The European Stroke Conference returned to Stockholm for its 18th meeting, 15 years after it first came to the Swedish capital. Meeting chair Bo Norrving remarked that these days there is a distinctly international flavour to the meeting, with representatives from 85 countries, including the first non-European winner of the Johann Jacob Wepfer award in the form of American JP Mohr. Mohr, a lover of French cars and bow ties, reflected on the achievements of the past 50 years in the field of stroke research and clinical practice, starting with the days when it was considered such an intractable condition that it was ├óÔé¼┼ødiagnose and adios├óÔé¼┼Ñ. Nevertheless, despite all the progress, the ├óÔé¼┼øholy grail: stroke monotherapy├óÔé¼┼Ñ was still proving to be elusive, he said.
Results of several large trials were presented at ESC 2009.
C Torp-Pedersen (Denmark) presented a post-hoc analysis of the ATHENA atrial fibrillation trial, specifically investigating the effects of dronedarone versus placebo on stroke. No previous antiarrhythmic agent has shown any impact on this outcome. More than 60% of the 4628 patients enrolled in ATHENA had at least two risk factors for stroke. Dronedarone reduced the risk of stroke from 1.8% to 1.2% per year (a 34% decrease).
Torp-Pedersen C, Connolly SJ, Crijns HJGM, van Eickels M, Gaudin C, Page RL, Hohnloser SH. The Effect of Dronedarone on Stroke in Patients with Atrial Fibrillation: Results of Athena. Cerebrovasc Dis 2009;27(suppl 6):1-241.
The most eagerly awaited results were presented by MM Brown (UK) and concerned the safety aspects of the ICSS trial of carotid stenting (CAS) versus endarterectomy (CEA). The multicentre trial of 1713 patients used a wide variety of approved stents, with or without protection devices, compared to surgery, with strict criteria for experts participating. The rates of stroke, myocardial infarction (MI) and death within 30 days were examined. For both intention to treat (ITT) and per protocol (PP) analyses, the primary outcome was roughly twice as common following CAS than CEA. ├óÔé¼┼øStroke or death├óÔé¼┼Ñ was 72 cases (8.5%) with CAS compared to 39 cases (4.6%) with CEA (p=0.001); the difference was largely accounted for by a large number of non-disabling strokes, said Brown. He concluded that there is ├óÔé¼┼østrong evidence├óÔé¼┼Ñ that CEA is the safer procedure; efficacy and sub-analyses (eg of the impact of protection) are yet to be published.
Brown MM, Ederle J, Bonati LH, Featherstone RJ, Dobson J. Safety Results of the International Carotid Stenting Study (ICSS): Early Outcome of Patients Randomised Between Carotid Stenting and Edarterectomy for Symptomatic Carotid Stenosis. Cerebrovasc Dis 2009;27(suppl 6):1-241.
The final presentation was on the effect of thigh-length stockings on risk of deep vein thombosis (DVT) in acute stroke patients (CLOTS1 trial), from M Dennis (UK). There are many national guidelines from all around the world that extrapolate on the benefits of stockings for stroke patients, but very little evidence. CLOTS1 aimed to conclusively determine their impact on symptomatic or asymptomatic DVT after a stroke. 2518 patients were enrolled. Overall there was only a 0.5% different in the rate of DVT between the two groups (stockings and no stockings), which was not significant. In fact there was very little evidence that the stockings had any impact at all on any sort of DVT or PE. The only difference was a significant increase in the number of skin lesions and leg ulcers in the stocking-wearers, although this assessment was not a blinded one, Dennis cautioned. It may seem frivolous, but the issue of stockings is highly important as it concerns primary care involving all members of the stroke care team, from patients and nurses to doctors and surgeons. If the results of CLOT1 and the 2 follow-up trials influence national guidelines and removes the need for compression stockings, Dennis estimated that around 320 hours of nursing time would be saved.
Dennis M. The CLOTS Trial: The Effect of Thigh-length Graduated Compression Stockings (GCS) on Risk of Proximal Deep Vein Thrombosis (DVT) in Acute Stroke Patients. Cerebrovasc Dis 2009;27(suppl 6):1-241.
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