STUDENT NAME STUDENT NUMBER: CANALE

Research Review - Predictive impact of daily physical activity on new

vascular events in patients with mild ischemic stroke

This article may be considered reputable because it follows the scientific

method and is arranged in the standard format: abstract,
introduction/background, methods and materials, results, discussion,
references. It was published in “International Journal of Stroke”, a journal
with an impact factor of 4.029. It is current, published on November, 9th,
2014. The title is scientific. The references are up-to-date. There are
multiple authors. The important authors concerning the article are Yuji
Kono and Sumio Yamada. Yuki Kono had the idea and has participated in
other publications, one of which is “Generation of superoxide radical
during autoxidation of hydroxylamine and an assay for superoxide
dismutase”. Sumio Yamada is head of department and coordinator of the
group and has other publications too:- “Improvement in physiological
outcomes and health-related quality of life following cardiac
rehabilitation in patients with acute myocardial infarction”

The main topic of the article is on how physical activity may have an
impact on recurrences of vascular events in patients who had suffered an
ischemic stroke. An observational study was designed measuring physical
activity in Japanese patients affected by ischemic stroke and how much
daily physical activity could contribute to maintaining health and to
investigate on how much physical exercise would be required to avoid
long term recurrences of vascular events. The study concluded that
exercise may help prevent new vascular events.

1. What is the problem and what is known about it so far?

It is known that fewer people die from the consequences of
ischemic stroke nowadays but it is also true that strokes that do not
come from the heart are on the increase and that there may be
recurrences of vascular events in the Japanese and worldwide
community (1-3). Physical activity and lifestyle changes have been
recommended to reduce these recurrences and vascular risk factors
in patients with noncardioembolic strokes and TIA
(Transient Ischemic Stroke) (4-6). Previous studies have documented
that people who are moderately or highly active are not as much at
risk as people who do not exercise (7,8).Nevertheless, literature is
lacking regarding the amount and target level of physical activity.

2. Why did the researchers do this study?

The researchers hypothesized that a low daily step count regarded
as a typical daily physical activity, as well as other clinical
parameters for non-cardioembolic stroke would have an impact on
vascular events. Therefore the aim of this study was to observe how
physical activity was related to long-term vascular recurrences and
to determine the cut-off values ( the parameters) of exercise in
Japanese patients.

3. Who was studied?

One hundred and sixty-six ischemic Japanese patients with a mean
age of 63·9 ± 9·2 took part in the study. The patients were
considered eligible if they had suffered an acute ischemic stroke of
TIA; they were selected according to an emergency hospital
admission with confirmation of conditions following MRI and were
then discharged and returned home. The patients were all able to
communicate. Patients had given consent to take part in the study.
Exclusion criteria included cardioembolic stroke, dementia,
psychiatric disorders, extracorporeal dialysis and reluctance to
participate.

4. How was the study done?

The study was a prospective observational study with patients taken
from a single centre registry. Consecutive ischemic stroke or TIA
patients who had received emergency admission into hospital were
included in the study and were not masked, thus aware of being
part of a study. Baseline characteristics were measured on the
patients while inpatients and were then followed up for
developments of vascular events. The primary outcomes were
composite stroke and cardiovascular death and admission into
hospital following recurrences of stroke or myocardial infarction,
angina pectoris or peripheral artery disease. Clinical features were
assessed as well as BMI, systolic blood pressure, HDL and LDL
cholesterol, triglycerides, fasting glucose, waist circumference, daily
step counts and salt intake. Blood pressure was taken and the mean
value was noted. Blood samples were collected following overnight
fast and blood tests were analyzed enzymatically. The step count
was taken blinding the patients by encouraging them to maintain
normal physical activity. Patients’ urine samples were taken in the
morning. Unpaired t-test and the Mann–Whitney U-test for
continuous variables and the chi square test or Fisher’s exact test
for the categorical variables. Univariate and multivariate Cox
proportional hazards analyses were used to measure the impact of a
patient’s clinical characteristics.

5. What did the researchers find?

All of the recruited patients were successfully followed up.

Following a period of 1332 days, the researchers observed 34
vascular recurrences (23 strokes and 11 coronary artery disease
subjects). The patients were assigned to two groups- a non
recurrence and a recurrence group and a lower daily step count was
noted in the nonsurvivor group. The results indicate that mild
physical activity may be useful for the prevention of recurrences of
new vascular events estimating an average of 6000 steps as an initial
target.

6. What were the limitations of the study?

The main drawback of this study was that the study patients
belonged to a hospital based group and therefore did not consider
other subjects. Another limitation was that intensity of the activity
was not considered which may have an impact on recurrences of
events. Therefore further studies need to be carried out on
exercise intensity. The population was limited to a Japanese
population and the study group number was not particularly
significant.

7. What are the implications of the study?

The study implies that physical activity could be important to avoid

or prevent further vascular events in patients with strokes and to
assess prognosis on a long term basis indicating 6000 steps per day
as an initial target to avoid recurrences. Furthermore, physical
activity mild or vigorous could also be indicated as an important
factor in the prevention of cardiovascular events in healthy
subjects.
References
1. Japan Ministry of Health, Labour and Welfare 2012. JinkouDoutai-
Souran (Summary of status report of Japanese population). Available
at http://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei12/dl/
11_h7.pdf.

2. van Wijk I, Kappelle LJ, van Gijn J et al. Long-term survival and
vascular event risk after transient ischaemic attack or minor
ischaemic stroke: a cohort study. Lancet 2005; 365:2098–104.

3. Kono Y, Yamada S, Kamisaka K et al. Recurrence risk after

noncardioembolic
mild ischemic stroke in a Japanese population. Cerebrovasc
Dis 2011; 31:365–72.

4. Furie KL, Kasner SE, Adams RJ et al. Guidelines for the prevention
of stroke in patients with stroke or transient ischemic attack: a
 guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 2011; 42:227–76.

5. European Stroke Organisation (ESO) Executive Committee.

Guidelines for management of ischaemic stroke and transient
ischaemic attack 2008. Cerebrovasc Dis 2008; 25:457–507.

6. Shinohara Y, Yanagihara T, Abe K et al. Japanese guidelines for the

management of stroke 2009. II. Cerebral infarction/transient
ischemic attack (TIA). J Stroke Cerebrovasc Dis 2011; 20:S31–73.

7. Wendel-Vos GC,Schuit AJ,Feskens EJ et al.Physical activity and

stroke. Ameta-analysis of observational data. Int J Epidemiol 2004;
33:787–98.

8. Lee CD, Folsom AR, Blair SN. Physical activity and stroke risk: a
meta-analysis. Stroke 2003; 34:2475–81.