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Clinical Practice
Secondary Prevention after Ischemic Stroke or Transient Ischemic Attack
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations. Stage. A 62-year-old…
- May 17, 2012
- Davis S.M. and Donnan G.A.
- N Engl J Med 2012; 366:1914-1922
- CME
- Full Text Audio
This article reviews recommended strategies to reduce the risk of a subsequent stroke in patients with a history of transient ischemic attack (TIA) or stroke.
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Original Article
Vorapaxar in the Secondary Prevention of Atherothrombotic Events
Platelets play a central role in atherothrombosis and are an important target for pharmacotherapy. In patients with acute coronary syndromes, the use of potent platelet inhibitors has been shown to reduce the rate of thrombotic events at the cost of increased bleeding.– In contrast, among…
- April 12, 2012
- Morrow D.A., Braunwald E., Bonaca M.P., et al.
- N Engl J Med 2012; 366:1404-1413
Patients with atherosclerotic vascular disease were randomly assigned to receive the thrombin antagonist vorapaxar or placebo. Vorapaxar reduced the rate of subsequent cardiovascular death, myocardial infarction, or stroke but increased the rate of moderate or severe bleeding.
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Original Article
A Randomized Trial of Tenecteplase versus Alteplase for Acute Ischemic Stroke
Thrombolytic treatment with alteplase, a recombinant tissue plasminogen activator, for acute ischemic stroke is of proven benefit. However, alteplase is far from ideal, with incomplete and often delayed reperfusion in many patients. Tenecteplase, a genetically engineered mutant tissue plasminogen…
- March 22, 2012
- Parsons M., Spratt N., Bivard A., et al.
- N Engl J Med 2012; 366:1099-1107
- CME
In this phase 2B trial involving 75 patients with acute ischemic stroke, tenecteplase was more effective than alteplase in achieving reperfusion and clinical improvement at 24 hours. Bleeding complications were similar in the two groups.
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Original Article
Closure or Medical Therapy for Cryptogenic Stroke with Patent Foramen Ovale
As many as 40% of acute ischemic strokes have no identifiable cause and are classified as cryptogenic.– Some cryptogenic strokes or transient ischemic attacks (TIAs) may be the result of an embolus from the venous system traversing from the right to left atrium and into the systemic circulation…
- March 15, 2012
- Furlan A.J., Reisman M., Massaro J., et al.
- N Engl J Med 2012; 366:991-999
Patients with a cryptogenic stroke or transient ischemic attack (TIA) who had a patent foramen ovale were randomly assigned to closure with a percutaneous device or to medical therapy. There was no significant between-group difference in the subsequent rate of stroke or TIA.
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Editorial
Patent Foramen Ovale Closure — Closing the Door Except for Trials
Patent foramen ovale is a well established cause of stroke. A thrombus from venous structures can embolize through a patent foramen ovale and ultimately reach the brain. However, a patent foramen ovale can also be present in 25% of healthy people. Although detected in nearly twice as many patients…
- March 15, 2012
- Johnston S.C.
- N Engl J Med 2012; 366:1048-1050
Patent foramen ovale is a well established cause of stroke. A thrombus from venous structures can embolize through a patent foramen ovale¹ and ultimately reach the brain.² However, a patent foramen ovale can also be present in 25% of healthy people. ...
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Review Article
Current Concepts: The Autosomal Recessive Cerebellar Ataxias
The autosomal recessive cerebellar ataxias are a group of little known and often neglected diseases that are best understood by following a practical, multidisciplinary approach that focuses on clinical rather than molecular considerations. This review focuses on the main forms in which cerebellar…
- February 16, 2012
- Anheim M., Tranchant C., Koenig M.
- N Engl J Med 2012; 366:636-646
- CME
- Video
Autosomal recessive cerebellar ataxia must be considered in any child or young adult with a progressive disorder of gait or balance or with hypotonia or excessive clumsiness. This review presents a practical approach to these neurodegenerative diseases.
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Review Article
Current Concepts: Cognitive and Neurologic Outcomes after Coronary-Artery Bypass Surgery
Patients referred for coronary revascularization procedures are older and are likely to have more extensive extracardiac vascular disease than those referred for such procedures in the past. Despite these trends, mortality rates for coronary-artery bypass grafting (CABG), without concurrent…
- January 19, 2012
- Selnes O.A., Gottesman R.F., Grega M.A., et al.
- N Engl J Med 2012; 366:250-257
- CME
For patients undergoing coronary-artery bypass grafting (CABG), adverse neurologic outcomes, including stroke and cognitive decline, are major concerns. Even mild cognitive deficits before surgery may be a marker for cerebrovascular disease and increased risk.
