda K et al. Stroke 2006;37: Dawson S. Stroke 2000;31: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Registro FINAPRES

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Dawson S. Stroke 2000;31: Registro FINAPRES

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Tomii Y. Strroke. 2011; 42: Registro MAPA

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Registro MAPA Tomii Y. Strroke. 2011; 42: Mean ambulatory BP monitoring values changed from 150.5±19.5/85.7±11.3 mmHg on Day 1 to 139.6±19.3/80.0±11.7 mmHg on Day 7.

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Registro MAPA Tomii Y. Strroke. 2011; 42: After multivariate adjustment, mean values of systolic BP (OR, 0.63; 95% CI, 0.45–0.85), diastolic BP (0.61; 0.37– 0.98), pulse pressure (0.55; 0.33–0.85), and HR (0.61; 0.37– 0.98) recorded on Day 1 as well as mean HR on Day 7 (0.47; 0.23–0.87) were inversely associated with independence.

Toyoda K et al. Stroke 2006;37: Factores de riesgo en el AVC agudo Presión arterial / HTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Tomii Y. Strroke. 2011; 42:

Factores de riesgo en el AVC agudo Presión arterial / HTA: Manejo en fase aguda del ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es There are several questions about the management of arterial hypertension in the setting of acute stroke. Should patients previously taking antihypertensive medications continue taking them during the first hours after stroke? Are some of these medications contraindicated or indicated? Should new antihypertensive agents be started? What level of blood pressure would mandate initiation of new antihypertensive treatment? Which medication should be administered in this situation? AHA/ASA Guideline. Stroke 2007; 38:

Factores de riesgo en el AVC agudo Presión arterial / HTA: Manejo en fase aguda del ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es There are several questions about the management of arterial hypertension in the setting of acute stroke. Should patients previously taking antihypertensive medications continue taking them during the first hours after stroke? Are some of these medications contraindicated or indicated? Should new antihypertensive agents be started? What level of blood pressure would mandate initiation of new antihypertensive treatment? Which medication should be administered in this situation? Unfortunately, definite answers to these questions are not available. AHA/ASA Guideline. Stroke 2007; 38:

PA en la fase aguda del ictus Estudios disponibles Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.esAcrónimoReferenciaMuestraIntervención Resultado final ACCES Stroke. 2003;34: Estudio de seguridad Candesartán vs. Placebo a 24h del ictus para ↓ PAS 15-20%. Menor morbimortalidad en candesartán al año (RR 0,475). Rodríguez-García JL Am J Hypertens.2005;18:379. Captopril vs. Amlodipino a las 24h del ictus Pequeñas reducciones de PA produjeron beneficio a corto plazo. Eames PJ Cerebrovasc Dis. 2005;19: ictus isquémicos Bendrofluazida vs. Placebo en 24h del AVC durante 7 días No efectiva en reducción de PA clínica ni latido a latido (FINAPRES). Eveson DJ Am J Hypertens.2007;20: hipertensos con ictus isquémico Lisinopril vs. Placebo en las primeras 24 h Sin diferencias funcionales a los 90 días.

PA en la fase aguda del ictus Estudios disponibles Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.esAcrónimoReferenciaMuestraIntervención Resultado final CHHIPS piloto Lancet Neurol. 2009; 8: hipertensos con AVC isquémico o hemorrágico Labetalolo vs. Lisinopril vs. Placebo en las 36 h iniciales Reducción de mortalidad a tres meses (RR 0,40) COSSACS Lancet Neurol. 2010;9: pacientes con antiHTA y AVC isquémico “mantener antiHTA habituales” vs. “suspenderlos” en las 48 h Lower blood pressure levels in those who continued antihypertensive treatment after acute mild stroke were not associated with an increase in adverse events. SCAST Stroke. 2011;42: Pacientes con AVC isquémico o hemorrágico Candesartán vs. Placebo a las 24h del ictus. Sin diferencias a 6 meses (Tendencia a efecto negativo funcional y morbimortalidad con candesartán a corto plazo) PIL-FAST Trials 2011; 12: hipertensos con ictus isquémico en fase pre-hospital (piloto) Lisinopril vs. Placebo en las primeras 3 h si PAS >160 mmHg En marcha

PA en la fase aguda del ictus Momento de inicio de tto antiHTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Scandinavian Candesartan Acute Stroke Trial (SCAST). Sandset EC. Stroke 2012 May 24. [Epub ahead of print] Effect of change in blood pressure during the first 2 days of stroke on the risk of early adverse events and poor outcome patients presenting within 30 hours of acute stroke and with systolic blood pressure (SBP) ≥140 mm Hg. Treatment was given for 7 days. Change in blood pressure was defined as the difference in SBP between baseline and Day 2.

