Secondary Prevention of MACEs Necessary Following Lobar ICH

Individuals who have had a spontaneous lobar intracerebral hemorrhage (ICH) vs a nonlobar ICH had higher rates of major adverse cardiovascular events (MACEs) following their stroke, highlighting the importance of secondary prevention strategies among this patient population.

The study findings published in JAMA Network Open also demonstrate that the higher MACE rate is primarily due to a higher rate of recurrent ICH, the study authors noted. They wanted to know if ICH location was associated with subsequent MACE risk.

“The location of an ICH can reflect its underlying pathophysiology, with a nonlobar location associated with hypertensive arteriolosclerosis compared with cerebral amyloid angiopathy, which almost exclusively involves lobar locations,” the study authors wrote. “The main objective of the current study was to examine the risk of MACEs by hematoma location from an unselected, large cohort of patients with spontaneous ICH.”

Included in this analysis were patients from the region of Southern Denmark who had a first ICH between January 1, 2009, and November 30, 2018. There were 1034 patients in the lobar ICH cohort (52.1% women; mean [SD] age, 75.2 [10.7] years) and 1255 in the nonlobar cohort (45.8% women; mean age, 73.5 [11.4] years).

Overall, more patients who had a lobar ICH survived beyond 30 days: 73.6% vs 64.3%.

At baseline, according to weighted data, the most common comorbidities among the patients who had lobar or nonlobar ICH, respectively, were hypertension (71.1%% and 70.9%), chronic obstructive pulmonary disease (28.6% each), and atrial fibrillation (21.8% and 21.5%). Antihypertensives were the most common medication class in each group, at 47.0% among those who had lobar ICH and 46.9% among those with nonlobar ICH, followed by platelet antiaggregants in 33.1% each, statins in 29.6% each, and anticoagulants in 18.6% of the lobar group and 18.4% of the nonlobar cohort.

The MACE incident rate per 100 person-years was higher in the lobar cohort (total follow-up, 2048 person-years; mean [SD] follow-up, 2.1 [2.5] years) than the nonlobar cohort (total follow-up, 2780 person-years, mean [SD] follow-up, 2.4 [2.7] years):

• Lobar cohort: 10.84 (95% CI, 9.51-12.37)
• Nonlobar cohort: 7.91 (95% CI, 6.93-9.03)

This difference represents a 26% greater risk of a MACE following a lobar ICH (HR, 1.26; 95% CI, 1.10-1.44) compared with a nonlobar ICH.

There were 115 patients who had a recurrent ICH, and the rate of this was more than twice as high in the lobar vs the nonlobar cohort: 3.74 (95% CI, 3.01-4.66) vs 1.24 (95% CI, 0.89-1.73) per 100 person-years. Further, the type of recurrent ICH typically mirrored the initial ICH. Among the 80 patients with an index lobar ICH, 70 had a recurrent lobar ICH, and among the 35 patients with an index nonlobar ICH, 27 had a recurrent nonlobar ICH.

Incident rates for ischemic stroke (IS) and myocardial infarction (MI) were similar between the groups:

• IS: 1.45 (95% CI, 1.02-2.06) and 1.77 (1.34-2.34) per 100 person-years in the lobar and nonlobar cohorts
• MI: 0.42 (95% CI, 0.22-0.81) and 0.64 (95% CI, 0.40-1.01), respectively

In contrast, patients with atrial fibrillation vs those who did not have atrial fibrillation had higher overall risks of MACEs, IS, and MI, and among patients who had comorbid diabetes at the time of their initial ICH, there were fewer instances of IS during follow-up compared with patients who did not have diabetes.

Lastly, patients who had an index lobar ICH but no occlusive vascular disease had a 120% greater risk of a recurrent ICH (adjusted HR [aHR], 2.20; 95% CI, 1.61-3.01), and this risk jumped to 515% greater when occlusive vascular disease was present (aHR, 6.15; 95% CI, 2.98-12.67).

“Together, these findings may have potential clinical implications because they identify a group of vulnerable patients who might benefit from more targeted prevention efforts,” the study authors concluded. “In this cohort study, lobar ICH was associated with a higher risk of MACEs than nonlobar ICH, and this higher risk was largely attributable to higher rates of recurrent ICH.”

Still, they recommend further study, particularly on the importance of secondary ICH prevention strategies in patients with lobar ICH.

Reference

Boe NJ, Hald SM, Jensen MM, et al. Major cardiovascular events after spontaneous intracerebral hemorrhage by hematoma location. JAMA Netw Open. Published online April 5, 2023. doi:10.1001/jamanetworkopen.2023.5882