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Original Article
Subclinical Atrial Fibrillation and the Risk of Stroke
Atrial fibrillation may be asymptomatic and consequently subclinical. Epidemiologic studies indicate that many patients with atrial fibrillation on screening electrocardiograms had not previously received a diagnosis of atrial fibrillation. About 15% of strokes are attributable to documented atrial…
- January 12, 2012
- Healey J.S., Connolly S.J., Gold M.R., et al.
- N Engl J Med 2012; 366:120-129
- CME
A cohort of 2580 patients with pacemakers or defibrillators were monitored for 3 months to detect subclinical atrial tachyarrhythmias. Patients with subclinical atrial tachyarrhythmias had a significantly increased risk of subsequent ischemic stroke.
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Editorial
How Much Atrial Fibrillation Is Too Much Atrial Fibrillation?
Modern cardiac pacemakers and defibrillators function as permanently implanted cardiac monitors, detecting atrial and ventricular arrhythmias. Although the principal purpose of collecting this information is to manage the patient's cardiac rhythm, these data can also be used to detect and study…
- January 12, 2012
- Lamas G.
- N Engl J Med 2012; 366:178-180
Modern cardiac pacemakers and defibrillators function as permanently implanted cardiac monitors, detecting atrial and ventricular arrhythmias. Although the principal purpose of collecting this information is to manage the patient's cardiac rhythm, these ...
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Editorial
Dronedarone in Atrial Fibrillation — Jekyll and Hyde?
Atrial fibrillation, the most common type of sustained cardiac arrhythmia, is associated with increased morbidity and mortality and is often therapeutically challenging. Dronedarone is a recently introduced antiarrhythmic drug that was developed by modifying the structure of amiodarone in an effort…
- December 15, 2011
- Nattel S.
- N Engl J Med 2011; 365:2321-2322
Atrial fibrillation, the most common type of sustained cardiac arrhythmia, is associated with increased morbidity and mortality and is often therapeutically challenging.¹ Dronedarone is a recently introduced antiarrhythmic drug that was developed by ...
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Original Article
Dronedarone in High-Risk Permanent Atrial Fibrillation
Dronedarone is a new antiarrhythmic agent that is used to restore sinus rhythm and to reduce rates of hospitalization for cardiovascular causes in patients with intermittent (paroxysmal or persistent) atrial fibrillation. In ATHENA (A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess…
- December 15, 2011
- Connolly S.J., Camm A.J., Halperin J.L., et al.
- N Engl J Med 2011; 365:2268-2276
Patients with permanent atrial fibrillation and additional cardiac risk factors were randomly assigned to receive either dronedarone or placebo. At a median of 3.5 months, the risk of major adverse cardiovascular events was significantly increased with dronedarone.
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Clinical Implications of Basic Research
Suppressing Immunosuppression after Stroke
Pneumonia is a major cause of death after acute cerebral ischemia. A recent study by Wong and colleagues provides some insight into susceptibility to infection after stroke. Specifically, they found that infections after stroke are promoted by noradrenergic-mediated dysfunction of a small subset of…
- December 1, 2011
- Meisel C. and Meisel A.
- N Engl J Med 2011; 365:2134-2136
There is growing evidence that acute injury of the central nervous system, including stroke, impairs the immune system. A recent study implicates the postischemic activation of a particular type of lymphocyte, by noradrenergic signaling, as a mediator of impairment.
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Perspective
Evaluating Rivaroxaban for Nonvalvular Atrial Fibrillation — Regulatory Considerations
On September 8, 2011, the Cardiovascular and Renal Drugs Advisory Committee of the Food and Drug Administration (FDA) discussed data submitted in support of the new drug application for rivaroxaban for preventing stroke and non–central nervous system systemic embolic events in patients with…
- October 27, 2011
- Fleming T.R. and Emerson S.S.
- N Engl J Med 2011; 365:1557-1559
- Free Full Text
An FDA advisory committee recently considered a new drug application for rivaroxaban for preventing stroke and systemic embolism in patients with nonvalvular atrial fibrillation, but there are important concerns about interpretation of the results of the key study.
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Perspective
The “Million Hearts” Initiative — Preventing Heart Attacks and Strokes
Each year, more than 2 million Americans have a heart attack or stroke, and more than 800,000 of them die; cardiovascular disease is the leading cause of death in the United States and the largest cause of lower life expectancy among blacks. Related medical costs and productivity losses approach…
- September 29, 2011
- Frieden T.R. and Berwick D.M.
- N Engl J Med 2011; 365:e27
- Free Full Text
Each year, more than 2 million Americans have a heart attack or stroke, and more than 800,000 of them die; cardiovascular disease is the leading cause of death in the United States and the largest cause of lower life expectancy among blacks. Related ...
