ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
Secondary prevention of ischemic strokeSudhir Kumar
A patient who has suffered ischemic stroke is at a higher risk of getting strokes in future. This is called recurrent stroke. The current presentation looks at the factors responsible for stroke recurrence, and discusses strategies to reduce the risk of stroke recurrence.
Stroke prevention for nonvalvular AF, summary of evidence-based guidelinesErsifa Fatimah
Ternyata... guideline yang ngebahas prevensi stroke pada nonvalvular AF tu banyak banget! Yang dirilis komunitas Neuro maupun Cardio, yang internasional maupun yang lokal. Dan pertanyaan besarnya tetep: What's the best strategy?
*Bonus special issue: manajemen prevensi stroke infark dengan antikoagulan pasca brain hemorrhage.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
Prevention of recurrent stroke in atrial fibrillation Jacek StaszewskiJacek Staszewski
Prevention of recurrent stroke in atrial fibrillation. Comaprison of NOAC vs VKA. Riks of hemorrhagic stroke. When anticoagulation should be initiated following acute stroke.
EVALUATING RISK OF HEART FAILURE WITH ERYTHROPOIETIN IN CHRONIC ANEMIAPARUL UNIVERSITY
Erythropoietin (EPO) is the primary regulatory hormone of
erythropoiesis. Hypoxia induces an increase in EPO hormone
production in the kidney which promotes the viability, proliferation,
and terminal differentiation of erythroid precursors, and causing an
increase in red blood cell mass. Any abnormality that reduces the renal
secretion of or bone marrow response to erythropoietin may result in
anemia. The approval of recombinant human erythropoietin
(epoetinalfa) by the US FDA in 1989, epoetinalfa and similar agents
now collectively known as erythropoietin stimulating agents (ESA)
have become the standard of care for the treatment of the
erythropoietin-deficient anemia. Studies suggest that in patients with
high serum erythropoietin is associated with risk of recurrent heart
failure (HF) and mortality. Thromboembolic complications can be
increased in patients receiving erythropoietin. the use of
erythropoiesis-stimulating agents though reduces the need for transfusions it is associated
with increased complications, including higher mortality and increased risk of
thromboembolic and cardiovascular events leading to congestive heart failure.
Secondary prevention of ischemic strokeSudhir Kumar
A patient who has suffered ischemic stroke is at a higher risk of getting strokes in future. This is called recurrent stroke. The current presentation looks at the factors responsible for stroke recurrence, and discusses strategies to reduce the risk of stroke recurrence.
Stroke prevention for nonvalvular AF, summary of evidence-based guidelinesErsifa Fatimah
Ternyata... guideline yang ngebahas prevensi stroke pada nonvalvular AF tu banyak banget! Yang dirilis komunitas Neuro maupun Cardio, yang internasional maupun yang lokal. Dan pertanyaan besarnya tetep: What's the best strategy?
*Bonus special issue: manajemen prevensi stroke infark dengan antikoagulan pasca brain hemorrhage.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
Prevention of recurrent stroke in atrial fibrillation Jacek StaszewskiJacek Staszewski
Prevention of recurrent stroke in atrial fibrillation. Comaprison of NOAC vs VKA. Riks of hemorrhagic stroke. When anticoagulation should be initiated following acute stroke.
EVALUATING RISK OF HEART FAILURE WITH ERYTHROPOIETIN IN CHRONIC ANEMIAPARUL UNIVERSITY
Erythropoietin (EPO) is the primary regulatory hormone of
erythropoiesis. Hypoxia induces an increase in EPO hormone
production in the kidney which promotes the viability, proliferation,
and terminal differentiation of erythroid precursors, and causing an
increase in red blood cell mass. Any abnormality that reduces the renal
secretion of or bone marrow response to erythropoietin may result in
anemia. The approval of recombinant human erythropoietin
(epoetinalfa) by the US FDA in 1989, epoetinalfa and similar agents
now collectively known as erythropoietin stimulating agents (ESA)
have become the standard of care for the treatment of the
erythropoietin-deficient anemia. Studies suggest that in patients with
high serum erythropoietin is associated with risk of recurrent heart
failure (HF) and mortality. Thromboembolic complications can be
increased in patients receiving erythropoietin. the use of
erythropoiesis-stimulating agents though reduces the need for transfusions it is associated
with increased complications, including higher mortality and increased risk of
thromboembolic and cardiovascular events leading to congestive heart failure.
