Prior antiplatelet or anticoagulant therapy and mortality in stroke

Kwok, Chun Shing; Skinner, Jane; Metcalf, Anthony K.; Potter, John F.; Myint, Phyo Kyaw

doi:10.1136/heartjnl-2011-301076

Cited by 20 publications

(25 citation statements)

References 31 publications

(29 reference statements)

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“…It has been hypothesized that aspirin, if administered before acute ischemic stroke onset, may be of value as an agent that may reduce initial stroke severity and improve overall clinical outcome 4, 5, 6, 7, 8, 9, 10. Some studies have shown an association between prestroke antiplatelet use and lesser stroke severity,4, 5, 6 whereas others have not 7, 8, 9.…”

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confidence: 99%

Comparative Effectiveness of Prestroke Aspirin on Stroke Severity and Outcome

Park

Kang

Cho

et al. 2016

Annals of Neurology

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ObjectiveThe effect of prestroke aspirin use on initial severity, hemorrhagic transformation, and functional outcome of ischemic stroke is uncertain.MethodsUsing a multicenter stroke registry database, patients with acute ischemic stroke of three subtypes (large artery atherosclerosis [LAA], small vessel occlusion [SVO], or cardioembolism [CE]) were identified. NIH stroke scale (NIHSS) and hemorrhagic transformation at presentation and discharge modified Rankin Scale (mRS) were compared between prestroke aspirin users and nonusers.ResultsAmong the 10,433 patients, 1,914 (18.3%) reported prestroke aspirin use. On crude analysis, initial NIHSS scores of aspirin users were higher than nonusers (mean difference: 0.35; 95% confidence interval [CI]: 0.04–0.66). However, a multivariable analysis with an application of inverse probability of treatment weighting based on a propensity score of prestroke aspirin, having an interaction effect of prestroke aspirin use and stroke subtype in the model, showed less stroke severity for aspirin users in LAA, but not in SVO and CE than for nonusers; mean difference in NIHSS scores in LAA was –0.97 (95% CI: –1.45 to –0.49). With respect to hemorrhagic transformation and mRS, no significant interaction effects were found. Prestroke aspirin use increased the risk of hemorrhagic transformation (adjusted odd ratio: 1.34; 95% CI: 1.05–1.73), but decreased the odds of the higher discharge mRS (0.86; 0.76–0.96).InterpretationPrestroke aspirin use may reduce initial stroke severity in atherothrombotic stroke and can improve functional outcome at discharge despite an increase of hemorrhagic transformation irrespective of stroke subtype. Ann Neurol 2016;79:560–568

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confidence: 99%

Comparative Effectiveness of Prestroke Aspirin on Stroke Severity and Outcome

Park

Kang

Cho

et al. 2016

Annals of Neurology

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“…2 Better understanding of such determinants is important because these stroke subtypes have different pathophysiologies, different risk profiles, and different survival trajectories. 12 These cannot be tested in randomized trial setting, and such real-world events needed to be observed and reported through registry data. In this study, we examined the determinants and outcomes of ischemic and hemorrhagic stroke associated with PCI for ACS compared with those who underwent elective PCI using the British Cardiovascular Intervention Society registry in England and Wales, including over half a million participants.…”

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confidence: 99%

Determinants and Outcomes of Stroke Following Percutaneous Coronary Intervention by Indication

Myint

Kwok

Roffe

et al. 2016

Stroke

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Background and Purpose-Stroke after percutaneous coronary intervention (PCI) is a serious complication, but its determinants and outcomes after PCI in different clinical settings are poorly documented. Methods-The British Cardiovascular Intervention Society (BCIS) database was used to study 560 439 patients who underwent PCI in England and Wales between 2006 and 2013. We examined procedural-type specific determinants of ischemic and hemorrhagic stroke and the likelihood of subsequent 30-day mortality and in-hospital major adverse cardiovascular events (a composite of in-hospital mortality, myocardial infarction or reinfarction, and repeat revascularization). Results-A total of 705 stroke cases were recorded (80% ischemic). Stroke after an elective PCI or PCI for acute coronary syndrome indications was associated with a higher risk of adverse outcomes compared with those without stroke; 30-day mortality and major adverse cardiovascular events outcomes in fully adjusted model were odds ratios 37.90 (21.43-67.05) and 21.05 (13.25-33.44) for elective and 5.00 (3.96-6.31) and 6.25 (5.03-7.77) for acute coronary syndrome, respectively. Comparison of odds of these outcomes between these 2 settings showed no differences; corresponding odds ratios were 1.24 (0.64-2.43) and 0.63 (0.35-1.15), respectively. Conclusions-Hemorrhagic and ischemic stroke complications are uncommon, but serious complications can occur after PCI and are independently associated with worse mortality and major adverse cardiovascular events outcomes in both the elective and acute coronary syndrome setting irrespective of stroke type. Our study provides a better understanding of the risk factors and prognosis of stroke after PCI by procedure type, allowing physicians to provide more informed advice around stroke risk after PCI and counsel patients and their families around outcomes if such neurological complications occur.

