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Integrated care pathways for acute stroke by flu11339

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									                                                                                                       Letters to the Editor

Integrated care pathways for acute stroke                          colleagues [3] demonstrated an increased risk of bleeding
                                                                   for every 10 year increase in age of 46 to 57%.
SIR—I read with interest the article ‘Integrated care path-             In 1998 Beyth and colleagues developed an Outpatient
ways for acute stroke’ [1]. We use a care pathway in our           Bleeding Risk Index (OBRI) on a large cohort of patients
Acute Stroke Assessment Area. Our audit showed the same            and subsequently evaluated it on a separate cohort [4]. The
benefits. We also found that it improved the interdiscipli-        OBRI evaluates age, history of stroke, diabetes, MI, GI
nary working and a source to identify the lack of resource.        bleeding, severe anaemia and significant renal impairment.
The difficulty is the time, supervision and training needed to     Patients can then be divided into low risk, intermediate risk
keep the process efficient.                                        and high risk. In the evaluated cohort the risk of bleeding in
                                                                   12 months was 3, 12 and 48% for these three groups.
                                  KRISHNAMURTHY GANESHRAM               Kuijer et al. [5] undertook a similar exercise. The varia-
                                 Countess of Chester Hospital,     bles which they found to be predictive of bleeding were age
                                       Chester CH2 1UL, UK         over 65, sex, with women more likely to bleed, and the pres-
                Email: Krishnamurthy.Ganeshram@coch.nhs.uk         ence of malignancy. In the validation group there was 4%
                                                                   bleeding in the low risk group, 8% in the intermediate risk
1. Kwan J, Hand P, Dennis M, Sandercock P. Effects of intro-       group and 17% in the high risk group.
   ducing an integrated care pathway an acute stroke unit. Age
                                                                        Both Kuijer and Beyth have developed a system that
   Ageing 2004; 33: 362–7.
                                                                   seems to predict patients most likely to bleed. What is fur-




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                                                                   ther needed is a refinement of this system, particularly for
                                       doi:10.1093/ageing/afh225   the elderly, which looks at the many social and cognitive fac-
                                                                   tors which Dr Morgan described in her review. Furthermore,
                                                                   the elderly do not escape the influence of genetics. Patients
More questions than answers for stroke                             with variant alleles for CYP2C9 in the cytochrome system can
prevention in the elderly with AF                                  present with unanticipated over-anticoagulation [6].
                                                                        Dr Morgan asks the question whether doctors are
SIR—Dr Morgan demonstrates well in her article ‘Between            under-treating AF in the elderly. There is already pub-
the devil and the deep blue sea’ [1] that there is a clear asso-   lished evidence that this is so. In a community-based
ciation between atrial fibrillation (AF) and stroke and that       study in the north-east of England a prevalence of AF in
the prevalence of AF increases with age. She reviews the           the elderly of 4.7% was demonstrated. Using criteria from
randomised trials and meta-analysis which have demon-              recent AF studies the authors estimated that anywhere
strated the efficacy of thromboprophylactic therapy and the        from one-third to two-thirds of these AF patients would
superiority of coumarin-derived anticoagulants such as war-        have benefited from anticoagulation, depending upon the
farin compared with aspirin. However, her review also              criteria used to measure risk, yet only a quarter of patients
raises all the problems which carers of the elderly have in        were receiving oral anticoagulants [7]. A survey conducted
interpreting this information. Many of the studies excluded        in Australia demonstrated that while general practitioners
the very old.                                                      were better than cardiologists at identifying the risk of
     One study, SPAF II, did have a cohort of 385 patients         stroke in AF patients, they were less likely to recommend
over the age of 75, but unfortunately the warfarin control         anticoagulation and were likely to overestimate the risk of
was based on the prothrombin time rather than the INR              bleeding [8].
although the results were translated into INR. The pro-                 A word of caution should be sounded however. A recent
thrombin time takes no account of the characteristics of the       report of statistical modelling, incorporating data from USA
thromboplastin used to measure the prothrombin time.               life tables up to age 100, demonstrated that the benefits of anti-
Two patients in two different hospitals can have the same          coagulation of ‘the oldest old’ were extremely small or non-
prothrombin time but be anticoagulated to quite different          existent [9]. Even for individuals in their model with additional
degrees. This study also used relatively high intensity antico-    risk factors for stroke as well as AF, anticoagulation appeared
agulation. In this cohort, warfarin showed no overall benefit      to be of little benefit for those over 80 years of age. This work
because of the incidence of intracranial haemorrhage [2].          needs to be confirmed in living patients but it serves to high-
     Dr Morgan’s review raises the argument that the inci-         light the dilemma for clinicians treating the elderly.
dence of stroke in different studies is variable. Also the              Dr Morgan has asked important questions concerning
importance of increasing age differs in different studies. To      anticoagulation of elderly AF patients. There needs to be a
the factors of AF and age have to be added other clinical          better method of predicting risk from anticoagulants in the
variables such as hypertension, previous stroke, diabetes          elderly which includes risk factors such as recurrent falls or
and poor left ventricular function when evaluating the risk        episodes of confusion particularly pertinent to the elderly.
of stroke. Dr Morgan points out that many other social and         There is also a need for more randomised clinical studies
cognitive risk factors could be added to these known clinical      which include the most difficult population: the over 75
factors which are particularly important in the elderly.           years age group. Finally, there needs to be improved and
     Three published studies have attempted to derive a pro-       continuing education of doctors so that those patients who
file of patients who are at higher than average risk of bleed-     would benefit from anticoagulation are offered safe, well-
ing while taking oral anticoagulants. Van der Meer and             monitored therapy.

