Risk of recurrent stroke and antiplatelet choice in breakthrough stroke while on aspirin

Abstract Uncertainty regarding an optimal antiplatelet regimen still exists in patients with breakthrough acute ischemic stroke (AIS) while on aspirin. This study provides an analysis of a prospective multicenter registry between April 2008 and April 2014. Eligible patients were on aspirin at the time of AIS and treated with antiplatelet regimens (aspirin, clopidogrel, or clopidogrel-aspirin). Potential factors associated with the choice of each antiplatelet regimen were explored and included a predictive risk score for future vascular events, the Essen Stroke Risk Score (ESRS). A total of 2348 patients (age, 69 ± 11 years; male, 57.7%) were analyzed, and 55.3%, 25.3% and 19.4% were treated with clopidogrel-aspirin, aspirin and clopidogrel, respectively. While the likelihood of choosing clopidogrel-aspirin increased as the ESRS increased, the likelihood of choosing aspirin decreased as the ESRS increased (Ptrend < 0.001). The ESRS category (0–1/2–3/ ≥ 4) modified the effect of antiplatelet regimens for 1-year vascular events (Pinteraction < 0.01). Among patients with ESRS ≥ 4, clopidogrel-aspirin (HR 0.47 [0.30–0.74]) and clopidogrel (HR 0.30 [0.15–0.60]) significantly reduced the risk of outcome events. Our study showed that more than half of the patients with aspirin failure were treated with clopidogrel-aspirin. In particular, a higher ESRS, which indicates an increased risk of recurrent stroke, was associated with the choice of clopidogrel-aspirin rather than aspirin.

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Risk Factors Associated With Outcomes of Non-cardioembolic Ischemic Stroke In Patients Stratified By Essen Stroke Risk Score

10.21203/rs.2.22244/v1 ◽

2020 ◽

Author(s):

Yanting Ping Ping ◽

Qianqian Yang Yang ◽

Yuwen Huang Huang ◽

Huimin Xu Xu ◽

Haibin Dai

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Risk Score ◽

Protective Factor ◽

Stroke Risk ◽

Recurrent Stroke ◽

Univariate Analysis ◽

Tertiary Care ◽

Vascular Events ◽

Stroke Outcomes

Abstract Background: Identifying risk factors of cardiovascular events is crucial for stroke prevention and they can be used as predictive factors of stroke outcomes.In this study, it is to evaluate the risk factors that predict outcomes of acute non-cardioembolic ischemic stroke in patients stratified by Essen Stroke Risk Score (ESRS). Methods: A retrospective study was carried out in acute non-cardioembolic ischemic stroke patients in a Chinese tertiary-care teaching hospital. ESRS stratification and factors that might influence the outcomes of stroke, as indicated by fatal or non-fatal combined vascular events of recurrent stroke, myocardial infarction, or primary intracranial hemorrhage, were documented. Univariate analysis and multivariable regression analysis was used to identify independent predictors of stroke outcomes. Results: A total of 878 patients with acute non-cardioembolic ischemic stroke who completed a mean follow-up of 5.2 years were enrolled, and 163 patients experienced at least one component of the combined vascular event. In patients with an ESRS ≤ 3, age ≥ 65 years (OR , 2.935; 95% CI 1.625-5.301, P < 0.001) and clopidogrel treatment (OR , 1.685 ; 95% CI , 1.026-2.768; P = 0.041) were significantly associated with stroke outcomes. In patients with an ESRS > 3, age ≥ 65 years (OR , 2.107, 95% CI , 1.208-3.673 ; P = 0.008) and history of diabetes (OR , 1.465 ; 95% CI , 1.041–2.062 ; P = 0.027) were risk factors for stroke outcomes , whereas clopidogrel treatment (OR , 0.542; 95% CI , 0.356–0.824; P = 0.003) was a protective factor for stroke outcomes. Conclusions: According to this study, clopidogrel treatment, blood pressure control, and glycemic control are protective factors for stroke outcomes in high-risk patients (ESRS>3).

