COAGULATION & THROMBOSIS RELATED RESEARCH
1. Mitigating Stroke Risk is Necessary for Cancer Patients
BACKGROUND: Death from stroke is linked to cancer due to its pathogenesis and side effects of treatment. Despite this, guidelines regarding identifying cancer patients at the highest risk of mortality from stroke are unclear.
AIMS: To determine which cancer subtypes are associated with higher risk of death from stroke.
METHODS: The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program was used to obtain data regarding patients with cancer who died of a stroke. We calculated standardized mortality ratios (SMRs) using SEER*Stat software, version 8.4.0.1.
RESULTS: Out of 6,136,803 patients with cancer, 57,523 (0.9%) died from stroke, and this rate was higher than general population (SMR= 1.05, 95%CI [1.04-1.06]). Deaths due to stroke decreased across years, from 24,280 deaths between 2000-2004 to 4,903 deaths between 2015-2019. Of the 57,523 stroke deaths, greatest numbers were observed in cancers of the prostate (n=11,761, 20.4%), breast (n=8,946, 15.5%), colon and rectum (n=7,401, 12.8%), and lung and bronchus (n=4,376, 7.6%). Patients with colon and rectum cancers (SMR= 1.08 95%CI [1.06-1.11]), lung and bronchus cancers (SMR=1.70 95%CI [1.65-1.75]) had a greater rate of death from stroke compared to the general population.
CONCLUSIONS: The risk of death from stroke in cancer patients is significantly higher than in the general population. Patients with colorectal cancer and lung and bronchus cancer are at higher risk of death by stroke compared to the general population.
Sonbol YT, et al. Stroke as a cause of death in patients with cancer: a SEER-based study. J Stroke Cerebrovasc Dis. 2023 Aug;32(8):107154. doi: 10.1016/j.jstrokecerebrovasdis. 2023.107154. Epub 2023 May 10.
2. Secondary Analysis of the ASPREE Data Again Confirms That Daily Aspirin has No Primary Stroke Prevention Benefit in Healthy Seniors
IMPORTANCE: Low-dose aspirin has been widely used for primary and secondary prevention of stroke. The balance between potential reduction of ischemic stroke events and increased intracranial bleeding has not been established in older individuals.
OBJECTIVE: To establish the risks of ischemic stroke and intracranial bleeding among healthy older people receiving daily low-dose aspirin.
DESIGN, SETTING AND PARTICIPANTS: This secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized, double-blind, placebo-controlled trial of daily low-dose aspirin was conducted among community-dwelling people living in Australia or the US. Participants were older adults free of symptomatic cardiovascular disease. Recruitment took place between 2010 and 2014, and participants were followed up for a median (IQR) of 4.7 (3.6-5.7) years. This analysis was completed from August 2021 to March 2023.
INTERVENTIONS: Daily 100-mg enteric-coated aspirin or matching placebo.
MAIN OUTCOMES AND MEASURES: Stroke and stroke etiology were predetermined secondary outcomes and are presented with a focus on prevention of initial stroke or intracranial bleeding event. Outcomes were assessed by review of medical records.
RESULTS: Among 19 114 older adults (10 782 females [56.4%]; median [IQR] age, 74 [71.6-77.7] years), 9525 individuals received aspirin and 9589 individuals received placebo. Aspirin did not produce a statistically significant reduction in the incidence of ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.71-1.11). However, a statistically significant increase in intracranial bleeding was observed among individuals assigned to aspirin (108 individuals [1.1%]) compared with those receiving placebo (79 individuals [0.8%]; HR, 1.38; 95% CI, 1.03-1.84). This occurred by an increase in a combination of subdural, extradural, and subarachnoid bleeding with aspirin compared with placebo (59 individuals [0.6%] vs 41 individuals [0.4%]; HR, 1.45; 95% CI, 0.98-2.16). Hemorrhagic stroke was recorded in 49 individuals (0.5%) assigned to aspirin compared with 37 individuals (0.4%) in the placebo group (HR, 1.33; 95% CI, 0.87-2.04).
CONCLUSIONS AND RELEVANCE: This study found a significant increase in intracranial bleeding with daily low-dose aspirin but no significant reduction of ischemic stroke. These findings may have particular relevance to older individuals prone to developing intracranial bleeding after head trauma.
Cloud GC, et al. Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People. JAMA Netw Open. 2023 Jul; 6(7): e2325803. Published online 2023 Jul 26.
doi: 10.1001/jamanetworkopen.2023.25803
3. Secondary Analysis of the ASPREE Data Again Confirms That Daily Aspirin has No Primary Stroke Prevention Benefit in Healthy Seniors
IMPORTANCE: Low-dose aspirin has been widely used for primary and secondary prevention of stroke. The balance between potential reduction of ischemic stroke events and increased intracranial bleeding has not been established in older individuals.
