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Shanahan RM, Hudson JS, Hasan DM. Response to: Aspirin and Subarachnoid Haemorrhage in the UK Biobank. Transl Stroke Res 2024; 15:863-864. [PMID: 37548879 DOI: 10.1007/s12975-023-01184-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Regan M Shanahan
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph S Hudson
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David M Hasan
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
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2
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Hoz SS, Hudson JS, Ma L, Lang MJ, Gross BA. Medications and "Risk" of Aneurysm Rupture Based on Presentation: Setting the Record Straight. World Neurosurg 2024; 188:e573-e577. [PMID: 38823446 DOI: 10.1016/j.wneu.2024.05.158] [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: 03/15/2024] [Revised: 05/25/2024] [Accepted: 05/26/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Studies assessing aneurysm rupture "risk" based on comparative retrospective analyses of medications taken on presentation may be subject to presentation bias. Are patients with ruptured aneurysms simply less likely to be taking medications than those with unruptured aneurysms? METHODS A retrospective chart review was conducted among patients with treated aneurysms from June 2016 to July 2023. A step-wise comparison of demographics, clinical characteristics (rupture status), and medications taken upon presentation was performed between ruptured and unruptured cases. RESULTS One thousand three hundred eleven patients with intracranial aneurysms were included. The majority of patients presenting with ruptured aneurysms took no medications (68%), in contrast to 22% with unruptured aneurysms (P < 0.001). The majority of patients with unruptured aneurysms took 2-5 medications (51%), in contrast to 15% of patients with ruptured aneurysms taking 2-5 medications (P < 0.001). Twelve percent of patients with unruptured aneurysms took more than 5 medications, while only 1% with ruptured aneurysms did (P < 0.001). Thirty-five different medications were associated with unruptured presentation, including all evaluated antiplatelet agents, anti-hypertensives, antacids, pulmonary inhalers, and psychiatric medications (P < 0.05); no medications were associated with rupture on presentation. CONCLUSIONS One cannot derive conclusions about medications and "risk" of rupture based on analyses at the time of presentation. This study identifies 35 different medications that were statistically significant and associated with an unruptured presentation; it is doubtful that each is "protective" against aneurysm rupture.
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Affiliation(s)
- Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Shimizu K, Aoki T, Etminan N, Hackenberg KAM, Tani S, Imamura H, Kataoka H, Sakai N. Associations Between Drug Treatments and the Risk of Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-analysis. Transl Stroke Res 2023; 14:833-841. [PMID: 36242746 DOI: 10.1007/s12975-022-01097-2] [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: 05/07/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022]
Abstract
There is increasing interest in drug therapy for preventing aneurysmal subarachnoid hemorrhage (aSAH). We aimed to comprehensively evaluate the association between drug use and the risk of aSAH. We searched PubMed and Scopus from the databases' inception until December 2021. Observational studies reporting the association between any drug therapy and aSAH were included. The odds ratios (ORs) for each drug used in aSAH were meta-analyzed with a random-effect model. According to the systematic review, 25 observational studies were eligible for the present study. Four therapeutic purpose-based classes (e.g., lipid-lowering agents) and 14 mechanism-based classes (e.g., statins) were meta-analyzed. Anti-hypertensive agents (OR, 0.50; 95% confidence interval [95% CI], 0.33-0.74), statins (OR, 0.55; 95% CI, 0.35-0.85), biguanides (OR, 0.57; 95% CI, 0.34-0.96), and acetylsalicylic acid (ASA) (OR, 0.62; 95% CI, 0.41-0.94) were inversely associated with the risk of aSAH. Non-ASA non-steroidal anti-inflammatory drugs (OR, 1.73; 95% CI, 1.07-2.79), selective cyclooxygenase-2 inhibitors (OR, 2.04; 95% CI, 1.24-3.35), vitamin K antagonists (OR, 1.50; 95% CI, 1.18-1.91), and dipyridamole (OR, 1.77; 95% CI, 1.23-2.54) were positively associated with the incidence of aSAH. There was also a trend toward a positive association between glucocorticoids (OR, 1.38; 95% CI, 0.97-1.94) and aSAH. The present study suggests that anti-hypertensive agents, statins, biguanides, and ASA are candidate drugs for preventing aSAH. By contrast, several drugs (e.g., anti-thrombotic drugs) may increase the risk of aSAH. Thus, the indications of these drugs in patients with intracranial aneurysms should be carefully determined.
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Affiliation(s)
- Kampei Shimizu
- Department of Neurosurgery, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan.
- Department of Molecular Pharmacology, Research Institute, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Tomohiro Aoki
- Department of Molecular Pharmacology, Research Institute, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Katharina A M Hackenberg
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Shoichi Tani
- Department of Neurosurgery, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Meng Y, Lin Y, Zhang JW, Zou WL, Liu YM, Shen XG, Shen QQ, Wang MM, Shao LN, Feng HY, Zhu Y, Yu JT, Lin B, Zhu B. Aspirin intervention before ICU admission reduced the mortality in critically ill patients with acute kidney injury: results from the MIMIC-IV. Front Pharmacol 2023; 14:1292745. [PMID: 38034989 PMCID: PMC10682711 DOI: 10.3389/fphar.2023.1292745] [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: 09/14/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Background: Aspirin, with its pleiotropic effects such as anti-inflammatory and anti-platelet aggregation, has been widely used for anti-inflammatory, analgesic, and cardiovascular diseases. However, the association between the use of aspirin before the intensive care unit (ICU) and clinical outcomes in critically ill patients with acute kidney injury (AKI) is unknown. Methods: Patients with AKI in this retrospective observational study were selected from the Marketplace for Medical Information in Intensive Care IV (MIMIC-IV). The association between aspirin intervention and 30-day mortality was assessed using Cox proportional hazards model. Logistic regression models were used to assess the association of aspirin intervention with the risks of intracranial hemorrhage, gastrointestinal bleeding and blood transfusion. The propensity score matching (PSM) method was adopted to balance the baseline variables. Sensitivity analysis was performed to validate the results by multiple interpolations for the missing data. Results: The study included 4237 pre-ICU aspirin users and 9745 non-users. In multivariate models, we found a decreased risk of mortality in those who received aspirin before ICU compared to those who did not (30-day:hazard ratio [HR], 0.70; 95% CI, 0.62-0.79; p < 0.001; 90-day:HR, 0.70; 95% CI, 0.63-0.77, p < 0.001; 180-day:HR, 0.72; 95%CI,0.65-0.79, p < 0.001). This benefit was consistent in the post-PSM analyses, sensitivity analyses, and subgroup analyses. Moreover, aspirin intervention was associated with a reduced risk of intracranial hemorrhage and gastrointestinal bleeding (HR, 0.16; 95% CI, 0.10-0.25; p < 0.001; HR, 0.59; 95% CI, 0.38-0.88, p = 0.012) after being adjusted by relating covariates, whereas with a increased risk of blood transfusion (HR, 1.28; 95% CI, 1.16-1.46; p < 0.001). Conclusion: Patients with AKI treated with aspirin before ICU admission might have reduced 30-day, 90-day and 180-day mortality without increasing the risk of intracranial hemorrhage (ICH) or gastrointestinal bleeding, but may increase the risk of transfusion.
