Abstract 148: Evaluation of Sex, Racial and Geographic Demographics and Outcomes in Clinical Trials of Spontaneous Intracerebral Hemorrhage

Introduction: As large clinical trials for spontaneous intracerebral hemorrhage (ICH) increasingly influence management, recruitment of diverse populations must be ensured to fully understand the disease process and benefit of interventions to the general public. There is little data on sex, race and outcomes in ICH trials. We hypothesize that women and geographic minorities are underrepresented in ICH clinical trials and that there exist population specific differences in mortality, functional outcomes and response to interventions.

Methods: Pooled analysis of 5456 subjects from the following clinical trials: VISTA (985), INTERACT I (404) and II (2829), STICH II (597), MISTIE II (141) and CLEAR III (500). Patients were grouped by sex, race, and geographic location. Modified Rankin Scale [mRS] was obtained at 30 days and 3 months.

Results: More men than women participated in ICH trials (61.9% vs. 38.1%); women were older and more likely to have hypertension; men had more coronary artery disease. Women presented with lower Glasgow Coma scale, higher ICH score and more intraventricular hemorrhage. Day 90 mortality was 13.9% in women and 16.6 % in men (p=0.01); 90 day poor outcome (mRS 3-5) was 57.2% in women and 51.0% in men (p<0.001). Only mortality was significantly different between sexes after adjustment for ICH score. Race representation varied in these clinical trials: 1.5% Hispanic; 6.6% black; 14% Arabic; 31% white and 43.4% Asian. Day 90 mortality and mRS 3-5 were highest in Hispanics (22.1%, 78.3%, respectively) and lowest in Asians (9.5%, 43.8%). Hispanics had higher ICH score, but blacks and Hispanics had lower day 90 mortality compared to whites in adjusted models. Asians had both lower mortality and less day 90 mRS 3-5 vs. whites while Arabics and blacks were more likely to have day 90 mRS 3-5. Study interventions were well balanced by sex and race.

Conclusions: Sex and race representation in ICH clinical trials only partially equate to current understanding of epidemiology of ICH. There is a lack of trial evidence from Africa and South America and under-representation of women, Hispanics and blacks. Despite higher ICH severity, Hispanics had lower adjusted mortality risk while males had higher risk and Arabics and blacks had worse adjusted poor outcomes.

Abstract T MP104: The Role of Antithrombotics Therapy in Recent Ischaemic Stroke Patients with Atrial Fibrillation: Analysis from VISTA

Background and Purpose: There is uncertainty on the optimal latency after acute ischaemic stroke at which antithrombotic treatment should commence for atrial fibrillation (AF) patients, in order to prevent recurrent stroke (RS) without provoking symptomatic intracranial haemorrhage (SICH). We sought to describe the risk factors and patterns of RS and SICH in a cohort of patients with AF and recent stroke.

Methods: We assessed the association of antihrombotic treatment (i.e. anticoagulants and antiplatelets) with the distribution of the modified Rankin Scale (mRS) at day 90, and the occurrence of RS and SICH. We developed statistical models for the prediction of RS and SICH in the first 90 days after stroke, using univariate and multivariate analysis.

Results: Data were available for 1,644 patients. Combined antithrombotic therapy with both anticoagulation and antiplatelet (n=782) was associated with more favourable functional outcome across full scale mRS OR=1.785 (95% CI: 1.316, 2.421; P=0.0002), and significantly lower risk of mortality by day 90, SICH by day 90 and RS by day 90: Mortality day 90 OR=0.344 (95% CI: 0.235, 0.502; P<0.0001), SICH day 90 OR=0.18 (95% CI: 0.086, 0.37; P<0.0001) and RS day 90 OR=0.33 (95% CI: 0.21, 0.53; P<0.0001). Patients with ischaemic stroke who had high baseline glucose had a high risk of both RS and SICH events after stroke. Additionally, patients who had increased neurological impairment, previous history of TIA and received no antithrombotic treatment were at increased risk of RS. The relative risk of RS versus SICH appeared constant over time.

Conclusions: It seems justified to initiate anticoagulation immediately the patient attains medical and neurological stability, taking into account the potential of haemorrhagic transformation as part of the natural progression in stroke and the increasing risk of recurrent stroke with time if left untreated. Antiplatelet treatment pending introduction of anticoagulation is reasonable.