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Wang X, Chen T, Zhou J, Qin Y. Racial and ethnic differences in restarting antiplatelet therapy in patients with primary intracranial hemorrhage: a systematic review and meta-analysis. BMC Neurol 2024; 24:280. [PMID: 39127615 DOI: 10.1186/s12883-024-03790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND There has long been clinical disagreement over the resumption of antiplatelet therapy in patients with primary intracranial hemorrhage (ICH). This meta-analysis aimed to systematically evaluate the efficacy and safety of restarting antiplatelet therapy after ICH among different races and ethnicities. METHODS All relevant medical studies involving adults with antiplatelet-associated ICH published in PubMed, The Cochrane Library and Chinese National Knowledge Infrastructure from inception to March 2024 were sourced. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects model to assess the strength of association between resumption of antiplatelet therapy and our outcomes.The review was not registered and the review protocol was not prepared. RESULTS Thirty-five studies were included, with 9758 ICH patients. Subgroup analysis revealed that restarting antiplatelet therapy was associated with a significantly higher risk of recurrence or aggravation of cerebral hemorrhage in Asians[OR = 1.48, 95% CI (1.13-1.94), P = 0.004]; in Caucasians, on the contrary, reinitiation of antiplatelet therapy was not associated with a significantly higher risk of recurrence or aggravation of cerebral hemorrhage [OR = 0.85, 95% CI (0.67-1.06), P = 0.149]. Reinitiation of antiplatelet therapy was associated with a significantly lower risk of cerebral infarction [OR = 0.61, 95% CI (0.39-0.96), P = 0.033]. Restarting antiplatelet therapy after cerebral hemorrhage was not associated with a higher incidence rate of mortality [OR = 0.79, 95% CI (0.57, 1.08), P = 0.138], myocardial infarction [OR = 2.40, 95%CI (0.53,10.79), P = 0.253], hemiparesis [OR = 0.38, 95%CI (0.03,4.81), P = 0.451], neurological deficit [OR = 0.86,95%CI(0.32,2.33),P = 0.766]. CONCLUSION Reinstitution of antiplatelet therapy after ICH was associated with a lower risk of thromboembolic complications.Resumption of antiplatelet therapy was not associated with a higher incidence of cerebral hemorrhage in Caucasians, but may be associated with a higher risk of cerebral hemorrhage recurrence in Asian populations.
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Affiliation(s)
- Xuechang Wang
- Department of Pharmacy, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Anning, Yunnan Province, 650302, China
| | - Ting Chen
- Department of Pharmacy, Yancheng No.1 People's Hospital, Yancheng, Jiangsu Province, 224000, China
| | - Junning Zhou
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, Shandong Province, 252037, China
| | - Yuan Qin
- Department of Pharmacy, The Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan Province, 646000, China.
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Al-Shahi Salman R, Greenberg SM. Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage. Stroke 2023; 54:3173-3181. [PMID: 37916459 DOI: 10.1161/strokeaha.123.036886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.
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Affiliation(s)
| | - Steven M Greenberg
- Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
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3
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Teo KC, Keins S, Abramson JR, Leung WCY, Leung IYH, Wong YK, Yeung C, Kourkoulis C, Warren AD, Chan KH, Cheung RTF, Ho SL, Gurol ME, Viswanathan A, Greenberg SM, Anderson CD, Lau KK, Rosand J, Biffi A. Blood Pressure Control Targets and Risk of Cardiovascular and Cerebrovascular Events After Intracerebral Hemorrhage. Stroke 2023; 54:78-86. [PMID: 36321455 DOI: 10.1161/strokeaha.122.039709] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) survivors are at high risk for recurrent stroke and cardiovascular events. Blood pressure (BP) control represents the most potent intervention to lower these risks, but optimal treatment targets in this patient population remain unknown. We sought to determine whether survivors of ICH achieving more intensive BP control than current guideline recommendations (systolic BP <130 mmHg and diastolic BP <80 mmHg) were at lower risk of major adverse cardiovascular and cerebrovascular events and mortality. METHODS We analyzed data for 1828 survivors of spontaneous ICH from 2 cohort studies. Follow-up BP measurements were recorded 3 and 6 months after ICH, and every 6 months thereafter. Outcomes of interest were major adverse cardiovascular and cerebrovascular events (recurrent ICH, incident ischemic stroke, myocardial infarction), vascular mortality (defined as mortality attributed to recurrent ICH, ischemic stroke, or myocardial infarction), and all-cause mortality. RESULTS During a median follow-up of 46.2 months, we observed 166 recurrent ICH, 68 ischemic strokes, 69 myocardial infarction, and 429 deaths. Compared with survivors of ICH with systolic BP 120 to 129 mmHg, participants who achieved systolic BP <120 mmHg displayed reduced risk of recurrent ICH (adjusted hazard ratio [AHR], 0.74 [95% CI, 0.59-0.94]) and major adverse cardiovascular and cerebrovascular events (AHR, 0.69 [95% CI, 0.53-0.92]). All-cause mortality (AHR, 0.76 [95% CI, 0.57-1.03]) and vascular mortality (AHR, 0.68 [95% CI, 0.45-1.01]) did not differ significantly. Among participants aged >75 years or with modified Rankin Scale score 4 to 5, systolic BP <120 mmHg was associated with increased all-cause mortality (AHR, 1.38 [95% CI, 1.02-1.85] and AHR, 1.36 [95% CI, 1.03-1.78], respectively), but not vascular mortality. We found no differences in outcome rates between survivors of ICH with diastolic BP <70 versus 70 to 79 mmHg. CONCLUSIONS Targeting systolic BP <120 mmHg in select groups of survivors of ICH could result in decreased major adverse cardiovascular and cerebrovascular events risk without increasing mortality. Our findings warrant investigation in dedicated randomized controlled trials.