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Affiliation(s)
- Yao Meng
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Yi Lin
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia-Wei Zhang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Wen-Li Zou
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yue-Ming Liu
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiao-Gang Shen
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Quan-Quan Shen
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Min-Min Wang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Li-Na Shao
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Hong-Yuan Feng
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Yan Zhu
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Jing-Ting Yu
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Bo Lin
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Bin Zhu
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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5
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Ewbank F, Birks J, Bulters D. The association between acetylsalicylic acid and subarachnoid haemorrhage: the Framingham Heart Study. Sci Rep 2023; 13:6533. [PMID: 37085588 PMCID: PMC10121705 DOI: 10.1038/s41598-023-33570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/14/2023] [Indexed: 04/23/2023] Open
Abstract
Studies investigating the association between acetylsalicylic acid (ASA) use and spontaneous subarachnoid haemorrhage (SAH) in the general population have produced conflicting results. The aim of this study is to clarify the relationship between SAH and ASA. We included all participants who reported on ASA use during interim examinations of the Framingham Heart Study Cohorts. Using Cox proportional-hazards regression modelling, we estimated the hazard ratio (HR) associated with ASA use. 7692 participants were included in this study. There were 30 cases of SAH during follow up, with an estimated incidence of 10.0 per 100,000 person- years (CI 6.90-14.15). Univariate analysis showed no association between regular ASA use and SAH (HR, 0.33 [0.08-1.41]; p = 0.14). This was similar when accounting for smoking (HR, 0.35 [0.08-1.51]; p = 0.16). Using a large longitudinal dataset from the Framingham Heart Study, we observed some evidence suggesting fewer SAH in those participants taking regular ASA. However, multivariate statistical analysis showed no significant association between ASA use and SAH. Due to the low incidence of SAH in the general population, the absolute number of SAH events was low and it remains uncertain if a significant effect would become apparent with more follow up.
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Affiliation(s)
- Frederick Ewbank
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK.
| | - Jacqueline Birks
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Diederik Bulters
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
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Luo C, Jin L, Dong J, Fu Z, Liu E, Yin S, Jian L, Luo P, Liu B, Huang W, Zhou S. Clinical outcomes of pipeline embolization devices with shield technology for treating intracranial aneurysms. Front Neurol 2022; 13:971664. [PMID: 36452166 PMCID: PMC9702813 DOI: 10.3389/fneur.2022.971664] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/24/2022] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION As a common endovascular treatment for intracranial aneurysms, the pipeline embolization device (PED) is considered a standard treatment option, especially for large, giant, wide-necked, or dissecting aneurysms. A layer of phosphorylcholine biocompatible polymer added to the surface of the PED can substantially improve this technology. This PED with shield technology (pipeline shield) is relatively novel; its early technical success and safety have been reported. We conducted a systematic literature review with the aim of evaluating the efficacy and safety of the pipeline shield. METHODS We searched the PubMed, Embase, and Cochrane databases, following the preferred reporting items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS We selected five prospective and two retrospective studies for review. A total of 572 aneurysms were included; of these, 506 (88.5%) were unruptured. The antiplatelet regimens were heterogeneous. The rate of perioperative and postoperative complications was 11.1% [95% confidence interval (CI): 6.5-18.9%]. The adequate occlusion rate at 6 months was 73.9% (95% CI: 69.1-78.7%). The adequate occlusion rate of more than 12 months was 80.9% (95% CI: 75.1-86.1%). The mortality rate was 0.7% (95% CI: 0.2-1.5%). Subgroup analyses showed that aneurysm rupture status had no effect on aneurysm occlusion rate, patient morbidity, or mortality. CONCLUSION This review demonstrates the safety and efficacy of the pipeline shield for treating intracranial aneurysms. However, direct comparisons of the pipeline shield with other flow diverters are needed to better understand the relative safety and effectiveness of different devices.
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Affiliation(s)
- Chao Luo
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lide Jin
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Jigen Dong
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Zaixiang Fu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Erheng Liu
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Shi Yin
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lipeng Jian
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Pengren Luo
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Bo Liu
- College of Clinical Medicine, Jilin University, Changchun, China
| | - Wei Huang
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Shuai Zhou
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
- Medical Faculty, Kunming University of Science and Technology, Kunming, China
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7
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UNO M, YAGI K, TAKAI H, HIRAI S, MINAMI-OGAWA Y, TAO Y, SUNADA Y, MATSUBARA S. Clinical Presentation, Treatment, and Outcome of Nontraumatic Subarachnoid Hemorrhage in Patients with Preceding Antithrombotic Therapy. Neurol Med Chir (Tokyo) 2022; 63:9-16. [PMID: 36223946 PMCID: PMC9894618 DOI: 10.2176/jns-nmc.2022-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of nontraumatic subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade ≥4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.
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Affiliation(s)
- Masaaki UNO
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kenji YAGI
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroyuki TAKAI
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Satoshi HIRAI
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yukari MINAMI-OGAWA
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshifumi TAO
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshihiro SUNADA
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shunji MATSUBARA
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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8
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Ewbank F, Birks J, Gaastra B, Hall S, Galea I, Bulters D. Aspirin and Subarachnoid Haemorrhage in the UK Biobank. Transl Stroke Res 2022:10.1007/s12975-022-01060-1. [PMID: 35809217 DOI: 10.1007/s12975-022-01060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/26/2022] [Indexed: 10/17/2022]
Abstract
Previous studies investigating the relationship between aspirin use and subarachnoid haemorrhage (SAH) have yielded conflicting results. In this study, we aimed to clarify the association between aspirin and SAH in the general population. The UK Biobank is a prospective population-based cohort study. Sex, age, smoking, alcohol, medication use, hypertension, blood pressure, ischaemic heart disease and stroke were recorded at baseline assessments. Follow-up is conducted through linkages to National Health Service data including electronic, coded death certificate, hospital and primary care data. Cox proportional hazards modelling was used to analyse the association between aspirin use and SAH. Of the 501,060 participants included in the analysis, a total of 579 suffered from spontaneous SAH after their baseline assessment. There was no relationship between aspirin and SAH of all causes (HR, 1.16 [0.92-1.46]), aneurysmal SAH (HR, 1.15 [0.91-1.47]) or non-aneurysmal SAH (HR, 1.29 [0.54-3.09]). Aspirin use was associated with SAH resulting in death (HR, 1.69 [1.14-2.51]), especially out of hospital death (HR, 2.10 [1.13-3.91]). Despite reports of a protective association between aspirin and SAH in patients with known unruptured aneurysms, this study has not demonstrated the same effect in the general population. However, aspirin users were more likely to suffer SAH resulting in death, especially out of hospital.
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Affiliation(s)
- Frederick Ewbank
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Jacqueline Birks
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Benjamin Gaastra
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Samuel Hall
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Galea
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Diederik Bulters
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
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9
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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10
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Letter to the Editor Regarding "Association Between Aspirin Use and Risk of Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis". World Neurosurg 2021; 146:394. [PMID: 33607731 DOI: 10.1016/j.wneu.2020.09.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/20/2022]
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11
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Petersen JM, Ranker LR, Barnard-Mayers R, MacLehose RF, Fox MP. A systematic review of quantitative bias analysis applied to epidemiological research. Int J Epidemiol 2021; 50:1708-1730. [PMID: 33880532 DOI: 10.1093/ije/dyab061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19. METHODS We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility. RESULTS Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale. CONCLUSIONS QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.
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Affiliation(s)
- Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lynsie R Ranker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Ewbank F, Birks J, Bulters D. A meta-analysis of aspirin and subarachnoid hemorrhage in patients with intracranial aneurysms yields different results to the general population. Int J Stroke 2021; 17:341-353. [PMID: 33705214 DOI: 10.1177/17474930211004888] [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] [Indexed: 12/18/2022]
Abstract
BACKGROUND Some studies have shown a protective association between aspirin use and subarachnoid hemorrhage. Other studies have found no relationship or the reverse. These studies differ in their study populations and definitions of subarachnoid hemorrhage. AIMS Our aim was to establish (1) if there is an association between aspirin and subarachnoid hemorrhage, (2) how this differs between the general population and those with intracranial aneurysms. SUMMARY OF REVIEW Studies reporting aspirin use and the occurrence of subarachnoid hemorrhage were included and grouped based on population (general population vs. aneurysm population). Odds ratios, hazard ratios, and confidence intervals were combined in random-effects models. Eleven studies were included. Overall, there was an association between aspirin and subarachnoid hemorrhage (OR 0.68 [0.48, 0.96]). However, populations were diverse and heterogeneity between studies high (p < 0.00001), questioning the validity of combining these studies and justifying analysis by population. In the general population, there was no difference in aspirin use between individuals with and without subarachnoid hemorrhage (OR 1.15 [0.96, 1.38]). In patients with intracranial aneurysms, aspirin use was greater in patients without subarachnoid hemorrhage (OR 0.37 [0.24, 0.58]), although these studies were at higher risk of bias. CONCLUSIONS There is an association between aspirin use and subarachnoid hemorrhage in patients with intracranial aneurysms. This apparent protective relationship is not seen in the general population. Prospective randomized studies are required to further investigate the effect of aspirin on unruptured intracranial aneurysms.