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Validation of the Essen Stroke Risk Score and the Stroke Prognosis Instrument II in Chinese Patients

Stroke ◽

10.1161/strokeaha.111.624148 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3619-3620 ◽

Cited By ~ 11

Author(s):

Xia Meng ◽

Yilong Wang ◽

Xingquan Zhao ◽

Chunxue Wang ◽

Hao Li ◽

...

Keyword(s):

Risk Score ◽

Transient Ischemic Attack ◽

Stroke Risk ◽

Predictive Accuracy ◽

Recurrent Stroke ◽

Chinese Patients ◽

Vascular Events ◽

Ischemic Attack ◽

Event Rates ◽

Prognostic Instrument

Background and Purpose— Little was known about the predictive accuracy of the Essen Stroke Risk Score and the Stroke Prognostic Instrument II in Chinese patients with stroke. Methods— We evaluated the predictive accuracy of both Essen Stroke Risk Score and Stroke Prognostic Instrument II scores for both recurrent stroke and combined vascular events using data from a prospective cohort of 11 384 patients with acute ischemic stroke and transient ischemic attack admitted to 132 urban hospitals throughout China. Results— The cumulative 1-year event rates were 16% (95% CI, 15%–16%) for recurrent stroke and 18% (95% CI, 18%–19%) for combined vascular events. Both event rates were significantly higher in patients with transient ischemic attack and increased significantly from lower to higher Essen Stroke Risk Score and Stroke Prognostic Instrument II categories. Essen Stroke Risk Score and Stroke Prognostic Instrument II had similar predictive accuracies for each study outcome. Conclusions— In Chinese patients with ischemic stroke or transient ischemic attack, both Essen Stroke Risk Score and Stroke Prognostic Instrument II scores are equally able to stratify the risk of recurrent stroke and combined vascular events.

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Intermediate risk of cardiac events and recurrent stroke after stroke admission in young adults

International Journal of Stroke ◽

10.1177/1747493017733929 ◽

2017 ◽

Vol 13 (6) ◽

pp. 576-584 ◽

Cited By ~ 3

Author(s):

Peter Jin ◽

Ivan Matos Diaz ◽

Laura Stein ◽

Alison Thaler ◽

Stanley Tuhrim ◽

...

Keyword(s):

Risk Factors ◽

Young Adults ◽

Ischemic Stroke ◽

Cardiovascular Events ◽

Recurrent Stroke ◽

Intermediate Risk ◽

Cardiac Events ◽

Vascular Events ◽

Increased Risk ◽

Index Stroke

Background In older adults with stroke, there is an increased risk of cardiovascular events in the intermediate period, up to one year after stroke. The risk of cardiovascular events in this period in young adults after stroke has not been studied. We hypothesized that in the intermediate risk period, young adults with ischemic stroke have an increased risk of recurrent stroke and a smaller increase of cardiac events. Methods Using the National Readmissions Database during the year 2013, we identified ischemic stroke admissions among those aged 18–45 years using International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index vascular events and risk factors. Primary outcomes were readmission for cardiac events and stroke. Multivariable Cox proportional hazard models and Kaplan–Meier analysis were used to estimate risk of primary outcomes. Results We identified 12,392 young adults with index stroke. The readmission rate due to recurrent stroke was higher than for cardiac events (2913.3.1 vs. 1132.4 per 100,000 index hospitalizations at 90 days). There was a higher cumulative risk of both cardiac events and recurrent stroke in the presence of baseline diabetes and hypercholesterolemia. Conclusion In a large, nationally representative database, the intermediate risk of recurrent stroke after index stroke in young adults was higher than the risk of cardiac events. The presence of vascular risk factors augmented this risk but did not entirely account for it. The aggressive control of hypercholesterolemia and diabetes may play an important role in secondary prevention in young adults with stroke.

