Time Trends in Intracerebral Hemorrhage Associated with Oral Anticoagulation and Its Risks Factors in Spain from 2008 to 2015

BACKGROUND

Intracerebral hemorrhage (ICH) is 7- to 10-fold higher in anticoagulated patients. Given the more extended use of oral anticoagulants, an increase in the prevalence of ICH associated with oral anticoagulation (ICH-OAC) could be expected. However, there is no previous study that assesses the time trends of ICH-OAC in Spain.

METHODS

We conducted a combined data analysis after creating a joint database of the 3 most important epidemiological studies on ICH-OAC of our country: the EPICES study (2008-2009), the TAC Registry (TR) study (2012-2013) and the TAC Registry 2 (TR2) study (2015). We finally included 65, 235, and 366 patients from the EPICES, TR, and TR2 studies, respectively.

RESULTS

We have observed a 3.73-fold increase in the crude annual incidence of ICH-OAC throughout the period of study, with proportion of ICH-OAC out of total ICH increasing from 8.4% in 2008 to 18.2% in 2015. Age, dyslipidemia, and prior antiplatelet treatment increased during the study, but we found no statistically significant differences in other risk factors for ICH-OAC.

CONCLUSIONS

The incidence of ICH-OAC is increasing in our country. It might at least be partly explained by aging of the population, with mean age at presentation being higher in the last years.

Epidemiology of Intracranial Hemorrhage Associated with Oral Anticoagulants in Spain: Trends in Anticoagulation Complications Registry - The TAC 2 Study

Objective

Patients receiving treatment with oral anticoagulants (OACs) are at risk of intracranial hemorrhage (ICH). In this study, we describe the epidemiological and clinical characteristics of patients receiving OACs who experience ICH and compare those receiving vitamin K antagonists (ICH-VKAs) with those receiving direct OACs (ICH-DOACs).

Methods

We performed a national, multicenter, descriptive, observational, retrospective study of all adult patients receiving OACs who were admitted to the neurology department with ICH over a 1-year period. The study population was divided into 2 groups (ICH-VKAs and ICH-DOACs). Epidemiological, clinical, radiological, and therapy-related variables, as well as functional outcome, were compared at 3 months. A total of 366 cases were included (331 ICH-VKAs, 35 ICH- DOACs).

Results

The crude annual incidence of OAC-induced ICH was 3.8 (95% CI, 2.78-3.41) per 100,000 inhabitants/year. The mean (± SD) age was greater for ICH-DOACs (81.5 ± 8.3 vs. 77.7 ± 8.3 years; p = 0.012). The median (IQR) volume of the hemorrhage was lower for ICH-DOACs (11 [30.8] vs. 25 [50.7] mL; p = 0.03). The functional independence rate at 3 months (modified Rankin Scale, mRS < 3) was similar in both groups, although stroke-related mortality was greater in ICH-VKAs (40 vs. 72.7%; p = 0.02). The most frequently indicated poststroke antithrombotic therapy was DOACs (38.7%).

Conclusion

We found that the incidence of OAC-induced ICH was greater than in previous studies. Hemorrhage volume and mortality were lower in ICH-DOACs than in ICH-VKAs. After stroke, DOACs were the most frequently indicated antithrombotic treatment.

Identification of alpha 1L-adrenoceptor in mice and its abolition by alpha 1A-adrenoceptor gene knockout

BACKGROUND AND PURPOSE

The alpha(1L)-adrenoceptor has pharmacological properties that distinguish it from three classical alpha(1)-adrenoceptors (alpha(1A), alpha(1B) and alpha(1D)). The purpose of this was to identify alpha(1L)-adrenoceptors in mice and to examine their relationship to classical alpha(1)-adrenoceptors.

EXPERIMENTAL APPROACH

Radioligand binding and functional bioassay experiments were performed on the cerebral cortex, vas deferens and prostate of wild-type (WT) and alpha(1A)-, alpha(1B)- and alpha(1D)-adrenoceptor gene knockout (AKO, BKO and DKO) mice.

