ABSTRACT
We report a case of ischaemic stroke in a 34-year-old male recreational bodybuilder following a 3-month period of anabolic androgenic steroid (AAS) use and 1-month period of 'post-cycle therapy' (tamoxifen and clomiphene citrate), the latter treatments aimed at restoring normal endogenous testosterone production after initial AAS use. We hypothesise a transient drug-related prothrombotic state with paradoxical embolisation via an atrial septal defect which was later found on bubble echocardiogram. We highlight a rare but important cause of stroke in younger patients which is relevant given the increasing use of AAS misuse among casual fitness enthusiasts. We explore the various possible mechanisms by which AAS use can increase ischaemic stroke risk in such patients.
Subject(s)
Brain Ischemia/chemically induced , Brain Ischemia/diagnostic imaging , Doping in Sports , Exercise/physiology , Ischemic Stroke/chemically induced , Ischemic Stroke/diagnostic imaging , Testosterone Congeners/adverse effects , Administration, Intravenous , Adult , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Anticholesteremic Agents/therapeutic use , Aspirin/therapeutic use , Atorvastatin/therapeutic use , Brain Ischemia/drug therapy , Clomiphene/administration & dosage , Clomiphene/adverse effects , Echocardiography , Estrogen Antagonists/administration & dosage , Estrogen Antagonists/adverse effects , Heart Septal Defects, Atrial/surgery , Humans , Ischemic Stroke/drug therapy , Male , Tamoxifen/administration & dosage , Tamoxifen/adverse effectsABSTRACT
OBJECTIVE: Compared to medical therapy alone, percutaneous closure of patent foramen ovale (PFO) further reduces risk of recurrent ischemic strokes in carefully selected young to middle-aged patients with a recent cryptogenic ischemic stroke. The objective of this study was to evaluate the cost-effectiveness of this therapy in the context of the United Kingdom (UK) healthcare system. METHODS: A Markov cohort model consisting of four health states (Stable after index stroke, Post-Minor Recurrent Stroke, Post-Moderate Recurrent Stroke, and Death) was developed to simulate the economic outcomes of device-based PFO closure compared to medical therapy. Recurrent stroke event rates were extracted from a randomized clinical trial (RESPECT) with a median of 5.9-year follow-up. Health utilities and costs were obtained from published sources. One-way and probabilistic sensitivity analyses (PSA) were performed to assess robustness. The model was discounted at 3.5% and reported in 2016 Pounds Sterling. RESULTS: Compared with medical therapy alone and using a willingness-to-pay (WTP) threshold of £20,000, PFO closure reached cost-effectiveness at 4.2 years. Cost-effectiveness ratios (ICERs) at 4, 10, and 20 years were £20,951, £6,887, and £2,158, respectively. PFO closure was cost-effective for 89% of PSA iterations at year 10. Sensitivity analyses showed that the model was robust. CONCLUSIONS: Considering the UK healthcare system perspective, percutaneous PFO closure in cryptogenic ischemic stroke patients is a cost-effective stroke prevention strategy compared to medical therapy alone. Its cost-effectiveness was driven by substantial reduction in recurrent strokes and patients' improved health-related quality-of-life.
