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Trombara F, Cosentino N, Marenzi G. Intracranial haemorrhage in acute myocardial infarction: A rare but dramatic complication. Int J Cardiol 2023; 391:131300. [PMID: 37657670 DOI: 10.1016/j.ijcard.2023.131300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/03/2023]
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Park D, Kim MC, Hong D, Jeong YS, Kim HS, Kim JH. Recurrence and Mortality Risks in Patients with First Incident Acute Stroke or Myocardial Infarction: A Longitudinal Study Using the Korean National Health Insurance Service Database. J Clin Med 2023; 12:jcm12020568. [PMID: 36675497 PMCID: PMC9865804 DOI: 10.3390/jcm12020568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/12/2023] Open
Abstract
Background: We aimed to identify the long-term risk of recurrence and mortality in patients who experienced acute ischemic stroke (AIS), acute myocardial infarction (AMI), or acute hemorrhagic stroke (AHS) using a population-level database. Methods: This retrospective cohort study included adults aged ≥55 years diagnosed with AIS, AMI, and AHS in the National Health Insurance Service Database between 2004 and 2007. The target outcomes were secondary AIS, AMI, AHS, and all-cause mortality. Predetermined covariates, such as age, sex, socioeconomic status, hypertension, diabetes, and dyslipidemia, were adjusted. Results: We included 151,181, 49,077, and 41,636 patients in the AIS, AHS, and AMI groups, respectively. The AMI (adjusted hazard ratio [aHR], 0.318; 95% confidence interval [CI], 0.306−0.330; p < 0.001) and AHS (aHR, 0.489; 95% CI, 0.472−0.506; p < 0.001) groups had a significantly lower risk of developing secondary AIS than the AIS group. The risk of developing secondary AMI was significantly lower in the AMI (aHR, 0.388; 95% CI, 0.348−0.433; p < 0.001) and AHS (aHR, 0.711; 95% CI, 0.640−0.790; p < 0.001) groups than in the AIS group. Initial AHS was a decisive risk factor for secondary AHS (aHR, 8.546; 95% CI, 8.218−8.887; p < 0.001). The AMI (aHR, 1.436; 95% CI, 1.412−1.461; p < 0.001) and AHS (aHR, 1.328; 95% CI, 1.309−1.348; p < 0.001) groups were associated with a significantly higher risk of long-term mortality than the AIS group. Conclusion: Our results elucidated that initial AIS was a significant risk factor for recurrent AIS and AMI; initial AHS was a decisive risk factor for developing secondary AHS. Further, AMI and AHS were more closely related to long-term mortality than AIS.
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Affiliation(s)
- Dougho Park
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang 37659, Republic of Korea
- Department of Medical Science and Engineering, School of Convergence Science and Technology, Pohang University of Science and Technology, Pohang 37673, Republic of Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang 37659, Republic of Korea
| | - Daeyoung Hong
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang 37659, Republic of Korea
| | - Yong-Suk Jeong
- Department of Cardiology, Pohang Stroke and Spine Hospital, Pohang 37659, Republic of Korea
| | - Hyoung Seop Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang 10444, Republic of Korea
- Correspondence: (H.S.K.); (J.H.K.)
| | - Jong Hun Kim
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang 10444, Republic of Korea
- Correspondence: (H.S.K.); (J.H.K.)
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Kim JH, Lee PH, Kim HJ, Kim JB, Park S, Kyoung DS, Kang SJ, Lee SW, Kim YH, Lee CW, Chung CH, Lee JW, Park SW. Incidence and predictors of intracranial bleeding after coronary artery bypass graft surgery. Front Cardiovasc Med 2022; 9:863590. [PMID: 36035927 PMCID: PMC9411799 DOI: 10.3389/fcvm.2022.863590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background There is a paucity of direct data on the incidence and predictors of intracranial bleeding (ICB) after coronary artery bypass graft surgery (CABG). Methods The Korean National Health Insurance database was used to identify patients without prior ICB who underwent CABG. The outcomes of interest were the time-dependent incidence rates of ICB and the associated mortality. Results Among 35,021 patients who underwent CABG between 2007 and 2018, 895 (2.6%) experienced an ICB during a median follow-up of 6.0 years. The 1-year cumulative incidence of ICB was 0.76%, with a relatively high incidence rate (9.93 cases per 1,000 person-years) within the first 1–30 days. Subsequent incidence rates showed a sharp decline until 3 years, followed by a steady decrease up to 10 years. The 1-year mortality rate after ICB was 38.1%, with most deaths occurring within 30 days (23.6%). The predictors of ICB after CABG were age ≥ 75 years, hypertension, pre-existing dementia, history of ischemic stroke or transient ischemic attack, and end-stage renal disease. Conclusions In an unselected nationwide population undergoing CABG, the incidence of ICB was non-negligible and showed a relatively high incidence rate during the early postoperative period. Post-CABG ICB was associated with a high risk of premature death. Further research is needed to stratify high-risk patients and personalize therapeutic decisions for preventing ICB after CABG.