KEY RESULTS

The radioligand [(3)H]-silodosin bound to intact segments of the cerebral cortex, vas deferens and prostate of WT, BKO and DKO but not of AKO mice. The binding sites were composed of two components with high and low affinities for prazosin or RS-17053, indicating the pharmacological profiles of alpha(1A)-adrenoceptors and alpha(1L)-adrenoceptors. In membrane preparations of WT mouse cortex, however, [(3)H]-silodosin bound to a single population of prazosin high-affinity sites, suggesting the presence of alpha(1A)-adrenoceptors alone. In contrast, [(3)H]-prazosin bound to two components having alpha(1A)-adrenoceptor and alpha(1B)-adrenoceptor profiles in intact segments of WT and DKO mouse cortices, but AKO mice lacked alpha(1A)-adrenoceptor profiles and BKO mice lacked alpha(1B)-adrenoceptor profiles. Noradrenaline produced contractions through alpha(1L)-adrenoceptors with low affinity for prazosin in the vas deferens and prostate of WT, BKO and DKO mice. However, the contractions were abolished or markedly attenuated in AKO mice.

CONCLUSIONS AND IMPLICATIONS

alpha(1L)-Adrenoceptors were identified as binding and functional entities in WT, BKO and DKO mice but not in AKO mice, suggesting that the alpha(1L)-adrenoceptor is one phenotype derived from the alpha(1A)-adrenoceptor gene.

The alpha(1A/C)- and alpha(1B)-adrenergic receptors are required for physiological cardiac hypertrophy in the double-knockout mouse

Catecholamines and alpha(1)-adrenergic receptors (alpha(1)-ARs) cause cardiac hypertrophy in cultured myocytes and transgenic mice, but heart size is normal in single KOs of the main alpha(1)-AR subtypes, alpha(1A/C) and alpha(1B). Here we tested whether alpha(1)-ARs are required for developmental cardiac hypertrophy by generating alpha(1A/C) and alpha(1B) double KO (ABKO) mice, which had no cardiac alpha(1)-AR binding. In male ABKO mice, heart growth after weaning was 40% less than in WT, and the smaller heart was due to smaller myocytes. Body and other organ weights were unchanged, indicating a specific effect on the heart. Blood pressure in ABKO mice was the same as in WT, showing that the smaller heart was not due to decreased load. Contractile function was normal by echocardiography in awake mice, but the smaller heart and a slower heart rate reduced cardiac output. alpha(1)-AR stimulation did not activate extracellular signal-regulated kinase (Erk) and downstream kinases in ABKO myocytes, and basal Erk activity was lower in the intact ABKO heart. In female ABKO mice, heart size was normal, even after ovariectomy. Male ABKO mice had reduced exercise capacity and increased mortality with pressure overload. Thus, alpha(1)-ARs in male mice are required for the physiological hypertrophy of normal postnatal cardiac development and for an adaptive response to cardiac stress.

Use of polarography as a quality-control method for determining diacetyl in citrus and vegetable juices, yoghurt and butter

The determination of diacetyl permits the detection of microbial growth in the processing of citrus fruit before the appearance of other organoleptic, chemical or microbiological changes. It also makes it possible to detect a break in the cold chain during distribution and sale. The study proposed a polarographic method for the determination of diacetyl that allowed routine analysis with the aim of detecting possible contamination in the citrus juice manufacturing chain (orange and orange-carrot). The analytical performance of the method in terms of a linearity from 0 to 960 microg ml(-1), a recovery of 97 to 98%, a precision of 3.2 to 4.8%, and a sensitivity of 0.2 ng ml(-1) for juices indicated the robustness of the method. The same method was also applied to butter and yoghurt with detection limits of and 0.4 ng g(-1).

