ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
Blood Pressure Targets 2017.Still Struggling for the Right Answermagdy elmasry
Blood Pressure Targets 2017.Guidelines For Hypertension 2011-2015.Does SPRINT change our approach to BP targets?
SPRINT vs. ACCORD.Updated Hypertension Guidelines Released by ACP, AAFP
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Blood Pressure Targets 2017.Still Struggling for the Right Answermagdy elmasry
Blood Pressure Targets 2017.Guidelines For Hypertension 2011-2015.Does SPRINT change our approach to BP targets?
SPRINT vs. ACCORD.Updated Hypertension Guidelines Released by ACP, AAFP
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
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.
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.
Instability and rupture of atherosclerotic plaques result in acute coronary syndrome.
LDL-C is usually related to ASCVD.
Statin medications are first-line therapy for LDL-C lowering Post ACS.
Rosuvastatin 20mg and 40 mg significantly increase HDL-C levels compared with Atorvastatin 80 mg
Diabetic Peripheral Neuropathy and Vitamin B12 IssueUsama Ragab
Diabetic Peripheral Neuropathy and Vitamin B12 Issue
By Dr. Usama Ragab Youssif
Diabetic neuropathies are the most prevalent chronic complications of diabetes
Central and Peripheral Precocious PubertyUsama Ragab
Precocious Puberty
By Dr. Usama Ragab Youssif
Precocious puberty (PP) is defined as the development of pubertal changes (2ry sexual characters), at an age younger than the accepted lower limits for age of onset of puberty.
Algorithms for Diabetes Management for StudentsUsama Ragab
Algorithms for Diabetes Management for Students
By Usama Ragab Youssif
Lecturer of Medicine - Zagazig University
Agenda
Type 2 Diabetes 101
Incretin based therapy
Algorithms of management
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Classification & Diagnosis of Diabetes.pptx
By Dr. Usama Ragab Youssif
Lecturer of Internal Medicine Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Renal System - History Taking
By Dr. Usama Ragab Youssif
Lecturer of Medicine, Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Clinical Endocrinology Round
By Dr. Usama Ragab Youssif
Lecturer of Medicine
Zagazig University
Acromegaly
Cushing
Diabetes
Thyroid
Addison
Techniques and clinical insights
Functional Bowel Disorders
By Dr. Usama Ragab
Esophageal Disorders
Gastroduodenal Disorders
Bowel disorders
Centrally Mediated Disorders of GI Pain
Gallbladder and Sphincter of Oddi Disorders
Anorectal disorders
Childhood Functional GI Disorders: Neonate/Toddler
Childhood Functional GI Disorders: Child/Adolescent
Heat, Cold and High Altitude Related illnessUsama Ragab
Heat, Cold and High Altitude Related illness
By Dr Usama Ragab
Lecturer of Medicine
Topics are heat and cold related illness and high altitude medical disorders
Imeglimin, What is new?
By Dr. Usama Ragab Youssif
Lecturer of Medicine - Zagazig University
Agenda
Mitochondrial function and dysfunction
Mitochondrial (dys)function in diabetes
Diabetes core defects and Imeglimin
Imeglimin drug development and approval
Imeglimin and Heart
Diabetes and Gut interplay
By Dr. Usama Ragab Youssif
In Gastro Canal Association Annual Conference
Agenda
Diabetes as the main player
Gut as the main player
Diabetes and gut in a separate game
Gut as game changer
Tips and tricks: diabetes drugs
Guidelines in Obesity management
By Dr. Usama Ragab Youssif
Obesity-related counseling should be offered to those with BMI ≥25 kg/m2
A 3% to 5% weight loss can result in meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes
Set an initial weight loss goal of 5% to 10% of current body weight over 6 mo
After 6 mo, focus on weight maintenance before attempting further weight loss
Participating in a weight loss program long-term can help improve weight maintenance
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
Insulin Lispro Revisited
By Dr. Usama Ragab Youssif
The discovery of insulin was one of the most dramatic and important milestones in medicine - a Nobel Prize-winning moment in science.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
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2. Agenda
• Hypertension and dyslipidemia impact on stoke
development and prevention
• SPRINT and HOPE-3
• ASA/AHA 2014 guidelines for the Primary Prevention of
Stroke
3. Epidemiology
• Globally, about 17
million strokes occur
every year and stroke is
the second leading
cause of death after
coronary heart disease,
and the third most
common cause of
disability.
