Last reviewed: November 2017
Last updated: November  2017

Important updates

Landmark cohort study on long-term antiplatelet treatment use in over-75s (post myocardial infarction/stroke/TIA) and risk of major GI bleeding

  • Older people receiving daily aspirin-based antiplatelet treatment without routine proton-pump inhibitor (PPI) use are at higher and more sustained risk of major bleeding than younger patients.

  • Half of the major bleeding events in patients ages 75 years or older are upper gastrointestinal. The estimated number needed to treat for routine PPI use to prevent major upper gastrointestinal bleed was low. The authors concluded that co-prescription should be encouraged. See: Prevention: secondary.

See Diagnosis: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • patient/caregiver report of focal neurologic deficit
  • brief duration of symptoms

Other diagnostic factors

  • hx of extracranial atherosclerosis
  • hx of cardiac disease
  • unilateral symptoms
  • increased BP on presentation
  • focal neurologic deficit on exam
  • absence of positive symptoms (shaking, scotoma, spasm)
  • absence of headache
  • hx of migraine
  • absence of seizure prior to neurologic deficit
  • no history of epilepsy
  • family or personal hx of premature stroke, miscarriage, or venous thromboembolism
  • carotid bruit

Risk factors

  • atrial fibrillation
  • valvular disease
  • patent foramen ovale (PFO)
  • carotid stenosis
  • congestive heart failure
  • hypertension
  • hyperlipidemia
  • diabetes mellitus
  • cigarette smoking
  • alcohol abuse
  • advanced age
  • inactivity
  • obesity
  • hypercoagulability

Diagnostic investigations

1st investigations to order

  • blood glucose
  • chemistry profile
  • CBC
  • prothrombin time, INR, and activated PTT
  • ECG
  • brain MRI with diffusion
  • fasting lipid profile
Full details

Investigations to consider

  • head CT
  • ESR
  • telemetry/Holter monitor
  • echocardiogram with bubble study
  • carotid Doppler ultrasound
  • CT angiography
  • magnetic resonance angiography
  • transcranial Doppler
  • hypercoagulability studies
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

Ethan Cumbler

Associate Professor

Section of Hospital Medicine

Department of Internal Medicine

Division of Medicine

University of Colorado School of Medicine

Denver

CO

Disclosures

EC declares that he has no competing interests..

Jennifer Simpson

Assistant Professor

Department of Neurology

University of Colorado School of Medicine

Denver

CO

Disclosures

JS is a site investigator for the POINT trial.

Peer reviewers VIEW ALL

Staff Physician

Section of Geriatric Medicine

Cleveland Clinic

Cleveland

OH

Disclosures

RF declares that he has no competing interests.

Stroke Physician

Guy’s and St Thomas’ NHS Foundation Trust

Stroke Programme Director

Royal College of Physicians

London

UK

Disclosures

TR declares that he has no competing interests.

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