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Lower Serum Potassium Levels at Admission are Associated with the Risk of Recurrent Stroke in Patients with Acute Ischemic Stroke or Transient Ischemic Attack

Cerebrovascular Diseases ◽

10.1159/000520052 ◽

2021 ◽

pp. 1-9

Author(s):

Anxin Wang ◽

Shuang Cao ◽

Xue Tian ◽

Yingting Zuo ◽

Xia Meng ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Serum Potassium ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Vascular Events ◽

Lower Serum ◽

Increased Risk ◽

Ischemic Attack

Introduction: Serum potassium abnormality is a risk factor of incident stroke, but whether it is associated with recurrent stroke in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) remains unknown. This study aimed to investigate the association of serum potassium with the risk of recurrent stroke in patients with AIS or TIA. Methods: We included 12,425 patients from the China National Stroke Registry III. Patients were classified into 3 groups according to tertiles of potassium. The outcomes were recurrence of stroke and combined vascular events at 1 year. Cox proportional hazards regression was adopted to explore the associations by calculating hazard ratios (HRs) and their 95% confidence intervals (CIs). Results: Among 12,425 enrolled patients, the median (interquartile range) of potassium was 3.92 (3.68–4.19) mmol/L. Compared with the highest tertile, after adjusted for confounding factors, the lowest tertile potassium was associated with increased risk of recurrent stroke at 1 year. The adjusted HR with 95% CI was 1.21 (1.04–1.41). There was an independent, linear association between serum potassium and stroke recurrence. Per 1 mmol/L decrease of potassium was associated with 19% higher risk of recurrent stroke (HR, 1.19; 95% CI, 1.04–1.37). Similar trends were found in ischemic stroke and combined vascular events. Conclusions: Lower serum potassium level was independently associated with elevated risk of recurrent stroke in patients with AIS or TIA. The finding suggested that monitoring serum potassium may help physicians to identify patients at high risk of recurrent stroke and to stratify risk for optimal management.

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Validation of the ability of ESER score to predict recurrent stroke: a meta-analysis

Archives of Medical Science ◽

10.5114/aoms/127199 ◽

2021 ◽

Author(s):

chengju liao ◽

zhe luo ◽

ying ru ◽

jian yang ◽

chenghong luo ◽

...

Keyword(s):

Ischemic Stroke ◽

Confidence Intervals ◽

Risk Score ◽

Stroke Risk ◽

Recurrent Stroke ◽

Meta Analysis ◽

Risk Groups ◽

Low Risk ◽

Risk Stratification Model ◽

One Year

IntroductionA risk stratification model is pretty important to prevent the recurrent stroke for ischemic stroke patients. The present study aimed to meta-analysis the ability of Essen Stroke Risk Score (ESRS) to accurately predict recurrence of ischemic stroke.Material and methodsStudies on the diagnostic performance of Essen Stroke Risk Score in predicting recurrent stroke were searched by electronic and manual methods. Quality pooled C-statistics, and 95% confidence intervals (95% CI) were evaluated.ResultsFifteen studies with a total of 94,052 patients were included in the meta-analysis. The pooled C-statistics of ESER for patients without atrial fibrillation (AF) experiencing recurring strokes at 90-day or one-year were 0.65 (95% CI: 0.58-0.73) and 0.57 (95% CI: 0.53-0.60), and the heterogeneity was weak. The average ratio of one-year recurrent stroke in the low-risk and high-risk groups classified according to ESRS is 5.6%(range 1.4 to 12.1%) and 9.2%( range 3.2 to 20.1%), respectively. And the calibration analysis showed the pooled RR in the low-risk group is 0.88 (95%CI: 0.24-3.19) and 0.88 (0.24-3.31) with wide confidence intervals and high levels of heterogeneity, indicating the calibration ability was low.ConclusionsESRS had low to moderate ability to predict recurrence of stroke in patients with ischemic stroke and low calibration ability, which need to be further improved.

