Antiplatelet therapy and incident cognitive impairment or dementia-a systematic review and meta-analysis of randomised clinical trials

OBJECTIVE

The benefit of antiplatelet therapy in preventing cognitive impairment or dementia is uncertain. We investigated the association between antiplatelet therapy and incident cognitive impairment or dementia in randomised clinical trials.

METHODS

We searched PubMed, EMBASE and CENTRAL for randomised clinical trials published from database inception through 1 February 2023. Trials that evaluated the association of antiplatelet therapy with incident cognitive impairment or dementia were included. For single-agent antiplatelet, the control group was placebo. For dual agent antiplatelet therapy, the control group was single-agent monotherapy. A random-effects meta-analysis model was used to report pooled treatment effects and 95% confidence intervals (CIs). The primary outcome was incident cognitive impairment or dementia. Secondary outcomes included change in cognitive test scores.

RESULTS

A total of 11 randomised clinical trials were included (109,860 participants). All reported the incidence of cognitive impairment or dementia on follow-up. The mean (SD) age of trial participants was 66.2 (7.9) years. Antiplatelet therapy was not significantly associated with a reduced risk of cognitive impairment or dementia (11 trials; 109,860 participants) (3.49% versus 4.18% of patients over a mean trial follow-up of 5.8 years; odds ratio [OR], 0.94 [95% CI, 0.88-1.00]; absolute risk reduction, 0.2% [95% CI, -0.4% to 0.009%]; I2 = 0.0%). Antiplatelet therapy was not significantly associated with mean change in cognitive test scores.

CONCLUSION

In this meta-analysis, antiplatelet therapy was not significantly associated with a lower risk of incident cognitive impairment or dementia, but the CIs around this outcome do not exclude a modest preventative effect.

19 COMPARATIVE COST ANALYSIS OF ALTEPLASE VERSUS TENECTEPLASE FOR ISCHAEMIC STROKE IN A SINGLE CENTRE TERTIARY HOSPITAL

Background

Stroke thombolysis has been a proven effective treatment for acute stroke since 1995. Since then Alteplase has been the standard thrombolytic agent used in the hyperacute stroke patient, the dose being decided by body weight (0.9mg/kg). 10% of the dose is given as a bolus, and the remaining 90% given as an infusion. As the dose is weight based, more than one vial of Alteplase can be required.

Tenecteplase is a more recent thrombolytic agent, and the 2017 large multi-centre randomised control trial NOR-TEST 2 indicated that Tenecteplase is similarly effective compared to Alteplase. Tenecteplase is given entirely as a bolus dose, with a maximum dose of 40mg administered, equivalent to one vial. A single of vial of Alteplase (Actilyse) costs €536, and a single vial of Tenecteplase (Metalyse) costs €986. Our study was set up to compare potential costs of the two treatments based on our patient cohort.

Methods

We retrospectively looked at patients given Alteplase for acute ischaemic stroke in our institution in the year 2019 (n=29). We recorded the weight of the patient, and the number of vials used to administer the appropriate dose of Alteplase. We calculated the cost of the number of vials of Alteplase used over the year, and compared that to the cost of Tenectaplase, if that were to be used instead.

Results

Over the course of the calendar year, 29 patients received Alteplase. All 29 patients had a requirement for two vials of Alteplase based on their admission weight, at a total cost of €31,088 over the year 2019. The cost of Tenectaplase for the same patient cohort would have been €28,594, with a potential cost saving of €2,494.

Conclusion

Based on our acute ischaemic stroke patient cohort for the year 2019, there is a potential cost saving benefit in a move towards using Tenecteplase instead of Alteplase.

335 AN AUDIT OF ANTI-COAGULATION AND ANTI-PLATELET PRESCRIBING POST-INTRACEREBRAL HEMORRHAGE

Background

Choosing if, and when antithrombotic therapy should be re-started after Intracerebral Haemorrhage (ICH) is a decision commonly faced by clinicians working in stroke medicine. In spite of this, there is a dearth of international guidelines to support clinicians in decision making. Two recent Randomised-Controlled Trials (RCT), RESTART and SO-START, have indicated that anti-thrombotic therapy may have a better benefit:risk ratio than previously thought for patients post ICH. We conducted an audit of our practice in our tertiary hospital in 2020, a centre dealing with acute stroke.

Methods

Data was sourced from the local HIPE repository and included patients with acute, spontaneous ICH. Data was examined for variables which may influence decision to re-introduce anti-thrombotics such as indication for anti-thrombotic, type of anti-thrombotic, length of time to re-start anti-thrombotic post ICH, survival at discharge, and follow-up imaging. Our practice was compared to the intervention arms of the two previously mentioned RCT's.

Results

Of 56 included patients, 42 patients (75%) survived to discharge. Chi-squared analysis was used to assess for associations between variables. Of patients taking anti-platelets at time of ICH, only 25% were restarted on anti-platelet therapy at one year. Mean time to restarting anti-platelets post ICH was 20 weeks. For patients on oral anti-coagulation, 70% were restarted on oral anti-coagulation at one year. Mean time post ICH for restarting oral-anticoagulation was 14 weeks. No patients with amyloid angiopathy confirmed on MR Brain (n=5), were restarted on anti-thrombotic therapy, which was statistically significant. (p<0.01).