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Editorial
The Challenges of Intracranial Revascularization for Stroke Prevention
The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial (SAMMPRIS, ClinicalTrials.gov number, NCT00576693), as reported by Chimowitz et al. in this issue of the Journal, showed that aggressive medical management alone was superior to…
- September 15, 2011
- Broderick J.P.
- N Engl J Med 2011; 365:1054-1055
The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial¹ (SAMMPRIS, ClinicalTrials.gov number, NCT00576693), as reported by Chimowitz et al. in this issue of the Journal, showed that aggressive medical ...
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Editorial
A New Era for Anticoagulation in Atrial Fibrillation
For more than 50 years, warfarin has been the primary medication used to reduce the risk of thromboembolic events in patients with atrial fibrillation. Despite its clinical efficacy, warfarin has multiple, well-known limitations, including numerous interactions with other drugs and the need for…
- September 15, 2011
- Mega J.L.
- N Engl J Med 2011; 365:1052-1054
For more than 50 years, warfarin has been the primary medication used to reduce the risk of thromboembolic events in patients with atrial fibrillation. Despite its clinical efficacy, warfarin has multiple, well-known limitations, including numerous ...
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Original Article
Apixaban versus Warfarin in Patients with Atrial Fibrillation
Patients with atrial fibrillation are at increased risk for stroke. Warfarin and other vitamin K antagonists are highly effective treatments, reducing the risk of stroke by about two thirds, but their use is limited by a narrow therapeutic range, drug and food interactions, required monitoring, and…
- September 15, 2011
- Granger C.B., Alexander J.H., McMurray J.J.V., et al.
- N Engl J Med 2011; 365:981-992
- Free Full Text
- CME
The oral direct factor Xa inhibitor, apixaban, was compared with warfarin in atrial fibrillation. Apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and lowered mortality.
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Original Article
Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis
Atherosclerotic intracranial arterial stenosis is one of the most common causes of stroke worldwide– and is associated with a high risk of recurrent stroke.– Patients with a recent transient ischemic attack (TIA) or stroke and severe stenosis (70 to 99% of the diameter of a major intracranial…
- September 15, 2011
- Chimowitz M.I., Lynn M.J., Derdeyn C.P., et al.
- N Engl J Med 2011; 365:993-1003
- Free Full Text
In patients with a recent transient ischemic attack or stroke attributed to 70 to 99% stenosis of a major intracranial artery, aggressive medical management was superior to aggressive medical management plus percutaneous transluminal angioplasty and stenting.
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Original Article
Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation
Atrial fibrillation is associated with an increase in the risk of ischemic stroke by a factor of four to five and accounts for up to 15% of strokes in persons of all ages and 30% in persons over the age of 80 years. The use of vitamin K antagonists is highly effective for stroke prevention in…
- September 8, 2011
- Patel M.R., Mahaffey K.W., Garg J., et al.
- N Engl J Med 2011; 365:883-891
- Free Full Text
- CME
In this trial, 14,264 patients with atrial fibrillation were randomly assigned to receive either rivaroxaban or warfarin. In a per-protocol, as-treated analysis, rivaroxaban was noninferior to warfarin with respect to the primary end point of stroke or systemic embolism.
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Editorial
New Options in Anticoagulation for Atrial Fibrillation
The presence of atrial fibrillation significantly increases the risk and burden of thromboembolic stroke. Warfarin is the reference standard treatment for the primary prevention of embolic stroke during atrial fibrillation. However, the long-term use of warfarin has its limitations. Although…
- September 8, 2011
- del Zoppo G.J. and Eliasziw M.
- N Engl J Med 2011; 365:952-953
The presence of atrial fibrillation significantly increases the risk and burden of thromboembolic stroke.¹ Warfarin is the reference standard treatment for the primary prevention of embolic stroke during atrial fibrillation.² However, the long-term use of ...
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Medical Meetings Pediatrics Conferences and Meetings

2012 Certifying Examinations of the American Board of Pediatrics

The general pediatrics examination will be held in various cities, Oct. 16-18. Registration for first-time applicants is ongoing through May 3. Registration for re-registrants is ongoing through May 24. The following subspecialty examinations will be held in various cities: "Hospice and Palliative Medicine" (Oct. 4); "Pediatric Transplant Hepatology" (Oct. 11); "Pediatric Cardiology" (Nov. 7); "Pediatric Pulmonology" (Nov. 8); "Medical Toxicology" (Nov. 12); and "Pediatric Critical Care Medicine" (Nov. 14). Registration for first-time applicants is ongoing through April 30. Registration for re-registrants is ongoing through June 15.

Contact the American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC 27514-1513; or call (919) 929-0461; or fax (919) 918-7114 or (919) 929-9255; or see http://www.abp.org .

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