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Coagulation factor XII, XI, and VIII activity levels and secondary events after first ischemic stroke

10.1101/2019.12.26.19015818 ◽

2019 ◽

Author(s):

Jessica L. Rohmann ◽

Shufan Huo ◽

Pia S. Sperber ◽

Sophie K. Piper ◽

Frits R. Rosendaal ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Recurrent Stroke ◽

Coagulation Factor ◽

Cox Proportional Hazards ◽

Factor Xii ◽

Activity Levels ◽

Continuous Variables ◽

Vascular Events ◽

Increased Risk

AbstractBackground and PurposeThough risk for recurrent vascular events is high following ischemic stroke, little is known about risk factors for secondary events post-stroke. The coagulation factors XII, XI, and VII (FXII, FXI, and FVIII) have already been implicated in first thrombotic events, and our aim was to estimate their effects on vascular outcomes within 3 years after first stroke.MethodsIn the PROSpective Cohort with Incident Stroke Berlin (PROSCIS-B) study, we followed participants aged 18 and older for three years after first mild to moderate ischemic stroke event or until occurrence of recurrent stroke, myocardial infarction or all-cause mortality (combined endpoint). High coagulation factor activity levels were compared to normal and low levels, and activities were also analyzed as continuous variables. We used Cox proportional hazards models adjusted for age, sex, and cardiovascular risk factors to estimate hazard ratios (HRs) for the combined endpoint.ResultsIn total, 92 events occurred in 570 included participants, resulting in an absolute rate of 6.6 events per 100 person-years. After confounding adjustment, high FVIII activity showed the strongest relationship with the combined endpoint (HR=2.05, 95%CI 1.28-3.29). High FXI activity was also associated with an increased risk (HR=1.80, 95%CI 1.09-2.98). Contrarily, high FXII activity was not associated with the combined endpoint (HR=0.86, 95%CI 0.49-1.51). Continuous analyses per standard deviation of each biomarker yielded similar results.ConclusionsIn our study of mild to moderate ischemic stroke patients, high activity levels of FXI and FVIII but not FXII were associated with worse vascular outcomes in the three-year period after first ischemic stroke. This is of special interest in light of the ongoing trials of antithrombotic treatments targeting FXI.

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Abstract TP416: Comparative Effectiveness of Addition of Antiplatelet to Oral Anticoagulant in Acute Ischemic Stroke With Atrial Fibrillation

Stroke ◽

10.1161/str.51.suppl_1.tp416 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Joon-tae Kim ◽

Hee-Joon Bae ◽

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Oral Anticoagulant ◽

Recurrent Stroke ◽

Cox Proportional Hazards ◽

Large Artery ◽

Vascular Events ◽

Nihss Score ◽

Composite Events

Introduction: Atrial fibrillation (AF) and large artery diseases (LAD) share several risk factors and often coexist in the same patient. Optimal treatments for acute ischemic stroke (AIS) patients with concomitant AF and LAD have not been extensively studied so far. Objective: This study aimed to compare the effectiveness of the addition of antiplatelet (AP) to oral anticoagulant (OAC) with that of OAC alone in AIS with AF according to the LAD. Methods: Using a multicenter stroke registry, acute (within 48h of onset) and mild-to-moderate (NIHSS score ≤15) stroke patients with AF were identified. Propensity scores using IPTW were used to adjust baseline imbalances between the OAC+AP group and the OAC alone group in all patients and in each subgroup by LAD. The primary outcome was major vascular events, defined as the composite of recurrent stroke, MI, and all-cause mortality at up to 3 months after index stroke. Results: Among the 5469 patients (age, 72±10yrs; male, 54.9%; initial NIHSS score, 4 [2-9]), 79.0% (n=4323) received OAC alone, and 21.0% (n=1146) received OAC+AP. By weighted Cox proportional hazards analysis, a tendency of increasing the risk of 3-months primary composite events in the OAC+AP group vs the OAC alone (HR 1.36 [0.99-1.87], p=0.06), with significant interaction with treatments and LAD (Pint=0.048). Briefly, among patients with moderate-to-severe large artery stenosis, tendency of decrease in 3-months primary composite events of the OAC+AP group, compared with OAC alone group, was observed (HR 0.54 [0.17-1.70]), whereas among patients with complete occlusion, the OAC+AP group markedly increased the risk of 3-months composite events (HR 2.00 [1.27-3.15]), compared with the OAC alone group. No interaction between direct oral anticoagulant and warfarin on outcome was observed (Pint=0.35). Conclusion: In conclusion, treatment with addition of AP to OAC had a tendency to increase the risk of 3-months vascular events, compared with OAC alone in AIS with AF. However, the effects of antithrombotic treatment could be modified according to the LAD, with substantial benefits of OAC alone in subgroup of large artery occlusion. Our results address the need for the further study to tailor the optimal treatment in AIS with concomitant AF and LAD.

