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L Nelson Hopkins

Publications and source records attributed to L Nelson Hopkins.

At least 73 records · Page 4Linked to original sources
PubMed2004

Emergency stent placement for symptomatic acute carotid artery occlusion after endarterectomy. Case report.

The authors report a case of emergency carotid artery (CA) stent placement for a symptomatic acute CA occlusion following carotid endarterectomy (CEA). This 43-year-old man underwent a right-sided CEA for an asymptomatic 80% CA stenosis detected using duplex ultrasound testing. The patient experienced hypotension and possibly a myocardial infarction intraoperatively and a left hemiplegia immediately postoperatively. He was referred to the authors' institution for consideration of emergency coronary intervention and evaluation of stroke. A computerized tomography scan of the head demonstrated subtle early ischemic changes in the right posterior parietal region. Cerebral angiography revealed occlusion of the right common CA (CCA) at the CA bifurcation. Two coronary stents (Magic Wall; Boston Scientific Scimed, Maple Grove, MN) were placed in tandem in the right CCA and internal CA (ICA), overlapping at the proximal cervical ICA. Complete recanalization of the CA was achieved, and the patient made a clinically significant recovery. Diagnostic angiography can provide important information about CA and intracranial circulation that will aid in the evaluation of postoperative stroke after CEA. Stent placement should be considered as an alternative method of treatment for acute CA occlusion or dissection following CEA.

Acute Disease↗
PubMed2004

Effects of arterial geometry on aneurysm growth: three-dimensional computational fluid dynamics study.

OBJECT: Few researchers have quantified the role of arterial geometry in the pathogenesis of saccular cerebral aneurysms. The authors investigated the effects of parent artery geometry on aneurysm hemodynamics and assessed the implications relative to aneurysm growth and treatment effectiveness. METHODS: The hemodynamics of three-dimensional saccular aneurysms arising from the lateral wall of arteries with varying arterial curves (starting with a straight vessel model) and neck sizes were studied using a computational fluid dynamics analysis. The effects of these geometric parameters on hemodynamic parameters, including flow velocity, aneurysm wall shear stress (WSS), and area of elevated WSS during the cardiac cycle (time-dependent impact zone), were quantified. Unlike simulations involving aneurysms located on straight arteries, blood flow inertia (centrifugal effects) rather than viscous diffusion was the predominant force driving blood into aneurysm sacs on curved arteries. As the degree of arterial curvature increased, flow impingement on the distal side of the neck intensified, leading to elevations in the WSS and enlargement of the impact zone at the distal side of the aneurysm neck. CONCLUSIONS: Based on these simulations the authors postulate that lateral saccular aneurysms located on more curved arteries are subjected to higher hemodynamic stresses. Saccular aneurysms with wider necks have larger impact zones. The large impact zone at the distal side of the aneurysm neck correlates well with other findings, implicating this zone as the most likely site of aneurysm growth or regrowth of treated lesions. To protect against high hemodynamic stresses, protection of the distal side of the aneurysm neck from flow impingement is critical.

Anthropometry↗
PubMed2004

Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke.

BACKGROUND AND PURPOSE: Early reocclusion of recanalized arteries has been observed after thrombolysis for acute coronary occlusion and has been attributed to platelet activation after exposure to thrombolytic agents. We conducted a retrospective study to determine the rate of reocclusion during intra-arterial thrombolysis for acute ischemic stroke and the effect of reocclusion on functional outcome. METHODS: Patients treated for acute ischemic stroke at our center between September 2000 and May 2002 received a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. Pharmacologic thrombolysis was supplemented by mechanical thrombolysis with balloon angioplasty or snare manipulation at the occlusion site. Angiography was performed after each unit of reteplase or mechanical maneuver, and the images were interpreted by a blinded reviewer. Reocclusion was defined as partial or complete initial recanalization with occlusion recurring at the same site as documented by angiography during the endovascular treatment. Reocclusions were treated by further pharmacologic and/or mechanical thrombolysis according to the discretion of the treating physician. Clinical evaluations were performed before and 24 hr, 7 to 10 days, and 1 to 3 months after treatment. RESULTS: Forty-six consecutive patients underwent intra-arterial thrombolysis. Reocclusion was observed in eight (17%). Among these patients, initial sites of occlusion were in the following arteries: intracranial internal carotid artery (n = 2), M1 segment of the middle cerebral artery (n = 3), M1 and M2 segments of the middle cerebral artery (n = 2), and basilar artery (n = 1). The mean initial National Institutes of Health Scale score for these eight patients was 23.3 +/- 6.2; mean time from symptom onset to treatment was 4.4 +/- 1.2 hr. The reocclusions were treated by using additional doses of reteplase alone (n = 1), reteplase with snare maneuver and/or angioplasty (n = 5), reteplase with angioplasty or snare and then stent placement (n = 1), and angioplasty with stent placement (n = 1). The reocclusions resolved in six of eight patients after further treatment. Six patients died and two survived but were severely disabled at 1 month (modified Rankin Scale scores of 4 and 5, respectively). Independent functional outcome scores (modified Rankin Scale scores of 0-2) were significantly lower among patients with angiographically shown reocclusion than in those without (0 of 8 versus 17 of 38, P =.02). CONCLUSION: Reocclusion occurs relatively frequently during intra-arterial thrombolysis for ischemic stroke and seems to be associated with poor clinical outcomes.