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“…In the aforementioned Canadian study, in-hospital mortality rates also did not differ between patients who were on clopidogrel prior to ischemic stroke and those who were not on antiplatelet agents [13] . In a more recent small study, mortality at 7 and 30 days after stroke did not differ between patients who were receiving clopidogrel prior to ischemic stroke (n = 63) and those who were not [20] . However, all types of ischemic stroke were included in the former report and stroke severity at admission was not evaluated and not adjusted for in the analysis of mortality risk [20] .…”

Section: Discussionmentioning

confidence: 99%

“…However, other reports did not confirm these beneficial effects of aspirin [15][16][17][18][19] . On the other hand, very few studies assessed the effects of prior treatment with clopidogrel on acute non-cardioembolic ischemic stroke severity and outcome and yielded conflicting results [13,17,20] . If treatment with clopidogrel before stroke attenuates stroke severity and improves outcome, this would further support its use as a first-line agent in patients with non-cardioembolic ischemic stroke, who are at high risk for recurrent stroke.…”

Section: Introductionmentioning

confidence: 99%

Treatment with Clopidogrel Prior to Acute Non-Cardioembolic Ischemic Stroke Attenuates Stroke Severity

Τζιόμαλος

Giampatzis²,

Bouziana³

et al. 2016

Cerebrovasc Dis

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Background: Clopidogrel reduces the risk of non-cardioembolic ischemic stroke, but it is unclear whether it affects the severity and outcome of stroke. We aimed at evaluating the effect of prior treatment with clopidogrel on acute non-cardioembolic ischemic stroke severity and in-hospital outcome. Methods: We prospectively studied 608 consecutive patients (39.5% males, age 79.1 ± 6.6 years) who were admitted with acute ischemic stroke. The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS ≥21. The outcome was assessed using the dependency rates that prevailed at the time of discharge (i.e. modified Rankin scale between 2 and 5) and with in-hospital mortality. Results: At admission, 397 patients did not have atrial fibrillation or heart valve disease. Among these 397 patients, 69 were receiving monotherapy with clopidogrel prior to stroke, 69 were receiving monotherapy with aspirin and 236 patients were not on any antiplatelet treatment. The prevalence of severe stroke was lower in patients who were receiving clopidogrel than in patients who were receiving aspirin and patients who were not on antiplatelets (1.4, 13.0 and 11.0%, respectively; p < 0.05). Independent predictors of severe stroke at admission were male gender (relative risk (RR) 0.31, 95% CI 0.12-0.78, p < 0.05) and treatment with clopidogrel prior to stroke compared with no antiplatelet treatment (RR 0.13, 95% CI 0.02-0.97, p < 0.05). Treatment with aspirin prior to stroke did not predict severe stroke compared with no antiplatelet treatment (RR 1.24, 95% CI 0.51-2.98, p = NS). The rate of dependency at discharge did not differ between patients who were receiving clopidogrel, patients who were receiving aspirin and those who were not on antiplatelets (57.9, 47.8 and 59.7%, respectively; p = NS). Independent predictors of dependency at discharge were age (RR 1.12, 95% CI 1.05-1.19, p < 0.001) and NIHSS at admission (RR 1.67, 95% CI 1.46-1.92, p < 0.001). In-hospital mortality rate also did not differ between patients who were receiving clopidogrel, patients who were receiving aspirin and those who were not on antiplatelets (4.3, 4.3 and 5.0%, respectively; p = NS). The only independent predictor of in-hospital mortality was NIHSS at admission (RR 1.22, 95% CI 1.14-1.30, p < 0.001). Conclusions: Treatment with clopidogrel prior to acute non-cardioembolic ischemic stroke attenuates the severity of stroke at admission but does not appear to affect the functional outcome at discharge or the in-hospital mortality of these patients.

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Prior antiplatelet or anticoagulant therapy and mortality in stroke

Cited by 20 publications

References 31 publications

Comparative Effectiveness of Prestroke Aspirin on Stroke Severity and Outcome

Comparative Effectiveness of Prestroke Aspirin on Stroke Severity and Outcome

Determinants and Outcomes of Stroke Following Percutaneous Coronary Intervention by Indication

Treatment with Clopidogrel Prior to Acute Non-Cardioembolic Ischemic Stroke Attenuates Stroke Severity

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