Evidence base for secondary prevention – Antihypertensive therapy in cerebrov...Apollo Hospitals
Antihypertensive therapy for preventing recurrence in survivors of stroke and transient ischemic attack patients requires much caution. Cutting the right balance between benefit and harm calls for the classical individual evidence based considerations. Current understanding to guide practices is briefly reviewed as stroke emerges as huge challenge with increasing longevity and chronic diseases.
Coronary heart disease is best addressed by a comprehensive approach aimed at halting atherosclerotic disease and reducing the risk of thrombosis. Unfortunately, our success in optimal risk factor modification in patients with stable CHD remains poor: only 41% of patients achieved all basic goals in the recent ISCHEMIA trial, with success rates likely even lower outside the rigorous clinical trial context. A greater focus on achieving prevention goals in patients with CHD will have a substantial impact on patient outcome and rates of hospitalization and more resources and incentives should be allocated for improved secondary prevention.
The ISCHEMIA trial suggests that even selected, high-risk patients with extensive ischemic burden do not benefit from revascularization barring unacceptable angina despite OMT. As ISCHEMIA excluded patients with unacceptable angina, advanced heart failure, and those with unprotected left main disease, our evaluation may be geared to identify such patients for consideration of revascularization alongside an initial strategy of OMT.
Atherosclerosis is a systemic disease of the arterial circulation, with focal areas of more severe manifestation. From an imaging standpoint, the paradigm of ischemia testing may have come to an end. Recent evidence from COURAGE, PROMISE, SCOT-HEART, and ISCHEMIA has demonstrated that functional testing for inducible myocardial ischemia is inferior to anatomic assessment for risk stratifying and managing patients with suspected or known CHD. Consistent with a large body of evidence, risk from CHD is mediated by the extent of atherosclerotic disease burden and not by the extent of inducible ischemia. Given that 55% of patients had nonobstructive CHD by CT in PROMISE, which was associated with 77% of cardiovascular deaths and myocardial infarctions at follow-up, there is immense opportunity to impact the disease at an earlier stage in a very large population of patients with occult CHD.
There is a Primary Prevent Indication in Diabetes | Mubashar A ChoudryMubashar A Choudry MD
Dr. Mubashar A Choudry, MD, is proud to serve patients at Washington Vascular Specialists, the first outpatient vascular treatment center in the mid-Atlantic region, with locations in Takoma Park, Largo, and Frederick, Maryland. He is a specialist in cardiology medical field.
Serum uric acid as a marker of left ventricular failure in acute myocardial i...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Addressing hypertension to reduce the burden of stroke 19 feb2018 (1)Sudhir Kumar
Hypertension is the commonest risk factor for stroke. Management of hypertension is important in ensuring best outcomes for stroke patients. Adequate control of bP is also important to prevent stroke recurrence. This presentation looks at the role of high BP in stroke occurrence and antihypertensive agents that can be used to achieve target BP.
carotid stenosis is a progressive gradual narrowing of carotid artery resulting in TIA and stroke. managemnet of this is challenging owing to various factors and different management options available to choose from.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...
Lipid and Stroke
1. Latest Update In Lipid
Management to Reduce
Stroke Incidence
TRI WAHYUDI
PERDOSSI CABANG BANTEN
2. Stroke
• Definition of CNS infarction: CNS infarction is brain, spinal cord, or
retinal cell death attributable to ischemia, based on pathological,
imaging, or other objective evidence of cerebral, spinal cord, or
retinal focal ischemic injury in a defined vascular distribution; or
clinical evidence of cerebral, spinal cord, or retinal focal ischemic
injury based on symptoms persisting ≥24 hours or until death, and
other etiologies excluded.
https://www.ahajournals.org/doi/epub/10.1161/STR.0b013e318296aeca
3. Indonesia is rank #7 worldwide in
terms of the highest death rate
caused by Stroke
WorldHealthRangking. Awailable from: http://www.worldlifeexpectancy.com/country-health-profile/indonesia (Cited Oct 2020)
3
IHME. Available from: http://www.healthdata.org/indonesia (Cited Oct 2020)
5. Definition of silent CNS infarction: Imaging or
neuropathological evidence of CNS infarction,
without a history of acute neurological
dysfunction attributable to the lesion.
https://www.ahajournals.org/doi/epub/10.1161/STR.0b013e318296aeca
7. Definition of stroke caused by intracerebral
hemorrhage: Rapidly developing clinical signs of neurological
dysfunction attributable to a focal collection of blood within the
brain parenchyma or ventricular system that is not caused by
trauma.