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Affiliation(s)
- Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Pil Hyung Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- *Correspondence: Pil Hyung Lee,
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sojeong Park
- Data Science Team, Hanmi Pharmaceutical Co., Ltd., Seoul, South Korea
| | - Dae-Sung Kyoung
- Data Science Team, Hanmi Pharmaceutical Co., Ltd., Seoul, South Korea
| | - Soo-Jin Kang
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Hak Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheol Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong-Wook Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Boyanpally A, Cutting S, Furie K. Acute Ischemic Stroke Associated with Myocardial Infarction: Challenges and Management. Semin Neurol 2021; 41:331-339. [PMID: 33851390 DOI: 10.1055/s-0041-1726333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) may co-occur simultaneously or in close temporal succession, with occurrence of one ischemic vascular event increasing a patient's risk for the other. Both employ time-sensitive treatments, and both benefit from expert consultation. Patients are at increased risk of stroke for up to 3 months following AMI, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, provided anterior wall myocardial involvement has been carefully evaluated. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality.
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Affiliation(s)
- Anusha Boyanpally
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Shawna Cutting
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island
| | - Karen Furie
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island
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Intracranial Hemorrhage Complicating Acute Myocardial Infarction: An 18-Year National Study of Temporal Trends, Predictors, and Outcomes. J Clin Med 2020; 9:jcm9092717. [PMID: 32842643 PMCID: PMC7565584 DOI: 10.3390/jcm9092717] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is a paucity of contemporary data on the burden of intracranial hemorrhage (ICH) complicating acute myocardial infarction (AMI). This study sought to evaluate the temporal trends, predictors, and outcomes of ICH in AMI. METHODS The National Inpatient Sample (2000-2017) was used to identify adult (>18 years) AMI admissions with ICH. In-hospital mortality, hospitalization costs, length of stay, and measure of functional ability were the outcomes of interest. The discharge destination along with use of tracheostomy and percutaneous endoscopic gastrostomy were used to estimate functional burden. RESULTS Of a total 11,622,528 AMI admissions, 23,422 (0.2%) had concomitant ICH. Compared to those without, the ICH cohort was on average older, female, of non-White race, had greater comorbidities, and had higher rates of arrhythmias (all p < 0.001). Female sex, non-White race, ST-segment elevation AMI presentation, use of fibrinolytics, mechanical circulatory support, and invasive mechanical ventilation were identified as individual predictors of ICH. The AMI admissions with ICH received less frequent coronary angiography (46.9% vs. 63.8%), percutaneous coronary intervention (22.7% vs. 41.8%), and coronary artery bypass grafting (5.4% vs. 9.2%), as compared to those without (p < 0.001). ICH was associated with a significantly higher in-hospital mortality (41.4% vs. 6.1%; adjusted OR 5.65 (95% CI 5.47-5.84); p < 0.001), longer hospital length of stay, higher hospitalization costs, and greater use of percutaneous endoscopic gastrostomy (all p < 0.001). Among ICH survivors (N = 13, 689), 81.3% had a poor functional outcome at discharge. CONCLUSIONS ICH causes a substantial burden in AMI due to associated higher in-hospital mortality and poor functional outcomes.
