Incidence and determinants of cerebrovascular events in outpatients with stable coronary artery disease

Introduction There are limited data on cerebrovascular events in patients with stable coronary artery disease. To study the risk of cerebrovascular event, the relative proportion of ischaemic stroke and intracranial haemorrhage, and their prognostic factors in stable coronary artery disease are investigated. Patients and methods The CORONOR registry prospectively recruited, between February 2010 and April 2011, 4184 unselected stable coronary artery disease outpatients. All events occurring during a five-year follow-up were adjudicated. Results Ninety-six patients had an ischaemic stroke and 34 had an intracranial haemorrhage, reaching a cumulative incidence after five years of 3.2 (2.7-3.8)%. During the same period, 677 deaths and 170 myocardial infarctions (ST-elevation MI, n=55; non-ST-elevation MI, n=115) occurred. In elderly individuals, the number of cerebrovascular events was higher than that of myocardial infarctions and largely exceeded that of ST-elevation myocardial infarctions. Predictors of ischaemic stroke were: previous history of stroke (subhazard ratio (SHR)=3.16(1.95-5.14)), absence of statin therapy at inclusion (SHR=2.45(1.47-4.10), increasing age (SHR=1.45(1.16-1.82) per 10-year increase) and diabetes mellitus (SHR=1.65(1.10-2.49)). Predictors of intracranial haemorrhage were: combination of vitamin K antagonists with an antiplatelet agent at inclusion (SHR=5.41(2.49-11.75), single antiplatelet therapy as reference), and increasing age (SHR=1.47(1.12-1.93) per 10-year increase). Discussion In stable coronary artery disease patients, the brain deserves attention. In patients at high risk of ischaemic stroke, secondary prevention could be intensified. Our results raise awareness of the hazard of the association of antiplatelet drugs with oral anticoagulants in stable coronary artery disease patients. Conclusion While improving the prevention of future vaso-occlusive events should be our ultimate goal in coronary artery disease patients, the net clinical benefit of our treatments should carefully be studied.