Effect of pre-stroke use of ACE inhibitors on ischemic stroke severity

Magdy Selim 1 Sean Savitz 1 Italo Linfante 0 Louis Caplan 1 Gottfried Schlaug 1 0 Interventional Neuroradiology, Jackson Memorial Hospital , Miami , USA 1 Department of Neurology, Beth Israel DeaconessMedical Center , Boston , USA Background: Recent trials suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in prevention of ischemic stroke, as measured by reduced stroke incidence. We aimed to compare stroke severity between stroke patients who were taking ACEI before their stroke onset and those who were not, to examine the effects of pretreatment with ACEI on ischemic stroke severity. Methods: We retrospectively studied 126 consecutive patients presenting within 24 hours of ischemic stroke onset, as confirmed by diffusion-weighted magnetic resonance imaging (DWI). We calculated the NIHSS score at presentation, as the primary measure of clinical stroke severity, and categorized stroke severity as mild (NIHSS [less than or equal to] 7), moderate (NIHSS 8-13) or severe (NIHSS [greater than or equal to] 14). We analyzed demographic data, risk-factor profile, blood pressure (BP) and medications on admissions, and determined stroke mechanism according to TOAST criteria. We also measured the volumes of admission diffusion- and perfusion-weighted (DWI /PWI) magnetic resonance imaging lesions, as a secondary measure of ischemic tissue volume. We compared these variables among patients on ACEI and those who were not. Results: Thirty- three patients (26%) were on ACE-inhibitors. The overall median baseline NIHSS score was 5.5 (range 2-21) among ACEI-treated patients vs. 9 (range 1-36) in non-ACEI patients (p = 0.036). Patients on ACEI prior to their stroke had more mild and less severe strokes, and smaller DWI and PWI lesion volumes compared to non-ACEI treated patients. However, none of these differences were significant. Predictably, a higher percentage of patients on ACEI had a history of heart failure (p = 0.03). Age, time-to-imaging or neurological evaluation, risk-factor profile, concomitant therapy with lipid lowering, other antihypertensives or antithrombotic agents, or admission BP were comparable between the two groups. Conclusion: Our results suggest that ACE-inhibitors may reduce the clinical severity of stroke, as measured by NIHSS score. Further, larger-scale, prospective studies areneeded to validate our findings, and to elucidate the mechanism(s) of ACEImediated benefits in patients with ischemic stroke. - Background Data from the heart outcomes prevention evaluation study (HOPE) suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in prevention of ischemic stroke, as measured by reduced stroke incidence in subjects randomized to treatment with ACEI [1]. In this trial, the use of the ACEI, ramipril, resulted in a 32% reduction in ischemic stroke risk despite minimal reduction in blood pressure (BP) [1], leading some to suggest that ACEI may also exert direct neuroprotective effects. To further elucidate if ACEI have potential neuroprotective effects, we tested whether their use prior to ischemic stroke onset might also reduce the severity of stroke. We examined clinical and admission magnetic resonance imaging (MRI) data from patients with ischemic stroke to determine the effects of prestroke use of ACEI on stroke severity. Methods Study design and patient selection We retrospectively reviewed our prospectively collected stroke database over a 30-month period from 1998 to 2000, and identified consecutive patients who presented with acute ischemic stroke within 24 hours of onset and had DWI/PWI upon presentation. Onset time was defined, as the last time the patient was known to be in his/her usual state of health. The diagnosis of ischemic stroke was confirmed by diffusion-weighted imaging (DWI) showing evidence of acute cerebral infarction, combined with serial neurological examinations performed by stroke-trained neurologists. We included patients who had received thrombolytic, endovascular or experimental neuroprotective treatment. We only excluded patients who had transient ischemic attacks (TIAs), in whom DWI/PWI was negative. Data collection and assessments We retrieved the following data for each patient: (1) demographics; (2) risk factors for stroke, i.e. hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, coronary artery disease (CAD), atrial fibrillation (AF), heart failure (CHF), history of TIA and smoking, as reported by the patient andhis/her family; (3) vital signs at presentation (BP and temperature); (4) blood glucose level at admission; (5) medications upon admission, with particular attention to antiplatelets, anticoagulants, lipid-lowering agents, and antihypertensives including ACEI. We did not collect information about the duration of medication(s) use, daily use or compliance. Patients and families were only questioned about patient's use of medication(s), including ACEI, in the week before stroke; (6) the baseline Na (...truncated)