1- Krishnamurthi RV: Lancet Glob Health. 2013;1(5):e259.
Figure: http://www.who.int/mediacentre/factsheets/fs310/en/
4.
5. Polypill concept
BMJ. 2003 Jun 28; 326(7404): 1419.
• The Polypill strategy could largely prevent heart attacks and stroke if
taken by everyone aged 55 and older and everyone with existing
cardiovascular disease.
Simvastatin , hydrochlorothiazide, atenolol,
enalapril, folic acid, and aspirin
9. Risk factors for stroke (cont.)
TIA is a risk factor for future stroke
SC Johnston et al: Validation and refinement of score to predict very early stroke risk after transient ischaemic attack.
Lancet 369:283, 2007.
10. Risk factors for stroke (cont.)
Heart disease — Heart
disease, including atrial
fibrillation, valvular disease,
recent myocardial infarction,
and endocarditis, increases
the probability of a stroke
due to embolism. Of these,
atrial fibrillation is the most
prominent, causing nearly
half of all cardioembolic
strokes.
Wolf et al. 1991. Stroke. 1991; 22: 983-988
11. Risk factors for stroke (cont.)
Hypertension — Hypertension is an
important stroke risk factor, including
isolated systolic hypertension.
Epidemiologic studies show that
there is a gradually increasing
incidence of both coronary disease
and stroke as the blood pressure
rises above 110/75 mmHg. Both
prior blood pressure and current
blood pressure are important risk
factors (for both ischemic and
hemorrhagic stroke).
Data from Prospective Studies Collaboration, Lancet 2002; 360:1903.
12. Risk factors for stroke (cont.)
JAMA. 2002;287(8):1003-1010.
10 years 15 years 20 years 25 years
Men 56% 78% 88% 93%
Women 52% 72% 83% 91%
0%
20%
40%
60%
80%
100%
%
Residual lifetime risk for developing
hypertension
16. Physical inactivity
Stroke. 2014;45:3754–3832.
• Physical activity is recommended because it is
associated with a reduction in the risk of stroke (Class I;
Level of Evidence B).
• Healthy adults should perform at least moderate- to
vigorous-intensity aerobic physical activity at least 40
min/d 3 to 4 d/wk (Class I; Level of Evidence B).
17. Diet
Stroke. 2014;45:3754–3832.
• Reduced intake of sodium and increased intake of potassium as
indicated in the US Dietary Guidelines for Americans are
recommended to lower BP (Class I; Level of Evidence A).
• A DASH-style diet, which emphasizes fruits, vegetables, and low-fat
dairy products and reduced saturated fat, is recommended to lower
BP (Class I; Level of Evidence A).
• A Mediterranean diet supplemented with nuts may be considered in
lowering the risk of stroke (Class IIa; Level of Evidence B).
20. Dyslipidemia
Stroke. 2014;45:3754–3832.
• In addition to therapeutic lifestyle changes, treatment
with an HMG coenzyme-A reductase inhibitor (statin)
medication is recommended for the primary prevention
of ischemic stroke in patients estimated to have a high
10-year risk for cardiovascular events as recommended
in the 2013 “ACC/AHA Guideline on the Treatment of
Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults” (Class I; Level of
Evidence A).
23. ASCOT LLA Secondary End Point: Fatal
and Nonfatal Stroke
23Sever PS et al. Lancet. 2003;361:1149-1158.
27% relative risk
reduction
HR = 0.73 (0.56 – 0.96) P = .0236
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
0
1
2
3
Years
CumulativeIncidence,%
Atorvastatin 10 mg
Placebo
Number of Events 89
Number of Events 121
24. The HOPE-3 Trial
Argentina, Australia, Brazil, Canada, China, Colombia, Czech
Republic, Ecuador, Hungary, India, Israel, Korea, Malaysia,
Netherlands, Philippines, Russia, Slovakia, South Africa, Sweden,
United Kingdom, Ukraine
Global Trial: 228 centers in 21 countries
25. Intermediate-Risk Population
Inclusion Criteria (Target Risk 1.0%/yr)
Women ≥ 60 yrs, men ≥ 55 yrs with at least one additional
Risk Factor
• Increased WHR • Dysglycemia
• Smoking • Mild renal dysfunction
• Low HDL • Family history of CHD
Exclusion Criteria:
CVD or indication(s) or contraindication(s) to study drugs
No strict BP or LDL-C criteria for entry
Uncertainty principle
26. Rosuvastatin
Cand+HCTZ
n = 3,180
HOPE-3:
2 by 2 Factorial Design
14,682 Entered Single-blind 4 week Active Run-in
12,705 (87%) Randomized
Rosuvastatin
10 mg
n=6,361
Candesartan 16 mg +
HCTZ 12.5 mg
n= 6,356
Placebo
n = 6,349
Rosuvastatin
n = 3,181
Placebo
n = 6,344
Cand+HCTZ
n = 3,176
Double Placebo
n = 3,168
Simple follow-up and few blood tests
Median follow up = 5.6 years
31. Hypertension
Stroke. 2014;45:3754–3832.
