Lipid assessment and treatment patterns in hospitalized TIA and ischemic stroke patients

Cardiovascular Event Rates in Statin-Treated Korean Patients with Cardiovascular Disease: Estimates from a Real-World Population Using Electronic Medical Record Data

PURPOSE

To estimate the risk of recurrent cardiovascular events in a real-world population of very high-risk Korean patients with prior myocardial infarction (MI), ischemic stroke (IS), or symptomatic peripheral artery disease (sPAD), similar to the Further cardiovascular OUtcomes Research with proprotein convertase subtilisin-kexin type 9 Inhibition in subjects with Elevated Risk (FOURIER) trial population.

METHODS

This retrospective study used the Asan Medical Center Heart Registry database built on electronic medical records (EMR) from 2000 to 2016. Patients with a history of clinically evident atherosclerotic cardiovascular disease (ASCVD) with multiple risk factors were followed up for 3 years. The primary endpoint was a composite of MI, stroke, hospitalization for unstable angina, coronary revascularization, and all-cause mortality.

RESULTS

Among 15,820 patients, the 3-year cumulative incidence of the composite primary endpoint was 15.3% and the 3-year incidence rate was 5.7 (95% CI 5.5-5.9) per 100 person-years. At individual endpoints, the rates of deaths, MI, and IS were 0.4 (0.3-0.4), 0.9 (0.8-0.9), and 0.8 (0.7-0.9), respectively. The risk of the primary endpoint did not differ significantly between recipients of different intensities of statin therapy. Low-density lipoprotein cholesterol (LDL-C) goals were only achieved in 24.4% of patients during the first year of follow-up.

CONCLUSION

By analyzing EMR data representing routine practice in Korea, we found that patients with very high-risk ASCVD were at substantial risk of further cardiovascular events in 3 years. Given the observed risk of recurrent events with suboptimal lipid management by statin, additional treatment to control LDL-C might be necessary to reduce the burden of further cardiovascular events for very high-risk ASCVD patients.

Suboptimal lipid management before and after ischaemic stroke and TIA-the North Dublin Population Stroke Study

BACKGROUND

Few population-based studies have assessed lipid adherence to international guidelines for primary and secondary prevention in stroke/transient ischaemic attack (TIA) patients.

AIMS

This study aims to evaluate adherence to lipid-lowering therapy (LLT) guidelines amongst patients with ischaemic stroke/TIA.

METHODS

Using hot and cold pursuit methods from multiple hospital/community sources, all stroke and TIA cases in North Dublin City were prospectively ascertained over a 1-year period. Adherence to National Cholesterol Education Programme (NCEP) III guidelines, before and after index ischaemic stroke/TIA, was assessed.

RESULTS

Amongst 616 patients (428 ischaemic stroke, 188 TIA), total cholesterol was measured following the qualifying event in 76.5% (471/616) and low-density lipoprotein (LDL) in 60.1% (370/616). At initial stroke/TIA presentation, 54.1% (200/370) met NCEP III LDL goals. Compliance was associated with prior stroke (odds ratio [OR] 2.19, p = 0.02), diabetes (OR 1.91, p = 0.04), hypertension (OR 1.57, p = 0.03), atrial fibrillation (OR 1.78, p = 0.01), pre-event LLT (OR 2.85, p < 0.001) and higher individual LDL goal (p = 0.001). At stroke/TIA onset, 32.7% (195/596) was on LLT. Nonetheless, LDL exceeded individual NCEP goal in 29.2% (56/192); 21.6% (53/245) warranting LLT was not on treatment prior to stroke/TIA onset. After index stroke/TIA, 75.9% (422/556) was on LLT; 15.3% (30/196) meeting NCEP III criteria was not prescribed a statin as recommended. By 2 years, actuarial survival was 72.8% and 11.9% (59/497) experienced stroke recurrence. No association was observed between initial post-event target adherence and 2-year outcomes.

CONCLUSIONS

In this population-based study, LLT recommended by international guidelines was under-used, before and after index stroke/TIA. Strategies to improve adherence are needed.

Patterns and Predictors of Discharge Statin Prescription Among Hospitalized Patients With Intracerebral Hemorrhage

Background and Purpose— Many patients hospitalized with intracerebral hemorrhage are at high future risk for ischemic events and may benefit from stain therapy. However, little is known about patterns of statin prescription among patients with intracerebral hemorrhage, especially after the finding of higher hemorrhagic stroke risk in the statin treatment arm of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. We evaluated recent nationwide trends in discharge statin treatment after intracerebral hemorrhage hospitalization.

Methods— Using data from 25 673 patients with hemorrhagic stroke admitted to Get With Guidelines–Stroke participating hospitals between January 1, 2005, and December 31, 2007, we assessed factors associated with discharge statin prescription, including treatment over time and in relation to dissemination of the SPARCL results. Piecewise logistic multivariable regression models were fit to track statin use in various periods.