Definition of stroke caused by subarachnoid
hemorrhage: Rapidly developing signs of neurological
dysfunction and/or headache because of bleeding into the
subarachnoid space (the space between the arachnoid
membrane and the pia mater of the brain or spinal cord), which
is not caused by trauma.
https://www.ahajournals.org/doi/epub/10.1161/STR.0b013e318296aeca
NEW DEFINITION OF STROKE
8. Definition of stroke caused by cerebral venous
thrombosis: Infarction or hemorrhage in the brain, spinal cord, or
retina because of thrombosis of a cerebral venous structure.
Symptoms or signs caused by reversible edema without infarction
or hemorrhage do not qualify as stroke.
https://www.ahajournals.org/doi/epub/10.1161/STR.0b013e318296aeca
NEW DEFINITION OF STROKE
9. Statin
• Statins lower serum cholesterol level by inhibiting
hydroxymethylglutaryl-coenzymeA (HMG-CoA) reductase.
• Statins have been found to improve endothelial function,
modulate thrombogenesis, attenuate inflammatory and
oxidative stress damage, and facilitate angiogenesis far beyond
lowering cholesterol levels.
• Statins have also been proved to significantly decrease
cardiovascular risk and to improve clinical outcome.
Current Neuropharmacology, 2014, 12, 564-574
10.
11.
12.
13.
14.
15. Recommendations for pharmacological low-density lipoprotein cholesterol lowering
2019 ESC/EAS Guidelines for the management of dyslipidaemias:
lipid modification to reduce cardiovascular risk
Adapted from: Mach F, et al. European Heart Journal (2019) 00, 1-78
ESC = European Society of Cardiology; EAS = European Atherosclerosis Society; FH = familial
hypercholesterolaemia; LDL-C = low-density lipoprotein cholesterol; PCSK9 = Proprotein
convertase subtilisin/kexin type 9; ASCVD = atherosclerotic cardiovascular disease;
16. Secondary
ASCVD
Prevention
Diabetes
Mellitus in
Adults
Primary
Prevention
Severe
Hyperchole
sterolemia
Secondary ASCVD Prevention
Clinical atherosclerotic
cardiovascular disease (ASCVD)
includes acute coronary
syndrome (ACS), those with
history of myocardial infarction
(MI), stable or unstable angina or
coronary or other arterial
revascularization, stroke,
transient ischemic attack (TIA),
or peripheral artery disease
(PAD) including aortic aneurysm,
all of atherosclerotic origin.
Adapted from Grundy SM, et al. Circulation. 2019;139:e1082–e1143
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA
Guideline on the Management of Blood Cholesterol
17. Guidelines for the Early Management of Patients With Acute Ischemic
Stroke: 2019 Update to the 2018 Guidelines for the Early Management of
Acute Ischemic Stroke
Adapted from Powers WJ, et al. Stroke. 2019;50:e344–e418 AIS = Acute Ischemic Stroke; AHA = American Heart Association; ACC = American College of Cardiology; COR = Class of recommendation; LOE = Level of Evidence
18. Guidelines for the Early Management of Patients With Acute Ischemic
Stroke: 2019 Update to the 2018 Guidelines for the Early Management of
Acute Ischemic Stroke
Adapted from Powers WJ, et al. Stroke. 2019;50:e344–e418
*Clinical ASCVD includes acute coronary syndrome, those with history of Myocardial Infarction, stable or unstable angina, or coronary or other arterial revascularization, stroke, TIA (transient Ischemic
Attack), or peripheral artery disease, including aortic aneurysm, all of atherosclerotic origin.
ASCVD = atherosclerotic cardiovascular disease; COR = Class of recommendation; LOE = Level of Evidence; LDL-C = low-density lipoprotein cholesterol
19. BID = twice daily; FDA = US Food and Drug Administration; LDL-C = low-density lipoprotein cholesterol; RCT = randomized controlled trial
Adapted from Grundy SM, et al. Circulation. 2019;139:e1082–e1143
20. Conclusions
Evidence strongly suggests that statins are associated
with a reduction in the absolute risk of ischemic
strokes and cardiovascular events. Differences in
effects among statins were modest, signaling potential
therapeutic equivalence.