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Florez WA, García-Ballestas E, Maeda F, Joaquim A, Pavlov O, Moscote-Salazar LR, Tsimpas A, Martinez-Perez R. Relationship between aspirin use and subarachnoid hemorrhage: A systematic Review and meta-analysis. Clin Neurol Neurosurg 2020; 200:106320. [PMID: 33268193 DOI: 10.1016/j.clineuro.2020.106320] [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: 06/29/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aspirin has been associated with a decreasing risk of subarachnoid hemorrhage due to its anti-inflammatory mechanism of action and potential protective properties against aneurysm growth. OBJECTIVE To determine the association between aneurysmal subarachnoid hemorrhage and aspirin use. METHODS A systematic review of the literature and a meta-analysis were performed across the PubMed database. The following keywords were used: "aspirin, acetylsalicylic acid, 2-acetyloxy-benzoic acid, ruptured intracranial aneurysm, aneurysmal subarachnoid hemorrhage, spontaneous subarachnoid hemorrhage, intracerebral hemorrhage, spontaneous aneurysmal hemorrhage, spontaneous intracerebral bleeding". Studies that were performed with animals or analyzed patients with traumatic brain injury were excluded. A total of five studies were included in our meta-analysis, with a total of 19,222 patients evaluated. Statistical analysis was performed to determine the association between the use of aspirin and the risk of subarachnoid hemorrhage. RESULTS Aspirin use reduce the risk of subarachnoid hemorrhage (odds ratio [OR] 0.51, 95 % confidence interval [CI] 0.34-0.76). CONCLUSION Although some previous studies suggested that aspirin may potentially reduce the risk of subarachnoid hemorrhage, our meta-analysis found an association between the reduction of risk of aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- William A Florez
- Latinoamerican Council of Neurocritical Care, Cartagena, Colombia; Faculty of Health, Programa Medicina, Universidad Surcolombiana, Neiva, Huila, Colombia.
| | - Ezequiel García-Ballestas
- Latinoamerican Council of Neurocritical Care, Cartagena, Colombia; Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Fernando Maeda
- Department of Neurosurgery, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Andrei Joaquim
- Department of Neurosurgery, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Orlin Pavlov
- Departament of Neurosurgery, Klinikum Fulda gAG, Fulda, Germany
| | - Luis Rafael Moscote-Salazar
- Latinoamerican Council of Neurocritical Care, Cartagena, Colombia; Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Asterios Tsimpas
- Section of Neurosurgery, Department of Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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Qian C, He Y, Li Y, Chen C, Zhang B. Association Between Aspirin Use and Risk of Aneurysmal Subarachnoid Hemorrhage: A Meta-analysis. World Neurosurg 2020; 138:299-308. [DOI: 10.1016/j.wneu.2020.01.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
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Nisson PL, Meybodi T, Secomb TW, Berger GK, Roe DJ, Lawton MT. Patients Taking Antithrombotic Medications Present Less Frequently with Ruptured Aneurysms. World Neurosurg 2019; 136:e132-e140. [PMID: 31857268 DOI: 10.1016/j.wneu.2019.12.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Conflicting findings exist on the protective role of aspirin against aneurysmal subarachnoid hemorrhage (SAH). In this retrospective analysis, we compare the risk of SAH at presentation between patients treated microsurgically who were regularly taking an antithrombotic medication versus those who were not. METHODS Consecutive patients with solitary aneurysms treated by the senior author using a microsurgical approach were included from a database of patients treated between January 2010 and April 2013 at a tertiary academic medical center. χ2 and logistic regression analysis were performed, comparing the risk of SAH with antithrombotic use. RESULTS A total of 347 patients were included in the study, 156 (45%) of whom presented with SAH. A total of 63 patients (18%) were taking an antithrombotic medication (aspirin, 53; clopidogrel, 6; both, 4) and 12 (4%) were on anticoagulation medication. Multivariate analysis was conducted using SAH as the primary outcome and included patient age (odds ratio [OR], 0.99), gender (male, OR, 0.65), tobacco use (OR, 1.43), alcohol use (OR, 1.02), coronary artery disease (OR, 1.84), diabetes (OR, 1.03), hypertension (OR 0.91), and posterior circulation location (OR, 1.47). This analysis found that only antithrombotic use (OR, 0.20) was associated with a significantly lower rate of rupture at the time of presentation (P < 0.001). CONCLUSIONS Patients taking an antithrombotic were less likely to present with ruptured aneurysms. No difference was found for those taking anticoagulants. Patient outcomes did not differ between those on an antithrombotic versus those without. A randomized controlled trial is needed to further investigate the application of antithrombotics for preventing SAH.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA; Department of Neurosurgery, Cedars-Sinai, Los Angeles, California, USA
| | - Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Timothy W Secomb
- Department of Physiology, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Garrett K Berger
- College of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Denise J Roe
- Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
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16
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Can A, Rudy RF, Castro VM, Yu S, Dligach D, Finan S, Gainer V, Shadick NA, Savova G, Murphy S, Cai T, Weiss ST, Du R. Association between aspirin dose and subarachnoid hemorrhage from saccular aneurysms: A case-control study. Neurology 2018; 91:e1175-e1181. [PMID: 30135253 DOI: 10.1212/wnl.0000000000006200] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 06/20/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association between ruptured saccular aneurysms and aspirin use/aspirin dose. METHODS Four thousand seven hundred one patients who were diagnosed at the Massachusetts General Hospital and Brigham and Women's Hospital between 1990 and 2016 with 6,411 unruptured and ruptured saccular intracranial aneurysms were evaluated. Univariable and multivariable logistic regression analyses were performed to determine the association between aneurysmal subarachnoid hemorrhage and aspirin use, including aspirin dose. Inverse probability weighting using propensity scores was used to adjust for potential differences in baseline characteristics between cases and controls. Additional analyses were performed to examine the association of aspirin use and rerupture before treatment. RESULTS In multivariate analysis with propensity score weighting, aspirin use (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.45-0.80) was significantly associated with decreased risk of ruptured intracranial aneurysms. There was a significant inverse dose-response relationship between aspirin dose and aneurysmal subarachnoid hemorrhage (OR 0.65, 95% CI 0.53-0.81). In contrast, there was a significant association between aspirin use and increased risk of rerupture before treatment (OR 8.15, 95% CI 2.22-30.0). CONCLUSIONS In this large case-control study, aspirin therapy at diagnosis was associated with a significantly decreased risk of subarachnoid hemorrhage, with an inverse dose-response relationship among aspirin users. However, once rupture has occurred, aspirin is associated with an increased risk of rerupture before treatment.
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Affiliation(s)
- Anil Can
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Robert F Rudy
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Victor M Castro
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sheng Yu
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Dmitriy Dligach
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sean Finan
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Vivian Gainer
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Nancy A Shadick
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Guergana Savova
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Shawn Murphy
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Tianxi Cai
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Scott T Weiss
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rose Du
- From the Department of Neurosurgery (A.C., R.F.R., R.D.), Brigham and Women's Hospital, Harvard Medical School; Research Information Systems and Computing (V.M.C., V.G., S.M.); Department of Medicine (S.Y., S.T.W.), Division of Rheumatology, Immunology and Allergy (N.A.S.), and Channing Division of Network Medicine (S.T.W., R.D.), Brigham and Women's Hospital, Boston, MA; Center for Statistical Science (S.Y.), Tsinghua University, Beijing, China; Boston Children's Hospital Informatics Program (D.D., S.F., G.S.), MA; Department of Computer Science (D.D.), Loyola University, Chicago, IL; Department of Neurology (S.M.), Massachusetts General Hospital; and Biostatistics (T.C.), Harvard T.H. Chan School of Public Health, Boston, MA.