Acute Disease↗
PubMed2004

Site-specific thromboembolism: a novel animal model for stroke.

BACKGROUND AND PURPOSE: To develop a technique for site-specific placement of a thrombus of predetermined volume in an animal model for the purpose of evaluating methods of intravascular thrombolysis and clot retrieval. METHODS: Six swine were subjected to thrombus injection bilaterally in the ascending pharyngeal artery (APA). Each animal underwent transfemoral angiography while under general anesthesia. A nondetachable balloon catheter and a 3-French microcatheter were then advanced into the common carotid artery through a 7-French guide catheter. With the microcatheter in the proximal APA and the balloon inflated proximally, a bolus of preformed thrombus composed of 0.9 mL of autologous blood and 0.1 mL of bovine thrombin (200 IU/mL) was injected through the microcatheter while local flow arrest was maintained for 15 min. The balloon was deflated and removed. The occluded arteries were observed by serial angiography for 3 hr and then resected for gross examination and hematoxylin and eosin staining. RESULTS: Each APA was occluded angiographically and did not recanalize during the 3-hr observation period. Persistent, proximal progression of thrombus to the superior thyroid artery origin occurred in three animals. Gross inspection revealed that the resected arteries contained thrombus in the proximal APA but not in the common carotid artery. Histologic examination revealed organized thrombus, without evidence of intimal injury. CONCLUSION: Our model provides a simple, reliable method for site-specific injection of a thrombus of predetermined volume. Site-specific placement is important for evaluation of the efficacy of thrombolytic agents and techniques. Angiographic evidence of brain revascularization can be used to grade revascularization and clot volume. The ability to specifically localize and estimate clot volume makes our model well suited for the evaluation and comparison of thrombolytic agents and endovascular techniques.

Angiography, Digital Subtraction↗
PubMed2003

Extracellular glutamate and other amino acids in experimental intracerebral hemorrhage: an in vivo microdialysis study.