Effect of developmental age and hyperoxia exposure on kinase and phosphatase activities in newborn rat lungs

To better understand the biochemical events accompanying lung alveolarization and development, we studied the specific activity of the cAMP-dependent protein kinase (PKA) and the type 2A protein phosphastase (PP2A), and the activity and protein content of the calcium- and lipid-dependent protein kinase (PKC) in cytosolic preparations of lungs. Lungs were obtained from rat pups on day 2 of life and on days 7, 14, and 27 from pups exposed to hyperoxia (> 95% O2, days 4-14; 65% O2 days 15-27) or normoxia from day 4 onwards. There were no significant changes in PKA specific activity with developmental age or hyperoxic exposure. PKC specific activity increased significantly (P < .05) in normoxic animals from day 2 (64 +/- 13.5 pmol phosphate released/min/mg protein) to day 14 (105 +/- 9). The increase was sustained to day 27. There was no effect on PKC activity due to hyperoxia alone (ANOVA). This increase in PKC activity was accompanied by an increase in the mass of the delta, epsilon and zeta isoforms of PKC in normoxic pups. The gamma isoform of PKC was undetectable in all samples whereas the alpha and beta isoforms were detectable but showed no changes with developmental age. PP2A specific activity increased significantly (P < .05) from 13.3 +/- 0.5 nmol phosphate released/min/mg protein on day 2 to 17.7 +/- 0.9 on day 7 in normoxic pups, then returned to day 2 level at advanced developmental age. Hyperoxia exposure prevented the increase in enzyme activity observed on day 7 in normoxic animals. These data suggest that protein phosphorylation may be one mechanism by which alveolarization is regulated in developing lungs.

Protein phosphatase activity in the rat ovary throughout pregnancy and pseudopregnancy

Specific protein phosphatase activity against protein kinase C-phosphorylated substrate was measured in the rat ovary during pseudopregnancy and pregnancy. Tissues were processed in the presence of sodium fluoride and inorganic phosphate to inhibit the phosphatase and thereby prevent autodephosphorylation of the type 2A protein phosphatase (PP2A) during homogenization. Manganese was added at the time of enzyme assay to reactivate the phosphatase. The specific activity of the protein phosphatase did not vary significantly across pseudopregnancy (p > 0.05). In contrast, the specific activity of protein phosphatase decreased significantly between Day 7 and Day 10 of pregnancy (28.8 +/- 5 pmol/min x microg protein and 20.7 +/- 2 pmol/min x microg protein, respectively; p < 0.05) and remained at the decreased value for the remainder of pregnancy. To determine whether hormones of pregnancy could regulate PP2A activity in the ovaries, pseudopregnant rats were treated with prolactin (3 IU twice a day), bromocriptine (100 microg twice a day), or estradiol benzoate (50 microg). Bromocriptine and estradiol treatments caused a decrease in PP2A-specific activity, but prolactin had no effect. Bromocriptine treatment caused a decrease in the protein content of the PP2A catalytic subunit, but prolactin and estradiol treatments had no effect. The data suggest that the specific activity and protein content of PP2A in the rat ovary are hormonally regulated.

Venous tone in the developmental stages of spontaneous hypertension

The initial stages of hypertension in the spontaneously hypertensive rat (SHR) are characterized by an increase in cardiac output. Venous capacitance plays an important role in the control of cardiac output. This study tested the hypothesis that venous tone is elevated in the developmental stages of spontaneous hypertension. Male SHR or normotensive Wistar-Kyoto (WKY) rats were instrumented for the measurement of arterial pressure (FAP) and intrathoracic vena caval pressure (FVP). A latex-tipped catheter was advanced into the right atrium via the jugular vein. Mean circulatory filling pressure (MCFP), an index of integrated venomotor tone, was calculated as MCFP=FVP+(FAP-FVP)/VAR. FAP and FVP were recorded after 5 seconds of right atrial balloon inflation. The venous to arterial compliance ratio (VAR) was estimated as 76 for WKY and 106 for SHR. Mean arterial pressure (MAP), heart rate, and MCFP were recorded in conscious rats of 4 to 6 and 8 to 10 weeks of age. In 4- to 6-week-old rats, both MAP and MCFP were significantly elevated in the SHR (MAP, 129+/-6 mm Hg; MCFP, 6.6+/-0.4 mm Hg) compared with the age-matched WKY (MAP, 91+/-6 mm Hg; MCFP, 5.4+/-0.4 mm Hg), whereas heart rate was not significantly different. The elevations in MAP (SHR, 144+/-4 mm Hg; WKY, 102+/-3 mm Hg) and MCFP (SHR, 7.7+/-0.3 mm Hg; WKY, 6.0+/-0.2 mm Hg) in SHR were exaggerated at 8 to 10 weeks of age. After ganglionic blockade (chlorisondamine; 10 mg/kg), the differences in MCFP were no longer statistically significant between SHR and WKY at both 4 to 6 weeks of age (3.9+/-0.2 versus 4.0+/-0.3 mm Hg) and 8 to 10 weeks of age (5.0+/-0.3 versus 4.3+/-0.3 mm Hg, respectively). The differences in MAP at 4 to 6 weeks of age (79+/-7 versus 67+/-5 mm Hg, respectively) also were not statistically significant after ganglionic blockade. However, a significant difference in MAP between strains remained after ganglionic blockade in 8- to 10-week-old rats (90+/-5 versus 63+/-3 mm Hg, respectively). These findings indicate that venous tone is increased via autonomic effector systems during the developmental stages of spontaneous hypertension. These data also suggest that autonomic mechanisms predominate at very early stages, whereas nonautonomic mechanisms assume more importance in maintaining the elevated MAP as hypertension progresses.