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Yoon CH, Lee HW, Kim YS, Lee SW, Yeom JA, Roh J, Baik SK. Preliminary Study of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms. Neurosurgery 2018; 82:76-84. [PMID: 28419294 DOI: 10.1093/neuros/nyx177] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 03/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There have been some reports on the use of intra-arterial tirofiban in ruptured intracranial aneurysms, but few studies have reported on the use of 24 h of intravenous tirofiban infusion in patients with subarachnoid hemorrhage. OBJECTIVE To present our experience with intravenous tirofiban infusion, in the form of a monotherapy as well as in addition to intra-arterial tirofiban, as a prophylactic, and as a rescue management for thrombus in patients who have undergone embolization with coils for ruptured intracranial aneurysms. METHODS Between December 2008 and January 2015, we retrospectively reviewed 249 ruptured intracranial aneurysms that were treated with coiling at our institutions. A total of 28 patients harboring 28 ruptured and 3 unruptured intracranial aneurysms underwent intravenous tirofiban infusion during or after coil embolization of an aneurysm. Intra-arterial infusion of tirofiban via a microcatheter was also performed in 26 patients. RESULTS Thromboembolic formation during the procedure was detected in 25 cases. Intra-arterial tirofiban dissolved the thromboembolus under angiographic control after 10 or more minutes in 19 (76%) of 25 patients. Two intracranial hemorrhagic complications (increase in the extent of hematoma) occurred during the follow-up period. Two cases of other complications occurred: hematuria and perioral bleeding. CONCLUSION Intravenous tirofiban, as a monotherapy or in addition to intra-arterial tirofiban for thrombotic complications, seems to be useful as a treatment for acute aneurysm. However, alternatives to tirofiban should be considered if an associated hematoma is discovered before a patient receives a tirofiban infusion.
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Affiliation(s)
- Chang Hyo Yoon
- Department of Neurology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ho-Won Lee
- Department of Neurology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young Soo Kim
- Department of Neurosur-gery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Sang Won Lee
- Department of Neurosur-gery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jeong A Yeom
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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18
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Bruder M, Won SY, Wagner M, Brawanski N, Dinc N, Kashefiolasl S, Seifert V, Konczalla J. Continuous Acetylsalicylic Acid Treatment Does Not Influence Bleeding Pattern or Outcome of Aneurysmal Subarachnoid Hemorrhage: A Matched-Pair Analysis. World Neurosurg 2018; 113:e122-e128. [DOI: 10.1016/j.wneu.2018.01.188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/25/2018] [Accepted: 01/27/2018] [Indexed: 12/28/2022]
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Shono Y, Sugimori H, Matsuo R, Fukushima Y, Wakisaka Y, Kuroda J, Ago T, Kamouchi M, Kitazono T. Safety of antithrombotic therapy for patients with acute ischemic stroke harboring unruptured intracranial aneurysm. Int J Stroke 2018. [PMID: 29543141 DOI: 10.1177/1747493018765263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The safety of antithrombotic therapy for patients with acute ischemic stroke harboring unruptured intracranial aneurysms remains unclear. Aims This study was performed to determine whether treatment with antiplatelets, anticoagulants, or intravenous thrombolytic agents is safe for patients with acute ischemic stroke and unruptured intracranial aneurysms. Methods Among 9149 patients with acute ischemic stroke enrolled in the Fukuoka Stroke Registry from June 2007 to December 2014, 8857 patients with data on cerebrovascular imaging and three-month outcomes were included in this study. The frequency of adverse events, including intracranial hemorrhage, symptomatic intracranial hemorrhage, and in-hospital mortality, was compared between patients with and without unruptured intracranial aneurysms. The risk of a poor functional outcome (modified Rankin scale score of ≥3) at three months after stroke onset was estimated after adjusting for confounding factors by logistic regression analysis. Results Unruptured intracranial aneurysms were identified in 412 (4.7%) patients, and the mean diameter was 4.1 ± 3.2 mm. There was no significant difference in the frequency of any adverse events between patients with and without unruptured intracranial aneurysms among the overall patients or patients receiving antiplatelets, anticoagulants, or intravenous thrombolytic agents. The odds ratios of a poor functional outcome were not significantly higher in the presence of unruptured intracranial aneurysms, even in patients undergoing antiplatelet therapy, anticoagulation therapy, or intravenous thrombolysis. Conclusions These findings suggest that unruptured intracranial aneurysms are not associated with increased risks of adverse events or poor functional outcomes even after antithrombotic therapy for acute ischemic stroke. However, accumulation of cases is required to verify these findings.
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Affiliation(s)
- Yuji Shono
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,2 Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroshi Sugimori
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,3 Stroke Center, Saga Medical Centre Koseikan, Saga, Japan
| | - Ryu Matsuo
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,4 Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihisa Fukushima
- 5 Department of Cerebrovascular Medicine, St. Mary's Hospital, Kurume, Japan
| | - Yoshinobu Wakisaka
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,6 Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junya Kuroda
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Ago
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Kamouchi
- 4 Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,6 Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- 1 Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,6 Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Adiponectin Single Nucleotide Polymorphisms and Serum Levels Are Relevant to Prognosis of Patients With Aneurysmal Subarachnoid Hemorrhages. Am J Ther 2018; 24:e308-e316. [PMID: 26760913 DOI: 10.1097/mjt.0000000000000437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To investigate the association of adiponectin gene polymorphisms and its levels with aneurysmal subarachnoid hemorrhages (aSAHs) prognosis. This case-control study enrolled 138 patients with aSAH and 102 healthy controls as case group and control group, respectively. Prognosis of case group was evaluated using Glasgow Outcome Scale. Polymerase chain reaction-restriction fragment length polymorphism was used to examine the genotypes of 45T>G and -11377C>G. Enzyme-linked immunosorbent assay was used to detect adiponectin levels. Logistic regression analysis was applied to assess the association of adiponectin gene polymorphism with aSAH prognosis. Case group had increased GG genotype and G allele genotype frequencies of 45T>G and -11377C>G compared with control group (all P < 0.01). In case group, TT genotype had the highest adiponectin level compared with both TG and GC genotypes (both P < 0.05). As for -11377C>G, GG genotype had the lowest adiponectin levels, followed by CG genotype and CC genotype in both groups (P < 0.05). In general, case group had decreased adiponectin levels compared with control group (P < 0.05). Univariate analysis showed that hypertension, Hunt-Hess grade, aneurysm size, aneurysms multiplicity and -11377C>G were associated with aSAH prognosis, while multivariate logistic regression analysis confirmed that hypertension, Hunt-Hess grade, residual flow in aneurysms and aneurysm size were independent risk factors for aSAH prognosis. Decreased adiponectin levels may be a pathological index for aSAH, which may be explain by the G allele of -11377C>G in adiponectin. Moreover, hypertension, Hunt-Hess grade, residual flow in aneurysms and aneurysm size may be independent risk factors for aSAH prognosis.