22. SPARCL: High-intensity atorvastatin for reduction of CV events in
high-risk patients with previous stroke/TIA
Primary Hypothesis:
Treatment with 80 mg of Atorvastatin per day would reduce the risk of fatal or nonfatal
stroke among patients with history of stroke or TIA
Patient Population
Enrolled at 205 sites worldwide
from Sept 1998 to March 2001
Men and women with
previously documented stroke
or TIA (1 to 6 months before
study)
A Modified Rankin Score of ≤3
LDL-C levels 100 to 190 mg/dL
No known CHD
4731
Patients
Atorvastatin 80 mg/day
Placebo
Follow up visit 1,3,6 months after
enrollment and every 6 months thereafter
Median follow-up 4.9 years (4.0 to 6.6 years)
Amarenco P, et al. N Engl J Med 2006;355:549-559
SPARCL = Stroke Prevention by Aggressive Reduction in Cholesterol Levels; CV = Cardiovascular;
TIA = transient Ischemic Attack; LDL-C = low-density lipoprotein cholesterol; CHD = Coronary Heart Disease
23. SPARCL: Safety of high-intensity atorvastatin in high-risk
patients with prior stroke/TIA
1. Amarenco P, et al. N Engl J Med 2006;355:549-559
2. Huisa BN, et al. Vascular Health and Risk Management 2010;6:229-36
• In SPARCL, the overall incidence of hemorrhagic stroke was low (1.8%)2
• While mortality from hemorrhagic stroke was similar (17 in the atorvastatin vs 18 patients in the placebo group) there
was a statistically significant difference between the two groups (2.3% in the atorvastatin vs 1.4% in the placebo group;
P = 0.01)2
Patients, n/N (%) Placebo Atorvastatin 80 mg
Musculoskeletal AEs
Myalgia 141/2366 (6.0) 129/2365 (5.5)
Myopathy 7/2366 (0.3) 7/2365 (0.3)
Rhabdomyolysis 3/2366 (0.1) 2/2365 (0.1)
ALT or AST >3 × ULN* 11/2366 (0.5) 51/2365 (2.2)†
CK >10 × ULN* 0/2366 (0.0) 2/2365 (0.1)
*At 2 consecutive measurements
† There were no cases of liver failure in the study
SPARCL = Stroke Prevention by Aggressive Reduction in Cholesterol Levels; TIA = Transient Ischemic Attack; AE = Adverse Events;
ALT, alanine transaminase; AST, aspartate transaminase; CK, creatine kinase; ULN, upper limit of normal
24.
25. Hemorrhagic stroke was more frequently found in
patients treated with atorvastatin, especially in those
with a hemorrhagic stroke as an entry event, in men,
and in elderly patients.[92] A recent meta-analysis of
randomized controlled trials have found that high-
dose statin therapy is associated with a high risk of
ICH in patients with cardiovascular diseases.[97]
High Intensity statin and stroke hemorrhagic
https://www.neurologyindia.com/article.asp?issn=00283886;year=2019;volume=67;issue=4;spage=983;epage=992;aulast=Zhao
26. • increased risk of ICH with statin use in ischemic
patients treated with thrombolysis.
• Meier et al. found that prior statin use is
associated with a high incidence of ICH in
patients with ischemic stroke who received
intra-arterial thrombolysis.[98]
• High dose of statin use is associated with a high
incidence of symptomatic ICH in patents with
ischemic stroke after intravenous
thrombolysis.[99]
High Intensity statin and stroke hemorrhagic
https://www.neurologyindia.com/article.asp?issn=00283886;year=2019;volume=67;issue=4;spage=983;epage=992;aulast=Zhao
27. High Intensity statin and stroke hemorrhagic
• The favorable outcome of prior statin use in ICH patients was further confirmed
by a meta-analysis showing that prior statin use was associated with good
outcome and reduced mortality after ICH.[115]
• In a retrospective analysis of 190 ICH patients exposed to statin and 236 statin-
free ICH patients, statin use at the onset of ICH or during the acute hospitalization
(within 72 h after ICH) is associated with reduced mortality and disability in-
hospital and at 12 months after ICH.[116]
• Furthermore, in a meta-analysis of 3455 ICH patients exposed to statin and 11821
ICH patients not exposed to satin, continuing statin use after ICH onset is
associated with an improved outcome in ICH patients.[1
https://www.neurologyindia.com/article.asp?issn=00283886;year=2019;volume=67;issue=4;spage=983;epage=992;aulast=Zhao
28. Conclusion: Aspirin combined with atorvastatin has
synergistic effects in the treatment of ischemic stroke. It
has significant effects on regulating lipids, improving
atherosclerotic plaque, and improving quality of
life. It is also safe and worthy of clinical application.