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Affiliation(s)
- Kay-Cheong Teo
- Department of Medicine, Queen Mary Hospital (K.-C.T., W.C.Y.L., I.Y.H.L., Y.-K.W., C.Y., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong
| | - Sophia Keins
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Center for Genomic Medicine (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Jessica R Abramson
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Center for Genomic Medicine (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - William C Y Leung
- Department of Medicine, Queen Mary Hospital (K.-C.T., W.C.Y.L., I.Y.H.L., Y.-K.W., C.Y., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong
| | - Ian Y H Leung
- Department of Medicine, Queen Mary Hospital (K.-C.T., W.C.Y.L., I.Y.H.L., Y.-K.W., C.Y., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong
| | - Yuen-Kwun Wong
- Department of Medicine, Queen Mary Hospital (K.-C.T., W.C.Y.L., I.Y.H.L., Y.-K.W., C.Y., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong
| | - Charming Yeung
- Department of Medicine, Queen Mary Hospital (K.-C.T., W.C.Y.L., I.Y.H.L., Y.-K.W., C.Y., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong
| | - Christina Kourkoulis
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Center for Genomic Medicine (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Andrew D Warren
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Koon-Ho Chan
- Research Center of Heart, Brain, Hormone and Healthy Aging (K.-H.C., R.T.F.C., S.-L.H., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong.,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong (K.-H.C., R.T.F.C., K.-K.L.)
| | - Raymond T F Cheung
- Research Center of Heart, Brain, Hormone and Healthy Aging (K.-H.C., R.T.F.C., S.-L.H., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong.,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong (K.-H.C., R.T.F.C., K.-K.L.)
| | - Shu-Leong Ho
- Research Center of Heart, Brain, Hormone and Healthy Aging (K.-H.C., R.T.F.C., S.-L.H., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong
| | - M Edip Gurol
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Christopher D Anderson
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Center for Genomic Medicine (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.D.A.)
| | - Kui-Kai Lau
- Department of Medicine, Queen Mary Hospital (K.-C.T., W.C.Y.L., I.Y.H.L., Y.-K.W., C.Y., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong.,Research Center of Heart, Brain, Hormone and Healthy Aging (K.-H.C., R.T.F.C., S.-L.H., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong.,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong (K.-H.C., R.T.F.C., K.-K.L.)
