Stroke following percutaneous coronary intervention: type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007–12
EUROPEAN HEART JOURNAL- APRIL 2015

Aims
This study aims to evaluate temporal changes in stroke complications and their association with mortality and MACE outcomes in a national cohort of patients undergoing percutaneous coronary interventions (PCIs) in England and Wales.

Methods and results

A total of 426 046 patients who underwent PCI in England and Wales between 2007 and 2012 in the British Cardiovascular Intervention Society (BCIS) database were analysed.

Statistical analyses were performed evaluating the rates of stroke complications according to the year of PCI and multiple logistic regressions were
used to evaluate the odds of 30-day mortality and in-hospital major adverse cardiovascular events (MACE; a composite of in-hospital mortality, myocardial infarction or re-infarction, and revascularization) with stroke complications.

Four hundred and thirty-six patients (0.1%) sustained an ischaemic stroke/TIA complication and 107 patients (0.03%) sustained a haemorrhagic stroke complication. Ischaemic stroke/TIA complications increased non-linearly from 0.67 (95% CI 0.47–0.87) to 1.14 (0.94–1.34) per 1000 patients between 2007 and 2012 (P = 0.006),

whilst haemorrhagic stroke rates decreased non-linearly from 0.29 (0.19–0.39) to 0.15 (0.05–0.25) per 1000 patients in 2012 (P = 0.009).

Following adjustment for baseline clinical and procedural demographics, ischaemic stroke was independently associated with both 30-day mortality (OR 4.92, 3.06–7.92) and in-hospital MACE (OR 3.11, 1.83–5.27). An even greater impact on prognosis was observed with haemorrhagic complications (30-day mortality: OR 13.87, 6.37–30.21), in-hospital MACE (OR 13.50, 6.30–28.92).

Conclusions

Incident ischaemic stroke complications have increased over time, whilst haemorrhagic stroke complications have decreased, driven through changes in clinical, procedural, drug-treatment, and demographic factors.
Both ischaemic and haemorrhagic strokes are rare but devastating complications with high 30-day mortality and in-hospital MACE rates.

Introduction
Both major adverse cardiovascular events (MACE) and mortality following percutaneous coronary intervention (PCI) have declined over the past 25 years despite rising patient age, increases in co-morbidity, and a shift in indication from mostly elective to more emergent, higher risk interventions.
Although MACE have declined over time, the changes in patterns of stroke following PCI have not been fully described, particularly from a national perspective. Incident stroke rates have been reported between 0.1 and 0.6% in single-centre and other national registry data.

Stroke as a complication of PCI is associated with high in-hospital mortality rates and potentially causes significant and devastating life-changing disabilities in surviving patients.
The stroke complications of PCI can be ischaemic or haemorrhagic.
Guide catheter manipulation within the aortic arch or use of circulatory support devices during PCI can cause embolization of atherosclerotic material from the aorta leading to ischaemic stroke complications, and an ageing population undergoing PCI with high prevalence of co-morbid conditions further increases the risk of stroke complications during PCI.
In addition, the use of potent antiplatelet and anticoagulant therapies during PCI increases the risk of haemorrhagic stroke in such patients.

G Mohan.