Article

Ischemic Stroke and Secondary Prevention in Clinical Practice A Cohort Study of 14 529 Patients in the Swedish Stroke Register

Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden.
Stroke (Impact Factor: 5.72). 07/2010; 41(7):1338-42. DOI: 10.1161/STROKEAHA.110.580209
Source: PubMed

ABSTRACT

Secondary prevention is recommended after stroke, but adherence to guidelines is unknown. We studied the prescription of antiplatelet drugs, angiotensin-converting enzyme inhibitors, statins, and anticoagulant drugs and their relation to risk of death.
Patients with first-ever ischemic stroke in 2005 were registered in the Swedish Stroke Register. Odds ratios, hazard ratios, and 95% CIs were calculated using logistic and Cox proportional hazard regression models. Adjustments were performed for age, sex, cardiovascular risk factors, other drug therapies, and activities of daily living function.
In total, 14,529 patients with a mean age of 75.0 (+/-11.6) years were included. They were followed for 1.4 (+/-0.5) years: 52% had hypertension, 26% atrial fibrillation, 19% diabetes, and 15% were smokers. The odds ratio for prescription of antiplatelet was 2.20 (95% CI, 1.86 to 2.60) among the oldest patients (>or=85 years of age) compared with the youngest (18 to 64 years of age). The corresponding odds ratio was 0.38 (0.32 to 0.45) for prescriptions of angiotensin-converting enzyme inhibitors, 0.09 (0.08 to 0.11) for statins, and 0.07 (0.05 to 0.09) for anticoagulant therapy. Prescription of statin and anticoagulant therapy was associated with reduced risk of death (hazard ratio, 0.78 [0.65 to 0.91] and hazard ratio, 0.58 [0.44 to 0.76], respectively) but not the prescription of antiplatelet drugs or angiotensin-converting enzyme inhibitors.
The prescription of antiplatelet, angiotensin-converting enzyme inhibitors, statins, and anticoagulant therapy was strongly age related. Statin and anticoagulant therapy was associated with reduced risk of death and seemed to be underused among elderly patients. These findings should encourage physicians to follow today's guidelines for stroke care.

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    • "Among demographics, older age, previous disability and lower social status, have been previously reported to negatively influence the adherence to guidelines in many settings [33]. According to the Swedish Stroke Register [22] the prescription of statins was strongly age-related: statin therapy, even if associated with reduced risk of death, seemed to be underused among elderly patients, with an inverse correlation with increasing age. In line with these findings, in our setting younger patients and those without prestroke disability were more likely to be treated with statins. "
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    ABSTRACT: Statins, due to their well-established pleiotropic effects, have noteworthy benefits in stroke prevention. Despite this, a significant proportion of high-risk patients still do not receive the recommended therapeutic regimens, and many others discontinue treatment after being started on them. The causes of non-adherence to current guidelines are multifactorial, and depend on both physicians and patients. The aim of this study is to identify the factors influencing statin prescription at Stroke Unit (SU) discharge. This study included 12,750 patients enrolled on the web-based Lombardia Stroke Registry (LRS) from July 2009 to April 2012 and discharged alive, with a diagnosis of ischemic stroke or transient ischemic attack (TIA) and without contra-indication to statin therapy. By logistic regression analysis and classification trees, we evaluated the impact of demographic data, risk factors, tPA treatment, in-hospital procedures and complications on statin prescription rate at discharge. We observed a slight increase in statins prescription during the study period (from 39.1 to 43.9%). Lower age, lower stroke severity and prestroke disability, the presence of atherothrombotic/lacunar risk factors, a diagnosis of non-cardioembolic stroke, tPA treatment, the absence of in-hospital complications, with the sole exception of hypertensive fits and hyperglycemia, were the patient-related predictors of adherence to guidelines by physicians. Overall, dyslipidemia appears as the leading factor, while TOAST classification does not reach statistical significance. In our region, Lombardia, adherence to guidelines in statin prescription at Stroke Unit discharge is very different from international goals. The presence of dyslipidemia remains the main factor influencing statin prescription, while the presence of well-defined atherosclerotic etiopathogenesis of stroke does not enhance statin prescription. Some uncertainties about the risk/benefit of statin therapy in stroke etiology subtypes (cardioembolism, other or undetermined causes) may partially justify the underuse of statin in ischemic stroke. The differences that exist between current international guidelines may prevent a more widespread use of statin and should be clarified in a consensus.
    Full-text · Article · Mar 2014 · BMC Neurology
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    • "In view of the fact that this study was the first to discriminate major and minor CVD in very old age, we recommend that this analysis be repeated in another cohort. Evidence that medication for secondary cardiovascular prevention is recommendable up to the highest age groups is increasing (Andrawes et al. 2005; Alhusban and Fagan 2011; Castilla-Guerra et al. 2009; Asberg et al. 2010; Maroo et al. 2008; Ray et al. 2006; Deedwania et al. 2007; Shepherd et al. 2002; Wenger and Lewis 2010; Thomas et al. 2010). "

    Full-text · Dataset · Jul 2013
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    • "In view of the fact that this study was the first to discriminate major and minor CVD in very old age, we recommend that this analysis be repeated in another cohort. Evidence that medication for secondary cardiovascular prevention is recommendable up to the highest age groups is increasing (Andrawes et al. 2005; Alhusban and Fagan 2011; Castilla-Guerra et al. 2009; Asberg et al. 2010; Maroo et al. 2008; Ray et al. 2006; Deedwania et al. 2007; Shepherd et al. 2002; Wenger and Lewis 2010; Thomas et al. 2010). "
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    ABSTRACT: This study aimed to explore the prognosis of very old people depending on their cardiovascular disease (CVD) history. This observational prospective cohort study included 570 participants aged 85 years from the general population with 5-year follow-up for morbidity, functional status, and mortality. At baseline, participants were assigned to three groups: no CVD history, "minor" CVD (angina pectoris, transient ischemic attack, intermittent claudication, and/or heart failure), or "major" CVD (myocardial infarction [MI], stroke, and/or arterial surgery). Follow-up data were collected on MI, stroke, functional status, and cause-specific mortality. The composite endpoint included cardiovascular events (MI or stroke) and cardiovascular mortality. At baseline, 270 (47.4 %) participants had no CVD history, 128 (22.4 %) had minor CVD, and 172 (30.2 %) had major CVD. Compared to the no CVD history group, the risk of the composite endpoint increased from 1.6 (95 % confidence interval [CI], 1.1-2.4) for the minor CVD group to 2.7 (95 % CI, 2.0-3.9) for the major CVD group. Similar trends were observed for cardiovascular and all-cause mortality risks. In a direct comparison, the major CVD group had a nearly doubled risk of the composite endpoint (hazard ratio, 1.8; 95 % CI, 1.2-2.7), compared to the minor CVD group. Both minor and major CVD were associated with an accelerated decline in cognitive function and accelerated increase of disability score (all p < 0.05), albeit most pronounced in participants with major CVD. CVD disease status in very old age is still of important prognostic value: a history of major CVD (mainly MI or stroke) leads to a nearly doubled risk of poor outcome, including cardiovascular events, functional decline, and mortality, compared with a history of minor CVD.
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