PA en la fase aguda del ictus Momento de inicio de tto antiHTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Scandinavian Candesartan Acute Stroke Trial (SCAST). Sandset EC. Stroke 2012 May 24. [Epub ahead of print] OUTCOMES: Early adverse events (recurrent stroke, stroke progression, and symptomatic hypotension) during the first 7 days. Secondary effect parameters were neurological status at 7 days and functional outcome at 6 months

PA en la fase aguda del ictus Momento de inicio de tto antiHTA Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Scandinavian Candesartan Acute Stroke Trial (SCAST). Sandset EC. Stroke 2012 May 24. [Epub ahead of print] Patients with a large decrease or increase/no change in SBP had a significantly increased risk of early adverse events relative to patients with a small decrease (OR, 2.08; 95% CI, and OR, 1.96; 95% CI, , respectively).

PA en la fase aguda del ictus PA y fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Patients who have elevated blood pressure and are otherwise eligible for treatment of rtPA may have their blood pressure lowered so that their systolic blood pressure is <185 mmHg and their diastolic blood pressure is <110 mmHg (Class I, Level of Evidence B) before lytic therapy is started. AHA/ASA Guideline. Stroke 2007; 38:

PA en la fase aguda del ictus PA y fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es If medications are given to lower blood pressure, the clinician should be sure that the blood pressure is stabilized at the lower level before treating with rtPA and maintained below 180/105 mmHg for at least the first 24 hours after intravenous rtPA treatment. AHA/ASA Guideline. Stroke 2007; 38:

PA en la fase aguda del ictus PA y fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Butcher K. Stroke 2010;41:72-7.

PA en la fase aguda del ictus PA y Fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es HI: petechial hemorrhagic infarction. PH: parenchymal hematoma. HT: Hemorragic transformation Butcher K. Stroke 2010;41:72-7.

PA en la fase aguda del ictus PA y fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Because the maximum interval from stroke onset until treatment with rtPA is short, many patients with sustained hypertension above recommended levels cannot be treated with intravenous rtPA. AHA/ASA Guideline. Stroke 2007; 38:

PA en la fase aguda del ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es

PA en la fase aguda del ictus PA y fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es AHA/ASA Guideline. Stroke 2007; 38:

PA en la fase aguda del ictus PA y fibrinolisis Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es AHA/ASA Guideline. Stroke 2007; 38:

Glucemia

Factores de riesgo en el AVC agudo Glucemia Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Luitse MJ. Lancet Neurol. 2012;11:

Factores de riesgo en el AVC agudo Glucemia: Hiperglucemia inducida por el ictus agudo Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Nyika D. Nature Reviews Neurology. 2010; 6,

Factores de riesgo en el AVC agudo Glucemia Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Admission hyperglycaemia is associated with poor functional outcome, possibly through aggravation of ischaemic damage by disturbing recanalisation and increasing reperfusion injury. Luitse MJ. Lancet Neurol. 2012;11:

Factores de riesgo en el AVC agudo Glucemia Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Admission hyperglycaemia is associated with poor functional outcome, possibly through aggravation of ischaemic damage by disturbing recanalisation and increasing reperfusion injury. Uncertainty surrounds the question of whether glucose-lowering treatment for early stroke can improve clinical outcome. Achievement of normoglycaemia in the early stage of stroke can be difficult, and the possibility of hypoglycaemia remains a concern. Luitse MJ. Lancet Neurol. 2012;11:

Factores de riesgo en el AVC agudo Glucemia: Ensayos clínicos de control de la glucemia Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Kruyt ND. et al. Nat. Rev. Neurol doi: /nrneurol

Factores de riesgo en el AVC agudo Glucemia: Ensayos clínicos de control de la glucemia Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Kruyt ND. et al. Nat. Rev. Neurol doi: /nrneurol

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Insulin for glycaemic control in acute ischaemic stroke. Squizzato A, Romualdi E, Dentali F, Ageno W. Cochrane Database Syst Rev Sep 7;(9):CD Factores de riesgo en el AVC agudo Glucemia We included seven trials involving 1296 participants (639 participants in the intervention group and 657 in the control group). Outcomes: death, disability and dependence, hypoglicemia.