• Annual screening for high BP and health-
promoting lifestyle modification are
recommended for patients with prehypertension
(SBP of 120 to 139 mmHg or DBP of 80 to 89
mmHg) (Class I; Level of Evidence A).
• Patients who have hypertension should be
treated with antihypertensive drugs to a target
BP of <140/90 mm Hg (Class I; Level of
Evidence A).
34. SPRINT trial
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
9361 persons was randomly assigned were at least 50 years old with a
systolic blood pressure of 130 mm Hg or higher (180 mmHg) and an
increased cardiovascular risk, but without diabetes, to a systolic blood-
pressure target of less than 120 mm Hg (intensive treatment) or a target of
less than 140 mm Hg (standard treatment).
35. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
All participants had at least 1 other significant cardiovascular
risk factor, including chronic kidney disease; age 75 years or
older; a previous cardiovascular event (except stroke); or an
elevated cardiovascular risk based on their Framingham risk
score.
36. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
The primary composite outcome was myocardial infarction,
other acute coronary syndromes, stroke, heart failure, or death
from cardiovascular causes. (Funded by the National Institutes
of Health; ClinicalTrials.gov
37.
38. The intervention was stopped early after a median
follow-up of 3.26 years in stead of December
2018 which was the Estimated Study Completion
Date1
1- ClinicalTrials.gov. Systolic Blood Pressure Intervention Trial (SPRINT).
https://clinicaltrials.gov/ct2/show/NCT01206062?term=Systolic+Blood+Pressure+Intervention+Trial&rank=1. Accessed November 9,
2015.
42. SPRINT trial (cont.)
The SPRINT Research Group N Engl J Med 2015; 373:2103-2116
Rates of serious adverse events of hypotension,
syncope, electrolyte abnormalities, and acute
kidney injury or failure, but not of injurious falls,
were higher in the intensive-treatment group than in
the standard-treatment group.
43. SPRINT trial (cont.)
Dr Marc Pfeffer (Harvard Medical School, Boston, MA)
CAUTIONS AS REGARD STUDY
A lot of effort is required to hit this target, including initial combination therapy
and frequent office visits “marathon effort”.
Excluding diabetics is "a black hole" in the study and limits its applicability.
Only approximately half of adults achieve a blood pressure of 140 mm Hg or
less, as consistent with current recommendations.
“Physicians "shouldn't expect a 'thank you' from patients
when you add another pill to reduce their blood pressure.“1
49. BP Lowering vs. Placebo
N Engl J Med 2016;374:2009-20
• Learnt lessons from hypertension arm:
I. Blood pressure lowering doesn’t affect
CVD outcome in normtensive individuals
II. Blood pressure lowering affect CVD
outcome in hypertensive individuals
51. Obesity
Stroke. 2014;45:3754–3832.
• Among overweight (BMI=25 to 29 kg/m2) and obese
(BMI >30 kg/m2) individuals, weight reduction is
recommended for lowering BP (Class I; Level of
Evidence A).
• Among overweight (BMI=25 to 29 kg/m2) and obese
(BMI >30 kg/m2) individuals, weight reduction is
recommended for reducing the risk of stroke (Class I;
Level of Evidence B).
56. Obesity Paradox (cont.)
Neurology 2016;87:1–2
BMI is a crude measure of obesity and does not take into account fitness,
nutritional status, or body fat distribution.
57. Diabetes mellitus
Stroke. 2014;45:3754–3832.
• Control of BP in accordance with an AHA/ACC/CDC
Advisory to a target of <140/90 mmHg is recommended
in patients with type 1 or type 2 diabetes mellitus (Class
I; Level of Evidence A).
• The usefulness of aspirin for primary stroke prevention
for patients with diabetes mellitus but low 10-year risk of
CVD is unclear (Class IIb; Level of Evidence B).