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Low-dose Aspirin, Nonsteroidal Anti-inflammatory Drugs, Selective COX-2 Inhibitors and Breast Cancer Recurrence. Epidemiology 2018; 27:586-93. [PMID: 27007644 DOI: 10.1097/ede.0000000000000480] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and selective COX-2 inhibitors may improve outcomes in breast cancer patients. We investigated the association of aspirin, NSAIDs, and use of selective COX-2 inhibitors with breast cancer recurrence. METHODS We identified incident stage I-III Danish breast cancer patients in the Danish Breast Cancer Cooperative Group registry, who were diagnosed during 1996-2008. Prescriptions for aspirin (>99% low-dose aspirin), NSAIDs, and selective COX-2 inhibitors were ascertained from the National Prescription Registry. Follow-up began on the date of breast cancer primary surgery and continued until the first of recurrence, death, emigration, or 1 January 2013. We used Cox regression models to compute hazard ratios (HR) and corresponding 95% confidence intervals (95% CI) associating prescriptions with recurrence, adjusting for confounders. RESULTS We identified 34,188 breast cancer patients with 233,130 person-years of follow-up. Median follow-up was 7.1 years; 5,325 patients developed recurrent disease. Use of aspirin, NSAIDs, or selective COX-2 inhibitors was not associated with the rate of recurrence (HRadjusted aspirin = 1.0, 95% CI = 0.90, 1.1; NSAIDs = 0.99, 95% CI = 0.92, 1.1; selective COX-2 inhibitors = 1.1, 95% CI = 0.98, 1.2), relative to nonuse. Prediagnostic use of the exposure drugs was associated with reduced recurrence rates (HRaspirin = 0.92, 95% CI = 0.82, 1.0; HRNSAIDs = 0.86, 95% CI = 0.81, 0.91; HRsCOX-2inhibitors = 0.88, 95% CI = 0.83, 0.95). CONCLUSIONS This prospective cohort study suggests that post diagnostic prescriptions for aspirin, NSAIDs, and selective COX-2 inhibitors have little or no association with the rate of breast cancer recurrence. Prediagnostic use of the drugs was, however, associated with a reduced rate of breast cancer recurrence.
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Abstract
Unruptured intracranial aneurysms (UIA) occur in approximately 2-3 % of the population. Most of these lesions are incidentally found, asymptomatic and typically carry a benign course. Although the risk of aneurysmal subarachnoid hemorrhage is low, this complication can result in significant morbidity and mortality, making assessment of this risk the cornerstone of UIA management. This article reviews important factors to consider when managing unruptured intracranial aneurysms including patient demographics, comorbidities, family history, symptom status, and aneurysm characteristics. It also addresses screening, monitoring, medical management and current surgical and endovascular therapies.
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Phan K, Moore JM, Griessenauer CJ, Ogilvy CS, Thomas AJ. Aspirin and Risk of Subarachnoid Hemorrhage. Stroke 2017; 48:1210-1217. [DOI: 10.1161/strokeaha.116.015674] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/15/2017] [Accepted: 02/01/2017] [Indexed: 01/07/2023]
Abstract
Background and Purpose—
Recent studies have suggested that the use of low-dose aspirin may reduce the risk of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate any association between aspirin use and risk of aSAH based on the literature, and whether this is influenced by duration or frequency of aspirin use.
Methods—
A search of electronic databases was done from inception to September 2016. For each study, data on risk of aSAH in aspirin versus nonaspirin users were used to generate odds ratios and 95% confidence intervals, and combined using inverse variance–weighted averages of logarithmic odds ratios in a random-effects models.
Results—
From 7 included studies, no significant difference was noted between aspirin use of any duration or frequency and nonaspirin users (odds ratio, 1.00; 95% confidence interval, 0.81–1.24;
P
=0.99). We found a significant association between short-term use of aspirin (<3 months) and the risk of aSAH (odds ratio, 1.61; 95% confidence interval, 1.20–2.18;
P
=0.002). No significant difference was found in terms of risk of aSAH for 3 to 12 months, 1 to 3 years, and >3 years of durations of use. No significant association was found between infrequent aspirin use (≤2× per week) or frequent use (≥3× per week) with risk of aSAH.
Conclusions—
Current evidence suggests that short-term (<3 months) use of aspirin is associated with increased risk of aSAH. Limitations include substantial heterogenity of the included studies. The role of long-term aspirin in reducing risk of aSAH remains unclear and ideally should be addressed by an appropriately designed randomized controlled trial.
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Affiliation(s)
- Kevin Phan
- From the NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia (K.P.); Sydney Medical School, University of Sydney, New South Wales, Australia (K.P.); Department of Neurosurgery, Stanford University School of Medicine, CA (J.M.M.); and Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.M.M., C.J.G., C.S.O., A.J.T.)
| | - Justin M. Moore
- From the NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia (K.P.); Sydney Medical School, University of Sydney, New South Wales, Australia (K.P.); Department of Neurosurgery, Stanford University School of Medicine, CA (J.M.M.); and Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.M.M., C.J.G., C.S.O., A.J.T.)
| | - Christoph J. Griessenauer
- From the NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia (K.P.); Sydney Medical School, University of Sydney, New South Wales, Australia (K.P.); Department of Neurosurgery, Stanford University School of Medicine, CA (J.M.M.); and Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.M.M., C.J.G., C.S.O., A.J.T.)
| | - Christopher S. Ogilvy
- From the NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia (K.P.); Sydney Medical School, University of Sydney, New South Wales, Australia (K.P.); Department of Neurosurgery, Stanford University School of Medicine, CA (J.M.M.); and Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.M.M., C.J.G., C.S.O., A.J.T.)
| | - Ajith J. Thomas
- From the NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia (K.P.); Sydney Medical School, University of Sydney, New South Wales, Australia (K.P.); Department of Neurosurgery, Stanford University School of Medicine, CA (J.M.M.); and Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.M.M., C.J.G., C.S.O., A.J.T.)
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Dasenbrock HH, Yan SC, Gross BA, Guttieres D, Gormley WB, Frerichs KU, Ali Aziz-Sultan M, Du R. The impact of aspirin and anticoagulant usage on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis. J Neurosurg 2017; 126:537-547. [DOI: 10.3171/2015.12.jns151107] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE
Although aspirin usage may be associated with a decreased risk of rupture of cerebral aneurysms, any potential therapeutic benefit from aspirin must be weighed against the theoretical risk of greater hemorrhage volume if subarachnoid hemorrhage (SAH) occurs. However, few studies have evaluated the association between prehemorrhage aspirin use and outcomes. This is the first nationwide analysis to evaluate the impact of long-term aspirin and anticoagulant use on outcomes after SAH.
METHODS
Data from the Nationwide Inpatient Sample (NIS; 2006–2011) were extracted. Patients with a primary diagnosis of SAH who underwent microsurgical or endovascular aneurysm repair were included; those with a diagnosis of an arteriovenous malformation were excluded. Multivariable logistic regression was performed to calculate the adjusted odds of in-hospital mortality, a nonroutine discharge (any discharge other than to home), or a poor outcome (death, discharge to institutional care, tracheostomy, or gastrostomy) for patients with long-term aspirin or anticoagulant use. Multivariable linear regression was used to evaluate length of hospital stay. Covariates included patient age, sex, comorbidities, primary payer, NIS-SAH severity scale, intracerebral hemorrhage, cerebral edema, herniation, modality of aneurysm repair, hospital bed size, and whether the hospital was a teaching hospital. Subgroup analyses exclusively evaluated patients treated surgically or endovascularly.
RESULTS
The study examined 11,549 hospital admissions. Both aspirin (2.1%, n = 245) and anticoagulant users (0.9%, n = 108) were significantly older and had a greater burden of comorbid disease (p < 0.001); severity of SAH was slightly lower in those with long-term aspirin use (p = 0.03). Neither in-hospital mortality (13.5% vs 12.6%) nor total complication rates (79.6% vs 80.0%) differed significantly by long-term aspirin use. Additionally, aspirin use was associated with decreased odds of a cardiac complication (OR 0.57, 95% CI 0.36%–0.91%, p = 0.02) or of venous thromboembolic events (OR 0.53, 95% CI 0.30%–0.94%, p = 0.03). Length of stay was significantly shorter (15 days vs 17 days [12.73%], 95% CI 5.22%–20.24%, p = 0.001), and the odds of a nonroutine discharge were lower (OR 0.63, 95% CI 0.48%–0.83%, p = 0.001) for aspirin users. In subgroup analyses, the benefits of aspirin were primarily noted in patients who underwent coil embolization; likewise, among patients treated endovascularly, the adjusted odds of a poor outcome were lower among long-term aspirin users (31.8% vs 37.4%, OR 0.63, 95% CI 0.42%–0.94%, p = 0.03). Although the crude rates of in-hospital mortality (19.4% vs 12.6%) and poor outcome (53.6% vs 37.6%) were higher for long-term anticoagulant users, in multivariable logistic regression models these variations were not significantly different (mortality: OR 1.36, 95% CI 0.89%–2.07%, p = 0.16; poor outcome: OR 1.09, 95% CI 0.69%–1.73%, p = 0.72).