OBJECTIVE: To establish the risks of ischemic stroke and intracranial bleeding among healthy older people receiving daily low-dose aspirin.
DESIGN, SETTING AND PARTICIPANTS: This secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized, double-blind, placebo-controlled trial of daily low-dose aspirin was conducted among community-dwelling people living in Australia or the US. Participants were older adults free of symptomatic cardiovascular disease. Recruitment took place between 2010 and 2014, and participants were followed up for a median (IQR) of 4.7 (3.6-5.7) years. This analysis was completed from August 2021 to March 2023.
INTERVENTIONS: Daily 100-mg enteric-coated aspirin or matching placebo.
MAIN OUTCOMES AND MEASURES: Stroke and stroke etiology were predetermined secondary outcomes and are presented with a focus on prevention of initial stroke or intracranial bleeding event. Outcomes were assessed by review of medical records.
RESULTS: Among 19 114 older adults (10 782 females [56.4%]; median [IQR] age, 74 [71.6-77.7] years), 9525 individuals received aspirin and 9589 individuals received placebo. Aspirin did not produce a statistically significant reduction in the incidence of ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.71-1.11). However, a statistically significant increase in intracranial bleeding was observed among individuals assigned to aspirin (108 individuals [1.1%]) compared with those receiving placebo (79 individuals [0.8%]; HR, 1.38; 95% CI, 1.03-1.84). This occurred by an increase in a combination of subdural, extradural, and subarachnoid bleeding with aspirin compared with placebo (59 individuals [0.6%] vs 41 individuals [0.4%]; HR, 1.45; 95% CI, 0.98-2.16). Hemorrhagic stroke was recorded in 49 individuals (0.5%) assigned to aspirin compared with 37 individuals (0.4%) in the placebo group (HR, 1.33; 95% CI, 0.87-2.04).
CONCLUSIONS AND RELEVANCE: This study found a significant increase in intracranial bleeding with daily low-dose aspirin but no significant reduction of ischemic stroke. These findings may have particular relevance to older individuals prone to developing intracranial bleeding after head trauma.
Cloud GC, et al. Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People. JAMA Netw Open. 2023 Jul; 6(7): e2325803. Published online 2023 Jul 26.
doi: 10.1001/jamanetworkopen.2023.25803
Product Q & A From Our Major Sponsor
Q: A clot, approximately four feet in length, formed in the cephalic vein of the forearm where a patient had recently received an intravenous (IV) line. They were unable to flush it without causing the patient pain, so they left it.
The patient was informed that it would take about 4 months to clear. At present, he is still in discomfort and would like to know if we are able to do anything to relieve his syptoms process. I suggested lumbrokinase and would like to have your opinion and any suggestions you may have. Thank you very much. Dr. Jean-Luc LP, ND (Phoenix, AZ)
A: If there is a clot present, then lumbrokinase asap would likely be beneficial. The dosage is 2 caps tid for 3-6 weeks (it may resolve earlier).
However, if it is not a clot, but rather a sclerotic vein due to IV solutions or repeated needle puncture, then lumbrokinase is not likely to help.
Q: I have a patient who recently was diagnosed with almost complete occlusion of the jugular vein post catheterization and was placed on rivaroxaban for 3 months. Would Boluoke® be contraindicated in this case, or will it help to break down the clots? Can clots be dislodged with the use of Boluoke®?
Dr. Jennifer S., ND (Scottsdale, AZ)
A: Rivaroxaban can prevent the occlusion from getting worse, but it leaves the clot to the body to break it down — that’s where Boluoke® can be helpful. At this point, there is not enough information about the combination use of Boluoke® with the newer anti-coagulants (like rivaroxaban) and the potential risks.
Mechanistically, there is no overlap between Boluoke® and rivaroxaban, thus the risk should be low. Clinically some doctors have used Boluoke® together with patients who were put on Xeralto® or Pradaxa®, and there have not been any issues so far. However, we usually recommend the use of Sonoclot® test as a monitoring tool to make sure that patients were not over-dosed or under-dosed on the anti-coagulants prior to introducing Boluoke®; occasionally the standard dose of rivaroxaban may be too high for some patients.
As for clot dislodging from the thrombosis site, the risk is theoretically there (with or without the use of Boluoke®); but clinical studies and experiences over the past 20 years have not shown that to be a concern with Boluoke®’s use. In addition, by up-regulating the person’s innate fibrinolytic system, any small clots (if any) that break off from the original thrombosis would be more easily and quickly resolved.