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RCT: Thrombectomy improves outcomes in acute stroke with large infarcts – N Engl J Med

25 May, 2024 | 19:35h | UTC

Study Design and Population: This randomized clinical trial investigated the efficacy of thrombectomy in combination with standard medical care versus medical care alone in patients with acute stroke and large infarcts. Participants included 333 patients with proximal cerebral vessel occlusion in the anterior circulation, presenting within 6.5 hours of symptom onset. They were randomized in a 1:1 ratio to either undergo thrombectomy or receive only medical care. An Alberta Stroke Program Early Computed Tomographic Score of ≤5 was used to define large infarcts.

Main Findings: The primary outcome, assessed by the modified Rankin scale score at 90 days, showed a median score of 4 in the thrombectomy group compared to 6 in the control group, indicating better functional outcomes with thrombectomy (generalized odds ratio, 1.63; 95% CI, 1.29 to 2.06; P<0.001). Mortality at 90 days was significantly lower in the thrombectomy group (36.1%) compared to the control group (55.5%) with an adjusted relative risk of 0.65. However, thrombectomy was associated with a higher rate of symptomatic intracerebral hemorrhage (9.6% vs. 5.7% in the control group).

Implications for Practice: The findings suggest that thrombectomy, when added to standard medical care, can significantly improve functional outcomes and reduce mortality in patients with large infarct strokes. However, the increased risk of symptomatic intracerebral hemorrhage must be considered when deciding on this intervention. These results support the broader use of thrombectomy in clinical settings with similar patient profiles but underscore the need for careful risk-benefit analysis due to the potential for serious hemorrhagic complications.

Reference (link to abstract – $ for full-text):

Costalat, V. et al. (2024). Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size. N Engl J Med, 390(18), 1677-1689. DOI: 10.1056/NEJMoa2314063

New ACC/AHA Guidelines for the Management of Lower Extremity Peripheral Artery Disease

16 May, 2024 | 11:05h | UTC

Introduction

The 2024 ACC/AHA guidelines, along with several associated societies, highlight the significance of peripheral artery disease (PAD) as a major public health issue, often underestimated, and linked to high risks of amputation and serious cardiovascular events. This document is crucial for clinicians seeking to optimize treatment and improve the quality of life for affected patients.

Key Points

1 – Risk Assessment: It is crucial to evaluate risks associated with PAD and health disparities that may impact treatment outcomes.

2 – Diagnosis: Diagnosis of PAD typically involves physical examination, medical history, and the resting ankle-brachial index.

3 – Medical Therapy: Management includes antiplatelet therapy (usually single), high-intensity statins, antihypertensive therapy, diabetes management, and smoking cessation. Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg) has proven effective and can be included in the therapy for patients at low risk of bleeding.

4 – Structured Exercise: A central component of care, including supervised exercise therapy and community-based programs.

5 – Revascularization: Indicated to prevent limb loss in chronic limb-threatening ischemia and can improve quality of life in cases of claudication.

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