Conclusion

Results of our audit revealed a smaller proportion of patients were re-started on anti-platelet therapy compared to anti-coagulant therapy, despite trial evidence suggesting both are reasonable options for patients post ICH. Confirmed amyloid angiopathy was associated with a reduced rate of re-starting anti-thrombotic therapy. Further research is needed to examine outcomes amongst those restarted on antithrombotic therapy and to develop practice guidelines in this area.

337 AN INVESTIGATION OF UNDER-TREATMENT OF KNOWN OSTEOPOROSIS IN PATIENTS WITH SUBSEQUENT HIP FRACTURE

Background

Hip fractures have long been associated with significant morbidity and mortality and threat to independent living. A major, treatable risk factor for the development of a hip fracture is osteoporosis. The objective of this study was to investigate what proportion of patients with a prior osteoporosis diagnosis admitted to acute hospitals with a new hip fracture are receiving suboptimal osteoporosis treatment. We further aimed to investigate if any demographic variables or features from clinical history and exam were associated with undertreatment.

Methods

Using the Irish Hip Fracture Database (IHFD), we prospectively examined patients over the age of 60 who were admitted to an acute trauma centre with a diagnosis of hip fracture, between January 2019 and December 2021. Patients were excluded if they had a pubic rami fracture or other non-hip fracture, or if they were under the age of 60. History of osteoporosis was either diagnosed by DEXA imaging or by previous fragility fracture. We also collected data on demographic and clinical variables that may be associated with being more likely to be treated with osteoporosis medications, such as age, sex, New Mobility Score, Abbreviated Mental Test Score and the American Society of Anesthesiologists grade.

Results

Initial data collection showed 246 patients who met our inclusion criteria, with only 97 patients (39.4%) on appropriate treatment for osteoporosis. We then applied a binary logistic regression model to our predictor variables in estimating the likelihood of a patient to be prescribed “appropriate” osteoporosis medication as previously described, however none of the selected variables were shown to have any significant value in predicting the likelihood of being undertreated with appropriate medication for osteoporosis.

Conclusion

This study demonstrated that 60% of patients admitted with hip fracture who had a known diagnosis of osteoporosis were undertreated for same. Treatment inertia in prescribing medications for osteoporosis must be tackled to try and remedy this.

Irish Medical Students Understanding of the Intern Year

Upon completion of medical school in Ireland, graduates must make the transition to becoming interns. The transition into the intern year may be described as challenging as graduates assume clinical responsibilities. Historically, a survey of interns in 1996 found that 91% felt unprepared for their role. However, recent surveys in 2012 have demonstrated that this is changing with preparedness rates reaching 52%. This can be partially explained by multiple initiatives at the local and national level. Our study aimed evaluate medical student understanding of the intern year and associated factors. An online, cross-sectional survey was sent out to all Irish medical students in 2013 and included questions regarding their understanding of the intern year. Two thousand, two hundred and forty-eight students responded, with 1,224 (55.4%) of students agreeing or strongly agreeing that they had a good understanding of what the intern year entails. This rose to 485 (73.7%) among senior medical students. Of junior medical students, 260 (42.8%) indicated they understood what the intern year, compared to 479 (48.7%) of intermediate medical students. Initiatives to continue improving preparedness for the intern year are essential in ensuring a smooth and less stressful transition into the medical workforce.

Ireland's medical brain drain: migration intentions of Irish medical students

BACKGROUND

To provide the optimum level of healthcare, it is important that the supply of well-trained doctors meets the demand. However, despite many initiatives, Ireland continues to have a shortfall of physicians, which has been projected to persist. Our study aimed to investigate the migration intentions of Irish medical students and identify the factors that influence their decisions in order to design appropriate interventions to sustain the supply of trained doctors in order to maintain a viable medical system.

METHODS

An online cross-sectional survey was undertaken of all Irish medical students studying in the Republic of Ireland. The survey included nominal, ordinal, and scale items to determine migration intentions, factors influencing their decisions, and understanding of the Irish healthcare system.

RESULTS

A total of 2 273 medical students responded (37% response rate), of whom 1 519 were classified as Irish medical students (having completed secondary school in Ireland). Of these, 88% indicated they were either definitely migrating or contemplating migrating following graduation or completion of the pre-registration intern year. Forty percent expressed an intention of returning to Ireland within 5 years. The factors most influencing their decision to leave were career opportunities (85%), working conditions (83%), and lifestyle (80%).

CONCLUSION

The migration intentions expressed in this study predict an immediate and severe threat to the sustainability of the Irish healthcare service. Urgent interventions such as providing information about career options and specialty training pathways are required. These must begin in the undergraduate phase and continue in postgraduate training and are needed to retain medical school graduates.