| | - Jonathan Rosand
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Center for Genomic Medicine (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
| | - Alessandro Biffi
- Department of Neurology (S.K., J.R.A., C.K., A.D.W., M.E.G., A.V., S.M.G., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Center for Genomic Medicine (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (S.K., J.R.A., C.K., C.D.A., J.R., A.B.), Massachusetts General Hospital, Boston
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4
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Wang K, Mo S, Liu Q, Pu J, Huang X, Kang D, Lin F, Zou D, Sun X, Ren J, Tong X, Li J, Salman RAS, Wang N, Guo S, Liu Y, Zhang Y, Li X, Wu J, Wang S. Early-start antiplatelet therapy after operation in patients with spontaneous intracerebral hemorrhage and high risk of ischemic events (E-start): Protocol for a multi-centered, prospective, open-label, blinded endpoint randomized controlled trial. Front Aging Neurosci 2022; 14:1020224. [PMID: 36506468 PMCID: PMC9727252 DOI: 10.3389/fnagi.2022.1020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/17/2022] [Indexed: 11/24/2022] Open
Abstract
Background For severe spontaneous intracerebral hemorrhage (sSICH) patients with high risk of ischemic events, the incidence of postoperative major cardiovascular/cerebrovascular and peripheral vascular events (MACCPE) is notable. Although antiplatelet therapy is a potential way to benefit these patients, the severe hemorrhagic complications, e.g., intracranial re-hemorrhage, is a barrier for early starting antiplatelet therapy. Objectives This randomized controlled trial aims to identify the benefit and safety of early starting antiplatelet therapy after operation for sSICH patients with high risk of ischemic events. Methods This study is a multicenter, prospective, randomized, open-label, blinded-endpoint trial. We will enroll 250 sSICH patients with a high risk of ischemic events (including cerebral infarcts, transient ischemic attack, myocardial infarction, pulmonary embolism, and deep venous thrombosis). The participants will be randomized in a 1:1 manner to early-start group (start antiplatelet therapy at 3 days after operation) and normal-start group (start antiplatelet therapy at 30 days after operation). The early-start group will receive aspirin 100 mg daily. The control group will not receive antithrombotic therapy until 30 days after operation. The efficacy endpoint is the incidence of MACCPE, and the safety endpoint is the incidence of intracranial re-hemorrhage. Discussion The Early-Start antiplatelet therapy after operation in patients with spontaneous intracerebral hemorrhage trial (E-start) is the first randomized trial about early start antiplatelet therapy for operated sSICH patients with a high risk of ischemic events. This study will provide a new strategy and evidence for postoperative management in the future. Clinical trial registration ClinicalTrials.gov, identifier NCT04820972; Available at: https://clinicaltrials.gov/ct2/show/NCT04820972?term=NCT04820972&draw=2&rank=1.Chinese Clinical Trial Registry, identifier ChiCTR2100044560; Available at: http://www.chictr.org.cn/showproj.aspx?proj=123277.
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Affiliation(s)
- Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun Pu
- Department of Neurosurgery, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Xiaobin Huang
- Department of Neurosurgery, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, China
| | - Fixin Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, China
| | - Dewei Zou
- Department of Neurosurgery, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Xinguo Sun
- Department of Neurosurgery, Binzhou People's Hospital, Binzhou, China
| | - Jinrui Ren
- Department of Neurosurgery, The People's Hospital of Shanxi Province, Taiyuan, China
| | - Xianzeng Tong
- Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jiangan Li
- Department of Neurosurgery, Affiliated Wuxi No. 2 Hospital, Nanjing Medical University, Wuxi Medical School, Jiangnan University, Wuxi, China
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Nuochuan Wang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuaiwei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yanan Zhang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiong Li
- Department of Neurosurgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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5
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Jung NY, Cho J. Clinical effects of restarting antiplatelet therapy in patients with intracerebral hemorrhage. Clin Neurol Neurosurg 2022; 220:107361. [DOI: 10.1016/j.clineuro.2022.107361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/03/2022] [Indexed: 11/26/2022]
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6
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Castello JP, Teo K, Abramson JR, Keins S, Takahashi CE, Leung IYH, Leung WCY, Wang Y, Kourkoulis C, Pavlos Myserlis E, Warren AD, Henry J, Chan K, Cheung RTF, Ho S, Gurol ME, Viswanathan A, Greenberg SM, Anderson CD, Lau K, Rosand J, Biffi A. Long‐Term Blood Pressure Variability and Major Adverse Cardiovascular and Cerebrovascular Events After Intracerebral Hemorrhage. J Am Heart Assoc 2022; 11:e024158. [PMID: 35253479 PMCID: PMC9075304 DOI: 10.1161/jaha.121.024158] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Survivors of intracranial hemorrhage (ICH) are at increased risk for major adverse cardiovascular and cerebrovascular events (MACCE), in the form of recurrent stroke and myocardial Infarction. We investigated whether long‐term blood pressure (BP) variability represents a risk factor for MACCE after ICH, independent of average BP. Methods and Results We analyzed data from prospective ICH cohort studies at Massachusetts General Hospital and the University of Hong Kong. We captured long‐term (ie, visit‐to‐visit) BP variability, quantified as individual participants’ variation coefficient. We explored determinants of systolic and diastolic BP variability and generated survival analyses models to explore their association with MACCE. Among 1828 survivors of ICH followed for a median of 46.2 months we identified 166 with recurrent ICH, 68 with ischemic strokes, and 69 with myocardial infarction. Black (coefficient +3.8, SE 1.3) and Asian (coefficient +2.2, SE 0.4) participants displayed higher BP variability. Long‐term systolic BP variability was independently associated with recurrent ICH (subhazard ratio [SHR], 1.82; 95% CI, 1.19–2.79), ischemic stroke (SHR, 1.62; 95% CI, 1.06–2.47), and myocardial infarction (SHR, 1.54; 95% CI, 1.05–2.24). Average BP during follow‐up did not modify the association between long‐term systolic BP variability and MACCE. Conclusions Long‐term BP variability is a potent risk factor for recurrent hemorrhage, ischemic stroke, and myocardial infarction after ICH, even among survivors with well‐controlled hypertension. Our findings support the hypothesis that combined control of average BP and its variability after ICH is required to minimize incidence of MACCE.
