The Incidence of Intracerebral Haemorrhage in Complex Chronic Patients

Background: Demographic aging is a generalised event and the proportion of
older adults is increasing rapidly worldwide with chronic pathologies,
disability, and complexity of health needs. The intracerebral haemorrhage
(ICH) has devastating consequences in high risk people. This study aims to
quantify the incidence of ICH in complex chronic patients (CCP). Methods:
This is a multicentre, retrospective and community-based cohort study of
3594 CCPs followed up from 01/01/2013 to 31/12/2017 in primary care
without a history of previous ICH episode. The cases were identified from
clinical records encoded with ICD-10 (10th version of the International
Classification of Diseases) in the e-SAP database of the Catalan Health
Institute. The main variable was the ICH episode during the study period.
Demographic, clinical, functional, cognitive and pharmacological variables
were included. Descriptive and logistic regression analyses were carried
out to identify the variables associated with suffering an ICH. The
independent risk factors were obtained from logistic regression models,
ruling out the variables included in the HAS-BLED score, to avoid
duplication effects. Results are presented as odds ratio (OR) and 95%
confidence interval (CI). The analysis with the resulting model was also
stratified by sex. Results: 161 (4.4%) participants suffered an ICH
episode. Mean age 87±9 years; 55.9% women. The ICH incidence density was
151/10000 person-years [95%CI 127-174], without differences by sex.
Related to subjects without ICH, presented a higher prevalence of arterial
hypertension (83.2% vs. 74.9%; p=0.02), hypercholesterolemia (55.3% vs.
47.4%, p=0.05), cardiovascular disease (36.6% vs. 28.9%; p=0.03), and use
of antiaggregants drugs (64.0% vs. 52.9%; p=0.006). 93.2% had a HAS-BLED
score ≥3. The independent risk factors for ICH were identified: HAS-BLED
≥3 [OR 3.54; 95%CI 1.88-6.68], hypercholesterolemia [OR 1.62; 95%CI
1.11-2.35], and cardiovascular disease [OR 1.48 IC95% 1.05-2.09]. The
HAS_BLED ≥3 score showed a high sensitivity [0.93 CI95% 0.97-0.89] and
negative predictive value [0.98 (CI95% 0.83-1.12)].  
Conclusions:  In the CCP subgroup the incidence density of ICH
was 5-60 times higher than that observed in elder and general population.
The use of bleeding risk score as the HAS-BLED scale could improve the
preventive approach of those with higher risk of ICH.

背景：人口老龄化是一个全球性现象，全球范围内老年人占比快速上升，其伴随的慢性疾病、残疾及健康需求复杂性日益凸显。脑出血（intracerebral haemorrhage, ICH）对高危人群具有毁灭性后果。本研究旨在量化复杂慢性患者（complex chronic patients, CCP）中ICH的发病率。

方法：本研究为多中心、回顾性社区队列研究，纳入3594例CCP患者，于2013年1月1日至2017年12月31日在初级保健机构随访，所有患者无既往ICH发作史。病例来源于加泰罗尼亚卫生研究所e-SAP数据库中采用国际疾病分类第10版（ICD-10）编码的临床记录。主要变量为研究期间的ICH发作情况，纳入人口学、临床、功能、认知及药理学变量。采用描述性分析和逻辑回归分析识别与ICH发生相关的变量；通过逻辑回归模型获取独立危险因素，排除HAS-BLED评分中已包含的变量以避免重复效应。结果以比值比（odds ratio, OR）及95%置信区间（95% confidence interval, CI）表示，并按性别分层进行模型分析。

结果：161例（4.4%）参与者发生ICH发作，平均年龄87±9岁，女性占55.9%。ICH发病密度为151/10000人年[95%CI 127-174]，性别间无差异。与未发生ICH的受试者相比，ICH患者动脉高血压（83.2% vs. 74.9%；p=0.02）、高胆固醇血症（55.3% vs. 47.4%；p=0.05）、心血管疾病（36.6% vs.28.9%；p=0.03）及抗血小板药物使用（64.0% vs.52.9%；p=0.006）的患病率更高。93.2%的患者HAS-BLED评分≥3。ICH的独立危险因素包括：HAS-BLED≥3[OR 3.54；95%CI1.88-6.68]、高胆固醇血症[OR1.62；95%CI1.11-2.35]及心血管疾病[OR1.48 IC95%1.05-2.09]。HAS-BLED≥3评分显示出高敏感性[0.93 CI95%0.97-0.89]及阴性预测值[0.98（CI95%0.83-1.12）]。

结论：在CCP亚组中，ICH的发病密度较老年人群及普通人群高5-60倍。使用HAS-BLED量表等出血风险评分可优化ICH高危人群的预防策略。