Santiago Palacio

Lacunar Strokes in Patients With Diabetes Mellitus: Risk Factors, Infarct Location, and Prognosis The Secondary Prevention of Small Subcortical Strokes Study

Background and Purpose Diabetes is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for diabetic patients with lacunar stroke.Background and Purpose— Diabetes mellitus is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for patients with diabetes mellitus with lacunar stroke. Methods— We compared features at study entry and prognosis during 3.6 years of follow-up of patients with diabetes mellitus versus patients without diabetes mellitus with recent lacunar stroke participating in the Secondary Prevention of Small Subcortical Strokes (SPS3) randomized trial. Results— Among the 3020 participants, the prevalence of diabetes mellitus was 37% with a mean duration of 11 years. Diabetes mellitus was independently associated with slightly younger age (63 versus 64 years; P<0.001), Hispanic ethnicity (36% versus 28%; P<0.0001), ischemic heart disease (11% versus 6%; P=0.002), and peripheral vascular disease (5% versus 2%; P<0.001). Patients with diabetes mellitus more frequently had intracranial stenosis ≥50% (P<0.001), infarcts involving the brain stem or cerebellum (P<0.001), and more extensive white matter abnormalities (P<0.001). Patients with diabetes mellitus were almost twice as likely to have a recurrent stroke (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.4–2.3), recurrent ischemic stroke (HR, 1.8; 95% CI, 1.4–2.4), disabling/fatal stroke (HR, 1.8; 95% CI, 1.2–2.9), myocardial infarction (HR, 1.7; 95% CI, 1.0–2.8), and death (HR, 2.1 95% CI, 1.6–2.8) compared with patients without diabetes mellitus. Conclusions— Patients with diabetes mellitus with lacunar stroke have a distinctive clinical profile that includes double the prevalence of systemic and intracranial atherosclerosis, preferential involvement of the posterior circulation, and a poor prognosis for recurrent stroke and death. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Effect of addition of clopidogrel to aspirin on mortality: systematic review of randomized trials.

Background and Purpose— In the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, addition of clopidogrel to aspirin was associated with an unexpected increase in mortality in patients with lacunar strokes. We assessed the effect of the addition of clopidogrel to aspirin on mortality in a meta-analysis of published randomized trials. Methods— Randomized trials in which clopidogrel was added to aspirin in subjects with vascular disease or vascular risk factors were identified. Trials were restricted to those with a mean follow-up of ≥14 days in which both the combination of aspirin and clopidogrel was tested and mortality was reported. Results— Twelve trials included 90 934 participants (mean age, 63 years; 70% men; median follow-up, 1 year) with 6849 observed deaths. There was no significant increase in mortality with the combination therapy either in 4 short-term (14 days–3 months; OR, 0.93; 95% CI, 0.87–0.99) or in 7 long-term (>3 months; hazard ratio, 0.97; 95% CI, 0.91–1.04) trials after 1 long-term trial (the SPS3 trial) was excluded because of heterogeneity. Addition of clopidogrel was associated with an increase in fatal hemorrhage (OR, 1.35; 95% CI, 0.97–1.90) and a reduction in myocardial infarction (OR, 0.82; 95% CI, 0.74–0.91). Conclusions— The addition of clopidogrel to aspirin has no overall effect on mortality. The SPS3 trial results are outliers, possibly because of a lower prevalence of coronary artery ischemia. Addition of clopidogrel to aspirin increases fatal bleeding and reduces myocardial infarction. Clinical Trial Registration— URL: http//www.clinicaltrials.gov. Unique identifier: NCT00059306.

Regarding Article “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”

To the Editor: The recent American Heart Association Stroke Council guideline statement on the management of intracerebral hemorrhage includes the statement that “The recent Stroke Prevention with Aggressive Reductions in Cholesterol Levels (SPARCL) study found increased risk of subsequent ICH (unadjusted hazard ratio, 1.68; 95% confidence interval, 1.09 to 2.59) among subjects with prior stroke randomized to high-dose …