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Affiliation(s)
- Juan Pablo Castello
- Department of Neurology Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Kay‐Cheong Teo
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - Jessica R. Abramson
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Sophia Keins
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | | | - Ian Y. H. Leung
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - William C. Y. Leung
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - Yujie Wang
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - Christina Kourkoulis
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Evangelos Pavlos Myserlis
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Andrew D. Warren
- Department of Neurology Massachusetts General Hospital Boston MA
| | - Jonathan Henry
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Koon‐Ho Chan
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
- Research Center of HeartBrain, Hormone and Healthy AgingLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - Raymond T. F. Cheung
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
- Research Center of HeartBrain, Hormone and Healthy AgingLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - Shu‐Leong Ho
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
| | - M. Edip Gurol
- Department of Neurology Massachusetts General Hospital Boston MA
| | | | | | - Christopher D. Anderson
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Kui‐Kai Lau
- Department of Medicine Queen Mary HospitalLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
- Research Center of HeartBrain, Hormone and Healthy AgingLKS Faculty of MedicineThe University of Hong Kong Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences The University of Hong Kong Hong Kong SAR
| | - Jonathan Rosand
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Alessandro Biffi
- Department of Neurology Massachusetts General Hospital Boston MA
- Center for Genomic Medicine Massachusetts General Hospital Boston MA
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
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7
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Al-Shahi Salman R, Dennis MS, Sandercock PAG, Sudlow CLM, Wardlaw JM, Whiteley WN, Murray GD, Stephen J, Rodriguez A, Lewis S, Werring DJ, White PM. Effects of Antiplatelet Therapy After Stroke Caused by Intracerebral Hemorrhage: Extended Follow-up of the RESTART Randomized Clinical Trial. JAMA Neurol 2021; 78:1179-1186. [PMID: 34477823 PMCID: PMC8417806 DOI: 10.1001/jamaneurol.2021.2956] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance The Restart or Stop Antithrombotics Randomized Trial (RESTART) found that antiplatelet therapy appeared to be safe up to 5 years after intracerebral hemorrhage (ICH) that had occurred during antithrombotic (antiplatelet or anticoagulant) therapy. Objectives To monitor adherence, increase duration of follow-up, and improve precision of estimates of the effects of antiplatelet therapy on recurrent ICH and major vascular events. Design, Setting and Participants From May 22, 2013, through May 31, 2018, this prospective, open, blinded end point, parallel-group randomized clinical trial studied 537 participants at 122 hospitals in the UK. Participants were individuals 18 years or older who had taken antithrombotic therapy for the prevention of occlusive vascular disease when they developed ICH, discontinued antithrombotic therapy, and survived for 24 hours. After initial follow-up ended on November 30, 2018, annual follow-up was extended until November 30, 2020, for a median of 3.0 years (interquartile range [IQR], 2.0-5.0 years) for the trial cohort. Interventions Computerized randomization that incorporated minimization allocated participants (1:1) to start or avoid antiplatelet therapy. Main Outcomes and Measures Participants were followed up for the primary outcome (recurrent symptomatic ICH) and secondary outcomes (all major vascular events) for up to 7 years. Data from all randomized participants were analyzed using Cox proportional hazards regression, adjusted for minimization covariates. Results A total of 537 patients (median age, 76.0 years; IQR, 69.0-82.0 years; 360 [67.0%] male; median time after ICH onset, 76.0 days; IQR, 29.0-146.0 days) were randomly allocated to start (n = 268) or avoid (n = 269 [1 withdrew]) antiplatelet therapy. The primary outcome of recurrent ICH affected 22 of 268 participants (8.2%) allocated to antiplatelet therapy compared with 25 of 268 participants (9.3%) allocated to avoid antiplatelet therapy (adjusted hazard ratio, 0.87; 95% CI, 0.49-1.55; P = .64). A major vascular event affected 72 participants (26.8%) allocated to antiplatelet therapy compared with 87 participants (32.5%) allocated to avoid antiplatelet therapy (hazard ratio, 0.79; 95% CI, 0.58-1.08; P = .14). Conclusions and Relevance Among patients with ICH who had previously taken antithrombotic therapy, this study found no statistically significant effect of antiplatelet therapy on recurrent ICH or all major vascular events. These findings provide physicians with some reassurance about the use of antiplatelet therapy after ICH if indicated for secondary prevention of major vascular events. Trial Registration isrctn.org Identifier: ISRCTN71907627.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Martin S Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Peter A G Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Cathie L M Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute, University of Edinburgh, Edinburgh, United Kingdom.,Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,UK Dementia Research Institute at the University of Edinburgh, University of Edinburgh, Edinburgh, United Kingdom.,Edinburgh Imaging, University of Edinburgh, Edinburgh, United Kingdom
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Gordon D Murray
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | | | - Steff Lewis
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David J Werring
- Stroke Research Group, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, United Kingdom
| | - Phil M White