66. Primary Prevention (cont.)
HAS BLED score
HAS-BLED categorizes those into low (score 0-2) or high (≥3) risk, where the
latter can be identified for more regular review and follow-up.
67. Primary Prevention (cont.)
SAMe-TT2R2 Score
b= Two of the following: hypertension, diabetes mellitus, coronary artery disease
or myocardial infarctions, peripheral artery disease, congestive heart failure,
previous stroke, pulmonary disease, or hepatic or renal disease.
68. Atrial fibrillation(cont.)
SAMe-TT2R2 Score
The SAMe-TT2R2 score is proposed as a means to help with decision making,
to identify those newly diagnosed nonanticoagulated AF patients who have a
probability of doing well while taking a vitamin K antagonist (VKA) (with SAMe-
TT 2R2 score, 0-2) and achieve a time in therapeutic range (TTR) of at least
65% or 70%.
In contrast, a SAMe-TT2R2 score of more than 2 suggests that such patients
are unlikely to achieve a good TTR while taking a VKA, and a non-VKA oral
anticoagulant should be used upfront, without a “trial of warfarin” period.
69. Phase III RE-LY®: time to first stroke or systemic embolism
BID = twice daily; NI = non-inferiority; RR = relative risk; RRR = relative risk reduction; Sup = superiority
Years
0.0 0.5 1.0 1.5 2.0 2.5
0.01
0.02
0.03
0.05
0.04
Cumulativehazardrates
0.00
Warfarin
Dabigatran 110 mg BID
Dabigatran 150 mg BID
RR 0.90
(95% CI: 0.74–1.10)
P<0.001 (NI)
P=0.30 (Sup)
RR 0.65
(95% CI: 0.52–0.81)
P<0.001 (NI)
P<0.001 (Sup)
RRR
35%
Disclaimer: Dabigatran etexilate is not approved for clinical use in stroke prevention in atrial fibrillation outside the US and Canada.
This information is provided for medical education purposes only.
Please be aware that there may be national differences between countries regarding specific medical information,
including licensed uses, so please check local prescribing information for further details.
Connolly SJ et al. N Engl J Med 2010;363:1875–6
70. Phase III RE-LY®: haemorrhagic stroke
Connolly SJ et al. N Engl J Med 2009;361:1139–51; Connolly SJ et al. N Engl J Med 2010;363:1875–6
BID = twice daily; RR = relative risk; RRR = relative risk reduction; Sup = superiority
Haemorrhagicstroke(no.ofevents)
n: 6015 6076 6022
Dabigatran
110 mg BID
Dabigatran
150 mg BID
Warfarin
0
10
20
30
40
50
14
0.12% 12
0.10%
45
0.38%
RR 0.31 (95% CI: 0.17–0.56)
P<0.001 (Sup)
RR 0.26 (95% CI: 0.14–0.49)
P<0.001 (Sup)
RRR
69%
RRR
74%
Disclaimer: Dabigatran etexilate is not approved for clinical use in stroke prevention in atrial fibrillation outside the US and Canada.
This information is provided for medical education purposes only.
Please be aware that there may be national differences between countries regarding specific medical information,
including licensed uses, so please check local prescribing information for further details.
71. Phase III AVERROES: stroke or systemic
embolic event
Connolly SJ et al. Presented at ESC 2010; session number 708005-708006.
Available at: http://www.escardio.org/congresses/esc-2010/congress-
reports/Pages/708-3-AVERROES.aspx [Accessed September 2010]
RR = relative risk; CI = confidence interval
Cumulativerisk
0.02
0.04
0.05
0.06
0.07
0
0.01
0.03
0
Months
3 6 9 12 18 21
2791 2720 2541 2124 1541 626 329
2809 2761 2587 2127 1523 617 352
Aspirin
Apixaban
RR 0.46
95% CI: 0.33–0.64
P<0.001
Aspirin
Apixaban
72. Other Cardiac conditions
Stroke. 2014;45:3754–3832.
• Anticoagulation is indicated in patients with mitral
stenosis and a prior embolic event, even in sinus rhythm
(Class I; Level of Evidence B).
• Vitamin K antagonist therapy is reasonable for
patients with STEMI and asymptomatic left ventricular
mural thrombi (Class IIa; Level of Evidence C).
• Anticoagulant therapy may be considered for
patients with STEMI and anterior apical akinesis or
dyskinesis (Class IIb; Level of Evidence C).
73. Asymptomatic Carotid stenosis
Stroke. 2014;45:3754–3832.
