Current Status of Acute Stroke Management in Korea: A Report on a Multicenter, Comprehensive Acute Stroke Registry

Kim, Beom Joon; Han, Moon Ku; Park, Tai Hwan; Park, Sang Soon; Lee, Kyung Bok; Lee, Byung Chul; Yu, Kyung Ho; Kwan, Jae; Kim, Dae Hyun; Lee, Jun; Lee, Soo Joo; Ko, Young Hwii; Park, Jong‐Moo; Kang, Kyusik; Cho, Yong Jin; Hong, Kyung Soon; Cho, Ki-Hyun; Kim, Joon Tae; Kim, Dong Eog; Lee, Jun-Young; Lee, Ji Sung; Jang, Myung Suk; Broderick, Joseph P.; Yoon, Byung Woo; Bae, Hee Joon

doi:10.1111/ijs.12199

Cited by 106 publications

(102 citation statements)

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“…Using a multicenter stroke registry database, 12 this study aimed to elucidate whether switching aspirin to other antiplatelet agents or adding other antiplatelet agents to aspirin could be more effective in preventing further vascular events than maintaining aspirin monotherapy in patients who had a new ischemic stroke while taking aspirin and whether these effects may differ by ischemic stroke subtype.…”

Section: Kim Et Al Antiplatelet Strategies In Prior Aspirin Users 129mentioning

confidence: 99%

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Different Antiplatelet Strategies in Patients With New Ischemic Stroke While Taking Aspirin

Kim

Park

Choi

et al. 2016

Stroke

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A spirin is a first line antiplatelet agent for the secondary prevention of ischemic stroke or transient ischemic attack.1 In addition, aspirin is recommended in national guidelines for primary prevention of vascular events in patients with multiple cardiovascular risk factors. 2,3With its low cost and easy accessibility, prophylacticBackground and Purpose-Selecting among different antiplatelet strategies when patients experience a new ischemic stroke while taking aspirin is a common clinical challenge, currently addressed by a paucity of data. Methods-This study is an analysis of a prospective multicenter stroke registry database from 14 hospitals in South Korea.Patients with acute noncardioembolic stroke, who were taking aspirin for prevention of ischemic events at the time of onset of stroke, were enrolled. Study subjects were divided into 3 groups according to the subsequent antiplatelet therapy strategy pursued; maintaining aspirin monotherapy (MA group), switching aspirin to nonaspirin antiplatelet agents (SA group), and adding another antiplatelet agent to aspirin (AA group). The primary study end point was the composite of stroke (ischemic and hemorrhagic), myocardial infarction, and vascular death up to 1 year after stroke onset. Results-A total of 1172 patients were analyzed for this study. Antiplatelet strategies pursued in study patients were MA group in 212 (18.1%), SA group in 246 (21.0%), and AA group in 714 (60.9%). The Cox proportional hazards regression analysis showed that, compared with the MA group, there was a reduction in the composite vascular event primary end point in the SA group (hazard ratio, 0.50; 95% confidence interval, 0.27-0.92; P=0.03) and in the AA group (hazard ratio, 0.40; 95% confidence interval, 0.24-0.66; P<0.001). Conclusions-This study showed that, compared with maintaining aspirin, switching to or adding alternative antiplatelet agents may be better in preventing subsequent vascular events in patients who experienced a new ischemic stroke while taking aspirin. Kim et al Antiplatelet Strategies in Prior Aspirin Users 129aspirin use is frequent in the middle-aged and elderly population. [4][5][6] Therefore, patients who suffer a new ischemic stroke while taking aspirin are frequently encountered in a daily practice. Antiplatelet management options in these patients are to maintain aspirin monotherapy, replace aspirin with other antiplatelet agents, such as clopidogrel, or add other antiplatelet agents to aspirin.1,7-10 However, both randomized trial and large-scale registry data to guide this decision are sparse. Accordingly, the most recent American Heart Association/American Stroke Association guideline states that there is no evidence that switching or combining antiplatelet agents reduces the risk of subsequent vascular events in patients who have had stroke while receiving aspirin (Class IIb, Level of Evidence C). 1A post hoc analysis of 838 patients, who have had a recent lacunar stroke while taking aspirin from the Secondary Prevention of Small Subcortical Strok...