- Department of Neuroradiology, Newcastle-upon-Tyne Hospitals National Health Service Trust, Newcastle-upon-Tyne, United Kingdom.,Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle University, Newcastle-upon-Tyne, United Kingdom
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8
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Biffi A, Teo KC, Castello JP, Abramson JR, Leung IYH, Leung WCY, Wang Y, Kourkoulis C, Myserlis EP, Warren AD, Henry J, Chan KH, Cheung RTF, Ho SL, Anderson CD, Gurol ME, Viswanathan A, Greenberg SM, Lau KK, Rosand J. Impact of Uncontrolled Hypertension at 3 Months After Intracerebral Hemorrhage. J Am Heart Assoc 2021; 10:e020392. [PMID: 33998241 PMCID: PMC8483505 DOI: 10.1161/jaha.120.020392] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Survivors of intracerebral hemorrhage (ICH) are at high risk for recurrent stroke, which is associated with blood pressure control. Because most recurrent stroke events occur within 12 to 18 months of the index ICH, rapid blood pressure control is likely to be crucial. We investigated the frequency and prognostic impact of uncontrolled short‐term hypertension after ICH. Methods and Results We analyzed data from Massachusetts General Hospital (n=1305) and the University of Hong Kong (n=523). We classified hypertension as controlled, undertreated, or treatment resistant at 3 months after ICH and determined the following: (1) the risk factors for uncontrolled hypertension and (2) whether hypertension control at 3 months is associated with stroke recurrence and mortality. We followed 1828 survivors of ICH for a median of 46.2 months. Only 9 of 234 (4%) recurrent strokes occurred before 3 months after ICH. At 3 months, 713 participants (39%) had controlled hypertension, 755 (41%) had undertreated hypertension, and 360 (20%) had treatment‐resistant hypertension. Black, Hispanic, and Asian race/ethnicity and higher blood pressure at time of ICH increased the risk of uncontrolled hypertension at 3 months (all P<0.05). Uncontrolled hypertension at 3 months was associated with recurrent stroke and mortality during long‐term follow‐up (all P<0.05). Conclusions Among survivors of ICH, >60% had uncontrolled hypertension at 3 months, with undertreatment accounting for the majority of cases. The 3‐month blood pressure measurements were associated with higher recurrent stroke risk and mortality. Black, Hispanic, and Asian survivors of ICH and those presenting with severe acute hypertensive response were at highest risk for uncontrolled hypertension.
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Affiliation(s)
- Alessandro Biffi
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Kay-Cheong Teo
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - Juan Pablo Castello
- Department of Neurology Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Jessica R Abramson
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Ian Y H Leung
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - William C Y Leung
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - Yujie Wang
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - Christina Kourkoulis
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Evangelos Pavlos Myserlis
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Andrew D Warren
- Department of Neurology Massachusetts General Hospital Boston MA
| | - Jonathan Henry
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - Koon-Ho Chan
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR.,Research Center of Heart, Brain, Hormone and Healthy Aging LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - Raymond T F Cheung
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR.,Research Center of Heart, Brain, Hormone and Healthy Aging LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - Shu-Leong Ho
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR
| | - Christopher D Anderson
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
| | - M Edip Gurol
- Department of Neurology Massachusetts General Hospital Boston MA
| | | | | | - Kui-Kai Lau
- Department of Medicine Queen Mary Hospital LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR.,Research Center of Heart, Brain, Hormone and Healthy Aging LKS Faculty of Medicine The University of Hong Kong Hong Kong SAR.,The State Key Laboratory of Brain and Cognitive Sciences The University of Hong Kong Hong Kong SAR
| | - Jonathan Rosand
- Department of Neurology Massachusetts General Hospital Boston MA.,Center for Genomic Medicine Massachusetts General Hospital Boston MA.,Henry and Allison McCance Center for Brain Health Massachusetts General Hospital Boston MA
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9
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Cheng B, Li J, Peng L, Wang Y, Sun L, He S, Wei J, Zhang S. Efficacy and safety of restarting antiplatelet therapy for patients with spontaneous intracranial haemorrhage: A systematic review and meta-analysis. J Clin Pharm Ther 2021; 46:957-965. [PMID: 33537999 DOI: 10.1111/jcpt.13377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/22/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE The benefits and risks of restarting antiplatelet therapy (APT) for patients with spontaneous intracranial haemorrhage (ICH) remain controversial. This meta-analysis was performed to explore the efficacy and safety of restarting APT for these patients. METHODS We followed the recommended PRISMA guidelines for systematic reviews. Studies from PubMed, Embase, Web of Science, CNKI and the Cochrane Library were systematically retrieved from the inception of each database to 31 July 2020. We also manually retrieved studies of reference. RESULTS AND DISCUSSION In this study, seven cohort studies and one randomized controlled trial (RCT) with subjects were included. APT resumption after spontaneous ICH did not significantly increase the risk of major haemorrhagic events (HR 1.15; 95% CI: 0.70-1.89; p = .59). However, it did not significantly reduce the risk of a composite endpoint concerning occlusive/thromboembolic events (HR 0.98; 95% CI: 0.81-1.19; p = .83) and all-cause mortality (HR 0.93; 95% CI: 0.80-1.08; p = .35). WHAT IS NEW AND CONCLUSION Restarting APT for patients with spontaneous ICH is generally safe. However, the benefits of reducing the risk of ischaemic vascular events and all-cause mortality were not apparent. More RCTs are required.