OBJECTIVE: To determine whether extracellular concentrations of glutamate and other amino acids are significantly elevated after intracerebral hemorrhage and, if so, the temporal characteristics of these changes. Although the role of excitotoxic amino acids, particularly that of glutamate, has been described in ischemic stroke and head trauma, no information exists regarding their possible contribution to the pathogenesis of neuronal injury in intracerebral hemorrhage. DESIGN: Prospective, controlled, laboratory trial. SETTINGS: Animal research laboratory. SUBJECTS: Sixteen anesthetized New Zealand rabbits. INTERVENTION: We introduced intracerebral hemorrhage in each of eight anesthetized New Zealand rabbits by injecting 0.4 mL of autologous blood under arterial pressure into the deep gray matter of the cerebrum. MEASUREMENTS AND MAIN RESULTS: Extracellular fluid samples were collected from the perihematoma region and contralateral (right) hemisphere by in vivo microdialysis at 30-min intervals for 6 hrs. Corresponding samples were similarly collected from both hemispheres in each of eight control animals that underwent needle placement without introduction of a hematoma. Concentrations of amino acids (glutamate, aspartate, asparagine, glycine, taurine, and gamma-aminobutyric acid) in the samples were measured by use of high-pressure liquid chromatography with fluorescence detection. Glutamate concentrations (mean +/- sem) were significantly higher in the hemisphere ipsilateral to the hematoma than in the contralateral hemisphere (92 +/- 22 pg/microL vs. 22 +/- 6 pg/microL) at 30 mins after hematoma creation. A significant increase was observed at 30 mins posthematoma creation in the hemisphere ipsilateral to the hematoma compared with the baseline value. A nonsignificant increase in glutamate concentration persisted in the hemisphere ipsilateral to the hematoma, ranging from 134% to 187% of baseline value between 1 and 5 hrs after hematoma creation. In the hemisphere ipsilateral to the hematoma, a three-fold increase in the concentration of glycine was observed at 30 mins after hematoma creation compared with the baseline level (890 +/- 251 pg/microL vs. 291 +/- 73 pg/microL). There was a significant difference between the hemisphere ipsilateral to the hematoma compared with the ipsilateral (corresponding) hemisphere of the control group at 30 mins posthematoma (890 +/- 251 pg/microL vs. 248 +/- 66 pg/microL). A similar transient increase was observed in taurine and asparagine concentrations at 30 mins after hematoma creation, compared with baseline measurements. Taurine concentrations in the hemisphere ipsilateral to the hematoma were significantly higher than the ipsilateral hemisphere of the control group (622 +/- 180 pg/microL vs. 202 +/- 64 pg/microL) at 30 mins after hematoma creation. CONCLUSIONS: The present study suggests that glutamate and other amino acids accumulate transiently in extracellular fluids in the perihematoma region during the early period of intracerebral hemorrhage. The exact role of these amino acids in the pathogenesis of neuronal injury observed in intracerebral hemorrhage needs to be defined.

Analysis of Variance↗
PubMed2003

Fate of branch arteries after intracranial stenting.

OBJECTIVE: One concern with respect to stent procedures performed to treat patients with intracranial lesions is the fate of normal major arterial branches after stents are placed across them. Because most of these lesions occur at vessel bifurcations or at branch points, a normal major branch often arises near the lesion and may be difficult to avoid during stent positioning. The aim of this article is to describe the angiographic outcome of intracranial major branch arteries crossed by a stent in the intracranial circulation. METHODS: We examined the immediate postprocedural cerebral angiograms of the 40 patients who underwent intracranial stenting at the University at Buffalo, Buffalo, NY, between June 1998 and April 2000. In each of 10 patients, the stent was placed across a normal major branch artery. Stents were used to treat aneurysms in seven patients and intracranial stenosis in three patients. The latest cerebral angiogram available was reviewed, and the patency of the major branch arteries was evaluated. RESULTS: The angiographic follow-up period ranged from 4 days to 35 months (mean follow-up, 10 mo). Each of the 10 major branch arteries was patent. No infarcts were associated with the territory of the major branch arteries crossed by the stents, and no patient experienced a related episode of clinical ischemia. Four patients died as a result of causes unrelated to the stenting procedure. The histology of a middle cerebral artery stent that was placed across a lenticulostriate perforator is presented. CONCLUSION: The flexible, low-profile stents used in this study had no angiographically or clinically apparent effect on the major intracranial branches across which they were placed.

Adult↗
PubMed2003

Transradial stenting of the cervical internal carotid artery: technical case report.

OBJECTIVE AND IMPORTANCE: We describe a case of endoluminal stent placement for a cervical internal carotid artery stenosis in which percutaneous access was obtained via the radial artery. CLINICAL PRESENTATION: A 69-year-old man with known disease of the carotid, peripheral, and coronary arteries as well as chronic obstructive pulmonary disease presented for endoluminal revascularization of a severe, progressive right internal carotid artery stenosis. TECHNIQUE: Transfemoral access was complicated by the previous placement of a synthetic graft as the result of a previous right-to-left iliofemoral artery bypass procedure and an aortoiliac occlusion. A transradial approach was successfully attempted, and a Precise stent (Cordis Endovascular, Miami Lakes, FL) was successfully placed through a 6-French guide sheath. CONCLUSION: The transradial approach is becoming an increasingly viable alternative route for stent placement in patients with contraindicated or complicated femoral access routes. As devices become increasingly more pliable and smaller, the transradial route will be used with increasing frequency in this select patient population for stenting of both the cervical and intracranial circulation.