CONCLUSIONS
In this nationwide study, neither long-term aspirin nor anticoagulant use were associated with differential mortality or complication rates after SAH. Aspirin use was associated with a shorter hospital stay and lower rates of nonroutine discharge, with these benefits primarily observed in patients treated endovascularly.
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Affiliation(s)
- Hormuzdiyar H. Dasenbrock
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
- 4H.T. Chan Harvard School of Public Health, Boston, Massachusetts
| | - Sandra C. Yan
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 5Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; and
| | - Bradley A. Gross
- 6Barrow Neurological Institute, Division of Neurological Surgery, Phoenix, Arizona
| | | | - William B. Gormley
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
| | - Kai U. Frerichs
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
| | - M. Ali Aziz-Sultan
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
| | - Rose Du
- 1Cushing Neurosurgical Outcomes Center,
- 2Department of Neurological Surgery, Brigham and Women's Hospital,
- 3Harvard Medical School, and
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Cerebral hyperperfusion syndrome resulting in subarachnoid hemorrhage after carotid artery stenting. Ann Nucl Med 2016; 30:669-674. [PMID: 27485406 DOI: 10.1007/s12149-016-1108-5] [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] [Received: 04/04/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Abstract
A 64-year-old, right-handed man underwent endovascular treatment for internal carotid artery stenosis after experiencing a left-hemispheric transient ischemic attack. 15O-gas and H 215 O positron emission tomography revealed slightly reduced cerebral blood flow (CBF), elevated cerebral blood volume, and severely reduced cerebral vasoreactivity in the ipsilateral hemisphere as determined by an acetazolamide challenge test. The patient underwent left carotid artery stenting (CAS) via a prefemoral approach under local anesthesia without any complications. Follow-up examinations performed 20 h postoperatively showed subarachnoid hemorrhage (SAH) and cerebral hyperperfusion syndrome (CHS) in the left frontal lobe. Although it is a relatively rare phenomenon, SAH resulting from CHS was determined to be specifically caused by CAS. In this case, the causes of SAH may have been related to multiple factors including increased regional CBF, loss of cerebrovascular autoregulation, contrast agent-mediated disruption of major cerebral vessels, and strong antiplatelet therapy.
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26
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Analysis of Hemorrhage Volumes After Angiogram-Negative Subarachnoid Hemorrhage. World Neurosurg 2016; 94:453-457. [DOI: 10.1016/j.wneu.2016.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 11/19/2022]
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27
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Hunnicutt JN, Ulbricht CM, Chrysanthopoulou SA, Lapane KL. Probabilistic bias analysis in pharmacoepidemiology and comparative effectiveness research: a systematic review. Pharmacoepidemiol Drug Saf 2016; 25:1343-1353. [PMID: 27593968 DOI: 10.1002/pds.4076] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/16/2016] [Accepted: 07/11/2016] [Indexed: 11/06/2022]
Abstract
PURPOSE We systematically reviewed pharmacoepidemiologic and comparative effectiveness studies that use probabilistic bias analysis to quantify the effects of systematic error including confounding, misclassification, and selection bias on study results. METHODS We found articles published between 2010 and October 2015 through a citation search using Web of Science and Google Scholar and a keyword search using PubMed and Scopus. Eligibility of studies was assessed by one reviewer. Three reviewers independently abstracted data from eligible studies. RESULTS Fifteen studies used probabilistic bias analysis and were eligible for data abstraction-nine simulated an unmeasured confounder and six simulated misclassification. The majority of studies simulating an unmeasured confounder did not specify the range of plausible estimates for the bias parameters. Studies simulating misclassification were in general clearer when reporting the plausible distribution of bias parameters. Regardless of the bias simulated, the probability distributions assigned to bias parameters, number of simulated iterations, sensitivity analyses, and diagnostics were not discussed in the majority of studies. CONCLUSION Despite the prevalence and concern of bias in pharmacoepidemiologic and comparative effectiveness studies, probabilistic bias analysis to quantitatively model the effect of bias was not widely used. The quality of reporting and use of this technique varied and was often unclear. Further discussion and dissemination of the technique are warranted. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jacob N Hunnicutt
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Christine M Ulbricht
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Konczalla J, Kashefiolasl S, Brawanski N, Senft C, Seifert V, Platz J. Increasing numbers of nonaneurysmal subarachnoid hemorrhage in the last 15 years: antithrombotic medication as reason and prognostic factor? J Neurosurg 2016; 124:1731-7. [PMID: 26566212 DOI: 10.3171/2015.5.jns15161] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Subarachnoid hemorrhage (SAH) is usually caused by a ruptured intracranial aneurysm, but in some patients no source of hemorrhage can be detected. More recent data showed increasing numbers of cases of spontaneous nonaneurysmal SAH (NASAH). The aim of this study was to analyze factors, especially the use of antithrombotic medications such as systemic anticoagulation or antiplatelet agents (aCPs), influencing the increasing numbers of cases of NASAH and the clinical outcome.
METHODS
Between 1999 and 2013, 214 patients who were admitted to the authors’ institution suffered from NASAH, 14% of all patients with SAH. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Risk factors were identified based on the outcome.
RESULTS
The number of patients with NASAH increased significantly in the last 15 years of the study period. There was a statistically significant increase in the rate of nonperimesencephalic (NPM)-SAH occurrence and aCP use, while the proportion of elderly patients remained stable. Favorable outcome (mRS 0–2) was achieved in 85% of cases, but patients treated with aCPs had a significantly higher risk for an unfavorable outcome. Further analysis showed that elderly patients, and especially the subgroup with a Fisher Grade 3 bleeding pattern, had a high risk for an unfavorable outcome, whereas the subgroup of NPM-SAH without a Fisher Grade 3 bleeding pattern had a favorable outcome, similar to perimesencephalic (PM)-SAH.
CONCLUSIONS
Over the years, a significant increase in the number of patients with NASAH has been observed. Also, the rate of aCP use has increased significantly. Risk factors for an unfavorable outcome were age > 65 years, Fisher Grade 3 bleeding pattern, and aCP use. Both “PM-SAH” and “NPM-SAH without a Fisher Grade 3 bleeding pattern” had excellent outcomes. Patients with NASAH and a Fisher Grade 3 bleeding pattern had a significantly higher risk for an unfavorable outcome and death. Therefore, for further investigations, NPM-SAH should be stratified into patients with or without a Fisher Grade 3 bleeding pattern. Also, cases of spontaneous SAH should be stratified into NASAH and aneurysmal SAH.
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29
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Cronin-Fenton DP, Heide-Jørgensen U, Ahern TP, Lash TL, Christiansen PM, Ejlertsen B, Sjøgren P, Kehlet H, Sørensen HT. Opioids and breast cancer recurrence: A Danish population-based cohort study. Cancer 2015. [PMID: 26207518 DOI: 10.1002/cncr.29532] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Opioids may alter immune function, thereby potentially affecting cancer recurrence. The authors investigated the association between postdiagnosis opioid use and breast cancer recurrence. METHODS Patients with incident, early stage breast cancer who were diagnosed during 1996 through 2008 in Denmark were identified from the Danish Breast Cancer Cooperative Group Registry. Opioid prescriptions were ascertained from the Danish National Prescription Registry. Follow-up began on the date of primary surgery for breast cancer and continued until breast cancer recurrence, death, emigration, 10 years, or July 31, 2013, whichever occurred first. Cox regression models were used to compute hazard ratios and 95% confidence intervals associating breast cancer recurrence with opioid prescription use overall and by opioid type and strength, immunosuppressive effect, chronic use (≥6 months of continuous exposure), and cumulative morphine-equivalent dose, adjusting for confounders. RESULTS In total, 34,188 patients were identified who, together, contributed 283,666 person-years of follow-up. There was no association between ever-use of opioids and breast cancer recurrence (crude hazard ratio, 0.98; 95% confidence interval, 0.90-1.1; adjusted hazard ratio, 1.0; 95% confidence interval, 0.92-1.1), regardless of opioid type, strength, chronicity of use, or cumulative dose. Breast cancer recurrence rates were lower among users of strongly (but not weakly) immunosuppressive opioids, possibly because of channeling bias among those with a high competing risk, because mortality was higher among users of this drug type. CONCLUSIONS This large, prospective cohort study provided no clinically relevant evidence of an association between opioid prescriptions and breast cancer recurrence. The current findings are important to cancer survivorship, because opioids are frequently used to manage pain associated with comorbid conditions.