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Squizzato A. Cochrane Database Syst Rev Sep 7;(9):CD Factores de riesgo en el AVC agudo Glucemia We found that there was no difference between treatment and control groups in the outcome of death or disability and dependence (OR 1.00, 95% CI 0.78 to 1.28) or final neurological deficit (SMD , 95% CI to 0.00). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 25.9, 95% CI 9.2 to 72.7). In the subgroup analyses of diabetes mellitus (DM) versus non- DM, we found no difference for the outcom

PA en la fase aguda del ictus Glucemia en la fase aguda del ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es AHA/ASA Guideline. Stroke 2007; 38: Persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes, and thus it is generally agreed that hyperglycemia should be treated in patients with acute ischemic stroke.

PA en la fase aguda del ictus Glucemia en la fase aguda del ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es AHA/ASA Guideline. Stroke 2007; 38: The minimum threshold described in previous statements likely was too high, and lower serum glucose concentrations (possibly >140 to 185 mg/dL) probably should trigger administration of insulin, similar to the procedure in other acute situations accompanied by hyperglycemia Class IIa, Level of Evidence C

PA en la fase aguda del ictus Glucemia en la fase aguda del ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es AHA/ASA Guideline. Stroke 2007; 38: Close monitoring of glucose concentrations with adjustment of insulin doses to avoid hypoglycemia is recommended. Simultaneous administration of glucose and potassium also may be appropriate.

Lípidos

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Choi KH. J Neurol Sci [Epub ahead of print]

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Functional Neurology 2011; 26:133-9.

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Statin treatment for 4 days may increase circulating EPC (Endothelial progenitor cells) levels, probably by NO-related mechanisms. Sobrino T. Eur J Neurol 2012 May 28. doi: /j x. [Epub ahead of print]

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es The purpose of the present review is to systematically evaluate the effectiveness of statin pretreatment on functional outcome of acute ischemic stroke and to assess potential adverse events associated with statin use. Lakhan SE. Int Arch Med. 2010; 3::22. Recurrence of stroke in patients who had suffered from a previous stroke was analyzed with and without statin therapy. Incidence and severity of adverse reactions was reviewed.

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Lakhan SE. Int Arch Med. 2010; 3::22. Pretreatment with statins was associated with a favorable outcome in acute ischemic stroke, with few incidences of adverse reactions.

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Lakhan SE. Int Arch Med. 2010; 3::22. The beneficial effects of prior statin therapy in acute ischemic stroke were shown to be especially profound in whites, diabetics, elderly patients with hypertension and other vascular diseases, and in patients with ideal low density lipoprotein (LDL) levels.

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Statins for acute ischemic stroke. Squizzato A, Romualdi E, Dentali F, Ageno W. Cochrane Database Syst Rev 2011 Aug 10;(8):CD SELECTION CRITERIA: We included all randomized controlled trials (RCTs) comparing statins (any type and dosage) versus placebo or no treatment, administered within two weeks of the onset of acute ischemic stroke or TIA. The primary outcomes were mortality from ischemic stroke and mortality from adverse drug effects, bleedings and infections.

Factores de riesgo en el AVC agudo Lípidos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Statins for acute ischemic stroke. Squizzato A, Romualdi E, Dentali F, Ageno W. Cochrane Database Syst Rev 2011 Aug 10;(8):CD MAIN RESULTS: We included eight RCTs involving 625 participants. Only one study was judged as 'low risk' of bias. AUTHORS' CONCLUSIONS: Insufficient data were available from randomized trials to establish if statins are safe and effective in cases of acute ischemic stroke and TIA.