Aged↗
PubMed2003

In vivo model of intracranial stent implantation: a pilot study to examine the histological response of cerebral vessels after randomized implantation of heparin-coated and uncoated endoluminal stents in a blinded fashion.

OBJECT: No animal model currently exists for the examination of time-dependent histological changes occurring in intracranial vessels after endoluminal stent placement. The authors' goal was to develop a reproducible in vivo model of stent implantation in intracranial vessels in dogs that was capable of demonstrating stent-related vascular changes after the implantation of coated and uncoated devices. METHODS: The authors implanted heparin-coated or uncoated stents in the basilar arteries (BAs) of 11 mongrel dogs. In a 12th animal, one coated stent was implanted in the BA and a second uncoated one was implanted in the distalanterior spinal artery. All the devices were oversized to induce intimal injury. Surviving animals were observed for 12 weeks, after which they underwent repeated angiography before planned death and removal of the brain. Histological studies and computer-assisted morphometric analyses were conducted on stent-treated and untreated sections of the BAs to assess the percentage of stenosis, neointimal proliferation, vessel injury, and inflammation. Perforating vessels partially covered by stent struts ("jailing") were studied for evidence of stenosis or occlusion. The pathologist, interventionists, histopathologist, histopathology technicians, and radiologist were blinded to the stent type. Seven stents (three uncoated and four coated) were removed from the six animals that were observed during the follow-up period. The mean neointimal proliferation was 0.42 mm2 in the group treated with uncoated stents and 0.18 mm2 in the group treated with heparin-coated devices (p = 0.04). Neointimal thickness was significantly increased in the group with uncoated stents (p = 0.04). The mean percentage of occlusion was less (12%) in the group with heparin-coated stents, compared with 22% in the group with uncoated devices (p = 0.07). When comparing results between the heparin-coated and uncoated devices implanted in the five animals that received a single stent only, greater differences (indicating a benefit from heparin-coated stents) were observed in neointimal area (p = 0.009), neointima/media ratio (p = 0.001), neointimal thickness (p = 0.002), and percentage of occlusion (p = 0.009). All brainstem perforating vessels covered by stent struts remained patent. CONCLUSIONS: This in vivo intracranial stent model was developed to assess proliferative and inflammatory responses to endoluminal stent implantation in the cerebrovasculature. The results indicate that a lower percentage of occlusion occurs 12 weeks after implantation of heparin-coated compared with uncoated stents.

Angiography↗
PubMed2003

Intracranial stent placement for the treatment of a carotid-cavernous fistula associated with intracranial angioplasty. Case report.

The authors report a case of an iatrogenic carotid-cavernous fistula (CCF) associated with intracranial angioplasty. Angioplasty was performed using a 3 x 10-mm Open Sail coronary balloon in a patient with high-grade stenosis of the left cavernous internal carotid artery (ICA). After angioplasty, a perforation developed in the cavernous ICA, resulting in a CCF. A 3.5 x 9-mm S670 coronary stent was used to treat the fistula. To the authors' knowledge, this is the first reported case in which a CCF developed after angioplasty was performed using a coronary balloon. Long-term angiographic and clinical evaluation is needed to test the suitability and durability of intracranial angioplasty and stent placement in the treatment of symptomatic intracranial stenosis.

Aged↗
PubMed2003

Multicenter clinical trial of the NexStent coiled sheet stent in the treatment of extracranial carotid artery stenosis: immediate results and late clinical outcomes.

