A History of Stroke/Transient Ischemic Attack Indicates High Risks of Cardiovascular Event and Hemorrhagic Stroke in Patients With Coronary Artery Disease

Study Questions:

What are the implications of a prior history of stroke or transient ischemic attack (TIA) in patients with coronary artery disease?

Methods:

The authors assessed the impact of a prior history of stroke or TIA (n = 4,460) among 26,389 patients with coronary artery disease who were enrolled in the international REACH registry of atherothrombosis.

Results:

Patients with a prior history of stroke/TIA had a higher rate of all-cause death (17.8% vs. 11.2%) or composite of death, stroke, or myocardial infarction (MI) (24.9% vs. 13.3%). This was mainly driven by a large difference in the risk of stroke (13.1% vs. 4.1%). After adjusting for baseline differences, patients with prior stroke/TIA had a higher rate of cardiovascular death, MI, or stroke (adjusted hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.40-1.65; p < 0.001) and of nonfatal ischemic stroke (adjusted HR, 3.06; 95% CI, 2.62-3.57; p < 0.001) and nonfatal hemorrhagic stroke (adjusted HR, 1.76; 95% CI, 1.00-3.08; p = 0.05). The risk of stroke was highest immediately following the index stroke/TIA with the adjusted event rate of 14.6% in those with an index event within 1 year versus 9.6% for prior stroke/TIA >1 year before enrollment. The excess risk for nonfatal hemorrhagic stroke was most evident in the first year following a stroke/TIA (adjusted HR, 3.03; 95% CI, 1.51-6.08 for the first year), and was especially high in patients receiving dual antiplatelet therapy (adjusted HR, 5.21; 95% CI, 1.24-21.90).

Conclusions:

A history of stroke or TIA is common in patients with coronary artery disease, and is associated with an increased risk of death, MI, or stroke. An excess risk of hemorrhagic stroke was also noticed, and was particularly high in patients receiving dual antiplatelet therapy and in the first year following stroke/TIA.

Perspective:

A prior history of stroke or TIA was recognized as an important predictor of bleeding events and a lack of benefit with respect to ischemic events in the TRITON-TIMI 38 trial. A similar signal was detected in patients randomized to vorapaxar and apixaban, suggesting that the presence of prior cerebrovascular disease serves to identify a cohort of patients who are at an increased risk of future cardiac and cerebral mortality and morbidity, and also at an increased risk of major bleeding from more potent antithrombotic therapy. Prior TIA or stroke was surprisingly common in this registry of patients with coronary artery disease (~17%), and further studies are needed to define the optimal secondary preventive strategies for this population.

Clinical Topics: Atherosclerotic Disease (CAD/PAD)

Keywords: Risk, Registries, Coronary Artery Disease, Stroke, Intracranial Hemorrhages, Ischemic Attack, Transient, Cardiology, Lactones, Coronary Disease, Pyridines, Pyrazoles, Pyridones


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