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

Predicting Risk of Perioperative Death or Stroke After Carotid Endarterectomy in Asymptomatic Patients

Source: Calvillo-King, L, et.al. Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients: Derivation and validation of a clinical risk score. Stroke 2010;41:2786-2794.

Three quarters of the 117,000 carotid endarterecto- mies (CEA) performed in the United States every year are in patients who are asymptomatic. The benefits are small, and randomized trials have shown that CEA reduced the absolute risk of stroke or death by about 6% over 5 years. Therefore, current guidelines state that CEA should be performed on an asymptomatic patient only if the operative risk is less than 3%. The investigators set out to identify preoperative risk factors that would allow prediction of surgical risk, by reviewing 6,553 asymptomatic Medicare beneficiaries in New York State who underwent CEA. The following eight items were significant multivariable predictors of perioperative events and formed the basis of a "CEA-8 Clinical Risk Score": (1) female sex (OR = 1.8), (2) nonwhite race (OR = 1.8), (3) severe disability (OR = 3.7), (4) congestive heart failure (OR = 1.6), (5) coronary artery disease (OR = 1.6), (6) valvular heart disease (OR = 1.5), (7) history of prior stroke or TIA, and (8) nonoperated carotid stenosis > 50% (OR = 1.8). The combined score stratified patients with a risk of stroke or death from 0.6% to 9.6%.

Dabigatran Is as Effective as Warfarin in Preventing Stroke in Patients with Atrial Fibrillation

Source: Diener HC, et. al. Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurology 2010;9:1157-1164.

In the randomised evaluation of long-term anticoagu- lation Therapy (RE-LY) trial, dabigatran reduced the occurrence of both stroke and hemorrhage, compared to warfarin, in 18,113 patients with atrial fibrillation. In this subgroup analysis of patients who had a previous stroke or TIA, the investigators followed 1,195 patients who were in the 110 mg dabigatran group, and 1,233 patients who were in the 150 mg dabigatran group for a median duration of 2.0 years (IQR 1.14–2.86). Stroke or systemic embolism occurred in 65 patients (2.78% per year) on warfarin compared with 55 patients (2.32% per year) on 110 mg dabigatran (RR = 0.84) and 51 patients (2.07% per year) on 150 mg dabigatran (RR = 0.75). The rate of major bleeding was significantly lower on the 110 mg dose of dabigatran, and similar on the 150 mg dose, when compared to warfarin. The effects of dabigatran compared to warfarin were not significantly different between patients who had previous stroke or TIA and the other patients in the RE-LY trial.