Intracerebral hemorrhage may be an independent risk factor for arterial ischemic events

1. Patients with an intracerebral hemorrhage (ICH) had an increased risk of ischemic stroke and myocardial infarction events compared to those without a previous ICH.

Evidence Rating Level: 2 (Good)

Study Rundown: Intracerebral hemorrhage (ICH) and arterial ischemic events (AIEs), such as myocardial infarction (MI) and ischemic stroke, have several risk factors in common; however, it is not clear whether ICH independently increases the risk of AIEs. This analysis of four pooled cohort studies examined whether ICH led to increased incidence of AIE. The incidence rate of an AIE was approximately three times higher in those who had a previous ICH compared to those without one. After adjusting for baseline characteristics and anticoagulant medications, there was a two-fold increase in risk for AIE in those with a previous ICH. Given the large sample size (almost 50 000 included participants) from multiple population-based cohorts and adjustment of baseline covariates, this study demonstrated that ICH may be associated with an elevated risk of ischemic strokes and myocardial infarctions. One limitation of this study, however, was that several other measures of risk for cardiovascular events (obesity, peripheral vascular disease, and diet) were not recorded and, therefore, not adjusted for in the analysis.

Click to read the study in JAMA Neurology

Click to read an accompanying editorial in JAMA Neurology

Relevant Reading: Five-year risk of major ischemic and hemorrhagic events after intracerebral hemorrhage

In-Depth [prospective cohort]: This study included 47 866 participants (mean age, 62.2 years) from 4 population-based cohort studies between 1987 and 2007 in the analysis. Participants were followed up until death or the last available follow-up during the study period; median follow-up was 12.7 years (IQR, 7.7-19.5), with the final recorded follow-up on December 31, 2018. The primary outcome was an AIE (MI and/or ischemic stroke), which occurred in 7648 participants (16%). Participants were excluded if they had a previous AIE or an AIE concurrent with the ICH event. The incidence rate of an AIE was 3.6 events per 100 person-years (95% CI, 2.7-5.0) among patients who had an ICH compared to 1.1 events per 100 person-years (95% CI, 1.1-1.2) in those without any previous ICH. ICH was associated with an increased risk of an AIE (HR, 2.3; 95% CI, 1.7-3.1) after adjustment for baseline covariates (patient characteristics, vascular comorbidities, antithrombotic medications). The secondary outcomes were MI and ischemic stroke alone. After adjusting, an ICH event was associated with increased risk of MI (HR, 1.9; 95% CI, 1.2-2.9) and ischemic stroke (HR, 3.1; 95% CI, 2.1-4.5).

Image: PD

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