The prevalence of anticoagulant treatment in Sweden has increased in recent years. However, such treatment may be associated with a risk of serious complications. At 5-year follow-up of 115 primary care patients treated with anticoagulants in 1992, 39 were found to have died, eight of anticoagulant-induced bleeding complications (six of intracranial haemorrhages, and two after profuse gastro-intestinal haemorrhages). In only two of these cases, had an adverse reaction been diagnosed. The fatal complication rate was estimated to be 2.1 per cent per treatment year. There were 17 major complications requiring hospitalisation, the estimated rate being 4.4 per cent per treatment year. Three patients died of thromboembolic episodes during anticoagulant treatment, and a further three after completed treatment.
In patients with ischemic stroke of non-cardioembolic origin, acetylsalicylic acid, clopidogrel, or a combination of acetylsalicylic acid and dipyridamole are recommended for the prevention of a recurrent stroke. The purpose of this study was to examine the risk of bleeding or recurrent stroke associated with these three treatments.
Patients who were discharged with first-time ischemic stroke from 2007-2010, with no history of atrial fibrillation were identified from Danish nationwide registries. Hazard ratios (HRs) and 1-year risks of recurrent ischemic stroke and bleeding were calculated for each antiplatelet regimen.
Among patients discharged after first-time ischemic stroke, 3043 patients were treated with acetylsalicylic acid, 12,295 with a combination of acetylsalicylic acid and dipyridamole, and 3885 with clopidogrel. Adjusted HRs for clopidogrel versus the combination of acetylsalicylic acid and dipyridamole were 1.02 (95% confidence interval [CI]: 0.89-1.17) for ischemic stroke and 1.06 (95% CI: 0.83-1.35) for bleeding. Adjusted HRs for acetylsalicylic acid versus the combination of acetylsalicylic acid and dipyridamole were 1.48 (95% CI: 1.31-1.67) for stroke and 1.47 (95% CI: 1.18-1.82) for bleeding. Clopidogrel versus acetylsalicylic acid yielded HRs of 0.69 (95% CI: 0.59-0.81) and 0.72 (95% CI: 0.55-0.96) for stroke and bleeding, respectively. The 1-year predicted risks associated with acetylsalicylic acid, the combination of acetylsalicylic acid and dipyridamole, and clopidogrel were 11.1 (95% CI: 10.2-12.2), 7.7 (95% CI: 7.3-8.3), and 8.0 (95% CI: 6.9-8.7) for ischemic stroke, respectively; while, the risks for bleeding were 3.4 (95% CI: 2.8-3.9), 2.4 (95% CI: 2.1-2.7), and 2.4 (95% CI: 1.9-2.9), respectively.
Clopidogrel and the combination of acetylsalicylic acid and dipyridamole were associated with similar risks for recurrent ischemic stroke and bleeding; whereas acetylsalicylic acid was associated with higher risks for both ischemic stroke and bleeding. The latter finding may partially be explained by selection bias.
Cites: Circulation. 2007 Nov 6;116(19):2157-6417967776
Selective serotonin reuptake inhibitors (SSRIs) have been associated with an increased risk of bleeding but also a possible neuroprotective effect in stroke. We aimed to examine the implications of prestroke SSRI use in hemorrhagic and ischemic stroke.
We conducted a registry-based propensity score-matched follow-up study among first-ever patients with hemorrhage and ischemic stroke in Denmark (2003-2012). Multiple conditional logistic regression was used to compute adjusted odds ratios of severe stroke and death within 30 days.
Among 1252 hemorrhagic strokes (626 prestroke SSRI users and 626 propensity score-matched nonusers), prestroke SSRI use was associated with an increased risk of the strokes being severe (adjusted propensity score-matched odds ratios, 1.41; confidence interval, 1.08-1.84) and an increased risk of death within 30 days (adjusted propensity score-matched odds ratios, 1.60; confidence interval, 1.17-2.18). Among 8956 patients with ischemic stroke (4478 prestroke SSRI users and 4478 propensity score-matched nonusers), prestroke SSRI use was not associated with the risk of severe stroke or death within 30 days.