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Affiliation(s)
- Bo Cheng
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Jinze Li
- Department of Urology, People's Hospital of Deyang City, Deyang, China
| | - Lei Peng
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University, Nanchong, China
| | - Yirong Wang
- Department of Neurology, Chengdu Second People's Hospital, Chengdu, China
| | - Ling Sun
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Shijia He
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Jing Wei
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Shushan Zhang
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
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10
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Low-dose antiplatelet therapy survey after intracerebral hemorrhage in China: a retrospective hospital-based study. Neurosurg Rev 2021; 44:2923-2931. [PMID: 33502641 DOI: 10.1007/s10143-021-01483-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/10/2020] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
Restarting of antiplatelet therapy (AT) for patients with a history of intracerebral hemorrhage (ICH) is still a clinical dilemma in China. We aimed to investigate the association between low-dose AT and the long-term clinical outcome in Chinese ICH patients. A total of 312 patients with a history of ICH were retrospectively enrolled and followed. The ischemic vascular events, recurrent ICH, and all-cause death were reviewed retrospectively. We explored the predictors of ischemic vascular events and recurrent ICH from all patients using Cox proportional hazard regression model. One hundred fifty-one (48.4%) patients were treated with low-dose AT, and the median duration of follow-up was 4.0 years (interquartile range, 2.5-5 years). Compared to 30 (19.8%) of 151 participants who restarted low-dose AT had ischemic vascular events, 51 (31.7%) of 161 participants who did not receive AT showed ischemic vascular events (p=0.025). Eighteen (11.9%) of 151 participants treated with low-dose AT had recurrent ICH and 21 (13.0%) of 161 in non-AT participants (p=0.830). Cox regression analysis also showed that diabetes mellitus was an independent risk factor for ischemic vascular events (p=0.029). Uncontrolled blood pressure (BP) was independently associated with the risk for both ischemic vascular events (p=0.025) and recurrent ICH (p=0.001). Atrial fibrillation (AF) was an independent risk factor for recurrent ICH among patients with a history of ICH (p=0.018). In a Chinese population of patients with predominantly deep, mild to moderate severity ICH, restarting of low-dose AT at a median of 6.2 months was associated with a lower risk of ischemic vascular events without increased risk of recurrent ICH.
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11
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Larsen KT, Forfang E, Pennlert J, Glader EL, Kruuse C, Wester P, Ihle-Hansen H, Carlsson M, Berge E, Al-Shahi Salman R, Bruun Wyller T, Rønning OM. STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage: Protocol for a randomised controlled trial. Eur Stroke J 2020; 5:414-422. [PMID: 33598560 PMCID: PMC7856578 DOI: 10.1177/2396987320954671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/29/2020] [Indexed: 12/11/2022] Open
Abstract
Background and aims Many patients with prior intracerebral haemorrhage have indications for antithrombotic treatment with antiplatelet or anticoagulant drugs for prevention of ischaemic events, but it is uncertain whether such treatment is beneficial after intracerebral haemorrhage. STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage will assess (i) the effects of long-term antithrombotic treatment on the risk of recurrent intracerebral haemorrhage and occlusive vascular events after intracerebral haemorrhage and (ii) whether imaging findings, like cerebral microbleeds, modify these effects. Methods STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage is a multicentre, randomised controlled, open trial of starting versus avoiding antithrombotic treatment after non-traumatic intracerebral haemorrhage, in patients with an indication for antithrombotic treatment. Participants with vascular disease as an indication for antiplatelet treatment are randomly allocated to antiplatelet treatment or no antithrombotic treatment. Participants with atrial fibrillation as an indication for anticoagulant treatment are randomly allocated to anticoagulant treatment or no anticoagulant treatment. Cerebral CT or MRI is performed before randomisation. Duration of follow-up is at least two years. The primary outcome is recurrent intracerebral haemorrhage. Secondary outcomes include occlusive vascular events and death. Assessment of clinical outcomes is performed blinded to treatment allocation. Target recruitment is 500 participants. Trial status: Recruitment to STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage is on-going. On 30 April 2020, 44 participants had been enrolled in 31 participating hospitals. An individual patient–data meta-analysis is planned with similar randomised trials.