OBJECT: Carotid angioplasty with stent placement has been proposed as an alternative method for revascularization of carotid artery (CA) stenosis. A novel stent with a coiled sheet design (NexStent; EndoTex Interventional Systems, Inc., Cupertino, CA) has been introduced because it provides improved flexibility over conventional tubular designs during navigation through tortuous arterial segments. The authors report the results of a multicenter study in which they evaluated the safety, feasibility, and effectiveness of this stent in the treatment of CA stenosis. METHODS: Enrollment was limited to patients with 70% or more symptomatic or asymptomatic stenosis of the internal CA. The primary end point was a technically successful implantation procedure (delivery of the stent to the target siteand retrieval of the delivery device) resulting in less than 30% residual stenosis on angiograms obtained immediately postprocedure and no death or ipsilateral stroke immediately after or within 30 days following the procedure. The secondary effectiveness end point was prevention of an ipsilateral stroke within 31 days to 1 year postprocedure. The tertiary effectiveness end point was less than 70% residual stenosis demonstrated on CA Doppler ultrasonography performed at 6 and 12 months. Forty-four patients (mean age 71 years, range 51-89 years; 30 patients were men and 18 [41%] had symptomatic stenotic lesions) were treated using 45 NexStents (two stents were placed in one patient). Residual stenosis on postprocedure angiograms was less than 30% in all patients. The 1-month primary end point was achieved in 41 patients (93%). The three major adverse events that occurred within 30 days were one death related to congestive heart failure and two ipsilateral strokes, one of which resulted in death. No ipsilateral stroke occurred between 1 and 12 months postprocedure among 35 patients who completed the follow-up evaluation. Asymptomatic recurrent stenosis was identified in one patient at 6 months postprocedure, requiring the performance of repeated angioplasty. CONCLUSIONS: Placement of the NexStent was feasible and resulted in the effective treatment of patients with CA stenosis, with promising long-term results.

Aged↗
PubMed2003

Comparison of periprocedure complications resulting from direct stent placement compared with those due to conventional and staged stent placement in the basilar artery.

OBJECT: Medically refractory, symptomatic atherosclerotic disease of the basilar artery (BA) portends a poor prognosis. Studies have shown morbidity rates following placement of stents in these lesions to be quite variable, ranging from 0 to 30%. The authors review their experience with BA stent placement for severe atherosclerotic disease to determine whether an increase in neurological morbidity is associated with direct stent placement (that performed without predilation angioplasty) compared with conventional stent placement (that performed immediately after predilation angioplasty) or staged stent placement (angioplasty followed > or = 1 month later by stent placement with or without repeated angioplasty). METHODS: The authors retrospectively reviewed the medical records from a consecutive series of 10 patients who underwent stent placement for medically refractory, symptomatic atherosclerotic disease of the BA between February 1999 and November 2002. Patient records were analyzed for symptoms at presentation, percentage of angiographically visible stenosis, devices used, procedure-related morbidity, and clinical and radiographic outcomes. Patients with symptomatic intracranial vertebral artery stenosis but without concomitant severe (> 50%) BA stenosis were excluded from the study. Four patients were treated with direct stent placement, three with a staged procedure (these were included in a previous publication), and three with conventional stent placement. In the group treated with direct stent placement, a dense quadriparesis developed in two patients after the procedure. Computerized tomography or magnetic resonance imaging revealed infarction of the ventral pons in these patients. In the staged stent placement group, no permanent neurological complications occurred after the procedure and, in the conventional stent placement group, one of three patients experienced a neurological complication involving homonymous hemianopsia. CONCLUSIONS: Direct stent placement in the BA is associated with a relatively high complication rate, compared with a staged procedure. Complications may result from an embolic shower following disruption of atheromatous plaque debris attained using high-profile devices such as stents, as demonstrated by the postoperative imaging appearance of acute pontine infarctions. Additionally, displacement of debris by the stent into the ostia (snowplowing) of small brainstem perforating vessels may be responsible for the complications noted. Although direct stent placement in peripheral and coronary vessels has been shown to be safe, the authors suggest that direct stent placement in the BA should be avoided to minimize the risk of periprocedure morbidity.

Aged↗
PubMed2003

Cutting balloon to treat carotid in-stent stenosis: technical note.

Carotid artery in-stent stenosis, a possible long-term complication of carotid angioplasty and stenting, is currently treated by inflation of a non-compliant angioplasty balloon. Better initial results and less recurrence of stenosis have been documented in the coronary literature with the use of the Cutting Balloon (CB, Boston Scientific Interventional Technologies, San Diego, California) for angioplasty, in comparison with traditional balloon angioplasty. We report our collective experience with the use of the CB to treat carotid in-stent stenosis in three patients. Excellent angiographic and clinical results were achieved. No complications occurred. The lesions in two patients were successfully treated with the CB alone; adjunctive stent placement was required in a third patient. Our experience demonstrates the feasibility and safety of the CB for the treatment of carotid in-stent stenosis in three patients. Due to the less traumatic nature of this balloon, its use may result in a lower occurrence of in-stent stenosis as compared to a conventional angioplasty balloon. To our knowledge, this is the first report of the use of the CB for carotid in-stent stenosis.

