Comparative Effectiveness and Safety of Seizure Prophylaxis Among Adults After Acute Ischemic Stroke

Author:

Moura Lidia M.V.R.12ORCID,Donahue Maria A.1ORCID,Yan Zhiyu1,Smith Louisa H.12ORCID,Hsu John345ORCID,Newhouse Joseph P.3678ORCID,Schwamm Lee H.9ORCID,Haneuse Sebastien10ORCID,Hernandez-Diaz Sonia9ORCID,Blacker Deborah91112ORCID

Affiliation:

1. Department of Neurology, Massachusetts General Hospital, Boston (L.M.V.R.M., M.A.D., Z.Y., L.H.S.).

2. Department of Neurology, Harvard Medical School, Boston, MA (L.M.V.R.M., L.H.S.).

3. Department of Health Care Policy, Harvard Medical School, Boston, MA (J.H., J.P.N.).

4. Mongan Institute, Massachusetts General Hospital, Boston (J.H.).

5. Department of Medicine, Harvard Medical School, Boston, MA (J.H.).

6. National Bureau of Economic Research, Cambridge, MA (J.P.N.).

7. Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (J.P.N.).

8. Harvard Kennedy School, Cambridge, MA (J.P.N.).

9. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (L.H.S., S.H.-D., D.B.).

10. Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.H.).

11. Department of Psychiatry, Massachusetts General Hospital, Boston (D.B.).

12. Department of Psychiatry, Harvard Medical School, Boston, MA (D.B.).

Abstract

Background: Older adults occasionally receive seizure prophylaxis in an acute ischemic stroke (AIS) setting, despite safety concerns. There are no trial data available about the net impact of early seizure prophylaxis on post-AIS survival. Methods: Using a stroke registry (American Heart Association’s Get With The Guidelines) individually linked to electronic health records, we examined the effect of initiating seizure prophylaxis (ie, epilepsy-specific antiseizure drugs) within 7 days of an AIS admission versus not initiating in patients ≥65 years admitted for a new, nonsevere AIS (National Institutes of Health Stroke Severity score ≤20) between 2014 and 2021 with no recorded use of epilepsy-specific antiseizure drugs in the previous 3 months. We addressed confounding by using inverse-probability weights. We performed standardization accounting for pertinent clinical and health care factors (eg, National Institutes of Health Stroke Severity scale, prescription counts, seizure-like events). Results: The study sample included 151 patients who received antiseizure drugs and 3020 who did not. The crude 30-day mortality risks were 219 deaths per 1000 patients among epilepsy-specific antiseizure drugs initiators and 120 deaths per 1000 among noninitiators. After standardization, the estimated mortality was 251 (95% CI, 190–307) deaths per 1000 among initiators and 120 (95% CI, 86–144) deaths per 1000 among noninitiators, corresponding to a risk difference of 131 (95% CI, 65–200) excess deaths per 1000 patients. In the prespecified subgroup analyses, the risk difference was 52 (95% CI, 11–72) among patients with minor AIS and 138 (95% CI, 52–222) among moderate-to-severe AIS patients. Similarly, the risk differences were 86 (95% CI, 18–118) and 157 (95% CI, 57–219) among patients aged 65 to 74 years and ≥75 years, respectively. Conclusions: There was a higher risk of 30-day mortality associated with initiating versus not initiating seizure prophylaxis within 7 days post-AIS. This study does not support the role of seizure prophylaxis in reducing 30-day poststroke mortality.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Advanced and Specialized Nursing,Cardiology and Cardiovascular Medicine,Neurology (clinical)

Reference70 articles.

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