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Affiliation(s)
- Kristin Tveitan Larsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | | | - Johanna Pennlert
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Christina Kruuse
- Herlev Gentofte Hospital and University of Copenhagen, Herlev, Denmark
| | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden.,Department of Clinical Sciences, Karolinska Institute, Danderyds Hospital, Stockholm, Sweden
| | - Hege Ihle-Hansen
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maria Carlsson
- Department of Neurology, Nordland Hospital Trust, Bodø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eivind Berge
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Ole Morten Rønning
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
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12
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Casolla B, Cordonnier C. Intracerebral haemorrhage, microbleeds and antithrombotic drugs. Rev Neurol (Paris) 2020; 177:11-22. [PMID: 32747048 DOI: 10.1016/j.neurol.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/04/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022]
Abstract
Antithrombotic therapy is a cornerstone for secondary prevention of ischaemic events, cerebral and extra-cerebral. A number of clinical questions remain unanswered concerning the impact of antithrombotic drugs on the risk of first-ever and recurrent macro or micro cerebral haemorrhages, raising the clinical dilemma on the risk/benefit balance of giving antiplatelets and anticoagulants in patients with potential high risk of brain bleeds. High field magnetic resonance imaging (MRI) blood-weighted sequences, including susceptibility weighted imaging (SWI), have expanded the spectrum of these clinical questions, because of their increasing sensitivity in detecting radiological markers of small vessel disease. This review will summarise the literature, focusing on four main clinical questions: how do cerebral microbleeds impact the risk of cerebrovascular events in healthy patients, in patients with previous ischaemic stroke or transient ischaemic attack, and in patients with intracerebral haemorrhage? Is the risk/benefit balance of oral anticoagulants shifted by the presence of microbleeds in patients with atrial fibrillation after recent ischaemic stroke or transient ischaemic attack? Should we restart antiplatelet drugs after symptomatic intracerebral haemorrhage or not? Are oral anticoagulants allowed in patients with a history of atrial fibrillation and previous intracerebral haemorrhage?
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Affiliation(s)
- B Casolla
- University of Lille, Inserm, CHU of Lille, U1172-LilNCog-Lille Neuroscience & Cognition, 59000 Lille, France.
| | - C Cordonnier
- University of Lille, Inserm, CHU of Lille, U1172-LilNCog-Lille Neuroscience & Cognition, 59000 Lille, France
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13
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Girotra T, Feng W. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): are neurologists feeling more comfortable to RESTART antiplatelet? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S214. [PMID: 31656793 DOI: 10.21037/atm.2019.08.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Tarun Girotra
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Wuwei Feng
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
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14
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Del Brutto VJ, Chaturvedi S, Diener HC, Romano JG, Sacco RL. Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 74:786-803. [PMID: 31395130 PMCID: PMC7291776 DOI: 10.1016/j.jacc.2019.06.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 01/02/2023]
Abstract
Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.
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Affiliation(s)
- Victor J Del Brutto
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jose G Romano
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
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15
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Abstract
BACKGROUND Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. METHODS The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). FINDINGS Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29-146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0- 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25-1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39-1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65-1·60]; p=0·92). INTERPRETATION These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention. FUNDING British Heart Foundation.