Adult↗
PubMed2003

Apoptosis as a form of cell death in intracerebral hemorrhage.

OBJECTIVE: The goals of this study were to identify and quantify the presence of programmed cell death (apoptosis) in intracerebral hemorrhage (ICH) among human subjects. Recent evidence from laboratory models suggests that cell death in the perihematoma region may involve apoptosis. METHODS: Retrospective clinical and histological analyses were performed for patients with spontaneous ICH who underwent surgical evacuation. Quantification of apoptotic cells was performed in sections obtained from the perihematoma region from 12 patients with ICH and stained with the terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling method. Necrosis was identified on the basis of morphological criteria, using hematoxylin and eosin staining. RESULTS: Evidence of apoptosis was present in surgical specimens obtained from 10 of the 12 patients. The mean number of apoptotic cells in the perihematoma region in each patient specimen was 38% (range, 0-90%). For five patients, more than one-half of the total cells observed were apoptotic. Apoptosis was observed in specimens obtained within 1 day, 2 days, and 5 days after the onset of symptoms. No terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling-positive cells were observed in specimens from the two patients with cerebellar hematomas. The mean proportion of necrotic cells in the perihematoma region in each patient specimen was 25% (range, 0-100%). There was a prominent excess of apoptotic cells, in comparison with necrotic cells, for 6 of the 12 patients who underwent hematoma evacuation. For five other patients, similar proportions of apoptotic and necrotic cells were observed. Necrosis was the predominant finding for only one patient, who underwent late surgical evacuation on Day 5. CONCLUSION: These observations suggest that apoptosis represents a prominent form of cell death associated with ICH in the perihematoma region. Further studies are required to define the mediators of apoptosis in ICH.

Adult↗
PubMed2003

Coil embolization of intracranial aneurysms.

Since the introduction of Guglielmi detachable coils more than a decade ago, the coiling technique for the treatment of intracranial aneurysms has been enhanced with technical and technological refinements. Both neurosurgeons and neuroradiologists have participated in this process. Stents and nondetachable balloons have been useful in the coiling of some wide-necked aneurysms. An increasing number of neurosurgeons are pursuing fellowship training in neuroendovascular techniques. Moreover, most neurosurgeons work closely with neurointerventionists. In this communication, technical preferences developed during our experience with intracranial aneurysm coiling are summarized.

Attitude of Health Personnel↗
PubMed2003

Educational attainment and risk of stroke and myocardial infarction.

BACKGROUND: Prior reports have suggested that low educational attainment could be associated with higher incidence of some of the cardiovascular conditions. MATERIAL/METHODS: We evaluated the association of educational attainment (> or =12 years or <12 years) with the incidence of fatal strokes, ischemic stroke, intracerebral hemorrhage, and myocardial infarction in a cohort of 21,443 United States adults who participated in either the First National Health and Nutrition Examination Survey (NHANES-I) Epidemiologic Follow-up Study (NHEFS) or the Second National Health and Nutrition Examination Survey Mortality Follow-up Study (NHANES-II). Cox proportional hazards analyses were used to examine the relationships. RESULTS: During a mean follow-up period of 15.2+/-4.6 years, the risk for all fatal strokes was increased in persons who reported less than 12 years of education. The increased risk was more prominent in persons aged 50 years or less (relative risk [RR], 2.6; 95% confidence interval [CI], 1.1-6.0) compared with persons aged greater than 50 years (RR, 1.3, 95% CI, 1.0-1.6). A higher risk of myocardial infarction associated with less than 12 years of education was observed in both persons aged 50 years or less (RR 1.7, 95% CI 1.2-2.4) and those aged greater than 50 years (RR 1.3, 95% CI 1.1-1.5). The risk for fatal intracerebral hemorrhages (RR 2.0, 95% CI 1.1-3.5) was higher in persons with less than 12 years of education (no significant interaction demonstrated with age). CONCLUSIONS: Educational attainment has a significant effect on the risk for stroke and myocardial infarction, independent of socioeconomic status and other cardiovascular risk factors.

Age Factors↗