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Section: Kim Et Al Antiplatelet Strategies In Prior Aspirin Users 129mentioning

confidence: 99%

“…12,13 The collaborative registry study group consisted of 14 academic and regional tertiary stroke centers. Detailed information on the CRCS-5 registry is given in the online-only Data Supplement.…”

Section: Subjectsmentioning

confidence: 99%

Different Antiplatelet Strategies in Patients With New Ischemic Stroke While Taking Aspirin

Kim

Park

Choi

et al. 2016

Stroke

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“…Using a prospective multicenter stroke registry database,13 this study aimed to investigate the effect of prestroke aspirin use on stroke severity, hemorrhagic transformation at presentation, and functional outcome at discharge according to ischemic stroke subtype.…”

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Comparative Effectiveness of Prestroke Aspirin on Stroke Severity and Outcome

Park

Kang

Cho

et al. 2016

Annals of Neurology

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ObjectiveThe effect of prestroke aspirin use on initial severity, hemorrhagic transformation, and functional outcome of ischemic stroke is uncertain.MethodsUsing a multicenter stroke registry database, patients with acute ischemic stroke of three subtypes (large artery atherosclerosis [LAA], small vessel occlusion [SVO], or cardioembolism [CE]) were identified. NIH stroke scale (NIHSS) and hemorrhagic transformation at presentation and discharge modified Rankin Scale (mRS) were compared between prestroke aspirin users and nonusers.ResultsAmong the 10,433 patients, 1,914 (18.3%) reported prestroke aspirin use. On crude analysis, initial NIHSS scores of aspirin users were higher than nonusers (mean difference: 0.35; 95% confidence interval [CI]: 0.04–0.66). However, a multivariable analysis with an application of inverse probability of treatment weighting based on a propensity score of prestroke aspirin, having an interaction effect of prestroke aspirin use and stroke subtype in the model, showed less stroke severity for aspirin users in LAA, but not in SVO and CE than for nonusers; mean difference in NIHSS scores in LAA was –0.97 (95% CI: –1.45 to –0.49). With respect to hemorrhagic transformation and mRS, no significant interaction effects were found. Prestroke aspirin use increased the risk of hemorrhagic transformation (adjusted odd ratio: 1.34; 95% CI: 1.05–1.73), but decreased the odds of the higher discharge mRS (0.86; 0.76–0.96).InterpretationPrestroke aspirin use may reduce initial stroke severity in atherothrombotic stroke and can improve functional outcome at discharge despite an increase of hemorrhagic transformation irrespective of stroke subtype. Ann Neurol 2016;79:560–568

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“…The details of the registry have been published previously. 15,16 In all participating centers, approval was obtained from the institutional review board for collection of anonymized clinical data without patient consent as the goal of the study was to monitor and improve the quality of stroke care.…”

Section: Study Design and Populationmentioning

confidence: 99%

Impact of Guidelines on Clinical Practice

Chung

Kim

Han

et al. 2016

Stroke

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Background and Purpose-Since its introduction, controversy has existed about the administration of intravenous heparin for the treatment of acute ischemic stroke. We studied trends in the intravenous heparin use during a 6-year time period and the potential influence of clinical guidelines in national language on intravenous heparin administration in Korea. Methods-On the basis of a prospective nationwide multicenter stroke registry, we collected data on patients with acute ischemic stroke who arrived within 7 days of symptom onset during the time period 2008 to 2013. We studied patient demographics, prestroke medical history, stroke characteristics, and stroke treatment. Data from a total of 23 425 patients from 12 university hospitals or regional stroke centers were analyzed. Results-The administration of intravenous heparin steadily decreased throughout the study period: 9.7% in 2008, 10.9% in 2009, 9.4% in 2010, 6.0% in 2011, 4.7% in 2012, and 4.3% in 2013 (P for trend <0.001). The reduced intravenous heparin use was associated with moderate stroke severity, atrial fibrillation, and stroke of cardioembolic, other-, and undetermined etiology. In a multivariable logistic model, increase of 1 calendar year (odds ratio, 0.89; 95% confidence interval, 0.84-0.95; P<0.001) and release of clinical practice guidelines in Korean (odd ratio, 0.74; 95% confidence interval, 0.59-0.91; P<0.01) were independent factors associated with reduction in the frequency of intravenous heparin use. Conclusions-Use of intravenous heparin for acute ischemic stroke treatment has decreased in Korea, and this change may be attributable to the spread and successful implementation of regional clinical practice guidelines. (Stroke.

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Current Status of Acute Stroke Management in Korea: A Report on a Multicenter, Comprehensive Acute Stroke Registry

Cited by 106 publications

References 4 publications

Different Antiplatelet Strategies in Patients With New Ischemic Stroke While Taking Aspirin

Different Antiplatelet Strategies in Patients With New Ischemic Stroke While Taking Aspirin

Comparative Effectiveness of Prestroke Aspirin on Stroke Severity and Outcome

Impact of Guidelines on Clinical Practice

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