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Burlacu A, Genovesi S, Basile C, Ortiz A, Mitra S, Kirmizis D, Kanbay M, Davenport A, van der Sande F, Covic A. Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies. J Nephrol 2020; 34:39-51. [PMID: 32472526 DOI: 10.1007/s40620-020-00758-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/23/2020] [Indexed: 12/31/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to "therapeutic nihilism", which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Nephrology Unit, San Gerardo Hospital, Monza, Italy, University of Milan-Bicocca, Milan, Italy
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Via Battisti 192, Acquaviva delle Fonti, 74121, Taranto, Italy. .,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
| | - Alberto Ortiz
- FRIAT and REDINREN, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust and University of Manchester, Oxford Road, Manchester, UK
| | | | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Andrew Davenport
- Division of Medicine, UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Frank van der Sande
- Division of Nephrology, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center-'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania.,The Academy of Romanian Scientists (AOSR), Bucharest, Romania
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Dawson LP, Cole JA, Lancefield TF, Ajani AE, Andrianopoulos N, Thrift AG, Clark DJ, Brennan AL, Freeman M, O'Brien J, Sebastian M, Chan W, Shaw JA, Dinh D, Reid CM, Duffy SJ. Incidence and risk factors for stroke following percutaneous coronary intervention. Int J Stroke 2020; 15:909-922. [PMID: 32248767 DOI: 10.1177/1747493020912607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stroke rates and risk factors may change as percutaneous coronary intervention practice evolves and no data are available comparing stroke incidence after percutaneous coronary intervention to the general population. AIMS This study aimed to identify the incidence and risk factors for inpatient and subsequent stroke following percutaneous coronary intervention with comparison to age-matched controls. METHODS Data were prospectively collected from 22,618 patients undergoing percutaneous coronary intervention in the Melbourne Interventional Group registry (2005-2015). The cohort was compared to the North-East Melbourne Stroke Incidence Study population-based cohort (1997-1999) and predefined variables assessed for association with inpatient or outpatient stroke. RESULTS Inpatient stroke occurred in 0.33% (65.3% ischemic, 28.0% haemorrhagic, and 6.7% cause unknown), while outpatient stroke occurred in 0.55%. Inpatient and outpatient stroke were associated with higher rates of in-hospital major adverse cardiovascular outcomes (p < 0.0001) and mortality (p < 0.0001), as well as 12-month mortality (p < 0.0001). Factors independently associated with inpatient stroke were renal impairment, ST-elevation myocardial infarction, previous stroke, left ventricular ejection fraction 30-45%, and female sex, while those associated with outpatient stroke were previous stroke, chronic lung disease, previous myocardial infarction, rheumatoid arthritis, female sex, and older age. Compared to the age-standardized population-based cohort, stroke rates in the 12 months following discharge were higher for percutaneous coronary intervention patients <65 years old, but lower for percutaneous coronary intervention patients ≥65 years old. CONCLUSIONS Risk of inpatient stroke following percutaneous coronary intervention appears to be largely associated with clinical status at presentation, while outpatient stroke relates more to age and chronic disease. Compared to the general population, outpatient stroke rates following percutaneous coronary intervention are higher for younger, but not older, patients.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Justin A Cole
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Jessica O'Brien
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | - Martin Sebastian
- Department of Cardiology, University Hospital Geelong, Geelong, Australia
| | - William Chan
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - James A Shaw
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Australia
| | - Stephen J Duffy
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Bhandari M, Vishwakarma P, Sethi R, Pradhan A. Stroke Complicating Acute ST Elevation Myocardial Infarction-Current Concepts. Int J Angiol 2019; 28:226-230. [PMID: 31787820 DOI: 10.1055/s-0039-1695049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Myocardial infarction (MI) is one of the leading causes of mortality today both in developed and developing countries alike. Advancement in the pharmacotherapy and revascularization techniques has resulted in drastic improvement in survival. Most of the complications of MI can be managed adequately resulting in reduced mortality from MI in the recent years. However, mortality from stroke following acute MI remains high even today. Here, we discuss the incidence, risk factors, and management of stroke following acute ST elevation MI.
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Affiliation(s)
- Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow, India
| | | | - Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, India
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Ogunbayo GO, Pecha R, Misumida N, Hillerson D, Elbadawi A, Abdel-Latif A, Elayi CS, Messerli AW, Smyth SS. Relation of CHA 2DS 2VASC Score With Hemorrhagic Stroke and Mortality in Patients Undergoing Fibrinolytic Therapy for ST Elevation Myocardial Infarction. Am J Cardiol 2019; 123:212-217. [PMID: 30415795 DOI: 10.1016/j.amjcard.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 12/18/2022]
Abstract
Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA2DS2VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA2DS2VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA2DS2VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA2DS2VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort.
