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Hemorrhages After Ischemic Stroke: Relation to Age and Previous Hemorrhages in a Nationwide Cohort of 58 868 Patients
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences. (Akut- och internmedicin, Andreas Terént)
Lund University, Department of Laboratory Medicine.
Karolinska Institutet, Institute of Enviromental Medicine.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences. (Akut- och internmedicin, Andreas Terént)
2013 (English)In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 8, no 2, 80-86 p.Article in journal (Refereed) Published
Abstract [en]

Background:

In randomized controlled trials of secondary prevention after stroke, the risk of hemorrhage varies between 1% and 5% per year in patients with antithrombotic therapy, i.e. anticoagulants and antiplatelets.

Aim:

To explore the rate and the risk of hemorrhage after stroke in a nationwide cohort.

Methods:

We identified 58 868 first-ever ischemic stroke patients in the Swedish Stroke Register during 2001 to 2005 (=index stroke) and followed them by record linkage to the National Patient Register. Rates of hemorrhage and hazard ratios, for comparisons of rates between subgroups, were calculated.

Results:

Of the 58 586 ischemic stroke patients identified, 5527 (9.4%) had a history of hemorrhage. During follow-up (mean 2.0 years), 2876 patients endured a hemorrhage, giving an average hemorrhage rate of 2.6 (95% confidence interval 2.5-2.7) per 100 person-years. After index stroke, 11% of the patients were discharged with anticoagulants, and 79% with antiplatelets. Given the differences in baseline characteristics, the hemorrhage rates (per 100 person-years) were 2.5 (95% confidence interval 2.2-2.8), 2.4 (95% confidence interval 2.3-2.5), and 3.8 (95% confidence interval 3.5-4.2) in patients prescribed anticoagulants, antiplatelets, and no antithrombotics, respectively. There was an increased risk of hemorrhage in patients ≥75 years compared to those <75 years (hazard ratio = 1.61, 95% CI 1.49-1.73), and in patients with previous hemorrhages compared to those without (hazard ratio = 1.82, 95% confidence interval 1.64-2.02).

Conclusions:

When antithrombotics were used in large-scale clinical practice, the observed rates of hemorrhage were similar with anticoagulant therapy but increased with antiplatelet therapy, compared to rates reported in randomized controlled trials. Old age and previous hemorrhage were associated with an increased risk of hemorrhage after an ischemic stroke.

Place, publisher, year, edition, pages
2013. Vol. 8, no 2, 80-86 p.
Keyword [en]
Ischemic stroke, Age Groups, Antiplatelet and anticoagulant treatment for secondary stroke prevention, Hemorrhage
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-171611DOI: 10.1111/j.1747-4949.2011.00718.xISI: 000313880700006OAI: oai:DiVA.org:uu-171611DiVA: diva2:511758
Available from: 2012-03-23 Created: 2012-03-23 Last updated: 2017-12-07Bibliographically approved
In thesis
1. Outcome of Stroke Prevention: Analyses Based on Data from Riks-Stroke and Other Swedish National Registers
Open this publication in new window or tab >>Outcome of Stroke Prevention: Analyses Based on Data from Riks-Stroke and Other Swedish National Registers
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this thesis was to explore variations in stroke prevention and the effect of prevention on outcome. The studies were based on patients registered in the Swedish Stroke Register between 2001 and 2009 and although used to different extents in each paper, additional information was retrieved through linkage to The National Patient Register, the Cause of Death Register, the Prescribed Drug Register and the Total Population Register.

Cardiovascular risk factors were prevalent among ischemic stroke (IS) patients; however, they were not always prescribed the drugs recommended, and increasing age was an important negative predictor (Paper I).

After IS, the rate of hemorrhage in patients prescribed antiplatelet agents (2.4 per 100 person-years) was double to results from randomized controlled trails, but was similar for patients prescribed warfarin (2.5 per 100 person-years).  Age ≥75 years and previous hemorrhage were associated with a moderately increased risk of future hemorrhage (Paper II).

Among IS patients with atrial fibrillation, one-third was prescribed warfarin and two-thirds were prescribed antiplatelets. After adjustment for a propensity score (used to adjust for the non-randomized design), warfarin was associated with a reduced risk of death (0.67; 95% CI, 0.63-0.71) (Paper III). The rate of subsequent hemorrhagic stroke was 0.4 per 100 person-years and the risk did not change (HR 1.04; 95% CI, 0.73-1.48) when later years of the 2000s (inclusion period 2005-8: follow-up until 2009) was compared with earlier years (inclusion period 2001-4: follow-up until 2005) (Paper IV, cohort).

Although the risk of first-ever hemorrhagic stroke more than doubled with warfarin than without, the risk did not change between 2006 and 2009 (Paper IV, case-control).

In summary, the prescription of secondary preventive drugs varies with age, even though cardiovascular risk factors are prevalent in all ages. The risk of death and hemorrhage are affected by the type of antithrombotic prescribed. Therefore, it is important individual’s stroke and bleeding risks in stroke prevention are assessed.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. 52 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 757
Keyword
Stroke, Epidemiology, Age groups, Risk factors, Atrial fibrillation, Secondary prevention, Anticoagulants, Antiplatelets, Hemorrhage, Mortality.
National Category
Clinical Medicine
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-171871 (URN)978-91-554-8322-7 (ISBN)
Public defence
2012-05-16, Enghoffsalen, ing 50, Akademiska sjukhuset, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-04-24 Created: 2012-03-28 Last updated: 2012-08-01Bibliographically approved

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