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Abstract T P102: Recurrent Stroke Risk in Patients With ICAD Treated With Aggressive Medical Management: A Comparison With The Sammpris Trial

Stroke ◽

10.1161/str.46.suppl_1.tp102 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Rajbeer S Sangha ◽

Carlos Corado ◽

Richard A Bernstein ◽

Ilana Ruff ◽

Yvonne Curran ◽

...

Keyword(s):

Ischemic Stroke ◽

Real World ◽

Medical Management ◽

Stroke Risk ◽

Recurrent Stroke ◽

High Dose ◽

Stroke Subtype ◽

Anterior Circulation ◽

Intracranial Atherosclerotic Disease ◽

Aggressive Medical Management

Background: Since the SAMMPRIS trial, aggressive medical management (AMM) with the use of dual antiplatelets (aspirin, clopidogrel) and high dose statin therapy has been standard of care for patients with symptomatic intracranial atherosclerotic disease (ICAD). However, there is limited data on the “real-world” application of this regimen. We hypothesized that 30-day recurrent stroke risk among patients treated with AMM would be similar to that in SAMMPRIS medically-treated patients. Methods: Using the prospective Northwestern University Brain Attack Registry, we identified all patients admitted between 8/1/12 and 1/31/14 with 1) confirmed ischemic stroke or transient ischemic attack (TIA); 2) independently adjudicated symptomatic ICAD; and 3) discharged on AMM. At 30 days (28-35 day window) post-stroke, patients or proxies were contacted by telephone to review events and outcomes. We also utilized an electronic surveillance system of hospital records at any of 3 health system hospitals with confirmation by manual review of the medical record in all instances of reported recurrent stroke or TIA. Ischemic stroke in the territory of the symptomatic stenotic artery was the primary outcome. We calculated 30-day rate of stroke in the territory of the stenotic artery and 95% confidence intervals using the Wald method and compared it with that reported in the SAMMPRIS trial. Results: Among 36 patients who met study criteria, 13 (36.1%) were female and mean age was 65.4 (± 9.7) years. Median initial NIHSS score was 4 (interquartile range 0-17). Symptomatic ICAD was localized to the anterior circulation in 21 (58%) patients and posterior circulation in 15 (41.7%). At 30 days, 3 of the 36 patients (8.3%, 95% CI 2.1-22.6%) had recurrent stroke compared to 5.8% in the medical arm of SAMMPRIS (p=0.47). An additional 3 patients (8.3%) experienced TIA within 30 days. Conclusions: In a single-center observational cohort study, we found that AMM in patients with symptomatic ICAD yielded similar rates of recurrent stroke at 30-days as observed in the SAMMPRIS trial. Our study provides “real-world” confirmation of the potential benefits of AMM in this high-risk stroke subtype.

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Multiple biomarkers covering distinct pathways for predicting outcomes after ischemic stroke

Neurology ◽

10.1212/wnl.0000000000006717 ◽

2018 ◽

Vol 92 (4) ◽

pp. e295-e304 ◽

Cited By ~ 7

Author(s):

Chongke Zhong ◽

Zhengbao Zhu ◽

Aili Wang ◽

Tan Xu ◽

Xiaoqing Bu ◽

...

