ISCHEMIC AND HEMORRHAGIC STROKE IN PATIENTS ON ORAL ANTICOAGULANTS AFTER RECONSTRUCTION FOR CHRONIC LOWER-LIMB ISCHEMIA

Background and Purpose: Information on the long-term fate of patients with chronic lower limb ischemia is limited. We investigated the long- term risk of the first ischemic and hemorrhagic cerebral stroke in pat ients on long-term anticoagulant therapy after reconstruction for chro nic limb ischemia. Methods: In a retrospective study, 376 consecutive patients were seen at regular intervals according to a standard protoc ol. Only 3 (0.7%) were lost during follow-up (mean duration, 5.9 years ). Anticoagulation was with coumarin derivatives followed by prothromb in times periodically. Primary end points were ischemic and hemorrhagi c cerebral stroke events, which were confirmed by CT scan, autopsy, or operation in 85% of the cases. Major vascular events were analyzed as a composite secondary end point. The influence of several clinical va riables on these outcome events was evaluated in univariate and multiv ariate analyses. Results. Thirty-nine patients (10%) had 41 stroke eve nts (23 ischemic, 18 hemorrhagic); 22 of these patients (56%) died fro m stroke. The cumulative ischemic stroke risk was 5% at 5 years and 12 % at 15 years. Prior myocardial infarction was the only independent pr edictor (relative risk [RR], 3.1; P<.05). The cumulative hemorrhagic s troke risk was 3% at 5 years and 17% at 15 years. Systolic hypertensio n (RR, 4.8; P<.01) and insulin-dependent diabetes mellitus (RR, 5.4; P <.01) were significant and independent predictors. The risk for a majo r vascular event was 29% at 5 years and increased to 56% at 15 years. Independent predictors were advanced age (RR, 1.4; P<.005), insulin-de pendent diabetes (RR, 2.2; P<.005), and prior myocardial infarction (R R, 1.8; P<.01). Conclusions. Patients with chronic lower limb ischemia , notably those with prior myocardial infarction, are at high risk for ischemic stroke. Those with systolic hypertension or insulin-dependen t diabetes mellitus are at high risk for hemorrhagic stroke.