Introduction
Materials and methods
Study design
Calculation of sample size for specific objective
Definition and exclusion criteria
Neurological assessment
Imaging studies and laboratory investigations
Blood sampling and assessment of circulating EPC level by flow cytometry
Medications
Statistical analysis
Results
Baseline characteristics and laboratory findings of study patients and healthy controls
Variables | Group 1 (n= 83)† | Group 2 (n= 84)† | Healthy Control (n= 60) | P-value* |
---|---|---|---|---|
Age (y) (mean ± SD), | 63.7 ± 11.4 | 67.0 ± 11.1 | 64.1 ± 6.0 | 0.078 |
Male, % (n) | 65.1% (54) | 66.7% (56) | 65.0% (39) | 0.969 |
Hypertension, % (n) | 63.9% (53) | 73.8% (62) | -- | 0.165 |
Diabetes mellitus, % (n) | 37.4% (31) | 32.1% (27) | -- | 0.480 |
Current smoking, % (n) | 36.1% (30) | 273.4% (23) | -- | 0.224 |
Previous stroke by history, % (n) | 24.1% (20) | 21.4% (18) | -- | 0.681 |
Previous stroke by MRI, % (n) | 62.7% (52) | 57.1% (48) | -- | 0.468 |
Old myocardial infarction, % (n) | 8.4% (7) | 6.0% (5) | -- | 0.549 |
RBC count (×106/μL) | 4.74 ± 0.67 | 4.68 ± 0.68 | 4.81 ± 0.64 | 0.561 |
Hemoglobin (g/dL) | 14.0 ± 2.0 | 14.1 ± 1.8 | 14.05 ± 1.56 | 0.963 |
Hematocrit (%) | 41.3 ± 5.9 | 41.4 ± 6.0 | 40.9 ± 6.1 | 0.877 |
WBC count (×103/μL) | 7.82 ± 2.38a | 7.83 ± 2.37a | 5.91 ± 1.84b | <0.0001 |
Circulating level of EPCs at 48 h | ||||
CD31/CD34 (%) | 1.65 ± 0.91a | 1.75 ± 1.03a | 1.13 ± 0.74b | 0.0003 |
CD62E/CD34 (%) | 1.21 ± 0.86a | 1.16 ± 0.76a | 0.93 ± 0.83b | 0.025 |
KDR/CD34 (%) | 1.34 ± 0.77a | 1.37 ± 0.89a | 1.03 ± 0.79b | 0.03 |
Total cholesterol level (mg/dL) | 186.6 ± 41.2 | 190.1 ± 42.7 | 193.2 ± 36.4 | 0.621 |
HDL (mg/dL) | 44.6 ± 10.8a | 49.2 ± 17.3a | 53.8 ± 14.8b | 0.001 |
LDL (mg/dL) | 116.2 ± 35.7 | 115.2 ± 39.4 | 117.2 ± 30.9 | 0.949 |
Creatinine (mg/dL) | 1.00 ± 0.38 | 1.02 ± 0.43 | 1.01 ± 0.24 | 0.915 |
BMI (kg/m2) | 25.1 ± 3.5 | 24.2 ± 3.9 | 24.7 ± 3.1 | 0.225 |
HbA1C level, % | 6.73 ± 1.85 | 6.96 ± 1.88 | -- | 0.468 |
SBP (mm Hg) | 144 ± 20a | 143 ± 21a | 136 ± 18b | 0.031 |
DBP (mm Hg) | 83 ± 12 | 84 ± 11 | 85 ± 11 | 0.231 |
Significant ECCA stenosis, % (n) | 24.1% (20) | 17.9%% (15) | -- | 0.322 |
Statin therapy | 43.4% (36) | 45.2% (38) | -- | 0.808 |
ACEI/ARB therapy | 39.8% (33) | 38.1% (32) | -- | 0.826 |
EPO therapy-related adverse events | ||||
Allergy | 0% (0) | 0% (0) | -- | |
Polycythemia | 0% (0) | 0% (0) | -- | |
Thrombosis event | 0% (0) | 0% (0) | -- |
Laboratory findings, circulating level of EPCs at three time points, neurological status, and clinical outcome after acute IS
Variables | Group 1† (n= 83) | Group 2† (n= 84) | P- value* |
---|---|---|---|
Circulating level of EPCs at 48 h | |||
CD31/CD34 (%) | 1.65 ± 0.91 | 1.75 ± 1.03 | 0.530 |
CD62E/CD34 (%) | 1.21 ± 0.86 | 1.16 ± 0.76 | 0.704 |
KDR/CD34 (%) | 1.34 ± 0.76 | 1.37 ± 0.89 | 0.791 |
Circulating level of EPCs on day 7 | |||
CD31/CD34 (%) | 1.52 ± 1.06 | 1.48 ± 0.89 | 0.801 |
CD62E/CD34 (%) | 1.11 ± 0.76 | 1.14 ± 0.75 | 0.855 |
KDR/CD34 (%) | 1.16 ± 0.70 | 1.24 ± 0.80 | 0.523 |
Circulating level of EPCs on day 21 | |||
CD31/CD34 (%) | 2.28 ± 1.48 | 1.64 ± 0.79 | 0.002 |
CD62E/CD34 (%) | 1.50 ± 1.13 | 1.14 ± 0.72 | 0.030 |
KDR/CD34 (%) | 1.81 ± 1.25 | 1.22 ± 0.71 | 0.001 |
RBC count (×106/mL) on day 21 | 4.56 ± 0.73 | 4.62 ± 1.16 | 0.719 |
Hemoglobin (g/dL) on day 21 | 13.7 ± 1.9 | 13.8 ± 3.3 | 0.746 |
