Journals Watch - Stroke, BP and antidepressants

A review of this week's research impacting primary care. By GP Dr Tillmann Jacobi

Carotid angiogram of a stroke patient: the use of IV thrombolysis carries a risk of haemorrhage (Photograph: SPL)
Carotid angiogram of a stroke patient: the use of IV thrombolysis carries a risk of haemorrhage (Photograph: SPL)

Predicting haemorrhagic stroke with the SICH score
Stroke 2012 doi: 10.1161/STROKEAHA.111.644815

IV thrombolysis for the treatment of ischaemic strokes can be effective but bears the risk of serious symptomatic intracerebral haemorrhage (SICH).

The aim of this study was to develop a practical clinical score to predict the potential risk for the individual patient. An analysis of data from 31,627 patients on the International Stroke Thrombolysis Register who had been treated with IV alteplase revealed an overall rate of SICH of 1.8%.

Nine independent contributing risk factors were identified, including baseline National Institutes of Health Stroke Scale, serum glucose, systolic BP, age, body weight, stroke onset to treatment time, aspirin or combined aspirin and clopidogrel, and history of hypertension. These were integrated into a scoring tool for clinicians, the SICH risk score.

Weight gain and metabolic changes with olanzapine
J Child Adolesc Psychopharmacol 2012 doi: 10.1089/cap.2010.0020

This analysis aimed to confirm the need for careful monitoring of weight and other metabolic changes between adolescents and adults during long-term olanzapine treatment.

Long-term treatment was defined as at least 24 weeks with an oral or depot preparation. The adult database included 4,280 patients on long-term olanzapine from 86 studies. The adolescent database included 179 patients on long-term olanzapine from six studies. The median duration of the follow-up period was 201 days for the adolescent database and 280 days for the adult database.

This demonstrated a mean weight gain of 11.24kg in the adolescents from baseline to endpoint. In comparison, the mean weight gain for adults was only 4.81kg. Treatment also affected adolescents more than adults in terms of impact on lipid profiles and cholesterol.

Interference between NSAIDs and antidepressants
Psychol Med 2012 doi: 10.1017/S0033291712000190

This study looked at the potential impact of NSAIDs on the efficacy of antidepressants, using the SSRI escitalopram and the tricyclic antidepressant nortriptyline, and a possible contribution to treatment resistance in major depressive disorder.

About 10% of a cohort of 811 patients who were taking antidepressants were also taking NSAIDs during the 12-week study period. The study took into account the increased likelihood that patients on regular NSAIDs are on average older than patients who do not take regular NSAIDs.

There was no apparent measurable negative influence of NSAIDs on the efficacy of SSRIs or tricyclic antidepressants during the study period, so concurrent use appears unproblematic.

Should we measure BP in the left, the right, or both arms?
BMJ 2012; 344: e1327

This primary care based cohort study of 230 patients with hypertension looked at a possible correlation between differing systolic BP readings between arms of the same patient and the long-term cardiovascular outcomes.

All recruited patients had their BP checked bilaterally at three consecutive surgery attendances. A review of the outcomes of these patients 10 years later suggested a mean interarm difference in systolic BP of 10mmHg or more (as found in 76 of the 230 patients, 33%) was associated with higher risk of all-cause mortality.

The authors propose that an established difference of systolic BP between arms could be regarded as a valuable predictor of increased cardiovascular risk and complications, and should be considered as a routine part of cardiovascular risk assessment in primary care.

Anticholinergics and the blood/brain barrier
Drugs Aging 2012; 29(4): 259-73

Anticholinergics are often prescribed for overactive bladder, especially in the elderly. However, many anticholinergics cross the blood/brain barrier, even more so with increasing age, and may affect the CNS.

This article reviews a number of anticholinergics for their potential for crossing the blood/brain barrier and causing possible complications.

Apart from the interesting physiological explanations, it reminds us of the need to be alert about possible iatrogenically induced changes of behaviour in patients.

Migraine headache prophylaxis in children
Acta Neurol Belg 2012; 112(1): 51-5

In the search for additional safe options in migraine prophylaxis, this RCT with 113 children aged six to 17 years compared the efficacy and safety of cinnarizine with propranolol.

Cinnarizine reduced the baseline headache frequency by more than half in 74.6% of the cinnarizine group (57 patients). This exceeded the results achieved using propranolol, which showed a reduction of baseline headache frequency by more than half in 72.5% of the examined group (56 patients).

There were no complications or severe side-effects from treatment in either group. The reduction of the mean headache frequency per month was almost equally successful in both groups.

The conclusion of the researchers was that cinnarizine appeared to be as effective and safe as propranolol when used for the prophylaxis of migraine in children, but a double-blind placebo-controlled trial would be useful to determine its potential value.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Dr Jacobi is a GP in York and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Consider a search for adolescent patients on olanzapine and review the completeness and reliability of monitoring their weight, lipid profile, cholesterol and blood sugar.
  • Discuss with the nursing team the potential of routinely checking BP bilaterally in new patient checks or at hypertension reviews. Is there an easy or established system to indicate which arm has been used for each single BP check, to indicate and confirm trends over time?
  • Review management of migraine patients, including prophylaxis. Has the efficiency been assessed in the past year?

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