LONG-TERM ANTICOAGULANT-THERAPY IN CEREBROVASCULAR-DISEASE - DOES BLEEDING OUTWEIGH THE BENEFIT

Objective. The aim of the present study was to determine the risk of m ajor haemorrhagic complications, stroke and other cardiovascular event s, and mortality during long-term anticoagulant therapy (ACT) in patie nts with cerebrovascular disease not included in any prospective trial s. Design. The data were collected retrospectively. Setting. All patie nts with symptomatic cerebrovascular disease discharged from the Strok e Unit, Aker University Hospital, Oslo, with ACT (warfarin) during 198 3 through to 1986 were included. Subjects. The material consists of 16 1 patients with a mean age of 67.8 (range 40-90) years. The reason for initiating ACT was frequent transient ischaemic attacks (TIAs) in 52 patients, stroke in progression (SIP) in 33 patients, and probable emb olic stroke in 76 patients. International normalized ratio (INR) of 4. 2-2.8 was aimed at. Main outcome measures. Major haemorrhagic complica tions, recurrent stroke and survival was determined for the total mate rial, and in the subgroups non-valvular atrial fibrillation (NVAF, n = 49), TIAs, and SIP. Results. The mean duration of ACT was 21.1 (range 0.5-60.2) months with a total of 282.9 patient-years. The rate of maj or (including fatal) haemorrhagic complications was 4.6% per year, and the rate of fatal haemorrhagic complications was 1.4% per year. The c omplication rates in the subgroups of patients did not differ signific antly from that in the total material. Only two out of the 13 major ha emorrhagic complications occurred during the initial 6 months of ACT, No strokes occurred in the TIA subgroup. The rate of recurrent stroke (excluding intracranial haemorrhage) was 3.9% per year for all patient s, 4.7% per year for the patients with NVAF, and 4.2% per year for the patients with SIP. Conclusions. The total results suggest a positive net effect of ACT in patients with NVAF and TIAs. Without comparable d ata, no definite conclusions concerning the effect of ACT on patients with STP can be drawn. The rate of bleeding complications was similar to that in other studied materials and is not negligible. In patients with SIP and TIAs, ACT beyond 6 months should probably only be continu ed if aspirin is not tolerated or has proven ineffective in the partic ular patient.