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Affiliation(s)
| | | | - Thomas P Ahern
- Departments of Surgery and Biochemistry, University of Vermont, Burlington, Vermont
| | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Peer M Christiansen
- Breast and Endocrine Section, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.,Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark.,Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Pottegård A, García Rodríguez LA, Poulsen FR, Hallas J, Gaist D. Antithrombotic drugs and subarachnoid haemorrhage risk. A nationwide case-control study in Denmark. Thromb Haemost 2015. [PMID: 26202836 DOI: 10.1160/th15-04-0316] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The study objective was to investigate the relationship between use of antithrombotic drugs and subarachnoid haemorrhage (SAH). We identified patients discharged from Danish neurosurgery units with a first-ever SAH diagnosis in 2000 to 2012 (n=5,834). For each case, we selected 40 age-, sex- and period-matched population controls. Conditional logistic regression models were used to estimate odds ratios (aOR), adjusted for comorbidity, education level, and income. Low-dose aspirin (ASA) use for < 1 month was associated with an increased risk of SAH (aOR 1.75, 95 % confidence interval [CI] 1.28-2.40). This aOR decreased to 1.26 (95 %CI: 0.98-1.63) with 2-3 months of ASA use, and approached unity with use for more than three months (1.11, 95 %CI 0.97-1.27). Analyses with first-time users confirmed this pattern, which was also observed for clopidogrel. ASA treatment for three or more years was associated with an aOR of SAH of 1.13 (95 %CI: 0.86-1.49). Short-term use (< 1 month) of vitamin K-antagonists (VKA) yielded an aOR of 1.85 (95 %CI 0.97-3.51) which dropped after 3+ years to 1.24, 95 %CI: 0.86-1.77. The risk of SAH was higher in subjects in dual antithrombotic treatment (aOR 2.08, 95 %CI: 1.26-3.44), and in triple antithrombotic treatment (aOR 5.74, 95 %CI: 1.76-18.77). In conclusion, use of aspirin,clopidogrel and VKA were only associated with an increased risk of SAH in the first three months after starting treatment. Long-term aspirin use carried no reduced SAH risk. Results should be interpreted cautiously due to their observational nature.
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Affiliation(s)
| | | | | | | | - David Gaist
- David Gaist, professor, consultant, Dept. Neurology, Odense University Hospital &, Institute of Clinical Medicine, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark, E-mail:
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31
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Ellis JA, McDowell MM, Mayer SA, Lavine SD, Meyers PM, Connolly ES. The role of antiplatelet medications in angiogram-negative subarachnoid hemorrhage. Neurosurgery 2015; 75:530-5; discussion 534-5. [PMID: 25072111 DOI: 10.1227/neu.0000000000000490] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The use of antiplatelet medications has greatly expanded and this has been associated with an increased rate of complications after aneurysmal subarachnoid hemorrhage (SAH). The influence of antiplatelet medications on outcomes after non-aneurysmal SAH is unknown. OBJECTIVE To analyze the frequency and impact on outcome of antiplatelet medication use among patients with angiogram-negative SAH. METHODS An analysis of patients within the Columbia University SAH Outcomes Project database was performed. All patients who underwent catheter cerebral angiography after presenting with nontraumatic SAH between 1996 and 2013 were included. Outcomes were assessed by using the modified Rankin Scale. RESULTS A total of 1351 patients underwent catheter angiography for evaluation of SAH. Of these, 173 (13%) were designated angiogram-negative. The fraction of patients presenting with angiogram-negative SAH as well as the frequency of antiplatelet use among these patients significantly increased during the study period. Antiplatelet use was more commonly associated with angiogram-negative SAH than with angiogram-positive SAH (27% vs 14%, P = .001). At 14 days after presentation, poor outcome was significantly more frequent among patients who took antiplatelet agents than among those who did not (38% vs 20%, P = .017). This effect was also seen after multivariate analysis (odds ratio, 2.58; P = .034), although no difference was observed by 12 months (P > .05). CONCLUSION Antiplatelet medication use is associated with poor early, but not late, outcomes after angiogram-negative SAH. Corresponding increased rates of antiplatelet medication use and angiogram-negative SAH may be related. Additional studies are needed to confirm this association.
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Affiliation(s)
- Jason A Ellis
- *Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and ‡Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Unruptured Cerebral Aneurysms: Evaluation and Management. ScientificWorldJournal 2015; 2015:954954. [PMID: 26146657 PMCID: PMC4471401 DOI: 10.1155/2015/954954] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/30/2014] [Accepted: 12/15/2014] [Indexed: 11/21/2022] Open
Abstract
The evolution of imaging techniques and their increased use in clinical practice have led to a higher detection rate of unruptured intracranial aneurysms. The diagnosis of an unruptured intracranial aneurysm is a source of significant stress to the patient because of the concerns for aneurysmal rupture, which is associated with substantial rates of morbidity and mortality. Therefore, it is important that decisions regarding optimum management are made based on the comparison of the risk of aneurysmal rupture with the risk associated with intervention. This review provides a comprehensive overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management options for unruptured intracranial aneurysms based on the current evidence in the literature. Furthermore, the authors discuss the genetic abnormalities associated with intracranial aneurysm and current guidelines for screening in patients with a family history of intracranial aneurysms. Since there is significant controversy in the optimum management of small unruptured intracranial aneurysms, we provided a systematic approach to their management based on patient and aneurysm characteristics as well as the risks and benefits of intervention.
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Thorat MA, Cuzick J. Prophylactic use of aspirin: systematic review of harms and approaches to mitigation in the general population. Eur J Epidemiol 2015; 30:5-18. [PMID: 25421783 DOI: 10.1007/s10654-014-9971-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 10/30/2014] [Indexed: 12/26/2022]
Abstract
A careful assessment of benefits and harms is required to assess suitability of aspirin as a prophylactic public health measure. However, comprehensive population-level data on harms are lacking. We collected and synthesized age and sex-specific data on harms relevant to aspirin use in average-risk individuals aged 50 years or older. We conducted systematic literature searches to identify baseline rates of gastrointestinal (GI) bleeding, peptic ulcer, major extra-cranial bleeding, and case-fatality rates due to GI bleeding or peptic ulcer in general population. The magnitude of aspirin-associated increase, the prevalence and attributable risk of Helicobacter pylori infection on these events in aspirin users was also assessed. Baseline rates of major extracranial bleeding events and GI complications increase with age; an almost threefold to fourfold increase is observed from age 50-54 to 70-74 years. Low or standard-dose aspirin use increases GI bleeding events by 60% leading to an annual excess of 0.45 and 0.79 GI bleeding events per 1,000 women and men aged 50-54 years respectively. 5-10% of major GI complications are fatal; a clear age dependence--higher fatality in older individuals, is seen. Eradication of H. pylori infection before aspirin use could reduce the incidence of upper GI complications by 25-30%. GI complications are increased by about 60% due to aspirin use but are fatal only in a very small proportion of individuals younger than 70 years of age. Major bleeding events that are comparable in severity to cancer or CVD, are infrequent. Screening and eradication of H. pylori infection could substantially lower aspirin-related GI harms.
