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In a study of patients with kidney failure and atrial fibrillation, racial/ethnic minorities experienced higher rates of stroke compared with non-Hispanic White patients, and they were less likely to fill prescriptions of stroke-preventive medications. The findings, which appear in an upcoming issue of JASN, indicate that equalizing the distribution of such prescriptions may help address stroke-related disparities among patients.

Because patients with kidney failure and atrial fibrillation, or an irregular heartbeat, are at risk of developing strokes, they may benefit from taking blood thinners as a preventive measure. Prior studies of patients with atrial fibrillation, with or without kidney failure, have reported that minority racial/ethnic groups face a higher risk of stroke compared with Whites.

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To investigate the potential causes of such disparities, a team led by Paul L. Kimmel, MD (National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health) examined information from a national registry of patients with kidney failure.

For the study, the researchers analyzed information from the United States Renal Data System to identify patients with kidney failure who initiated hemodialysis from 2006 to 2013, and then they identified those with a subsequent atrial fibrillation diagnosis and Medicare Part A/B/D insurance coverage.

Among 56,587 patients who were followed for one year, the number of strokes per 1,000 people were 84, 94, 97, and 102 in non-Hispanic White, Black, Hispanic White, and Asian patients, respectively.

Black, Hispanic White, and Asian patients filled prescriptions of the blood-thinner warfarin less often than non-Hispanic White patients, and they were more likely to experience stroke. Specifically, Black, Hispanic White, and Asian patients were 10%, 17%, and 28% less likely than non-Hispanic Whites to fill a warfarin prescription, respectively, and they were 13%, 15%, and 16% more likely to experience stroke. (The database did not provide information on whether patients were prescribed drugs, only whether they filled prescriptions.)

Analyses suggested that equalizing the warfarin distribution to that in the non-Hispanic White patient population would prevent 7%, 10%, and 12% of the stroke disparity among Black, Hispanic White, and Asian patients, respectively.

Institutional features and medical choices may play key roles underlying differences between prescriptions received by members of different groups. Our estimates suggest equalization of prescription of warfarin, a relatively inexpensive anticoagulant medication, across all ethnic/racial groups would be associated with decreased stroke rates in Black, Asian, and Hispanic White patients on hemodialysis."

Dr. Paul L. Kimmel, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Source:

American Society of Nephrology

Journal reference:

Waddy, S.P., et al. (2020) Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States. JASN. doi.org/10.1681/ASN.2019050543.

After 50 years of research and the testing of over 1,000 drugs, there is new hope for preserving brain cells for a time after stroke. Treating acute ischemic stroke patients with an experimental neuroprotective drug, combined with a surgical procedure to remove the clot improves outcomes as shown by clinical trial results published today in The Lancet.

The multi-center, double-blinded, randomized trial, led by a team at the Cumming School of Medicine's (CSM) Hotchkiss Brain Institute and Alberta Health Services, investigates the use of the neuroprotective drug nerinetide, developed by NoNO Inc, in two scenarios in the same trial. In one scenario, nerinetide is given to patients in addition to the clot-busting drug alteplase. In the second scenario, patients who were not suitable for alteplase received only nerinetide. Both groups of patients had concurrent endovascular treatment (EVT) to remove the clot.

"Compared to placebo, almost 20 per cent more patients who received nerinetide along with endovascular treatment, but did not receive alteplase, recovered from a devastating stroke – a difference between paralysis and walking out of the hospital," says Dr. Michael Hill, MD, a neurologist at Foothills Medical Centre (FMC) and professor in the departments of Clinical Neurosciences and Radiology at the CSM. "In the patients who received both drugs, the alteplase negated the benefits of the nerinetide."

Hill says the study provides evidence of a biological pathway that protects brain cells from dying when they are deprived of blood flow. Nerinetide targets the final stage of the brain cell's life by stopping the production of nitric oxide within the cell.

"We really believe this is a new scientific observation," says Hill. "There is evidence nerinetide promotes brain cell survival, offering neuroprotection until we can extract the clot. It opens the door to a new way of treating stroke."

Images of patients' brains from the study show the expected size of the damage from the stroke is sizeably reduced when nerinetide is administered and EVT is performed among patients not concurrently receiving alteplase.

After so many studies investigating neuroprotective drugs failed, we are extremely excited by these results. While nerinetide is not approved for use yet, it shows the potential of a new tool to promote recovery from stroke."

Dr. Mayank Goyal, MD, PhD, neuroradiologist at the FMC, and clinical professor in the Department of Radiology at the CSM

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Worldwide, 15 million people suffer a stroke each year – that's one every nine minutes in Canada and every 90 seconds in the United States. The results can be devastating. Ischemic stroke, the most common, is caused by a clot in a blood vessel in the brain. The sudden loss of blood flow causes brain cells to die, which can permanently affect speech, vision, balance and movement.

The international trial enrolled 1,105 patients between March 2017 and August 2019 at centres in North America, Europe, Australia, and Asia – a global academic collaboration bringing together scientists, clinicians, funding agencies, and industry.

"The collaboration between NoNO Inc., the University of Calgary and investigators at 48 leading stroke hospitals around the world has shown how effective such an academic-industry partnership can be in running high-quality, foundational stroke trials that can lead to positive changes in clinical practice," says Dr. Michael Tymianski, MD, PhD, CEO of NoNO Inc. and the inventor of nerinetide.

The results in the current study, called the ESCAPE-NA1 Trial, build on the success of the ESCAPE trial, in which the Calgary Stroke Program proved that a clot retrieval procedure known as EVT can dramatically improve patient outcomes after an acute ischemic stroke. During the procedure, a catheter is inserted in the groin and guided through blood vessels into the brain. A tiny metal mesh device is used to grab the clot and pull it out. The current study investigates whether administering nerinetide in addition to clot retrieval improves the patient's ability to recover.

Source:

University of Calgary

Journal reference:

Hill, M.D, et al. (2020) Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial. The Lancet. doi.org/10.1016/S0140-6736(20)30258-0.