Lacunar strokes in patients with diabetes mellitus

Background and Purpose Diabetes is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for diabetic patients with lacunar stroke.Background and Purpose— Diabetes mellitus is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for patients with diabetes mellitus with lacunar stroke. Methods— We compared features at study entry and prognosis during 3.6 years of follow-up of patients with diabetes mellitus versus patients without diabetes mellitus with recent lacunar stroke participating in the Secondary Prevention of Small Subcortical Strokes (SPS3) randomized trial. Results— Among the 3020 participants, the prevalence of diabetes mellitus was 37% with a mean duration of 11 years. Diabetes mellitus was independently associated with slightly younger age (63 versus 64 years; P<0.001), Hispanic ethnicity (36% versus 28%; P<0.0001), ischemic heart disease (11% versus 6%; P=0.002), and peripheral vascular disease (5% versus 2%; P<0.001). Patients with diabetes mellitus more frequently had intracranial stenosis ≥50% (P<0.001), infarcts involving the brain stem or cerebellum (P<0.001), and more extensive white matter abnormalities (P<0.001). Patients with diabetes mellitus were almost twice as likely to have a recurrent stroke (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.4–2.3), recurrent ischemic stroke (HR, 1.8; 95% CI, 1.4–2.4), disabling/fatal stroke (HR, 1.8; 95% CI, 1.2–2.9), myocardial infarction (HR, 1.7; 95% CI, 1.0–2.8), and death (HR, 2.1 95% CI, 1.6–2.8) compared with patients without diabetes mellitus. Conclusions— Patients with diabetes mellitus with lacunar stroke have a distinctive clinical profile that includes double the prevalence of systemic and intracranial atherosclerosis, preferential involvement of the posterior circulation, and a poor prognosis for recurrent stroke and death. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Lacunar strokes in patients with diabetes: Risk factors, infarct location, and prognosis: The SPS3 Study

Background and Purpose Diabetes is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for diabetic patients with lacunar stroke.Background and Purpose— Diabetes mellitus is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for patients with diabetes mellitus with lacunar stroke. Methods— We compared features at study entry and prognosis during 3.6 years of follow-up of patients with diabetes mellitus versus patients without diabetes mellitus with recent lacunar stroke participating in the Secondary Prevention of Small Subcortical Strokes (SPS3) randomized trial. Results— Among the 3020 participants, the prevalence of diabetes mellitus was 37% with a mean duration of 11 years. Diabetes mellitus was independently associated with slightly younger age (63 versus 64 years; P<0.001), Hispanic ethnicity (36% versus 28%; P<0.0001), ischemic heart disease (11% versus 6%; P=0.002), and peripheral vascular disease (5% versus 2%; P<0.001). Patients with diabetes mellitus more frequently had intracranial stenosis ≥50% (P<0.001), infarcts involving the brain stem or cerebellum (P<0.001), and more extensive white matter abnormalities (P<0.001). Patients with diabetes mellitus were almost twice as likely to have a recurrent stroke (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.4–2.3), recurrent ischemic stroke (HR, 1.8; 95% CI, 1.4–2.4), disabling/fatal stroke (HR, 1.8; 95% CI, 1.2–2.9), myocardial infarction (HR, 1.7; 95% CI, 1.0–2.8), and death (HR, 2.1 95% CI, 1.6–2.8) compared with patients without diabetes mellitus. Conclusions— Patients with diabetes mellitus with lacunar stroke have a distinctive clinical profile that includes double the prevalence of systemic and intracranial atherosclerosis, preferential involvement of the posterior circulation, and a poor prognosis for recurrent stroke and death. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Lacunar Strokes in Patients With Diabetes Mellitus: Risk Factors, Infarct Location, and Prognosis

Background and Purpose Diabetes is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for diabetic patients with lacunar stroke.Background and Purpose— Diabetes mellitus is an independent risk factor for lacunar strokes. Few data are available regarding patient features, infarct location, and recurrent vascular events for patients with diabetes mellitus with lacunar stroke. Methods— We compared features at study entry and prognosis during 3.6 years of follow-up of patients with diabetes mellitus versus patients without diabetes mellitus with recent lacunar stroke participating in the Secondary Prevention of Small Subcortical Strokes (SPS3) randomized trial. Results— Among the 3020 participants, the prevalence of diabetes mellitus was 37% with a mean duration of 11 years. Diabetes mellitus was independently associated with slightly younger age (63 versus 64 years; P<0.001), Hispanic ethnicity (36% versus 28%; P<0.0001), ischemic heart disease (11% versus 6%; P=0.002), and peripheral vascular disease (5% versus 2%; P<0.001). Patients with diabetes mellitus more frequently had intracranial stenosis ≥50% (P<0.001), infarcts involving the brain stem or cerebellum (P<0.001), and more extensive white matter abnormalities (P<0.001). Patients with diabetes mellitus were almost twice as likely to have a recurrent stroke (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.4–2.3), recurrent ischemic stroke (HR, 1.8; 95% CI, 1.4–2.4), disabling/fatal stroke (HR, 1.8; 95% CI, 1.2–2.9), myocardial infarction (HR, 1.7; 95% CI, 1.0–2.8), and death (HR, 2.1 95% CI, 1.6–2.8) compared with patients without diabetes mellitus. Conclusions— Patients with diabetes mellitus with lacunar stroke have a distinctive clinical profile that includes double the prevalence of systemic and intracranial atherosclerosis, preferential involvement of the posterior circulation, and a poor prognosis for recurrent stroke and death. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.