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The very interesting and provocative paper by Kwok et al1 raises some important questions that have significant implications in terms of the clinical management of patients with haemorrhagic strokes. The Kwok study examined more than 3300 patients in the UK who were hospitalised with either an ischaemic stroke or a haemorrhagic stroke (intracerebral haemorrhage (ICH) only; patients with a subarachnoid haemorrhage were excluded). Almost half of the patients (47%) were taking either an antiplatelet agent or an anticoagulant.
A key finding of this study was that for patients with an ischaemic stroke, the use of either antiplatelet agents or anticoagulants did not impact mortality subsequent to the stroke, looking at intervals ranging from 7 days to 365 days post-ischaemic stroke. The results for patients admitted with a haemorrhagic stroke were quite different, with higher mortality rates for patients taking an antiplatelet agent or anticoagulant among this group. A closer examination of the results shows that much of the difference in outcomes was driven by the higher mortality associated with prior anticoagulant use, with ORs of 2.0 to 2.8 for most models related to anticoagulant use, compared to ORs of 1.5 to 1.8 for antiplatelet use.
Another curious finding is that most of the excess mortality occurred in a bi-modal pattern, with higher morality being seen early (0–30 days) and late (90–365 days) post-stroke. In a related manner, and a significant limitation of this study, is that the actual cause of death was not recorded, due largely to the administrative …
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