Clinical research study
Secondary Prevention after Ischemic Stroke or Transient Ischemic Attack

https://doi.org/10.1016/j.amjmed.2014.03.011Get rights and content

Abstract

Background

Patients with stroke or transient ischemic attack are at increased risk of recurrent stroke. Transient ischemic attack is a harbinger for stroke merely hours to days after the initial transient ischemic attack. There is thus a narrow window of opportunity to initiate evidence-based therapies for secondary prevention of stroke. Our objective was to assess hospital adherence at discharge to secondary prevention measures after transient ischemic attack or ischemic stroke.

Methods

Observational study of patients in the Get With The Guidelines-Stroke registry from 2007 to 2011. Patients were divided into 2 cohorts based on presentation: transient ischemic attack versus ischemic stroke. Adherence to evidence-based secondary prevention and other quality measures were assessed.

Results

Among the 858,835 patients with transient ischemic attack or ischemic stroke, 259,319 (30%) patients presented with a transient ischemic attack and 599,516 (70%) patients presented with an ischemic stroke. After adjusting for patient and hospital characteristics, adherence to secondary prevention measures was consistently lower for the transient ischemic attack cohort (vs ischemic stroke cohort), who had lower odds of being discharged on antithrombotics (odds ratio [OR] 0.63; 95% confidence interval [CI], 0.59-0.66; P <.0001), anticoagulants for atrial fibrillation (OR 0.65; 95% CI, 0.61-0.68; P <.0001), lipid-lowering medication for LDL >100 mg/dL (OR 0.52; 95% CI, 0.50-0.54; P <.0001), intensive statin therapy (OR 0.74; 95% CI, 0.72-0.76; P <.0001), LDL cholesterol measurement (OR 0.66; 95% CI, 0.64-0.68; P <.0001), smoking cessation counseling (OR 0.83; 95% CI, 0.78-0.89; P <.0001), stroke education (OR 0.71; 95% CI, 0.69-0.73; P <.0001), or weight loss recommendations (OR 0.88; 95% CI, 0.85-0.90; P <.0001). The adherence to evidence-based therapies increased significantly (P <.0001) over time (2007-2011) for both the cohorts, but the increasing trend was consistently lower for patients who presented with transient ischemic attack.

Conclusions

In patients surviving an ischemic stroke or transient ischemic attack, adherence to evidence-based secondary prevention discharge measures were consistently less for patients with transient ischemic attack, thus representing a missed opportunity at instituting preventive measures to reduce the risk of recurrent stroke.

Section snippets

Get With The Guidelines-Stroke (GWTG-Stroke) Program

The GWTG-Stroke program is a voluntary quality improvement program across the US, which collects information on stroke admission. The methods of the GWTG-Stroke program have been described previously.10, 11, 12 Briefly, for each hospitalization for stroke or transient ischemic attack, information on patient demographics, medical history, in-hospital diagnostic work-up, treatment, discharge medications, counseling, and disposition were collected using an Internet-based patient management tool

Results

Among the 1.4 million patients with stroke or transient ischemic attack, 858,835 patients with ischemic stroke or transient ischemic attack from 1545 sites fulfilled the inclusion criteria and were included in this analysis (Figure 1). Among them, 259,319 (30%) patients presented with a transient ischemic attack and 599,516 (70%) patients presented with an ischemic stroke.

Discussion

In this analysis of close to a million admissions for ischemic stroke or transient ischemic attack, adherence to evidence-based secondary prevention and other quality-of-care discharge measures were consistently lower (except for antihypertensives usage) for the transient ischemic attack cohort when compared with ischemic stroke cohort. In addition, although adherence to the secondary prevention and other quality-of-care measures increased with time (from 2007-2011), the magnitude of the

Study Limitations

Our data are from a prospective registry of patients from a voluntary quality-reporting program; therefore, adherence to guideline-recommended secondary prevention therapies may be higher in these hospitals than in hospitals not participating in GWTG-Stroke. If so, it is possible that the difference in quality of care between transient ischemic attack and ischemic stroke might be even greater in nonparticipating hospitals. However, this is still the largest series reporting secondary prevention

Conclusions

Data from over close to a million patients with ischemic stroke or transient ischemic attack suggest that the hospital adherence to evidence-based secondary prevention and other quality-of-care measures at the time of discharge is consistently lower for patients with transient ischemic attack when compared with patients with ischemic stroke. The adherence to these discharge measures has increased in GWTG-Stroke program from 2007 to 2011 but is still consistently lower for the transient ischemic

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    Funding: The GWTG-Stroke program is provided by the AHA/American Stroke Association. The GWTG-Stroke program is currently supported in part by a charitable contribution from Janssen Pharmaceutical Companies of Johnson & Johnson. GWTG-Stroke has been funded in the past through support from Boehringer Ingelheim, Merck, Bristol-Myers Squib/Sanofi Pharmaceutical Partnership, and the AHA Pharmaceutical Roundtable. The industry sponsors of GWTG-Stroke had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

    Conflicts of Interest: SB, EES, IMS, and LL report no disclosures. LS reports the following: Serves as the unpaid chair of the AHA GWTG Stroke Clinical Working Group; serves as a Stroke Systems of Care Expert Consultant and measure development expert to the Joint Commission, Coverdell Registry/MA Dept of Public Health; is on the steering committee for the Medtronic Victory AF trial, and the DSMB for the NovoNordisk DEVOTE trial. He receives research funding from NINDS and PCORI. GCF reports the following: Employment—UCLA Employee, which holds a patent on stroke retriever devices National Institutes of Health—Grants and grants pending. DLB discloses the following relationships: Advisory Board, Elsevier; Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Get With The Guidelines Steering Committee; Data Monitoring Committees: Duke Clinical Research Institute; Harvard Clinical Research Institute; Mayo Clinic; Population Health Research Institute; Honoraria: American College of Cardiology (Editor, Clinical Trials, Cardiosource), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology); Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), WebMD (CME steering committees); Other: Clinical Cardiology (Associate Editor); Journal of the American College of Cardiology (Section Editor, Pharmacology); Research Grants: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Roche, Sanofi Aventis, The Medicines Company; Unfunded Research: FlowCo, PLx Pharma, Takeda.

    Authorship: All authors had access to the data and a role in writing the manuscript.

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