Anti-depressants ‘up stroke risk’

Anti-depressants are widely prescribed

Post menopausal women who take anti-depressants face a small – but statistically significant – increased risk of a stroke, research suggests.

The US study was based on 136,293 women aged 50 to 79, who were followed for an average of six years.

Anti-depressant users were 45% more likely to have a stroke than women not taking the drugs.

The data, published in Archives of Internal Medicine, is taken from the Women’s Health Initiative Study.

When overall death rates were examined, those on anti-depressants were found to have a 32% higher risk of death from all causes during the study than non-users.

The researchers stressed that the overall risk of a stroke was relatively small. Even for women on anti-depressants, it was less than one in 200 chance in any given year.

You have to weigh the benefits that you get from these anti-depressants against the small increase in risk that we found in this study Dr Sylvia Wassertheil-Smoller Albert Einstein College of Medicine

However, they said that because so many women were taking anti-depressants the effect would be significant across the entire population.

It is not clear whether taking anti-depressants is solely responsible for the increased risk of a stroke.

Depression itself is known to be a risk factor for cardiovascular problems.

The researchers tried to take this into account in their analysis of the data – but could not rule out the possibility that it influenced the final results.

The study found no difference in stroke risk between the two major classes of anti-depressants, selective serotonin reuptake inhibitors (SSRIs) or tricyclic anti-depressants (TCAs).

However, the SSRIs did appear to convey a higher risk of hemorrhagic stroke caused by a bleed in the brain.

Lead researcher Dr Sylvia Wassertheil-Smoller, of Albert Einstein College of Medicine, stressed that treatment for depression was important, and that women should not stop taking prescribed medication without first consulting their doctor.

She said: “You have to weigh the benefits that you get from these antidepressants against the small increase in risk that we found in this study.”

Known links

The researchers said follow-up studies were needed before any firm conclusions could be drawn.

Dr Jordan Smoller, of Harvard Medical School, who also worked on the study, said: “We need to study this association more to determine exactly what it signifies.”

Joanne Murphy, for The Stroke Association stressed the study showed that overall risk for women taking anti-depressants was relatively small.

She said “We are already aware of links between depression and the risk of stroke and we are currently funding further studies to look into this.

“Everyone can help reduce their risk of stroke by making lifestyle changes, such as reducing their blood pressure, giving up smoking, reducing alcohol intake, improving their diet and getting plenty of exercise.”

Ellen Mason, of the British Heart Foundation, said: “Severe depression can be debilitating and even fatal, so it is important to weigh up any small increase in the risk of stroke with the benefits of treating depression.”

Bridget O’Connell, from the mental health charity Mind, said antidepressants produced a range of side effects that affected people in different ways.

She said: “Many people can experience huge benefits from taking antidepressants and it’s important they work with their GP to identify both the plus points and the drawbacks, and weigh up what treatment is best for them.”

Introduction: The National Institutes of Health Stroke Scale (NIHSS) and Scandinavian Stroke Scale (SSS) are both validated measures of neurologic impairment and have been used in many acute stroke trials. Methods for interconverting SSS and NIHSS are needed.Methods: Conversion equations were developed using linear regression (both unadjusted, and adjusted for age and sex) using a random 50% of the data at both baseline and 90 days. The remaining 50% of data were used to test the accuracy of the models produced.Results: Data from 5 acute stroke trials (2004 patients) were included. Fitted models at baseline were NIHSS = 25.68 – 0.43 ∗ SSS (R2 = 0.57, prediction error [PE] –0.2, P = .20), and SSS = 50.37 – 1.63 ∗ NIHSS (R2 = 0.59, PE 0.2, P = .35). The 90-day models were NIHSS = 22.99 – 0.39 ∗ SSS (R2 = 0.82, PE –0.3, P = .001), and SSS = 56.68 – 2.20 ∗ NIHSS (R2 = 0.80, PE –0.4, P = .08). Adjustment did not materially improve the R2 values.Conclusion: Total scores for NIHSS and SSS may be interconverted with good precision; the mathematic conversion equations may prove useful in clinical practice and in comparison of data from observational studies and randomized trials.