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Affiliation(s)
- Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK,
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Schmidt M, Hallas J, Friis S. Potential of prescription registries to capture individual-level use of aspirin and other nonsteroidal anti-inflammatory drugs in Denmark: trends in utilization 1999-2012. Clin Epidemiol 2014; 6:155-68. [PMID: 24872722 PMCID: PMC4026552 DOI: 10.2147/clep.s59156] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Due to over-the-counter availability, no consensus exists on whether adequate information on nonsteroidal anti-inflammatory drug (NSAID) use can be obtained from prescription registries. OBJECTIVES To examine utilization of aspirin and nonaspirin NSAIDs in Denmark between 1999 and 2012 and to quantify the proportion of total sales that was sold on prescription. METHOD Based on nationwide data from the Danish Serum Institute and the Danish National Prescription Registry, we retrieved sales statistics for the Danish primary health care sector to calculate 1-year prevalences of prescription users of aspirin or nonaspirin NSAIDs, and to estimate the corresponding proportions of total sales dispensed on prescription. RESULTS Both low-dose aspirin and nonaspirin NSAIDs were commonly used in the Danish population between 1999 and 2012, particularly among elderly individuals. The 1-year prevalence of prescribed low-dose aspirin increased throughout the study period, notably among men. Nonaspirin NSAID use was frequent in all age groups above 15 years and showed a female preponderance. Overall, the prevalence of prescribed nonaspirin NSAIDs decreased moderately after 2004, but substantial variation according to NSAID subtype was observed; ibuprofen use increased, use of all newer selective cyclooxygenase-2 inhibitors nearly ceased after 2004, diclofenac use decreased by nearly 50% after 2008, and naproxen use remained stable. As of 2012, the prescribed proportion of individual-level NSAID sales was 92% for low-dose aspirin, 66% for ibuprofen, and 100% for all other NSAIDs. CONCLUSION The potential for identifying NSAID use from prescription registries in Denmark is high. Low-dose aspirin and nonaspirin NSAID use varied substantially between 1999 and 2012. Notably, use of cyclooxygenase-2 inhibitors nearly ceased, use of diclofenac decreased markedly, and naproxen use remained unaltered.
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Affiliation(s)
- Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology, University of Southern Denmark, Odense, Denmark
| | - Søren Friis
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
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Garbe E, Kreisel SH, Behr S. Risk of subarachnoid hemorrhage and early case fatality associated with outpatient antithrombotic drug use. Stroke 2013; 44:2422-6. [PMID: 23813986 DOI: 10.1161/strokeaha.111.000811] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Subarachnoid hemorrhage (SAH) accounts for <7% of all strokes, but is an enormous individual and societal burden. We investigated the risk of SAH associated with prior use of antithrombotic drugs and their influence on 30-day case fatality. METHODS We conducted a nested case-control study in a cohort of 13.4 million members of the German Pharmacoepidemiological Research Database. Ten controls were matched to each case hospitalized for SAH between July 2004 and November 2006 by health insurance, year of birth, and sex using risk set sampling. Exposure was assessed for the warfarin analog phenprocoumon, heparin, clopidogrel/ticlopidine, and acetylsalicylic acid. Multivariable-adjusted odds ratios (ORs) for SAH were estimated by conditional logistic regression. Risk factors for 30-day case fatality were assessed in patients with SAH by logistic regression. RESULTS The nested case-control study included 2065 SAH cases and 20 649 matched controls. The risk of SAH was significantly increased for phenprocoumon (OR, 1.7; 95% confidence interval [CI], 1.3-2.3), clopidogrel/ticlopidine (OR, 1.7; 95% CI, 1.1-2.5), and for acetylsalicylic acid use (OR, 1.5; 95% CI, 1.2-2.0), but not for outpatient heparin use (OR, 1.2; 95% CI, 0.5-2.7). The early case fatality of 22.8% was associated with an age >70 years (OR, 2.3; 95% CI, 1.8-3.1) and arterial hypertension (OR, 1.3; 95% CI, 1.0-1.6), but not with any of the antithrombotic drugs. CONCLUSIONS Outpatient antithrombotic drug use was associated with an increased risk of SAH, but no association was observed with early case fatality.
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Affiliation(s)
- Edeltraut Garbe
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.
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Abstract
Unruptured intracranial aneurysms (UIA) are a common finding, occurring in about 2% of the population, making them very likely to be seen by most practitioners, and present a challenge in the recommendations for optimal management and screening. The consequences of aneurysm rupture are dire, with high likelihood of significant morbidity and mortality. Most aneurysms do not rupture and patients harboring these lesions often remain asymptomatic. There are effective surgical and endovascular interventions to prevent rupture, but these procedures carry a risk of adverse complications. This article addresses the challenges of screening and management of UIAs.
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Abstract
Cardiovascular disease (CVD) remains the main cause of mortality and morbidity in patients with diabetes. Prevention of CVD in diabetes involves a multifactorial approach that aims to treat the cluster of risk factors including hyperglycemia, dyslipidemia, obesity, hypertension, and hypercoagulation associated with this condition. Antiplatelets reduce the prothrombotic environment in diabetes, but complications of this therapeutic approach include a general risk of bleeding, specifically intracranial hemorrhage, the risk of which increases in the presence of hypertension. Current guidelines recommend the use of antiplatelet agents after tight control of blood pressure, which, in clinical practice, is not always possible. In this review, the evidence for antiplatelet use in diabetes with particular emphasis on patients with associated hypertension is examined. Safe levels of blood pressure with antiplatelet therapy, various studies, and general recommendations for diabetes patients, in light of current evidence, are explored.
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Affiliation(s)
- R. A. Ajjan
- From the Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Peter J. Grant
- From the Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
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Risselada R, Straatman H, van Kooten F, Dippel DWJ, van der Lugt A, Niessen WJ, Firouzian A, Herings RMC, Sturkenboom MCJM. Platelet aggregation inhibitors, vitamin K antagonists and risk of subarachnoid hemorrhage. J Thromb Haemost 2011; 9:517-23. [PMID: 21155965 DOI: 10.1111/j.1538-7836.2010.04170.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Use of platelet aggregation inhibitors and vitamin K antagonists has been associated with an increased risk of intracranial hemorrhage (ICH). Whether the use of these antithrombotic drugs is associated with an increased risk of subarachnoid hemorrhage (SAH) remains unclear, especially as confounding by indication might play a role. OBJECTIVE The aim of the present study was to investigate whether use of platelet aggregation inhibitors or vitamin K antagonists increase the risk of SAH. METHODS We applied population-based case-control, case-crossover and case-time-control designs to estimate the risk of SAH while addressing issues both of confounding by indication and time varying exposure within the PHARMO Record Linkage System database. This system includes drug dispensing records from community pharmacies and hospital discharge records of more than 3 million community-dwelling inhabitants in the Netherlands. Patients were considered a case if they were hospitalized for a first SAH (ICD-9-CM code 430) in the period between 1st January 1998 and 31st December 2006. Controls were selected from the source population, matched on age, gender and date of hospitalization. Conditional logistic regression was used to estimate multivariable adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of SAH during use of platelet aggregation inhibitors or vitamin K antagonists. In the case-crossover and case-time-control designs we selected 11 control periods preceding the index date in successive steps of 1 month in the past. RESULTS In all, 1004 cases of SAH were identified. In the case-control analysis the adjusted OR for the risk of SAH in current use of platelet aggregation inhibitors was 1.32 (95% CI: 1.02-1.70) and in current use of vitamin K antagonists 1.29 (95% CI: 0.89-1.87) compared with no use. In the case-crossover analysis the ORs for the risk of SAH in current use of platelet aggregation inhibitors and vitamin K antagonists were 1.04 (95% CI: 0.56-1.94) and 2.46 (95% CI: 1.04-5.82), respectively. In the case-time-control analysis the OR for platelet aggregation inhibitors was 0.50 (95% CI: 0.26-0.98) and for vitamin K antagonists 1.98 (95% CI: 0.82-4.76). CONCLUSION The use of platelet aggregation inhibitors was not associated with an increased SAH risk; the modest increase observed in the case-control analysis could be as a result of confounding. The use of vitamin K antagonists seemed to be associated with an increased risk of SAH. The increase was most pronounced in the case-crossover analysis and therefore cannot be explained by unmeasured confounding.
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Affiliation(s)
- R Risselada
- Department of Medical Informatics, Erasmus MC, Rotterdam, the Netherlands.
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