Keyword(s):

Ischemic Stroke ◽

Primary Outcome ◽

Prognostic Significance ◽

Complement C3 ◽

Vascular Events ◽

Net Reclassification Improvement ◽

Increased Risk ◽

Multiple Biomarkers ◽

Novel Biomarkers ◽

Integrated Discrimination Improvement

ObjectiveTo study the prognostic significance of multiple novel biomarkers in combination after ischemic stroke.MethodsWe derived data from the China Antihypertensive Trial in Acute Ischemic Stroke, and 12 informative biomarkers were measured. The primary outcome was the combination of death and major disability (modified Rankin Scale score ≥3) at 3 months after ischemic stroke, and secondary outcomes included major disability, death, and vascular events.ResultsIn 3,405 participants, 866 participants (25.4%) experienced major disability or died within 3 months. In multivariable analyses, elevated high-sensitive C-reactive protein, complement C3, matrix metalloproteinase-9, hepatocyte growth factor, and antiphosphatidylserine antibodies were individually associated with the primary outcome. Participants with a larger number of elevated biomarkers had increased risk of all study outcomes. The adjusted odds ratios (95% confidence intervals) of participants with 5 elevated biomarkers were 3.88 (2.05–7.36) for the primary outcome, 2.81 (1.49–5.33) for major disability, 5.67 (1.09–29.52) for death, and 4.00 (1.22–13.14) for vascular events, compared to those with no elevated biomarkers. Simultaneously adding these 5 biomarkers to the basic model with traditional risk factors led to substantial reclassification for the combined outcome (net reclassification improvement 28.5%, p < 0.001; integrated discrimination improvement 2.2%, p < 0.001) and vascular events (net reclassification improvement 37.0%, p = 0.001; integrated discrimination improvement 0.8%, p = 0.001).ConclusionWe observed a clear gradient relationship between the numbers of elevated novel biomarkers and risk of major disability, mortality, and vascular events. Incorporation of a combination of multiple biomarkers observed substantially improved the risk stratification for adverse outcomes in ischemic stroke patients.

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Risks of Stroke Recurrence and Mortality After First and Recurrent Strokes in Denmark: A Nationwide Registry Study

Neurology ◽

10.1212/wnl.0000000000013118 ◽

2021 ◽

pp. 10.1212/WNL.0000000000013118

Author(s):

Nils Skajaa ◽

Kasper Adelborg ◽

Erzsébet Horváth-Puhó ◽

Kenneth J Rothman ◽

Victor W. Henderson ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Risk Score ◽

Recurrent Stroke ◽

Recurrent Event ◽

Risk Scores ◽

Stroke Recurrence ◽

Stroke Severity ◽

Risk Of Death ◽

First Time

Background and Objectives:To examine risks of stroke recurrence and mortality after first and recurrent stroke.Methods:Using Danish nationwide health registries, we included patients (age ≥18 years) with first-time ischemic stroke (N = 105,397) or intracerebral hemorrhage (N = 13,350) during 2004–2018. Accounting for the competing risk of death, absolute risks of stroke recurrence were computed separately for each stroke subtype and within strata of age groups, sex, stroke severity, body mass index, smoking, alcohol, the Essen stroke risk score, and atrial fibrillation. Mortality risks were computed after first and recurrent stroke.Results:After adjusting for competing risks, the overall 1-year and 10-year risks of recurrence were 4% and 13% following first-time ischemic stroke and 3% and 12% following first-time intracerebral hemorrhage. For ischemic stroke, the risk of recurrence increased with age, was higher for men and following mild than more severe stroke. The most marked differences were across Essen risk scores, for which recurrence risks increased with increasing scores. For intracerebral hemorrhage, risks were similar for both sexes and did not increase with Essen risk score. For ischemic stroke, the 1-year and 10-year risks of all-cause mortality were 17% and 56% after a first-time stroke and 25% and 70% after a recurrent stroke; corresponding estimates for intracerebral hemorrhage were 37% and 70% after a first-time event and 31% and 75% after a recurrent event.Conclusion:The risk of stroke recurrence was substantial following both subtypes, but risks differed markedly among patient subgroups. The risk of mortality was higher after a recurrent than first-time stroke.

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