Objective: We sought to evaluate the success rates in achieving preventive therapeutic goals in patients who experienced an ischemic stroke (IS) and compare them with those achieved in patients with coronary artery disease (CAD).Methods: This was an observational multicenter case-control study (3 patients with IS and one control subject with CAD) performed in 1444 primary health centers in Spain. Preventive therapeutic objectives according to American Heart Association guidelines were predefined. Demographic data, vascular risk factors, and success/failure in achievement of objectives were recorded and compared between patients with IS and CAD.Results: A total of 5458 patients were included, 4098 (75.1%) had IS and 1360 (24.9%) had CAD. Although more than 90% of patients with hypertension, diabetes, or dyslipidemia were under specific drug regimens, only about 25% achieved the recommended therapeutic objective for each risk factor. Success rate was especially low among patients with IS compared with CAD: hypertension (23.8% v 27.2%; P = .028); dyslipidemia (13.6% v 20.3%; P < .001); and abdominal obesity (49.1% v 54.6%; P = .002). The only objective widely achieved in both groups was the use of antithrombotic drugs in atrial fibrillation (97.2% v 94.7%; P = .125). Only 3.3% of patients with IS had all risk factors under control, compared with 5.6% of those with CAD (P = .006). For all patients, multivariate logistic regression model showed that independent predictors of full risk factor control were: presence of CAD as compared with IS (odds ratio [OR] 2.11; 95% confidence interval [CI] 1.35-3.29; P = .001), older age (OR 1.02; 95% CI 1.00-1.04; P = .028), and having less than 3 risk factors (OR 16.98; 95% CI 9.02-31.97; P < .001).Conclusions: Success in achieving preventive therapeutic objectives for secondary prevention of vascular events is low, especially among patients with IS. There is an urgent need to devise strategies to improve risk factor control.

A 69-year-old man experienced left hemiparesis and confusion of sudden onset, followed by complete spontaneous recovery after about 20 minutes. When carotid ultrasound was performed in the neurovascular unit 12 hours later, an occluded right internal carotid artery was found. Transcranial ultrasound showed normal flow in the right middle and anterior cerebral arteries. How should he be treated?

Background: Detection of atrial fibrillation (AF) after ischemic stroke is important because anticoagulation is indicated to reduce the risk of recurrent stroke. However, no consensus exists about the optimum method for detecting underlying paroxysmal AF not apparent on presentation with stroke. The aim of this study was to characterize the rate, timing, and predictors of delayed detection of AF after stroke.Methods: The Virtual International Stroke Trials Archive provided data from 3464 patients in the placebo arms of 4 clinical trials of therapies for acute ischemic stroke. Patients who had AF by history or on the baseline electrocardiogram were excluded. Electrocardiograms were obtained routinely and as clinically indicated. The time to detection of AF was evaluated using Kaplan-Meier survival statistics. Cox proportional hazards analysis was used to evaluate risk factors for AF.Results: Among 2504 qualifying patients, AF was detected in 174 (6.9%; 95% confidence interval [CI] 6.0%-8.0%). In 68% of patients, AF was detected more than 48 hours after presentation. Detection of AF was associated with increasing age (hazard ratio [HR] 1.6/decade; 95% CI 1.4-1.9; P < .005), female sex (HR 1.7; CI 1.2-2.4; P < .005), congestive heart failure (HR 1.9; CI 1.1-3.4; P = .02), and the absence of hypertension (HR 1.6; CI 1.1-2.2; P = .01).Conclusions: Delayed detection of AF was common in this large cohort of patients carefully monitored after ischemic stroke. Current methods of screening may fail to detect underlying paroxysmal AF in a substantial proportion of patients.

Objective: We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being.Methods: This was a randomized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department. An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans. The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months. The intervention and usual care groups were compared using a global and closed hypothesis testing strategy. Outcomes fell into 5 domains: (1) neuromotor function, (2) institution time or death, (3) quality of life, (4) management of risk, and (5) stroke knowledge and lifestyle.Results: Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain, which showed a significant effect of the intervention (P = .0003).Conclusions: Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population. The intervention did, however, fill a postdischarge knowledge gap.

Objective: We sought to determine the responsible factors and clinical significance of dilatation of the internal carotid artery (ICA) and basilar artery (BA).Methods: ICA and BA diameters were measured using magnetic resonance imaging (MRI) and their association with age, sex, conventional atherosclerotic factors, and estimated glomerular filtration rate (eGFR) were evaluated in 175 outpatients aged 40 to 89 years. The arterial diameters were measured as the maximal width of the flow void on T2-weighted MRI around the brainstem. The relationship between the arterial diameters and deep white matter hyperintensities (DWMHs) on MRI graded from 0 to 3 was also examined. Comparisons were performed between groups with diameters smaller and larger than the mean value for younger (40-69 years) and older (70-89 years) patients, and multiple regression analysis was conducted.Results: Age differed significantly between the larger- and smaller-diameter groups in younger patients, but not in older patients. The larger-diameter group of older patients had a significantly lower eGFR (P = .0002 for ICA, P = .0035 for BA) and a higher DWMH grade (P = .0021 for ICA, P < .0001 for BA) compared to the smaller-diameter group. In multiple regression analysis adjusted for age and sex, a lower eGFR was an independent factor associated with larger arterial diameters (P = .0002 for ICA, P = .0021 for BA).Conclusion: Kidney dysfunction is an independent factor that is related to ICA and BA dilatation, which is also associated with DWMHs that reflect small vessel diseases in older patients.