Arritmias

Factores de riesgo en el AVC agudo Arritmias: Fibrilación Auricular (FA) Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Patients with infarctions of the right hemisphere, particularly those involving the insula, may have an increased risk of cardiac complications, presumably secondary to disturbances in autonomic nervous system function. ECG changes secondary to stroke include STsegment depression, QT dispersion, inverted T waves, and prominent U waves. The most common arrhythmia detected in the setting of stroke is atrial fibrillation, which either may be related to the cause of stroke or may be a complication AHA/ASA Guidelines. Stroke. 2007;38:

Factores de riesgo en el AVC agudo Arritmias: Fibrilación Auricular (FA) Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es AHA/ASA Guidelines. Stroke. 2007;38: No clinical trials have tested the utility of cardiac monitoring for most patients with ischemic stroke or the use of cardiac protective agents or medications to prevent serious cardiac arrhythmias. Still, general consensus exists that patients with acute ischemic stroke should have cardiac monitoring for at least the first 24 hours and that any serious cardiac arrhythmia should be treated. The utility of prophylactic administration of medications to prevent cardiac arrhythmias among patients with stroke is not known.

Factores de riesgo en el AVC agudo Arritmias: Fibrilación Auricular (FA) Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es General agreement supports the use of cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. It is generally agreed that cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke (Class I, Level of Evidence B). AHA/ASA Guidelines. Stroke. 2007;38:

The type of atrial fibrillation is associated with long-term outcome in patients with acute ischemic stroke. Ntaios GNtaios G, Vemmou A, Koroboki E, Savvari P, Makaritsis K, Saliaris M, Andrikopoulos G, Vemmos K.Vemmou AKoroboki ESavvari PMakaritsis KSaliaris MAndrikopoulos G Vemmos K Int J Cardiol May 16. [Epub ahead of print] Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es 811 patients (419 females, 392 males) with non-valvular AF and mean age of 75.8±9.4years: 34.2% paroxysmal, 20.3% persistent and 45.5% permanent AF. Stroke recurrence and mortality at hospital, 30 days and ten years. Patients with permanent AF had higher risk of stroke recurrence (HR: 1.78, 95%CI: ) and mortality (HR: 1.55, 95%CI: ) compared to patients with paroxysmal AF.

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Pathophysiological Determinants of Worse Stroke Outcome in Atrial Fibrillation Hans TH Tua, Bruce CV Campbella, Soren Christensen, et al. Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) Investigators Cerebrovasc Dis 2010;30: The reasons for worse outcome following ischemic stroke in patients with atrial fibrillation (AF) remain unclear. AF patients were older (79 vs. 73 years, p = 0.02), had more severe neurological impairment (National Institutes of Health Stroke Scale score 16 vs. 11, p = 0.006), larger infarcts (29 vs. 15 ml, p = 0.04) and greater volumes of more severe hypoperfusion. At outcome, AF patients had larger infarcts (52 vs. 16 ml, p = 0.05), more severe hemorrhagic transformation (29 vs. 5%, p = for parenchymal hematomas), greater disability (modified Rankin Scale score 4 vs. 3, p = 0.03) and higher mortality rates (31 vs. 12%, p = 0.04).

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Impact of Atrial Fibrillation on Outcome in Thrombolyzed Patients With Stroke: Evidence From the Virtual International Stroke Trials Archive (VISTA). Frank B, Fulton R, Weimar C, Shuaib A, Lees KR. Stroke 2012 May 24. [Epub ahead of print] Background and Purpose—Atrial fibrillation has been considered a risk factor for poor outcome from acute stroke and may influence response to thrombolysis, although supporting data are limited due to potential confounding with age and stroke severity. An association of treatment with outcome was seen independently and was of similar magnitude within patients with atrial fibrillation (OR, 1.44; 95% CI, 1.12–1.73; P<0.001) and without atrial fibrillation (OR, 1.53; 95% CI, 1.39–1.69; P<0.001). No association of atrial fibrillation and overall stroke outcome could be found (OR, 0.93; 95% CI, 0.84–1.03; P=0.409).

SAHS

Arch Bronconeumol 2004;40:

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Arch Bronconeumol 2004;40: RC: Roncopatía crónica. HS: Hipersomnia diurna.

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Arch Bronconeumol 2004;40: Antes del ictus, el 64,7% de los pacientes eran roncadores, el 21,6% presentaba apneas nocturnas repetidas y el 35,6%, somnolencia diurna.

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Arch Bronconeumol 2004;40:

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Stroke of respiratory centers can lead to apnea. Dyken ME. Chest. 2009;136:

Factores de riesgo en el AVC agudo SAHS post-AVC Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Dyken ME. Chest. 2009;136:

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Dyken ME. Chest. 2009;136: Stroke of respiratory centers can lead to apnea. Snoring preceding stroke, documentation of apneas immediately prior to transient ischemic attacks, the results of autonomic studies, and the circadian pattern of stroke, suggest that untreated OSA can contribute to stroke.

