Ischemic and hemorrhagic stroke in patients on oral anticoagulants after reconstruction for chronic lower limb ischemia.
OBJECTIVE
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 patients on long-term anticoagulant therapy after reconstruction for chronic limb ischemia.


METHODS
In a retrospective study, 376 consecutive patients were seen at regular intervals according to a standard protocol. Only 3 (0.7%) were lost during follow-up (mean duration, 5.9 years). Anticoagulation was with coumarin derivatives followed by prothrombin times periodically. Primary end points were ischemic and hemorrhagic 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 variables on these outcome events was evaluated in univariate and multivariate analyses.


RESULTS
Thirty-nine patients (10%) had 41 stroke events (23 ischemic, 18 hemorrhagic); 22 of these patients (56%) died from stroke. The cumulative ischemic stroke risk was 5% at 5 years and 12% at 15 years. Prior myocardial infarction was the only independent predictor (relative risk [RR], 3.1; P < .05). The cumulative hemorrhagic stroke risk was 3% at 5 years and 17% at 15 years. Systolic hypertension (RR, 4.8; P < .01) and insulin-dependent diabetes mellitus (RR, 5.4; P < .01) were significant and independent predictors. The risk for a major 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-dependent diabetes (RR, 2.2; P < .005), and prior myocardial infarction (RR, 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-dependent diabetes mellitus are at high risk for hemorrhagic stroke.
Dawson
I
I
Department of Surgery, University Hospital Leiden, The Netherlands.
van Bockel
J H
JH
Ferrari
M D
MD
van der Meer
F J
FJ
Brand
R
R
Terpstra
J L
JL
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D002545:Brain Ischemia / Q000453:epidemiology* / Q000209:etiology; D002423:Cause of Death; D002543:Cerebral Hemorrhage / Q000453:epidemiology* / Q000209:etiology; D002561:Cerebrovascular Disorders / Q000401:mortality; D003374:Coumarins / Q000009:adverse effects / Q000627:therapeutic use*; D016903:Drug Monitoring; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000401:mortality; D006801:Humans; D007511:Ischemia / Q000188:drug therapy* / Q000601:surgery; D007866:Leg / Q000098:blood supply*; D008171:Lung Diseases / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality; D011517:Prothrombin Time; D012307:Risk Factors; D014652:Vascular Diseases / Q000401:mortality
D000925:Anticoagulants; D003374:Coumarins