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Long-term anticoagulant therapy in cerebrovascular disease: does bleeding outweigh the benefit?
T Dahl1, U Abildgaard, P M Sandset
1Department of Internal Medicine, Aker University Hospital, Oslo, Norway.
Insights
Long-term anticoagulant therapy (ACT) for cerebrovascular disease showed a 4.6% annual rate of major bleeding complications. While beneficial for non-valvular atrial fibrillation and transient ischemic attacks, its use in stroke progression requires careful consideration.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Cerebrovascular disease necessitates long-term management strategies.
- Anticoagulant therapy (ACT) is a common treatment, but its long-term risks and benefits require ongoing evaluation.
- Real-world data on ACT in patients not enrolled in prospective trials are crucial for clinical decision-making.
Purpose of the Study:
- To assess the risks of major hemorrhagic complications and cardiovascular events during long-term anticoagulant therapy (ACT) in patients with cerebrovascular disease.
- To evaluate the impact of ACT on mortality in this patient population.
- To analyze outcomes in specific subgroups, including non-valvular atrial fibrillation (NVAF), transient ischemic attacks (TIAs), and stroke in progression (SIP).
Main Methods:
- Retrospective analysis of 161 patients with symptomatic cerebrovascular disease treated with warfarin.
- Patients received ACT between 1983 and 1986, with a target International Normalized Ratio (INR) of 2.8-4.2.
- Outcomes including major hemorrhage, recurrent stroke, and survival were tracked over a mean duration of 21.1 months.
Main Results:
- The annual rate of major hemorrhagic complications was 4.6%, with a 1.4% annual rate of fatal hemorrhages.
- The rate of recurrent stroke (excluding intracranial hemorrhage) was 3.9% annually for all patients.
- Complication rates did not significantly differ between subgroups; however, no strokes occurred in the TIA subgroup.
Conclusions:
- Anticoagulant therapy (ACT) appears to offer a positive net effect for patients with non-valvular atrial fibrillation (NVAF) and transient ischemic attacks (TIAs).
- Definitive conclusions regarding ACT for stroke in progression (SIP) cannot be drawn due to a lack of comparable data.
- The rate of bleeding complications is significant, suggesting that for patients with SIP and TIAs, ACT beyond six months should be reserved for cases where aspirin is ineffective or not tolerated.
Objective:
The aim of the present study was to determine the risk of major haemorrhagic complications, stroke and other cardiovascular events, and mortality during long-term anticoagulant therapy (ACT) in patients with cerebrovascular disease not included in any prospective trials.
Design:
The data were collected retrospectively.
Setting:
All patients with symptomatic cerebrovascular disease discharged from the Stroke Unit, Aker University Hospital, Oslo, with ACT (warfarin) during 1983 through to 1986 were included.
Subjects:
The material consists of 161 patients with a mean age of 67.8 (range 40-90) years. The reason for initiating ACT was frequent transient ischaemic attacks (TIAs) in 52 patients, stroke in progression (SIP) in 33 patients, and probable embolic stroke in 76 patients. International normalized ratio (INR) of 4.2-2.8 was aimed at.
Main Outcome Measures:
Major haemorrhagic complications, recurrent stroke and survival was determined for the total material, and in the subgroups non-valvular atrial fibrillation (NVAF, n = 49), TIAs, and SIP.
Results:
The mean duration of ACT was 21.1 (range 0.5-60.2) months with a total of 282.9 patient-years. The rate of major (including fatal) haemorrhagic complications was 4.6% per year, and the rate of fatal haemorrhagic complications was 1.4% per year. The complication rates in the subgroups of patients did not differ significantly from that in the total material. Only two out of the 13 major haemorrhagic complications occurred during the initial 6 months of ACT. No strokes occurred in the TIA subgroup. The rate of recurrent stroke (excluding intracranial haemorrhage) was 3.9% per year for all patients, 4.7% per year for the patients with NVAF, and 4.2% per year for the patients with SIP.
Conclusions:
The total results suggest a positive net effect of ACT in patients with NVAF and TIAs. Without comparable data, no definite conclusions concerning the effect of ACT on patients with SIP can be drawn. The rate of bleeding complications was similar to that in other studied materials and is not negligible. In patients with SIP and TIAs, ACT beyond 6 months should probably only be continued if aspirin is not tolerated or has proven ineffective in the particular patient.