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Graipe A, Söderström L, Mooe T. Increased Use of Ticagrelor After Myocardial Infarction Is Not Associated With Intracranial Hemorrhage. Stroke 2018; 49:2877-2882. [PMID: 30571411 DOI: 10.1161/strokeaha.118.022970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose- Guidelines recommend dual antiplatelet treatment with ticagrelor instead of clopidogrel after acute myocardial infarction. Ticagrelor increases major and minor noncoronary artery bypass graft bleeding compared with clopidogrel, but whether the risk of intracranial hemorrhage (ICH) increases is unknown. We aimed to examine any association between ticagrelor and ICH and to identify predictors of ICH among unselected patients after acute myocardial infarction. Methods- Patients with acute myocardial infarction were identified using the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions, and the data were combined with the Swedish National Patient Registry to identify ICH occurrence. To avoid obvious selection bias related to the choice of dual antiplatelet treatment, we divided the study cohorts into 2 time periods of similar length using the first prescription of ticagrelor as a cutoff point (December 20, 2011). The risk of ICH during the first period (100% clopidogrel treatment) versus the second period (52.1% ticagrelor and 47.8% clopidogrel treatment) was assessed using Kaplan-Meier analysis. Cox proportional-hazards regression analyses, with assessment of interactions between all significant variables, were used to identify predictors of ICH. Results- The analysis included 47 674 patients with acute myocardial infarction. The cumulative incidence of ICH during the first period was 0.59% (91 cases [95% CI, 0.49-0.69]) versus 0.52% (97 cases [95% CI, 0.43-0.61]) during the second period ( P=0.83). In multivariable Cox analysis, study period (second versus first period) was not predictive of ICH. Interaction analyses showed that age and prior cardiovascular morbidities were of importance in predicting the risk of ICH. Conclusions- The increased use of ticagrelor was not associated with ICH, whereas age and prior cardiovascular morbidities were related to the risk of ICH and interacted significantly.
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Affiliation(s)
- Anna Graipe
- From the Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden (A.G., T.M.)
| | - Lars Söderström
- Unit of Research, Development, and Education, Östersund Hospital, Sweden (L.S.)
| | - Thomas Mooe
- From the Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden (A.G., T.M.)
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Luo J, Li H, Qin X, Liu B, Zhao J, Maihe G, Li Z, Wei Y. Increased risk of ischemic stroke associated with new-onset atrial fibrillation complicating acute coronary syndrome: A systematic review and meta-analysis. Int J Cardiol 2018; 265:125-131. [DOI: 10.1016/j.ijcard.2018.04.096] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/28/2018] [Accepted: 04/20/2018] [Indexed: 01/31/2023]
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Sinnaeve PR, Danays T, Bogaerts K, Van de Werf F, Armstrong PW. Drug Treatment of STEMI in the Elderly: Focus on Fibrinolytic Therapy and Insights from the STREAM Trial. Drugs Aging 2016; 33:109-18. [PMID: 26849132 DOI: 10.1007/s40266-016-0345-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Elderly patients constitute a large and growing proportion of ST-elevation myocardial infarction (STEMI) patients, yet they have been under-represented or even excluded from reperfusion trials. Despite evidence that fibrinolysis improves outcomes irrespective of age, many elderly STEMI patients still remain undertreated or subject to major delays to primary percutaneous coronary intervention (PCI). The fear of an excessive risk of intracranial hemorrhage (ICH) in these patients can lead to avoidance of potentially life-saving reperfusion treatment, despite the fact that current STEMI guidelines do not exclude the elderly from a pharmaco-invasive strategy. Age-specific dose reductions have been succesfully made to antithrombotic drugs such as clopidogrel and enoxaparin as an adjunct to fibrinolysis, but until recently no dose adjustments for elderly patients have been applied to the fibrinolytic agents. In the pharmaco-invasive STREAM trial, halving the bolus of tenecteplase for patients aged >75 years because of an unacceptably high ICH rate in the elderly was associated with a more favorable safety/efficacy profile. Whether a pharmaco-invasive strategy including half-dose tenecteplase, age- and weight-adjusted enoxaparin, and a tailored P2Y12 inhibitor followed by routine angiography represents a safe and efficacious alternative reperfusion therapy for elderly patients remains to be prospectively assessed in a clinical trial in this age group.
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Affiliation(s)
| | | | - Kris Bogaerts
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven and University Hasselt, Hasselt, Belgium
| | | | - Paul W Armstrong
- The Canadian Virtual Coordinating Centre for Global Colloborative Cardiovascular Research, University of Alberta, Edmonton, AB, Canada.