Hematocrit (%) on day 21 | 41.0 ± 5.4 | 39.9 ± 6.4 | 0.309 |
WBC count (×103/mL) on day 21 | 7.68 ± 6.30 | 7.27 ± 2.47 | 0.645 |
Variables | Group 1† (n= 83) | Group 2† (n= 84) | P- value* |
---|---|---|---|
NIHSS at 48 h | 6.78 ± 4.60 | 7.35 ± 7.55 | 0.562 |
Modified Rankin Scale score at 48 h | 3.23 ± 1.38 | 2.89 ± 1.62 | 0.152 |
Barthel Index at 48 h | 55.7 ± 30.5 | 59.5 ± 36.0 | 0.467 |
NIHSS on day 90 | 4.27 ± 5.39 | 5.49 ± 7.77 | 0.239 |
Recurrent stroke, % (n) | 0% (0) | 9.5% (8) | 0.007 |
90-day mortality, % (n) | 2.4% (2) | 1.2% (1) | 0.621 |
Primary end point, % (n)‡ | 2.4% (2) | 10.7% (9) | 0.057 |
NIHSS ≥ 8.0 | 14.5% (12) | 29.8% (25) | 0.017 |
Combined MANE, % (n)¶ | 16.9% (14) | 36.9% (31) | 0.004 |
Correlation between three individualized neurological assessment scales upon presentation and the circulating level of EPCs
Time course of circulating level of EPCs
Variables | At 48 h | On Day 7 | On Day 21 | P- value* |
---|---|---|---|---|
Circulating EPCs in group 1 | ||||
CD31/CD34 (%) | 1.65 ± 0.91a | 1.52 ± 1.06a | 2.28 ± 1.48b | <0.0001 |
CD62E/CD34 (%) | 1.21 ± 0.86a | 1.11 ± 0.76a | 1.50 ± 1.13b | 0.0409 |
KDR/CD34 (%) | 1.34 ± 0.76a | 1.16 ± 0.70a | 1.81 ± 1.25b | 0.0001 |
Circulating EPCs in group 2 | ||||
CD31/CD34 (%) | 1.75 ± 1.03 | 1.48 ± 0.89 | 1.64 ± 0.79 | 0.071 |
CD62E/CD34 (%) | 1.16 ± 0.76 | 1.14 ± 0.75 | 1.14 ± 0.72 | 0.973 |
KDR/CD34 (%) | 1.37 ± 0.89 | 1.24 ± 0.80 | 1.22 ± 0.72 | 0.267 |
Univariate and multivariate analyses of predictors for 90-day MANE
Variables | Odds Ratio | 95% CI | P- value |
---|---|---|---|
Univariate
| |||
Systolic blood pressure* | 0.978 | 0.960 to 0.996 | 0.017 |
Diastolic blood pressure* | 0.962 | 0.931 to 0.994 | 0.019 |
Total cholesterol level | 1.012 | 1.003 to 1.021 | 0.006 |
Low-density lipoprotein | 1.013 | 1.003 to 1.022 | 0.010 |
EPO therapy | 0.347 | 0.168 to 0.717 | 0.004 |
KDR/CD34 | 0.609 | 0.373 to 0.995 | 0.048 |
Multiple Stepwise
| |||
Total cholesterol level | 1.012 | 1.003 to 1.021 | 0.010 |
Systolic blood pressure* | 0.979 | 0.960 to 0.998 | 0.031 |
KDR/CD34 | 0.583 | 0.341 to 0.997 | 0.049 |
EPO therapy | 0.334 | 0.153 to 0.730 | 0.006 |
Univariate and multivariate analyses of predictors for 90-day combined end point (recurrent stroke or death)
Variables | Odds Ratio | 95% CI | P-value |
---|---|---|---|
Univariate
| |||
High-density lipoprotein | 0.921 | 0.857 to 0.990 | 0.026 |
EPO therapy | 0.206 | 0.043 to 0.983 | 0.004 |
Creatinine | 3.250 | 1.045 to 10.109 | 0.042 |
Multiple Stepwise
| |||
High-density lipoprotein | 0.909 | 0.842 to 0.983 | 0.016 |
EPO therapy | 0.155 | 0.031 to 0.772 | 0.023 |
Discussion
Value and level of circulating EPCs after acute IS
Impact of EPO therapy effectively improves 90-day prognostic outcome after IS
Other independent predictors of 90-day MANE
Study limitations
Conclusions
Key messages
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EPO therapy in acute phase of IS was associated with an increase in circulating levels of EPCs at the convalescent phase of IS.
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EPO therapy was significantly associated with a reduction in the incidence of 90-day recurrent stroke.
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EPO therapy and increased circulating EPC (E3) levels were significantly and independently predictive of decreased 90-day MANE.