Stroke Alert: A Review of Current Clinical Stroke Literature
September 2, 2010
Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital
Stopping or Continuing Antihypertensive Medications after Acute Stroke Does Not Seem to Make a Difference in Outcome
Source: Robinson TG, et al. Lancet Neurology 2010;9:767-775.
A great debate continues regarding appropriate management of hypertension during acute stroke. In the U.S., permissive hypertension is popular with recommendations that antihypertensive medications be discontinued when an acute ischemic stroke occurs. In the UK, it is generally recommended that medications be continued and that hypertension be treated early. The Continue Or Stop post-Stroke Antihypertensives Collaborative Study (COSSACS) was a UK-sponsored, randomized trial to compare the effects of stopping antihypertensive medications versus continuation of those medications for the first two weeks after stroke. The primary outcome measures were death or dependency at two weeks (modified Rankin score > 3), and outcomes at six months.
Seven hundred sixty-three (763) patients were randomly assigned to the two groups and followed. Seventy-two (72) of 379 patients in the continue group and 82 of 384 patients in the stop group reached the primary endpoint (not significant). The difference between groups in systolic blood pressure (BP) was 13 mm and diastolic BP was 8 mm (p < 0.0001). No substantial differences were observed between groups in rates of serious adverse events, six-month mortality, or major cardiovascular events. Within the limits of the randomization, it appears that lower blood pressures in the continue group did not result in adverse outcomes. The decision to stop or continue antihypertensive medications after acute stroke does not seem to alter outcome.
Nonagenarians (age 90-99) Do Not Have Worse Outcomes after Thrombolysis than Octogenarians
Source: Mateen FJ, et al. Stroke 2010;41:1833-1835.
All records of patients >80 years old in the canadian stroke registry who received intravenous thrombolysis were divided into two groups – those who were 90-99 years of age and those who were 80-89 years of age – and compared. Twenty-eight (28) nonagenarians and 242 octogenarians were treated with IV tPA over a 2.5-year period. There were no differences in baseline characteristics other than age. Both groups were predominantly female, had hypertension, and had severe strokes. The rate of symptomatic intracerebral hemorrhage (7% vs 4%), 90-day mortality (52% vs 33%), and 30-day favorable functional outcomes (30% vs 26%) showed no statistically significant differences when comparing the two age groups. The very elderly do not appear to have any more complications or worse outcomes after IV thrombolysis than the younger patients.
Factor V Leiden Mutation Is Associated with Ischemic Stroke in Young Adults
Source: Hamedani AG, et al. Stroke 2010;41:1599-1603.
Factor v leiden mutation is associated with ischemic stroke in children, but has never been shown to be a significant risk factor in adults. The authors performed a meta-analysis of 18 case-control studies of ischemic stroke in adults younger than age 50, published before June 2009. Across all studies, factor V Leiden was found in 7.5% of cases and 4.1% of controls, yielding an OR = 2.00. But there was considerable heterogeneity across the studies, with those that were selected for stroke cases showing a much higher rate of factor V Leiden mutations compared to a non-selected group of neurology patients. However, overall it appears that factor V Leiden is a risk factor for ischemic stroke in adults younger than age 50.
A great debate continues regarding appropriate management of hypertension during acute stroke. In the U.S., permissive hypertension is popular with recommendations that antihypertensive medications be discontinued when an acute ischemic stroke occurs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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