Stroke following percutaneous coronary intervention: type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007–12

Selected in European Heart Journal by G.G. Toth

References

Authors

Chun Shing Kwok, Evangelos Kontopantelis, Phyo K. Myint, Azfar Zaman, Colin Berry, Bernard Keavney, Jim Nolan, Peter F. Ludman, Mark A. de Belder, Iain Buchan, Mamas A. Mamas

Reference

European Heart Journal (2015) 36, 1618–1628

Published

April 2015

Link

Read the abstract

My Comment

Background

Stroke as a complication of PCI is associated with high in-hospital mortality rates, as well as significant and devastating life-changing disabilities in surviving patients. This study evaluates the incidence and the predictors of in-hospital ischemic and hemorrhagic stroke over a 6-year period in an unselected cohort of patients undergoing PCI in England and Wales. Analysis was performed through the database of the British Cardiovascular Intervention Society (BCIS).

Major findings

  • 426 297 patients were included in the analysis. Out of them 543 experienced any periprocedural stroke: 436 patients (0.1%) with an ischemic stroke/transient ischemic attack complication and 107 patients (0.03%) with a hemorrhagic stroke complication.
  • Incidence of ischemic stroke/transient ischemic attack increased non-linearly over the six years [from 0.67 (0.47–0.87) to 0.114 (0.094–0.134) per 1000; p=0.006]. Among them incidence of transient ischemic attack remained stable and the increase was dominated by the incidence of ischemic strokes. In the meanwhile the incidence of hemorrhagic stroke decreased non-linearly [0.29 (0.19–0.39) to 0.15 (0.05–0.25) per 1000; p=0.009].
  • Patients with periprocedural ischemic stroke/transient ischemic attack were (1) older, (2) more likely to have a previous of stroke, (3) more likely to be female, (4) have valvular heart disease and (5) present as non-elective cases, as compared to patients without cerebrovascular complications.
  • Patients with periprocedural hemorrhagic stroke complications were (1) older, (2) more likely to be female, (3) undergo PCI for non-elective indications, (4) be more frequently in hemodynamically unstable condition, and (5) have been treated with warfarin, thrombolysis or glycoprotein IIb/III inhibitors.
  • 30-days mortality rates were significantly higher in patients, who experienced ischemic stroke (21%), transient ischemic attack (9%) or hemorrhagic stroke (48%), as compared to the control group (2%).

My comments 

  • Periprocedural stroke (ischemic/hemorrhagic) is a rare, but still severe complication after PCI with significant impact on 30-days mortality.
  • Incidence of ischemic stroke/transient ischemic attack is associated with clinical factors such as higher age, presence of valvular disease or acute presentation, etc. Accordingly, the increasing rate of ischemic stroke/transient ischemic attack might represent the trend of changing patient population undergoing PCI.
  • Reduction in the incidence of hemorrhagic stroke might be explained by the significantly decreased rate of thrombolysis, which might overrule the increase in other predictive factors (age, valvular disease, acute presentation, etc.)
  • Against common believe, radial approach was found NOT to be an independent predictor of ischemic stroke/transient ischemic attack.

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