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Title: Improving tolerability and concordance with antiplatelet therapy in older people (ITCAT)
Author: Fletcher, Emma Hall
Awarding Body: University of Newcastle Upon Tyne
Current Institution: University of Newcastle upon Tyne
Date of Award: 2012
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Antiplatelet therapy (APT) is key to the secondary prevention of stroke but is not without side-effects. Older people are potentially at greatest risk from gastrointestinal side-effects owing to age-related changes in the gastrointestinal tract. Helicobacter pylori may be one of the few modifiable risk factors. Previous randomised controlled trials (RCTs) of APT in secondary prevention have had highly selective eligibility criteria: the incidence of adverse events and associated risk factors in the general population is unknown. This research aimed to determine the bleeding incidence and associated risk factors in an unselected cohort of patients taking APT following stroke. The impact of these adverse events on tolerability and concordance were also examined. Following a systematic review of published evidence a prospective, inception, cohort study of consecutive patients admitted with acute ischaemic stroke and commenced on oral APT within seven days was undertaken. Helicobacter pylori status was determined by stool antigen testing and dyspepsia assessed using the Short-form Leeds Dyspepsia Questionnaire. Early and late bleeding events and APT concordance were determined at four and fifty-two weeks respectively. The study comprised 322 participants with a mean age of 71 years, older than previous secondary prevention RCTs. The point prevalence of Helicobacter pylori was 66.7% and 13.0% participants reported prior dyspepsia. Early and late all-cause bleeding events occurred in 19.7% and 25.3% participants respectively. Dual APT with aspirin and clopidogrel greatly increased bleeding risk. The incidence of early major upper gastrointestinal bleeding was 2.2%, with increasing age a significant risk factor. Early and late APT-associated intolerance occurred in 30 (9.6%) and 28 (11.1%) participants respectively. Dipyridamole was the least well tolerated APT. Neither Helicobacter pylori infection nor dyspepsia prior to the index stroke affected bleeding incidence or APT tolerability. Patients with stroke do not currently warrant screening for H. pylori infection prior to commencing APT. The co-prescription of aspirin and clopidogrel should be avoided where possible owing to the increased associated bleeding risk. Older people warrant careful monitoring following prescription of APT in the first six weeks following stroke.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available