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Letters to the Editor

                                                  CAROLINE SHIACH      4. Beyth RJ, Quinn LM, Landefeld S. Prospective evaluation of
                                     Department of Haematology,           an index for predicting the risk of major bleeding in outpa-
                                      Manchester Royal Infirmary,         tients treated with warfarin. Am J Med 1998; 105: 91–9.
                                                     Oxford Road,      5. Kuijer PMM, Hutten BA, Prins MH, Bûller HR. Prediction of
                                      Manchester M13 9WL, UK              risk of bleeding during anticoagulant treatment for venous
                                                                          thromboembolism. Arch Intern Med 1999; 159: 457–60.
                                       Fax: (+44) 161 276 4814
                                                                       6. Khan T, Kamali F, Daly A, King B, Wynne HA. Warfarin sensi-
                             Email: caroline.shiach@cmmc.nhs.uk           tivity: be aware of genetic influence. Age Ageing 2003; 32: 226–7.
                                                                       7. Sudlow M, Thomson R, Thwaites B, Rodgers H, Kenny RA.
1. Morgan SV. Between the Devil and the Deep Blue Sea –                   Prevalence of atrial fibrillation and eligibility for anticoagulants
   balancing the risks and potential benefits of warfarin for             in the community. Lancet 1998; 352: 1167–71.
   older people with atrial fibrillation. Age Ageing 2004; 33:         8. Petersen GM, Boom K, Jackson SL, Vial JH. Doctors beliefs on
   544–7.                                                                 the use of antithrombotic therapy in atrial fibrillation: identifying
2. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic             barriers to stroke prevention. Intern Med J 2002; 32: 15–23.
   therapy to prevent stroke in patients with atrial fibrillation: a   9. Desbiens NA. Deciding on anticoagulating the oldest old with
   meta-analysis. Ann Intern Med 1999; 131: 492–501.                      atrial fibrillation: insights from cost-effectiveness analysis. J
3. van der Meer FJM, Rosendaal FR, Vandenbroucke JP, Briët E.             Am Geriatr Soc 2002; 50: 863–9.
   Assessment of a bleeding risk in two cohorts of patients
   treated with oral anticoagulants. Thromb Haemostasis 1996;
   76: 12–16.                                                                                                       doi:10.1093/ageing/afi006




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