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16
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Ziai WC, Tsiskaridze A. Restarting antiplatelet therapy after intracerebral haemorrhage. Lancet 2019; 393:2567-2569. [PMID: 31128927 DOI: 10.1016/s0140-6736(19)31094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Wendy C Ziai
- Division of Brain Injury Outcomes, The Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Alexander Tsiskaridze
- Department of Neurology, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
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17
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Al-Shahi Salman R, Murray GD, Dennis MS, Newby DE, Sandercock PAG, Sprigg N, Sudlow CLM, Werring DJ, White PM, Whiteley WN. The REstart or STop Antithrombotics Randomised Trial (RESTART) after stroke due to intracerebral haemorrhage: statistical analysis plan for a randomised controlled trial. Trials 2019; 20:183. [PMID: 30909946 PMCID: PMC6434884 DOI: 10.1186/s13063-019-3270-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/01/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND For adults surviving stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) who had taken an antithrombotic (i.e. anticoagulant or antiplatelet) drug for the prevention of vaso-occlusive disease before the ICH, it is unclear whether starting antiplatelet therapy modifies the risks of recurrent ICH, major haemorrhagic events, major occlusive vascular events, or a composite of all major vascular events compared to avoiding antiplatelet therapy. METHODS/DESIGN The REstart or STop Antithrombotics Randomised Trial (RESTART) is an investigator-led, parallel group, open, assessor-blind, randomised trial comparing starting versus avoiding antiplatelet therapy for adults surviving antithrombotic-associated ICH. Recruitment began on 22 May 2013 and ended on 31 May 2018. Follow-up ended on 30 November 2018. This update to the protocol describes the statistical analysis plan (version 1.7, finalised on 25 January 2019). Database lock and un-blinding occurred on 29 January 2019, after which the un-masked trial statistician conducted the final analyses according to this statistical analysis plan. DISCUSSION Final results of RESTART will be analysed and disseminated in May 2019. TRIAL REGISTRATION ISRCTN registry 71907627 . Prospectively registered on 25 April 2013.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Gordon D. Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Martin S. Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - David E. Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Peter A. G. Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Nikola Sprigg
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Cathie L. M. Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Philip M. White
- Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle-upon-Tyne, UK
| | - William N. Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
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A practical guide on how to handle patients with bleeding events while on oral antithrombotic treatment. Neth Heart J 2018; 26:341-351. [PMID: 29740754 PMCID: PMC5968004 DOI: 10.1007/s12471-018-1117-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bleeding is a feared complication in patients who are treated with antithrombotic therapy (oral anticoagulation or antiplatelet therapy). Management of antithrombotic therapy after bleeding poses a dilemma where restarting the crucial medication could lead to recurrent bleeding, while interrupting or even discontinuing treatment could increase the thrombotic risk. In this review, we provide recommendations regarding the treatment of patients with a bleeding event while on oral antithrombotic therapy, based on the literature and expert opinion.
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Al-Shahi Salman R, Dennis MS, Murray GD, Innes K, Drever J, Dinsmore L, Williams C, White PM, Whiteley WN, Sandercock PAG, Sudlow CLM, Newby DE, Sprigg N, Werring DJ. The REstart or STop Antithrombotics Randomised Trial (RESTART) after stroke due to intracerebral haemorrhage: study protocol for a randomised controlled trial. Trials 2018; 19:162. [PMID: 29506580 PMCID: PMC5838871 DOI: 10.1186/s13063-018-2542-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/12/2018] [Indexed: 01/08/2023] Open
Abstract
Background For adults surviving stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) who had taken an antithrombotic (i.e. anticoagulant or antiplatelet) drug for the prevention of vaso-occlusive disease before the ICH, it is unclear whether starting antiplatelet drugs results in an increase in the risk of recurrent ICH or a beneficial net reduction of all serious vascular events compared to avoiding antiplatelet drugs. Methods/design The REstart or STop Antithrombotics Randomised Trial (RESTART) is an investigator-led, randomised, open, assessor-blind, parallel-group, randomised trial comparing starting versus avoiding antiplatelet drugs for adults surviving antithrombotic-associated ICH at 122 hospital sites in the United Kingdom. RESTART uses a central, web-based randomisation system using a minimisation algorithm, with 1:1 treatment allocation to which central research staff are masked. Central follow-up includes annual postal or telephone questionnaires to participants and their general (family) practitioners, with local provision of information about adverse events and outcome events. The primary outcome is recurrent symptomatic ICH. The secondary outcomes are: symptomatic haemorrhagic events; symptomatic vaso-occlusive events; symptomatic stroke of uncertain type; other fatal events; modified Rankin Scale score; adherence to antiplatelet drug(s). The magnetic resonance imaging (MRI) sub-study involves the conduct of brain MRI according to a standardised imaging protocol before randomisation to investigate heterogeneity of treatment effect according to the presence of brain microbleeds. Recruitment began on 22 May 2013. The target sample size is at least 720 participants in the main trial (at least 550 in the MRI sub-study). Discussion Final results of RESTART will be analysed and disseminated in 2019. Trial registration ISRCTN71907627 (www.isrctn.com/ISRCTN71907627). Prospectively registered on 25 April 2013. Electronic supplementary material The online version of this article (10.1186/s13063-018-2542-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| | - Martin S Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Gordon D Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Karen Innes
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jonathan Drever
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Lynn Dinsmore
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Carol Williams
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Philip M White
- Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle-upon-Tyne, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Peter A G Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Cathie L M Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Institute of Neurology, University College London, London, UK
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