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Stroke of respiratory centers can lead to apnea. Snoring preceding stroke, documentation of apneas immediately prior to transient ischemic attacks, the results of autonomic studies, and the circadian pattern of stroke, suggest that untreated OSA can contribute to stroke. Dyken ME. Chest. 2009;136:

Factores de riesgo en el AVC agudo SAHS e ictus: Mecanismos patofisiológicos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es  OSA has variably been reported to increase the odds of having the metabolic syndrome anywhere from fivefold to ninefold.  OSA elevates sympathetic nerve activity (SNA) as a result of the reflex effects of hypoxia, hypercapnia, and decreased input from thoracic stretch receptors.  Autonomic effects may also explain the high prevalence of cardiac arrhythmias reported in up to 48% of apneic individuals. In patients with atrial fibrillation, the risk of OSA has been estimated to be 49%, and noncompliance with CPAP has been associated with a greater recurrence rate of atrial fibrillation after cardioversion.  The elevation of catecholamines and platelet activation associated with OSA may further increase thrombus and embolus formation, and stroke risk Dyken ME. Chest. 2009;136:

Factores de riesgo en el AVC agudo SAHS e ictus: Mecanismos patofisológicos Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Netzer N. Stroke 1998;29:87-93.

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Stroke of respiratory centers can lead to apnea. Snoring preceding stroke, documentation of apneas immediately prior to transient ischemic attacks, the results of autonomic studies, and the circadian pattern of stroke, suggest that untreated OSA can contribute to stroke. Although cohort studies indicate that OSA is a stroke risk factor, controversy surrounds the cost-effectiveness of the screening for and treatment of OSA once stroke has occurred. Dyken ME. Chest. 2009;136:

Factores de riesgo en el AVC agudo SAHS e ictus Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es  Positional sleep apnea (OSA that is worse in the supine position secondary to gravitational effects on the oropharynx) appears to be a prominent feature in acute stroke. In a study of 43 subjects with acute stroke or TIA, the mean AHI determined with patients in the supine position of 17.7±20 was significantly higher than the mean AHI of 8.4±14.6 determined with patients in other than the supine position (p<0.001). Wierzbicka A. J Physiol Pharmacol. 2006; 57: subjects were assessed within 72 h of stroke, and after 6 months, by using cardiorespiratory polygraphy. Initially, 78% of patients had OSA (AHI ≥10), with 65% demonstrating positional apnea. After 6 months, the prevalence of OSA was only 49% (33% with positional apnea). Dziewas R. Neurol Res. 2008;30: Dyken ME. Chest. 2009;136:

Stroke. 2005; 36:

Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Stroke. 2012;43: Hypercapnia due to sleep apnea is assumed to contribute to early neurological deterioration by causing cerebral vasodilatation in arteries unaffected by ischemia with a subsequent steal of blood from ischemic and peri-ischemic areas of the brain. CPAP therapy improves neurological outcome and may reduce the mortality of patients with stroke with obstructive sleep apnea. CPAP therapy, however, might be beneficial as “acute prophylactic” treatment in the first night after stroke because hemodynamic disturbances due to sleep apnea have markedly detrimental effects at this stage.

Factores de riesgo en el AVC agudo SAHS en la fase aguda del ictus: recomendaciones Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es En todo ictus valorar posibilidad de SAHS previamente no conocido (cuatro peguntas a familiares). En todo ictus evitar decúbito supino (cabeza incorporada). En SAHS ya conocido mantener CAPP* previa. En sospecha de SAHS no conocida valorar CPAP*. *Valoración individual según estado neurológico del paciente.

Conclusiones

Factores de riesgo en el AVC agudo Conclusiones Hospital Verge dels Lliris. Alcoy. http//alcoi.san.gva.es Muy escasa evidencia. La moderación y la vigilancia parece ser la clave (Unidad de ictus). Es absolutamente necesaria la individualización de las actitudes (Unidad de ictus). Valorar nuevos abordajes aunque no probados poco invasivos (SAHS). Estricta necesidad de cambio conceptual (Código Ictus).