Intracerebral hemorrhage (ICH) is associated with an increased risk for ischemic stroke and myocardial infarction and may be a "novel risk marker for arterial ischemic events," researchers report. ICH and arterial ischemic disease share risk factors, but the association between the two conditions remains unclear, Dr. Santosh Murthy with Weill Cornell Medicine in New York City and colleagues note in JAMA Neurology. To investigate, they pooled participant-level data from more than 47,000 individuals (58% women; mean age, 62 years) who were enrolled in four population-based observational cohort studies in the United States between 1987 and 2007. Overall, they found that ICH was associated with an approximately two-fold increased risk of arterial ischemic events (hazard ratio, 2.3; 95% confidence interval, 1.7 to 3.1). "The degree of increased risk was found across subgroups and persisted after adjustment for basic demographic characteristics and traditional vascular risk factors," the researchers say. "Our findings indicate that patients with ICH are not only at risk for recurrent bleeding but also are at a higher risk of arterial ischemic events than the general population. Our study highlights the need for randomized clinical trials to assess the net clinical benefit of antithrombotic therapy and statin medications in this high-risk population," Dr. Murthy and colleagues conclude. In a linked editorial, Dr. Graeme Hankey of The University of Western Australia, in Perth, congratulates the research team for their "timely analysis." "The validity of the findings of an increased risk of ischemic stroke and myocardial infarction after ICH are supported by the sound methods of the studies, robust analyses, and results that are consistent with other studies and biologically plausible," Dr. Hankey notes. "The importance of the findings is that they ignite and inform efforts to improve risk stratification and secondary prevention of ischemic as well as hemorrhagic events after ICH. The analysis by Murthy et al did not include location of the index ICH or cause of the subsequent acute ischemic strokes, but other studies have reported that deep ICH is associated with future ischemic strokes, particularly lacunar ischemic strokes, and lobar ICH is associated with recurrent, particularly lobar, hemorrhagic strokes," Dr. Hankey points out. He says prevention efforts that target risk factors for ischemic events and hemorrhagic events after ICH and that prioritize common underlying mechanisms, such as lifestyle factors and hypertension, are "likely to have the greatest impact on improving the health and survival of ICH survivors." "Other potential strategies that may reduce ischemic events after ICH without increasing the risk of hemorrhage and may be worthy of further investigation include anti-inflammatory therapies (eg, low-dose colchicine), phosphodiesterase-3 inhibitors (eg, cilostazol), nitric oxide-donating organic nitrates (eg, isosorbide mononitrate), glucagon-like peptide-1 receptor agonists, antisense oligonucleotide therapies targeting lipoprotein(a) synthesis, and anticoagulants targeting factor XIa (eg, oral factor XIa inhibitors)," Dr. Hankey concludes. The study had no commercial funding. Source
