VPLIV DEMENCE NA PREVENTIVO IN ZDRAVLJENJE BOLNIKOV Z ISHEMIČNO MOŽGANSKO KAPJO

Šubic, Ana (author), Gregorič Kramberger, Milica (mentor), Winbald, Bengt (comentor)

Uvod: Bolniki z demenco imajo višjo prevalenco levkoaraioze in možganskih mikrokrvavitev, ki so lahko povezane z višjim tveganjem za hemoragične zaplete ob antikoagulantnem zdravljenju (AKZ) in trombolitičnem zdravljenju ishemične možganske kapi (IMK). Cilji: Preučiti, ali so bolniki z demenco, ki so zboleli z ishemično možgansko kapjo obravnavani drugače kot bolniki brez demence. Preučiti tveganje in učinkovitost AKZ z varfarinom za zdravljenje atrijske fibrilacije (AF) pri bolnikih z demenco. Preučiti značilnosti bolnikov z demenco, ki so umrli zaradi možganske kapi in jih primerjati z bolniki z drugimi vzroki smrti. Metode: V prvem delu je bil opravljen pregled literature o obravnavi bolnikov z demenco pri akutni IMK z uporabo podatkovne baze PubMed. V drugem in tretjem delu je bila izvedena longitudinalna kohortna študija, ki temelji na podatkih o bolnikih iz švedskega nacionalnega registra za demence (SveDem). V drugem delu smo primerjali osnovne značilnosti bolnikov z AKZ, z antiagregacijsko terapijo in tistimi brez antitrombotične terapije. Coxov regresijski model je bil uporabljen za oceno ogroženosti za IMK, znotrajmožgansko krvavitev (ZMK), krvavitev in smrt. V tretjem delu smo analizirali značilnosti bolnikov z demenco, ki so umrli zaradi IMK. Rezultati: V pregledani literaturi so bili bolniki z demenco ob akutni IMK manj pogosto zdravljeni z IV tPA, redkeje so prejeli sekundarno preventivo IMK, različne diagnostične preiskave, invazivne posege in bili redkeje sprejeti na enoto za možgansko kap kot bolniki brez demence. AKZ z varfarinom za zdravljenje AF pri bolnikih z demenco je bilo povezano z manjšim tveganjem za IMK in z manjšo umrljivostjo v primerjavi z bolniki brez terapije. Zdravljenje z varfarinom je bilo povezano z manjšim povečanjem tveganja za krvavitev v primerjavi z antiagregacijsko terapijo, vendar brez povečanega tveganja za ZMK. Bolniki, ki so umrli zaradi IMK in bolniki, ki so umrli zaradi drugih vzrokov, se med seboj niso razlikovali glede prejemanja nevropsihiatričnih zdravil. Več kot polovica bolnikov, pri katerih je bila IMK kot vzrok smrti, zabeležena na mrliškem listu, ni bila predhodno vpisanih v register za možganske kapi. Zaključki: Bolniki z demenco so ob akutni IMK redkeje deležni kompleksnih diagnostičnih preiskav in zdravljenja kot bolniki brez demence. Rezultati te raziskave podpirajo uporabo varfarina pri izbranih bolnikih z demenco. Nizek odstotek bolnikov z demenco, zdravljenih z varfarinom, kaže na možnost za izboljšave pri preventivi IMK. Zdravljenje z nevropsihiatričnimi zdravili ni bilo povezano z večjo umrljivostjo.

• Language: Slovenian
• Keywords: demenca, ishemična možganska kap, znotrajmožganska krvavitev, atrijska fibrilacija, antikoagulantno zdravljenje, smrt zaradi možganske kapi
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2019
• PID: 20.500.12556/RUL-111363
• COBISS.SI-ID: 302130688
• Publication date in RUL: 29.09.2019

Secondary language

• Language: English
• Title: IMPACT OF DEMENTIA ON PREVENTION AND TREATMENT OF PATIENTS WITH ISCHEMIC STROKE

Abstract

Background: Patients with dementia have a higher prevalence of leukoaraiosis and cerebral microbleeds, which may be associated with a higher risk for hemorrhagic complications with oral anticoagulant therapy (OAC) prescribed for atrial fibrillation (AF) and thrombolytic treatment of ischemic stroke (IS). Objective: We aimed to (1) summarize current knowledge about the management of IS in patients with preexisting dementia; (2) assess the risks and benefits of warfarin, antiplatelets, and no treatment in patients with dementia and AF; (3) analyse the characteristics of dementia patients that died from IS and compare them to those who died from other causes. Methods: In the first study, we reviewed literature on the management of IS. The second and third studies were observational longitudinal analyses of patients registered in the Swedish Dementia Registry. Information on treatment, comorbidities, death was obtained from Swedish nationwide health registers. In the second study, Cox proportional hazards models were used to calculate the risk for IS, intracranial hemorrhage (ICH), any-cause hemorrhage, and death. In the third study, characteristics of patients with dementia dying from IS were assessed. Results: In the reviewed literature, patients with dementia were less likely to receive intravenous thrombolysis (IV tPA), secondary stroke prevention, different diagnostic procedures, invasive interventions or be admitted on stroke units compared to patients without dementia. OAC with warfarin was associated with lower risk of IS and mortality in patients with dementia. There were no differences in ICH between the treatment with warfarin, antiplatelets or no treatment, with a higher risk for any-cause hemorrhage with warfarin compared to antiplatelets. There were no differences in the use of neuropsychiatric medications between the patients who died from IS and those dying from other causes. More than half of the patients that died from IS as shown in their death certificate had not been registered in the Swedish Stroke Register (Riksstroke) in the year before death. Conclusions: Patients with dementia are less likely to receive complex management of IS compared to patients without dementia. This study supports the use of warfarin in appropriate cases in patients with dementia. The low percentage of patients on warfarin treatment indicates that further gains in stroke prevention are possible. Concomitant treatment with neuropsychiatric medications for patients with dementia did not influence mortality.

• Keywords: dementia, ischaemic stroke, intracranial hemorrhage, atrial fibrillation, anticoagulant therapy, death from stroke