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Didier R, Gaglia MA, Koifman E, Kiramijyan S, Negi SI, Omar AF, Gai J, Torguson R, Pichard AD, Waksman R. Cerebrovascular accidents after percutaneous coronary interventions from 2002 to 2014: Incidence, outcomes, and associated variables. Am Heart J 2016; 172:80-7. [PMID: 26856219 DOI: 10.1016/j.ahj.2015.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cerebrovascular accident (CVA) and transient ischemic attack (TIA) related to percutaneous coronary intervention (PCI) are relatively rare complications, but they are associated with high morbidity and mortality. Given the evolution of both CVA risk and PCI techniques over time, this study was conducted to evaluate trends in CVA and TIA associated with PCI and to identify variables associated with neurologic events. METHODS Consecutive patients undergoing PCI at the Washington Hospital Center between January 2002 and June 2015 were included. Prespecified data were prospectively collected, including baseline and procedural characteristics, in-hospital outcomes, and 1-year mortality. The subjects who had a CVA or TIA during or immediately after PCI were compared with those without procedure-associated CVA or TIA. RESULTS Overall, 25,626 patients were included in the study. The mean age was 65.0 ± 12.4 years, 16,949 (65.2%) were male, and 7,436 (28.6%) were African American. From 2002 to 2015, 110 neurologic events post-PCI were diagnosed (0.43%); this included 86 CVAs (0.34%) and 24 TIAs (0.09%). The annual rate of postprocedural neurologic events was 0.42% ± 0.12%. There were significant changes in baseline risk factors over time, with increasing age, incidence of insulin-dependent diabetes, and chronic kidney disease. Patients with neurologic events were more often African American (43.6% vs 28.6%, P < .001) with prior history of CVA (24.5% vs 7.8%, P < .001), chronic renal insufficiency (26.6% vs 15.2%, P < .001), and insulin-dependent diabetes (19.1% vs 12.4%, P = .03). Acute myocardial infarction (56% vs 30.4%, P < .001) and cardiogenic shock (20.2% vs 3%, P < .001) were also more common among patients with neurologic events post-PCI. After multivariable adjustment, use of an intraaortic balloon pump was strongly associated with neurologic events (odds ratio [OR] 4.9, 95% CI 2.7-8.8, P < .001), as was prior CVA (OR 2.4, 95% CI 1.4-4.4, P = .002) and African American race (OR 2.4, 95% CI 1.5-3.9, P < .001); there was a borderline association with the use of a thrombus extraction device (OR 1.7, 95% CI 0.9-3.2, P = .09). In-hospital mortality (20.0% vs 1.5%, P < .001) and 1-year mortality (45.0% vs 7.3%, P < .001) were also much higher in patients with neurologic events. CONCLUSION Neurologic events post-PCI are associated with markedly worse in-hospital outcomes. The incidence of CVA and TIA post-PCI, however, remained stable over the last 12 years despite an increase in risk factors for CVA.
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Graipe A, Binsell‐Gerdin E, Söderström L, Mooe T. Incidence, Time Trends, and Predictors of Intracranial Hemorrhage During Long-Term Follow-up After Acute Myocardial Infarction. J Am Heart Assoc 2015; 4:e002290. [PMID: 26656860 PMCID: PMC4845264 DOI: 10.1161/jaha.115.002290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 10/23/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND To address the lack of knowledge regarding the long-term risk of intracranial hemorrhage (ICH) after acute myocardial infarction (AMI), the aims of this study were to: (1) investigate the incidence, time trends, and predictors of ICH in a large population within 1 year of discharge after AMI; (2) investigate the comparative 1-year risk of ICH in AMI patients and a reference group; and (3) study the impact of previous ischemic stroke on ICH risk in patients treated with various antithrombotic therapies. METHODS AND RESULTS Data about patients whose first AMI occurred between 1998 and 2010 were collected from the Swedish Register of Information and Knowledge about Swedish Heart-Intensive-Care Admissions (RIKS-HIA). Patients with an ICH after discharge were identified in the National Patient Register. Risk was compared against a matched reference population. Of 187 386 patients, 590 had an ICH within 1 year. The 1-year cumulative incidence (0.35%) was approximately twice that of the reference group, and it did not change significantly over time. Advanced age, previous ischemic or hemorrhagic stroke, and reduced glomerular filtration rate were associated with increased ICH risk, whereas female sex was associated with a decreased risk. Previous ischemic stroke did not increase risk of ICH associated with single or dual antiplatelet therapy, but increased risk with anticoagulant therapy. CONCLUSION The 1-year incidence of ICH after AMI remained stable, at ≈0.35%, over the study period. Advanced age, decreased renal function, and previous ischemic or hemorrhagic stroke are predictive of increased ICH risk.
