Stroke in patients with acute coronary syndromes - Incidence and outcomes in the platelet glycoprotein IIb/IIIa in unstable angina: Receptor suppression using integrilin therapy (PURSUIT) trial

Background-The incidence of stroke in patients with acute coronary syndrome s has not been clearly defined because few trials in this patient populatio n have been large enough to provide stable estimates of stroke rates. Methods and Results-We studied the 10 948 patients with acute coronary synd romes without persistent ST-segment elevation who were randomly assigned to placebo or the platelet glycoprotein IIb/IIIa receptor inhibitor eptifibat ide in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Supp ression Using Integrilin Therapy (PURSUIT) trial to determine stroke rates, stroke types, clinical outcomes in patients with stroke, and independent b aseline clinical predictors for nonhemorrhagic stroke. Stroke occurred in 7 9 (0.7%) patients, with 66 (0.6%) nonhemorrhagic, 6 intracranial hemorrhage s, 3 cerebral infarctions with hemorrhagic conversion, and 4 of uncertain c ause. There were no differences in stroke rates between patients who receiv ed placebo and those assigned high-dose eptifibatide (odds ratios and 95% c onfidence intervals 0.82 [0.59, 1.14] and 0.70 [0.49, 0.99], respectively). Of the 79 patients with stroke, 17 (22%) died within 30 days, and another 26 (32%) were disabled by hospital discharge or 30 days, whichever came fir st. Higher heart rate was the most important baseline clinical predictor of nonhemorrhagic stroke, followed by older age, prior anterior myocardial in farction, prior stroke or transient ischemic attack, and diabetes mellitus. These factors were used to develop a simple scoring nomogram that can pred ict the risk of nonhemorrhagic stroke. Conclusions-Stroke was an uncommon event in patients with acute coronary sy ndromes in the PURSUIT trial. These strokes are, however, associated with s ubstantial morbidity and mortality rates. The majority of strokes were of n onhemorrhagic causes. Eptifibatide was not associated with an increase in i ntracranial hemorrhage, and no significant effect on nonhemorrhagic stroke was observed. We developed a useful nomogram for assigning baseline nonhemo rrhagic stroke risk in this patient population.