Prestroke SSRI use is associated with increased stroke severity and mortality in patients with hemorrhagic stroke. Although prestroke depression in itself may increase stroke severity and mortality, this was not found in SSRI users with ischemic stroke.
Fibrinolytic therapy increases the risk of bleeding events. TNK-tPA (tenecteplase) is a variant of rt-PA with greater fibrin specificity and reduced plasma clearance that can be given as a single bolus. We compared the incidence and predictors of bleeding events after treatment with TNK-tPA and rt-PA.
In the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT)-2 trial, 16 949 patients with acute myocardial infarction were randomly assigned a single weight-adjusted bolus of TNK-tPA or a 90-min infusion of rt-PA. A total of 4.66% of patients in the TNK-tPA group experienced major non-cerebral bleeding, in comparison with 5.94% in the rt-PA group (P=0.0002). This lower rate was associated with a significant reduction in the need for blood transfusion (4.25% vs 5.49%, P=0.0003) and was consistent across subgroups. Independent risk factors for major bleeding were older age, female gender, lower body weight, enrolment in the U.S.A. and a diastolic blood pressure 75 years and body weight 75 years of age who weighed
Comment In: Eur Heart J. 2001 Dec;22(24):2221-311728139
Tools to predict the clinical response after intravenous thrombolytic therapy (tPA) are scarce. The iScore is an existing validated tool to estimate outcomes after an acute ischemic stroke. The purpose of this study was to determine the ability of the iScore to predict clinical response and risk of hemorrhagic transformation after tPA.
We applied the iScore (www.sorcan.ca/iscore) to patients presenting with an acute ischemic stroke at 11 stroke centers in Ontario, Canada, between 2003 and 2009 identified from the Registry of the Canadian Stroke Network. A cohort of patients with stroke treated at 154 centers in Ontario was used for external validation. We compared outcomes between patients receiving and not receiving tPA after adjusting for differences in baseline characteristics using propensity-score matching. Patients were stratified into 3 a priori defined groups according to stroke severity using the iScore.
Among 12 686 patients with an acute ischemic stroke, 1696 (13.4%) received intravenous thrombolysis. Higher iScores were associated with poor outcomes in both the tPA and non-tPA groups (P
BACKGROUND AND PURPOSE: Nonsteroidal anti-inflammatory drugs (NSAIDs) have effects on hemostasis and have been associated with an increased risk of bleeding. However, data relating the use of nonaspirin NSAIDs and risk of intracerebral hemorrhage (ICH) are sparse. METHODS: Using data from the County Hospital Patient Register and the Civil Registration System of North Jutland County, Denmark, we identified 912 cases of first-time ICH and 9059 sex- and age-matched population-based controls in the period of 1991 to 1999. All prescriptions for nonaspirin NSAIDs before the date of admission for ICH were identified through a population-based prescription database. Conditional logistic regression was used to adjust for potential confounding factors, including previous discharge diagnoses of hypertension, chronic bronchitis and emphysema, alcoholism, liver cirrhosis, diabetes mellitus, and prescriptions for insulin or oral hypoglycemic agents, antihypertensive agents, lipid-lowering agents, low-dose aspirin, high-dose aspirin, and oral anticoagulants. RESULTS: No overall association was found between prescription for nonaspirin NSAIDs in the preceding 30, 60, or 90 days and risk of ICH; ie, odds ratios ranged from 0.92 (95% CI, 0.70 to 1.21) to 1.13 (95% CI, 0.81 to 1.58). Furthermore, there was no increased risk of ICH associated with prescription for nonaspirin NSAIDs when the study population was stratified by age, sex, and a previous discharge diagnosis of hypertension. CONCLUSIONS: Patients prescribed nonaspirin NSAIDs were not at an overall increased risk of being hospitalized for ICH. This reassuring finding was seen in all examined subgroups, including the elderly and patients with a previous discharge diagnosis of hypertension.