A new study shows that although it is relatively uncommon, gastrointestinal (GI) hemorrhage during the hospital stay after an acute ischemic stroke is associated with a 3-fold increase in the risk for death and severe dependence at discharge.
Using data from the Registry of the Canadian Stroke Network, the researchers also found an increase in the risk for death at 6 months associated with GI hemorrhage during the initial hospital stay.
"One of the strengths of the Canadian stroke registry from which this was taken is that it affords us the opportunity to look at the natural history of medical complications after stroke," lead author Martin J. O\'Donnell, MB, PhD, from McMaster University, in Hamilton, Ontario, told Medscape Neurology & Neurosurgery.
GI bleeding is a complication that may lend itself to preventive measures, he noted. "Future research is required to determine whether interventions that reduce the risk of GI bleeding and other types of bleeding may result in improved outcomes after stroke."
The findings are published online August 6 ahead of the August 26 issue of Neurology.
Consequences Underestimated
Until recently, the authors write, the consequences of bleeding after a major vascular event have been "grossly underestimated."
"Compelling evidence now suggests that major bleeding after acute coronary syndrome is a strong and independent predictor of mortality and recurrent major vascular events," they note. "However, the association between major bleeding and clinical outcomes following acute ischemic stroke has been less well evaluated."
The most common type of extracranial bleeding after stroke is gastrointestinal bleeding, usually in the upper-GI tract, they write. In this study, Dr. O’Donnell and colleagues used data from the Registry of the Canadian Stroke Network to look at the incidence of and risk factors for gastrointestinal bleeding, as well as its association with clinical outcomes after ischemic stroke.
Stroke severity was measured using the Canadian Neurological Scale. Dependence was measured using the modified Rankin Scale (mRS), with a score of 0 to 3 considered no or mild to moderate dependence and an mRS of 4 to 6 encompassing death or severe dependence.
The registry includes consecutive patients with acute ischemic stroke admitted to 11 hospitals in Ontario, Canada; for this analysis, the researchers identified 6853 patients. Of the patients, 829 died during hospitalization and 1374 had died by 6 months.
One hundred (1.5%) patients had a GI hemorrhage during their hospitalization, 36 (0.5%) of whom required transfusion.
Multivariable logistic regression showed that gastrointestinal hemorrhage was associated with death or severe dependence at hospital discharge and with mortality at 6 months, independent of comorbidities and in-hospital medical complications.
Risk for Death or Dependence Associated with Gastrointestinal Hemorrhage
|
End Point
|
Odds Ratio
|
95% CI
|
|
Death or severe dependence at discharge
|
3.3
|
1.9 – 5.8
|
|
Mortality at 6 mo
|
1.5
|
1.1 – 2.0
|
"The association between gastrointestinal bleeding and poorer clinical outcomes is likely to be multifactorial," he noted. "For example, when patients experience major bleeding, their antithrombotic therapy is usually stopped, which increases their risk of recurrent major vascular events," suggesting the effect of these bleeds on mortality or dependence may be related to both direct and indirect results of the bleed.
A previous history of peptic-ulcer disease, cancer, and the severity of the stroke were all independent predictors of GI bleeding in this analysis.
"If we can identify patients who are at high risk of gastrointestinal bleeding after stroke, particularly upper-GI bleeding, 1 potential avenue of research would be to determine whether routine prophylactic use of acid-suppression therapies such as H2 antagonists or proton pump inhibitors in this high-risk group would have a beneficial effect on clinical outcomes," Dr. O\'Donnell said. |