Disinhibition of the hypothalamic paraventricular nucleus increases mean circulatory filling pressure in conscious rats

Venous capacitance plays an important role in the control of cardiac output. However, the central nervous system sites and neurochemical signals involved in modulating venous function remain to be fully elucidated. The hypothalamic paraventricular nucleus (PVN) is an important site modulating autonomic outflow to the cardiovascular system. The present study tested the hypothesis that removal of tonic GABAergic tone in the PVN would increase peripheral venous tone. Mean circulatory filling pressure was used as an index of venous tone. Arterial pressure, venous pressure, heart rate, and mean circulatory filling pressure (MCFP) were monitored in conscious male Sprague Dawley rats. The rats were challenged with microinjections of bicuculline methiodide (BMI) (25 ng) or vehicle (artificial cerebrospinal fluid) into the PVN. In one group of rats, BMI injections were performed before and after ganglionic blockade with chlorisondamine hydrochloride (10 mg/kg) and atropine (0.4 mg/kg) given subcutaneously. In a second group, BMI injections were performed in chlorisondamine-treated rats whose blood pressure had been returned to control with an infusion of norepinephrine. Injection of bicuculline into the PVN increased MAP (14 +/- 2 to 18 +/- 2 mmHg) and HR (49 +/- 12 to 74 +/- 14 bpm). MCFP also increased significantly by 1.00 +/- 0.17 to 1.39 +/- 0.18 mmHg, indicating an increase in the driving pressure for venous return. Injection of the vehicle did not affect these variables. In both groups, ganglionic blockade significantly attenuated the bicuculline-induced increases in MAP, HR and MCFP. These data indicate that sympathetic drive from the PVN to the venous system is under tonic GABAergic control.

Acute stress increases venomotor tone in conscious rats

This study tested the hypothesis that acute psychological stress causes venoconstriction. Male Sprague-Dawley rats were instrumented with indwelling catheters in a femoral artery and vein and a balloon-tipped catheter in the right atrium. Mean arterial pressure (MAP), venous pressure, heart rate (HR), and mean circulatory filling pressure (MCFP) were monitored in conscious rats. Air-jet stress was performed before and after treatment with saline, chlorisondamine, phentolamine, or prazosin. Air-jet stress caused MAP, HR, and MCFP to increase by 10 +/- 1 mmHg, 31 +/- 4 beats/min, and 0.95 +/- 0.09 mmHg, respectively. Treatment with either chlorisondamine or phentolamine was equally effective in abolishing the stress-induced increases in MAP, HR, and MCFP. Prazosin treatment abolished the pressor response to air-jet stress but did not significantly affect the HR and MCFP responses. In contrast, pretreatment with the alpha 2-receptor antagonist rauwolscine hydrochloride abolished both the MAP and MCFP responses to air-jet stress but did not affect the HR response. These findings indicate that venoconstriction is an important component of the cardiovascular response to acute psychological stress. Stress-induced venoconstriction appears to be mediated primarily via the alpha 2-receptor subtype.