(Stroke. 2000;31:3067.)
© 2000 American Heart Association, Inc.
Progress Review |
Diagnostic Testing for Coagulopathies in Patients With Ischemic Stroke
From the Department of Medicine (Neurology), Duke Center for Cerebrovascular Disease, Center for Clinical Health Policy Research, Duke University, and Durham VA Medical Center, Durham, NC.
Correspondence to Larry B. Goldstein, MD, Duke Center for Cerebrovascular Disease, Department of Medicine (Neurology), PO Box 3651, Durham, NC 27710. E-mail Golds004{at}mc.duke.edu
Background—Hypercoagulable states are a recognized, albeit uncommon, etiology of ischemic stroke. It is unclear how often the results of specialized coagulation tests affect management. Using data compiled from a systematic review of available studies, we employed quantitative methodology to assess the diagnostic yield of coagulation tests for identification of coagulopathies in ischemic stroke patients.
Summary of Review—We performed a MEDLINE search to identify
controlled studies published during 1966–1999 that reported the
prevalence of deficiencies of protein C, protein S, antithrombin III,
plasminogen, activated protein C resistance
(APCR)/factor V Leiden mutation (FVL), anticardiolipin antibodies
(ACL), or lupus anticoagulant (LA) in patients with
ischemic stroke. The cumulative prevalence rates (pretest
probabilities) and positive likelihood ratios for all studies and for
those including only patients aged 
50 years were used to calculate
posttest probabilities for each coagulopathy, reflecting
diagnostic yield. The cumulative pretest probabilities of
coagulation defects in ischemic stroke patients are as follows:
LA, 3% (8% for those aged 50 years); ACL, 17% (21% for those aged
50 years); APCR/FVL, 7% (11% for those aged 50 years); and
prothrombin mutation, 4.5% (5.7% for those aged 50 years). The
posttest probabilities of ACL, LA, and APCR increased with increasing
pretest probability, the specificity of the tests, and features of the
patients’ history and clinical presentation.
Conclusions—–The pretest probabilities of coagulation defects in ischemic stroke patients are low. The diagnostic yield of coagulation tests may be increased by using tests with the highest specificities and by targeting patients with clinical or historical features that increase pretest probability. Consideration of these data might lead to more rational ordering of tests and an associated cost savings.
Key Words: cerebral infarction • coagulation • decision analysis • diagnosis
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