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Affiliation(s)
- Anna Graipe
- Section of CardiologyDepartment of Internal MedicineÖstersund HospitalÖstersundSweden
- Department of Public Health and Clinical MedicineUmeå UniversityÖstersundSweden
| | - Emil Binsell‐Gerdin
- Department of Public Health and Clinical MedicineUmeå UniversityÖstersundSweden
- Department of Internal MedicineÖstersund HospitalÖstersundSweden
| | - Lars Söderström
- Unit of Research, Education and DevelopmentÖstersund HospitalÖstersundSweden
| | - Thomas Mooe
- Department of Public Health and Clinical MedicineUmeå UniversityÖstersundSweden
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Kwok CS, Kontopantelis E, Myint PK, Zaman A, Berry C, Keavney B, Nolan J, Ludman PF, de Belder MA, Buchan I, Mamas MA. Stroke following percutaneous coronary intervention: type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007–12. Eur Heart J 2015; 36:1618-1628. [DOI: 10.1093/eurheartj/ehv113] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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16
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Hachet O, Guenancia C, Stamboul K, Daubail B, Richard C, Béjot Y, Yameogo V, Gudjoncik A, Cottin Y, Giroud M, Lorgis L. Frequency and Predictors of Stroke After Acute Myocardial Infarction. Stroke 2014; 45:3514-20. [DOI: 10.1161/strokeaha.114.006707] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke is a serious complication after acute myocardial infarction (AMI) and is closely associated with decreased survival. This study aimed to investigate the frequency, characteristics, and factors associated with in-hospital and postdischarge stroke in patients with AMI.
Methods—
Eight thousand four hundred eighty-five consecutive patients admitted to a cardiology intensive care unit for AMI, between January 2001 and July 2010. Stroke/transient ischemic attack were collected during 1-year follow-up.
Results—
One hundred twenty-three in-hospital strokes were recorded: 65 (52.8%) occurred on the first day after admission for AMI, and 108 (87%) within the first 5 days. One hundred six patients (86.2%-incidence rate 1.25%) experienced in-hospital ischemic stroke, and 14 patients (11.4%-incidence rate 0.16%) were diagnosed with an in-hospital hemorrhagic stroke. In-hospital ischemic stroke subtypes according to the Trial of Org 10 172 in Acute Stroke Treatment (TOAST) classification showed that only 2 types of stroke were identified more frequently. As expected, the leading subtype of in-hospital ischemic stroke was cardioembolic stroke (n=64, 60%), the second was stroke of undetermined pathogenesis (n=38, 36%). After multivariable backward regression analysis, female sex, previous transient ischemic attack (TIA)/stroke, new-onset atrial fibrillation, left ventricular ejection fraction (odds ratio per point of left ventricular ejection fraction), and C-reactive protein were independently associated with in-hospital ischemic stroke. When antiplatelet and anticoagulation therapy within the first 48 hours was introduced into the multivariable model, we found that implementing these treatments (≥1) was an independent protective factor of in-hospital stroke. In-hospital hemorrhagic stroke was dramatically increased (5-fold) when thrombolysis was prescribed as the reperfusion treatment. However, the different parenteral anticoagulants were not predictors of risk in univariable analysis. Finally, only 45 postdischarge strokes were recorded. Postdischarge stroke subtypes showed a more heterogeneous distribution of mechanisms. The annual rate of stroke post-AMI remained stable throughout the 10-year study period.
Conclusions—
The present study describes specific predictors of in-hospital and postdischarge stroke in patients with AMI. It showed a marked increase in the risk of death, both during hospitalization and in the year after AMI. After hospital discharge, stroke remains a rare event and is mostly associated with high cardiovascular risk.
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Affiliation(s)
- Olivier Hachet
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Charles Guenancia
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Karim Stamboul
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Benoit Daubail
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Carole Richard
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Yannick Béjot
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Valentin Yameogo
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Aurélie Gudjoncik
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Yves Cottin
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Maurice Giroud
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
| | - Luc Lorgis
- From the Department of Cardiology, University Hospital, Dijon, France (H.O., G.C., S.K., R.C., Y.V., G.A., C.Y., L.L.); LPPCM, INSERM U866, University of Burgundy, Dijon, France (H.O., G.C., S.K., R.C., G.A., C.Y., L.L.); and The Dijon Stroke Registry (EA 4184), University of Burgundy, University Hospital and Faculty of Medicine of Dijon, Dijon, France (D.B., B.Y., G.M.)
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