• It is reasonable to repeat duplex ultrasonography annually to assess
the progression or regression of disease and response to therapeutic
interventions in patients with atherosclerotic stenosis >50% (Class
IIa; Level of Evidence C).
• Patients with asymptomatic carotid stenosis should be prescribed
daily aspirin and a statin. (Class I; Level of Evidence C).
• It is reasonable to consider performing CEA in asymptomatic patients
who have >70% stenosis of the internal carotid artery if the risk of
perioperative stroke, MI, and death is low (<3%). However, its
effectiveness compared with contemporary best medical management
alone is not well established (Class IIa; Level of Evidence A).
74. Aspirin for primary prevention
Stroke. 2014;45:3754–3832.
• The use of aspirin for cardiovascular (including but not specific to
stroke) prophylaxis is reasonable for people whose risk is sufficiently
high (10-y risk >10%) for the benefits to outweigh the risks
associated with treatment.
(Class IIa; Level of Evidence A).
• Aspirin is not useful for preventing a first stroke in low-risk
individuals (Class III; Level of Evidence A).
• Aspirin is not useful for preventing a first stroke in people with
diabetes mellitus in the absence of other high-risk conditions (Class
III; Level of Evidence A).
78. Combination vs Double Placebo:
Change in SBP and LDL-C
0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
120125130135140
Week 6
Combination
Cand + HTCZ
Rosuva
Double placebo
SBP
Month 6
0 Year 1 Year 3 Study End
8090100120140
Combination
Rosuva
Cand + HCTZ
Double placebo
LDL-C
Combination
Rosuva.
Double Placebo
Cand+HCTZ
Mean Δ 6.2 mmHg
Mean Δ 33.7 mg/dl
82. Combination vs
Double Placebo: Safety
Combination
N=3,180
N (%)
Double Placebo
N=3,168
N (%)
Permanent Discontinuation of Both 697 (21.9) 757 (23.9)
Rhabdomyolysis/Myopathy of Rosuva 1 (0) 1 (0)
Muscle pain/ weakness 196 (6.2) 131 (4.1)
Lightheadedness (BP Only) 48 (1.5) 40 (1.3)
Renal Dysfunction/Potassium Abn. 6 (0.2) 6 (0.2)
New Diabetes 123 (4.1) 113 (3.8)
Cataract Surgery 84 (2.8) 88 (2.9)
83. Combination vs
Double Placebo: Conclusions
• About a 30% reduction in major vascular
events
• Benefits of combination therapy:
– Largely seen in those in the upper third of
SBP (40% RRR in CVD)
– In lower two thirds the benefit is from
Rosuvastatin only (30% RRR in CVD)
84. Clinical Implications
• Statins beneficial in all participants
• BP lowering benefits only those with elevated BP
• Combination therapy:
– In hypertensives, leads to a 40% risk reduction
(benefits from both BP lowering and statin)
– In others, 30% RRR from statin alone
85.
86.
87. Franklin D. Roosevelt
President of US from 1933 until his death
in 1945
Died: April 12, 1945 (aged 63)
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
88. Howard G. Bruenn, "Clinical Notes On The Illness and Death of President Franklin D. Roosevelt," Ann. of Int. Med. 72 (1970): 579–59.
Franklin Delano Roosevelt:
represents a unique and superb
example of the natural history of
untreated hypertension and the
complications that can arise if left
untreated.
Dr Bruenn reported the President's
last words: "I have a terrific
headache.“
Of notable FDR had suffered also
from severe anemia (Hb: 4.5 gm%),
proteinuria 4+ and cholelithiasis!!!
89. Risk factors for stroke (cont.)
Bishop T, Figueredo VM. Hypertensive therapy: attacking the renin-angiotensin system. Western Journal of Medicine. 2001;175(2):119-124.
90. Joseph Stalin
The leader of the Soviet Union from the
mid-1920s until his death in 1953
Died: 5 March 1953 (aged 74)
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
91. Sir Winston Churchill
Prime Minister of the United Kingdom from
1940 to 1945 and again from 1951 to 1955
Died: 24 January 1965 (aged 90)
Famous People Who Died of Stroke
http://www.ranker.com/list/famous-people-who-died-of-stroke/reference
92.
93. Overall Bottom Line
Remember
• Prevention of risk is better than treating it.
• Exercise a lot.
• Stop smoking even before you start it.
• Lipid and BP leads to harmful consequences treat them
first.