Migraines Linked to Stroke and Vascular Disease Risk in Pregnant Women

Pregnant women who experience active peripartum migraine are at risk for stroke and other vascular diagnoses, according to a study in the March 10 BMJ.

Cheryl D. Bushnell, MD, MHS, Associate Professor in the Department of Neurology, Wake Forest University Medical Center, Winston-Salem, North Carolina, and colleagues examined a nationwide inpatient sample of 18,345,538 pregnancy-related discharges from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, from 2000 to 2003. Diagnosis of migraine, stroke, or other vascular diseases was the main outcome measure.

Among hospital discharges with a pregnancy code, 33,956 also had a discharge code for migraine (185 per 100,000 deliveries). Women 40 and older were 2.4-fold more likely to be discharged with migraine than were women younger than 20. Diagnosis was also more likely in white women than in any other race or ethnicity. A strong association was found between migraine discharge codes and all types of stroke discharge codes (odds ratio [OR], 15.8). Ischemic stroke had the strongest association (OR, 30.7), while no association was found for cerebral venous thrombosis and subarachnoid hemorrhage. A significant association was also seen with myocardial infarction (OR, 4.9), heart disease (OR, 2.1), pulmonary embolus (OR, 3.1), deep venous thrombosis (OR, 2.4), and thrombophilia (OR, 3.6). In addition, migraine was associated with vascular risk factors such as diabetes (OR, 2.3), hypertension (OR, 3.6), and smoking (OR, 2.7). Some pregnancy-related complications were also associated with migraine. An association was observed regarding preeclampsia/gestational hypertension (OR, 2.3) but not for gestational diabetes (OR, 1.0).

A multivariable logistic regression analysis was also performed to include age and to separate preeclampsia diagnoses from stroke, vascular diagnoses, hypertension, smoking, and diabetes. Related diagnoses, such as heart disease, acute myocardial infarction, or venous thromboembolism and pulmonary embolus were combined into one variable. Increasing age (OR, 1.03), diabetes (OR, 1.96), myocardial infarction/heart disease (OR, 2.11), preeclampsia (OR, 2.29), smoking (OR, 2.85), pulmonary embolus/venous thromboembolism (OR, 3.23), and stroke (OR, 15.05) were all independently associated with migraine discharge codes.

Suggested Reading
Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study. BMJ. 2009;338:b664. .
Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma-United States, 1960-1995. Mor Mortal Wkly Rep CDC Surveill Summ.1998;47:1-27.

Can One Pill Reduce Multiple Cardiovascular Risk Factors?

The Polycap—a polypill containing low doses of thiazide (12.5 mg), atenolol (50 mg), ramipril (5 mg), simvastatin (20 mg), and aspirin (100 mg)—could be conveniently used to reduce multiple risk factors, including cardiovascular risk, according to a study in the March 30 online Lancet.

Salim Yusuf, MD, from the Population Health Research Institute, Hamilton Health Sciences and McMaster University in Ontario, Canada, and colleagues conducted The Indian Polycap Study (TIPS), a double-blind trial in 50 centers in India. Each of the 2,053 participants (ages 45 to 80) had one cardiovascular risk factor but not cardiovascular disease. All subjects were randomly assigned to the polypill or to one of eight other groups that used a single drug or drug combination. Primary outcomes were LDL cholesterol level for the effect of lipids, blood pressure for antihypertensive drugs, and heart rate for the effects of atenolol.

“Compared with groups not receiving blood pressure–lowering drugs, the polypill reduced systolic blood pressure by 7.4 mm Hg and diastolic blood pressure by 5.6 mm Hg, which was similar when three blood pressure–lowering drugs were used, with or without aspirin,” the researchers stated.

Blood pressure reductions increased with the number of drugs used (2.2/1.3 mm Hg, 4.7/3.6 mm Hg, and 6.3/4.5 mm Hg with one, two, and three drugs, respectively). LDL cholesterol was reduced slightly less with the polypill (0.70 mmol/L), compared with simvastatin alone (0.83 mmol/L). Both reductions were greater than those for groups without simvastatin. Heart rate reductions were similar between those using the polypill and other groups using atenolol (7.0 beats per minute), and both groups had a significantly greater reduction than groups without atenolol.

“The reductions in 11-dehydrothromboxane B2 were similar with the Polycap (283.1 ng/mmol creatinine) compared with three blood pressure–lowering drugs plus aspirin (350.0 ng/mmol creatinine) and aspirin alone (348.8 ng/mmol creatinine) compared with groups without aspirin,” the investigators stated. In an accompanying editorial, Christopher P. Cannon, MD, of Brigham and Women’s Hospital in Boston, stated that despite discontinuation rates, a key finding from the study is the tolerability of the polypill. “Although TIPS does not provide all the answers, the study does take a first and crucial step forward and raises hope that, in conjunction with other global efforts to improve diet and exercise, the polypill could one day substantially reduce the burden of cardiovascular disease in the world.”

Suggested Reading
Indian Polycap Study (TIPS), Yusuf S, Pais P, et al. Effects of a polypill (Polycap) on risk factors in middle-aged individuals without cardiovascular disease (TIPS): a phase II, double-blind, randomised trial. Lancet. 2009;373(9672):1341-1351.

Cannon CP. Can the polypill save the world from heart disease? Lancet. 2009; 373(9672):1313-1314.

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