Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Department of Neurology and Neuroscience, Weill Cornell Medical College
Warfarin vs Aspirin in Patients with Heart Failure Showed No Difference in Mortality
Source: Homma S, et al, for the WARCEF Investigators. Warfarin and aspirin in patients with heart failure and sinus rhythm. New Engl J Med 2012;366:1859-1869; on-line 10.1056/NEJMoa1202299.
Over a 6-year period, 2305 patients with reduced left ventricular ejection fraction and normal sinus rhythm were randomized to warfarin treatment (target INR of 2.0 to 3.5) or aspirin (325 mg per day) and followed to determine the rate of a composite endpoint of ischemic stroke, intracerebral hemorrhage, or death from any cause.
The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P = 0.40). Therefore, there was no significant difference in the primary outcome between the groups. Warfarin, compared with aspirin, was associated with a significant reduction in ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P = 0.005). But there was a higher rate of major hemorrhage in the warfarin group compared to aspirin. The rates of intracranial hemorrhage did not differ significantly between the groups. Even though the primary composite outcomes did not differ between the warfarin and aspirin groups, there may be individual patients who would benefit from warfarin, rather than aspirin, and therapy should be individualized.
Use of the ABCD2 Score Helps Predict True Ischemic Stroke in Dizzy Patients
Source: Navi BB, et al. Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department. Stroke 2012;43:1484-1489.
The abcd2 score refers to a numerical scale, 0 to 7, based on a series of clinical features (age > 60, blood pressure > 140/90, clinical features such as weakness or speech disturbance, duration of symptoms > 10 minutes, presence of diabetes) that predicts with a high degree of validity a true ischemic TIA/stroke and helps to distinguish this from other disorders that may mimic a stroke (Lancet 2007;369:283-292). The authors reviewed the charts of 907 dizzy patients who presented to the emergency department at UCSF. Thirty-seven (4.1%) had a cerebrovascular cause, of which 24 were ischemic strokes. The median ABCD2 score was 3, and the score predicted the ultimate diagnosis of a cerebrovascular event (c statistic, 0.79; 95% confidence interval, 0.73-0.85). Only 5 of 512 patients (1%) with a score of < 3 had a cerebrovascular event, compared to 25 of 369 patients (6.8%) with a score of 4 or 5, and 7 of 26 patients (27%) who had a score of 6 or 7. Use of this score in the emergency department may help to stratify low-risk vs high-risk patients and result in more rational and efficient use of scarce resources.
Thrombotic Stroke Risk is Increased by the Use of Estradiol-Containing Oral Contraceptives
Source: Lidegaard O, et. al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med 2012;366:2257-2266.
In this 15-year danish historical cohort study, a total of 1,626,158 women, without any history of cardiovascular disease, contributed 14,251,063 person-years of observation, during which 3311 thrombotic strokes (21.4 per 100,000 person-years) and 1725 myocardial infarctions (10.1 per 100,000 person-years) occurred. Use of combination oral contraceptives that included ethinyl estradiol at a dose of 30 to 40 mg and various progestins was associated with relative risks (and 95% confidence intervals) for thrombotic stroke and myocardial infarction, ranging from 1.6 to 2.2 compared to non-users of oral contraceptives. The specific type of progestin had little effect on the risk of stroke or myocardial infarction. With ethinyl estradiol at a dose of 20 mg, the corresponding relative risks ranged from 0.9 to 1.7, again, with little influence from the progestin. For transdermal patches, the corresponding relative risk was 3.2 (0.8 to 12.6) and for a vaginal ring, 2.1 to 2.5.
Although the absolute risks for stroke and myocardial infarction in healthy young women who take oral contraceptives is very low, compared to non-users there is an increased risk based on the relative dosage of estradiol, and the particular progestin used in combination does not seem to have a significant effect. This study did not address the possible role of cigarette smoking, obesity, or hypertension as confounding variables.
Over a 6-year period, 2305 patients with reduced left ventricular ejection fraction and normal sinus rhythm were randomized to warfarin treatment (target INR of 2.0 to 3.5) or aspirin (325 mg per day) and followed to determine the rate of a composite endpoint of ischemic stroke, intracerebral hemorrhage, or death from any cause.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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