29. Conclusion: In primary hypercholesterolemia, atorvastatin 10
mg was more effective and nonequivalent to simvastatin 20 mg
and significantly more effective than simvastatin 10 mg for
reducing LDL cholesterol levels.
30. Conclusion : Atorvastatin 10 mg or simvastatin 20 mg after six weeks
therapy produce similar result in reducing lipid profiles (total cholesterol,
LDL-C, and triglyceride). Atorvastatin decreases the inflammation
marker Hs-CRP serums better than simvastatin.
31. Poly TN, et al. Neuroepidemiology 2020;54:214-226
• The overall pooled reduction of
Alzheimer disease in patients
with statin use was RR 0.69
(95% CI 0.60–0.80, p < 0.0001)
• The overall pooled RR of
statin use and vascular
dementia risk was RR 0.93
(95% CI 0.74–1.16, p = 0.54).
• The use of statin is
significantly associated with a
decreased risk of dementia.
a Statin use and AD risk. b Statin use and VaD risk
Association between Use of Statin and Risk of Dementia: A Meta-Analysis of
Observational Studies
30 observational studies from January 2000 to March 2018 including 9,162,509 participants
Adapted from: Poly TN, et al. Neuroepidemiology 2020;54:214-226
CI = Confidence Interval; RR = Risk Ratio
32. Adapted from: Poly TN, et al. Neuroepidemiology 2020;54:214-226
Possible biological effects of decreasing dementia risk by statins
HMG-CoA = β-Hydroxy β-methylglutaryl-CoA; LDL = low-density lipoprotein
33. Atorvastatin: Proven safety profile across the dose range
Adverse events, %
Atorvastatin 10 mg
(n=7,258)
Atorvastatin 80 mg
(n=4,798)
Placebo
(n=2,180)
Withdrawals due to
treatment-related adverse events
2.4 1.8 1.2
Serious treatment-related
nonfatal adverse events
0.2 0.5 4.2
Musculoskeletal 2.3 2.7 1.2
Treatment-related myalgia 1.4 1.5 0.7
Persistent ALT or AST >3 × ULN* 0.11 0.6 0.17
Persistent CPK >10 × ULN* 0 0.06 0
Rhabdomyolysis 0 0 0
Albuminuria 0.11 0.04 0
Hematuria 0.33 0.31 0.14
Data from a pooled analysis involving 14,236 patients from 49 trials
ALT = alanine transaminase; AST = aspartate transaminase; CPK = creatinine phosphokinase; ULN = upper limit of normal
*Based on the number of patients with laboratory measurements
Newman C, et al. Am J Cardiol 2006;97;61–67
34. Conclusion
• Indonesia is facing a high burden of cardiovascular disease & stroke. Control of
modifiable risk factors, such as dyslipidemia, is important in management of this
condition1,2
• Major guidelines recommend the use of high intensity statin in very-high risk patient
groups, such as those with stroke or TIA3
• High intensity statin (Atorvastatin 80 mg) is proven to reduce first and subsequent
vascular events across vascular territories (cerebrovascular, coronary, peripheral), in
post stroke / TIA patients4
• Use of statins is associated with neutral effect on risk of intracerebral hemorrhage in
persons without prior ischemic stroke.5
• The use of statin is significantly associated with a decreased risk of dementia6
1. IHME. Available from: http://www.healthdata.org/indonesia (Cited Oct 2020)
2. Amarenco P, Labreuche J. Lancet Neurol. 2009; 8:453-63
3. Mach F, et al. European Heart Journal (2019) 00, 1-78
4. Szarek M, et al. J Am Coll Cardiol 2020;75:2110–8
5. Lee M, et al. J Am Heart Assoc 2017;6e00568
6. Poly TN, et al. Neuroepidemiology 2020;54:214-226
