Titrated initiation of acetylsalicylic acid-dipyridamole therapy reduces adverse effects and improves tolerance in patients with stroke.

BACKGROUND: Standard aspirin (acetylsalicylic acid [ASA])-dipyridamole therapy twice daily is associated with high rates of discontinuation in large part because of headache and gastrointestinal side effects. Attempts to address dipyridamole-induced headache through reduced dose initiation have produced variable results. Moreover, it has been suggested that migraineurs are more likely to have a dipyridamole-induced headache. OBJECTIVE: We sought to evaluate whether titrated initiation of ASA-dipyridamole in patients with stroke/transient ischemic attack (TIA) improves tolerance and to assess the appearance of headache in those with pre-existing history of headaches. METHODS: ASA-dipyridamole (25/200 mg) once daily together with ASA (81 mg) daily was started in 130 patients given the diagnosis of stroke/TIA with instructions to increase ASA-dipyridamole to twice daily after 7 days and discontinue ASA (81 mg). Patients received a telephone call on days 7 and 14 to assess for adverse events, discontinuation, and recurrent stroke/TIA. RESULTS: Two patients were lost to follow-up. After 2 weeks, 113 patients were using the medication without any major complications. Fifteen patients were off therapy; 10 (8%) patients stopped because of headache and/or gastrointestinal symptoms, whereas 4 patients were switched to other antiplatelet agents by their primary care physician as a matter of choice rather than ASA-dipyridamole side effects. One patient had recurrent stroke because of intracranial dissection and was switched to anticoagulation. Only 4 of 27 (14%) patients with a history of headache discontinued therapy. CONCLUSIONS: Titrated initiation of ASA-dipyridamole (25/200 mg) appears to have low discontinuation rate and approximately 90% tolerance after 2 weeks. History of migraine or tension headaches was not directly associated with discontinuation because of headaches.

Serial electrocardiographic assessments significantly improve detection of atrial fibrillation 2.6-fold in patients with acute stroke.

BACKGROUND AND PURPOSE: Previous studies have reported a low, approximately 1% to 3%, rate of detection of occult atrial fibrillation (AF) with Holter monitor in patients with acute stroke. Furthermore, at least one study has reported that Holter monitoring could not always corroborate initial electrocardiographic (ECG) detection of AF suggesting underestimation of AF by Holter. We compare the detection of new-onset AF by serial ECG assessments and Holter after acute ischemic stroke. METHODS: One hundred forty-four patients with ischemic stroke admitted to a stroke unit were studied. The number of ECGs conducted within the first 3 days up to the detection of AF as well as the time interval for Holter "hookup" and subsequent reporting of AF was documented. RESULTS: ECGs were performed in 143 patients with a baseline of 10 (7%) patients having a history of AF. Serial ECGs detected 15 new AF cases in <2 days of admission, thereby increasing the total number of known AF cases to 25 (17.5%), a 2.6-fold increased realization of AF (P=0.011). Holter was also completed in 12 of 15 new cases of AF but surprisingly identified AF in only 50% (6 of 12). Holter monitoring was performed in 126 cases and in this subgroup, there was no statistically significant difference in the rate of AF detection with ECG or Holter. CONCLUSIONS: Serial ECG assessments within the first 72 hours of an acute stroke significantly improve detection of AF. The discordance regarding the corroboration of AF by Holter in ECG-positive patients with AF supports previous observations and suggests a high incidence of paroxysmal AF as a cause of ischemic stroke.

Usefulness of cardiovascular investigations in stroke management: clinical relevance and economic implications.

BACKGROUND AND PURPOSE: There are no prospective randomized studies assessing the clinical relevance of routine cardiovascular investigations in stroke patients. The objective of this study was to evaluate the utilization, relevance, and economics of cardiovascular investigations in an ambulatory stroke clinic. METHODS: The outcome of cardiovascular investigations in 200 patients with stroke/transient ischemic attack diagnosed in a stroke prevention clinic was assessed. Transthoracic echocardiography (TTE) was assessed for detection of thrombus or mass, poor left ventricle function, and other structural abnormalities. ECG and Holter monitor were felt to be relevant if they showed atrial fibrillation/flutter. Investigations were deemed to be clinically pertinent if they brought about a shift treatment paradigm. RESULTS: TTE and Holter were performed in >70% of cases and accounted for approximately 94% of total cardiovascular cost. Relevant TTE findings were identified in 6 (4%) patients, which did not alter antithrombotic therapy. Only 2 new cases of atrial fibrillation were identified by both ECG and Holter. CONCLUSIONS: TTE and Holter appear to be costly low-yield procedures in this clinical setting. Prospective analyses may help to provide cost effective criteria for selection of appropriate cardiovascular studies in stroke management.