Gastrointestinal Bleeding After Stroke Increases Mortality Rate
Gastrointestinal hemorrhage after acute ischemic stroke, though relatively uncommon, may increase the risk of death and severe dependence, according to a study in the August 26 Neurology.
A total of 6,853 patients with acute ischemic stroke who were admitted to 11 Ontario hospitals were identified prospectively from the Registry of the Canadian Stroke Network by Martin J. O’Donnell, MB, PhD, from McMaster University in Hamilton, Ontario, and colleagues. One hundred (1.5%) patients experienced gastrointestinal hemorrhage during hospitalization, 36 (0.5%) of whom required blood transfusion. Subjects’ mean age was 72, and 49% were female. The mean measurement of stroke severity per the Canadian Neurological Scale Score was 7.8. During the hospital stay, 829 (12.1%) patients died; by six months, 1,374 (20.1%) patients had died.
Previous history of peptic ulcer disease (odds ratio [OR], 3.8), cancer (OR, 2.0), and stroke severity score (OR, 0.9) were independent predictors of gastrointestinal bleeding. Thrombolytic therapy, preadmission antithrombotic therapy, and preadmission proton pump inhibitor/H2 antagonist therapy were not significantly associated with gastrointestinal bleeding.
Gastrointestinal hemorrhage was independently associated with death or severe dependence at discharge (OR, 3.3) and six-month mortality (hazard ratio, 1.5). “At hospital discharge, 2,732/6,739 (40.5%) patients who did not have a gastrointestinal hemorrhage subsequently had died or were severely dependent (modified Rankin [Scale score] 4 to 6), compared to 81/100 (81%) patients with gastrointestinal hemorrhage,” stated the investigators. Six months after ischemic stroke, 1,328 (19.7%) patients without gastrointestinal hemorrhage and 46 (46%) of those with gastrointestinal bleeding had died.
Recurrent ischemic stroke during hospitalization occurred in 164 (2.4%) patients without gastrointestinal hemorrhage and in nine (9%) patients with gastrointestinal hemorrhage.
From the cohort that survived to hospital discharge, 63 (87.5%) patients with gastrointestinal bleeding were receiving antithrombotic therapy, compared with 5,586 (93.9%) patients who did not have gastrointestinal bleeding.
“While we are unable to demonstrate a true cause-and-effect relationship between gastrointestinal bleeding and clinical outcomes, our findings may guide further clinical research,” Dr. O’Donnell and coauthors stated. “Prospective studies are required to determine the influence of major bleeding on recurrent major vascular events and death,” they concluded.
O’Donnell MJ, Kapral MK, Fang J, et al. Gastrointestinal bleeding after acute ischemic stroke. Neurology. 2008;71(9):650-655.
MCI Is Associated With Diabetes Mellitus
Mild cognitive impairment (MCI) is associated with the onset, duration, and severity of diabetes mellitus, reported Rosebud O. Roberts, MBChB, MS, in the August Archives of Neurology.
A total of 329 subjects with MCI and 1,640 subjects without MCI and dementia were studied. A physician’s diagnosis of, treatment for, or complications of diabetes mellitus was self-reported in 356 subjects (18.1%). The frequency of diabetes mellitus was similar in patients with MCI and in those without MCI (20.1% and 17.7%, respectively; odds ratio [OR], 1.16).
No significant associations were noted between diabetes mellitus and MCI overall or MCI subtypes. “However, there were significant associations with type of diabetes mellitus treatment and diabetes mellitus complications,” noted the researchers. The association increased significantly for insulin treatment alone (OR, 2.05). The risk of MCI was elevated twofold with the presence of complications of neuropathy and retinopathy and 1.5-fold for nephropathy.
No statistically significant interactions were observed between diabetes mellitus and demographic factors, clinical variables, or depression. However, diabetes mellitus was significantly associated with MCI in subjects with fewer than nine years of education (OR, 2.77) and in subgroups with depression, hypertension, BMI of 30 or higher, history of stroke or transient ischemic attack, and APOE ε3ε4 or ε4ε3 genotype.
For patients with diabetes mellitus based on self-report or on fasting blood glucose level that met criteria for diabetes mellitus (n = 54), the association with MCI was marginally significant after adjustment for vascular risk factors (OR, 1.33). There was a significant association of diabetes mellitus with nonamnestic MCI (OR, 1.63) but not with amnestic MCI, noted Dr. Roberts, from the Division of Epidemiology at the Mayo Clinic in Rochester, Minnesota, and colleagues.
Of 356 subjects who self-reported diabetes mellitus, 304 (85.4%) had confirmed diagnoses per the medical records linkage system. Of these patients, diabetes mellitus frequency was 17.6% in subjects with MCI and 15% in those without MCI. Adjusted ORs were significantly elevated for subjects with diabetes mellitus onset before age 65 (OR, 2.20), disease duration of 10 years or longer (OR, 1.76), treatment with insulin (OR, 2.02), and presence of diabetes mellitus complications (OR, 1.80).
“Long duration of diabetes mellitus may be associated with greater cerebral macrovascular disease, clinical cerebral infarctions, and subclinical infarctions that may impair cognitive function,” the researchers explained. “This is consistent with other findings in which vascular disease in midlife predicted late-life cognitive impairment or dementia,” they concluded.
Roberts RO, Geda YE, Knopman DS, et al. Association of duration and severity of diabetes mellitus with mild cognitive impairment. Arch Neurol. 2008;65(8):1066-1073.