Results— Mean age was 67.9±15 years, 48.1% female, and discharge statin treatment in 39.5%. Variables independently associated with lower discharge statin use included female sex (OR 0.87, 95% CI, 0.82 to 0.93), prior stroke/transient ischemic attack (OR 0.85, 95% CI, 0.78 to 0.92), academic center (OR 0.87, 95% CI, 0.82 to 0.93), and Midwest region (OR 0.65, 95% CI, 0.56 to 0.80). Statin prescription climbed over the study period from 66.9% to 74.5% ( P <0.001) among eligible patients with a decrease during SPARCL reporting ( P =0.03) and then a return to prior levels thereafter.

Conclusions— Discharge statin prescription among hospitalized patients with intracerebral hemorrhage has modestly risen over time. The clinical implications of this care pattern among patients with intracerebral hemorrhage require further study.

Recent nationwide trends in discharge statin treatment of hospitalized patients with stroke

BACKGROUND AND PURPOSE

The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial showed statins reduce vascular risk among patients with atherosclerotic stroke or transient ischemic attack. In this study, we assessed recent nationwide trends in discharge statin treatment after acute stroke and the influence of SPARCL on clinical practice.

METHODS

Using data from eligible patients with stroke and transient ischemic attack admitted to Get With The Guidelines-Stroke (GWTG-Stroke) -participating hospitals between January 1, 2005, and December 31, 2007, we assessed discharge statin use over time and in relation to dissemination of the SPARCL results.

RESULTS

Among 173,284 patients with ischemic stroke and transient ischemic attack, overall discharge statin treatment was 83.5%. Discharge statin prescription climbed steadily but modestly over the 2-year study period from 75.7% to 84.8% (P<0.001) with a nonsignificant increase during SPARCL reporting but a return to prior levels thereafter. Factors associated with lower discharge statin use in patients without contraindications included female sex and South region.

CONCLUSIONS

Discharge statin prescription among hospitalized patients with stroke increased over time, but 1 in 5 patients still leaves the hospital without treatment. Primary drivers of increased use were secular trends and individual/hospital site characteristics.

Pathways and tools of Stroke PROTECT: a hospital-based recurrent stroke prevention program

Patients hospitalized with recent symptomatic cerebral ischemia are at high early risk for subsequent cerebrovascular events. This notwithstanding, an unacceptably high proportion of these patients do not receive prompt and appropriate treatment with evidence-based, guideline-recommended, vascular risk-reduction therapies when exposed to conventional care. Studies of ischemic stroke and transient ischemic attack patients reveal that treatment guidelines are often not followed or variably applied, thereby impeding improvements in care quality and clinical outcomes. A likely contributor to this evidence-practice chasm has been the unavailability to care providers of user-friendly, broadly applicable tools/algorithms that could facilitate ready and uniform implementation of proven therapies.The Stroke PROTECT (Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment) program, was designed for inpatient, outpatient, and transitional care settings, and systematically implements evidence-based medication and behavioral secondary prevention measures following the occurrence of an ischemic stroke or transient ischemic attack. PROTECT program pathways and tools incorporate early recognition and prompt initiation of evidence-based, guideline-recommended care in eligible patients without contraindications. The program has been associated with significant increases in discharge treatment utilization, as well as better therapy adherence, target biomarker control and enhanced clinical outcomes in the postdischarge setting. By utilizing best-care practices, PROTECT aims to help practitioners caring for patients with established cerebrovascular disease, to improve the quality of in-hospital and postdischarge stroke care.

Trend in incidence of cardiovascular risk factors in elderly and over-aged stroke patients between 2003 and 2007 in Greece

The aim of this study is to identify the main cardiovascular risk factors (CRFs) in patients over 65 years with ischemic stroke. This is a retrospective study in 175 patients that were hospitalized in our department due to ischemic stroke in the period 2006-2007. The patients were divided in two groups: Group I--elderly (65-80 years) and Group II--over-aged (>or=81 years). The results were compared with a similar study performed in our department in the period 2002-2003 in 160 ischemic stroke patients. Statistical analysis was made by the chi2-test. Hypertension, either alone or in combination with other CRFs, constitutes the main CRF. Diabetes mellitus (DM) is not frequently the sole CRF but its coexistence with other CRFs ranks DM as the second most important CRF, with the largest percentage in the elderly. Dyslipipidemia is 4th CRF in order following the coronary heart disease (CHD). Taking into account that the provision of acute therapeutic intervention in elderly and over-aged ischemic stroke patients is in most cases difficult, because of their age and the high risk of thrombolysis in these patients, there is increased need to focus on primary prevention of ischemic stroke by treating associated CRF.

Lipid management in ischemic stroke patients

OBJECTIVES

In-hospital initiation and maintaining of lipid-lowering therapy (LLT) after discharge is recommended for dyslipidemic stroke patients. However, little is known about actual adherence to treatment in Taiwan. This study aims to describe the current practice of lipid testing and LLT and to identify predictors for patient to receive LLT.

METHODS

Between February 2001 and December 2002, a total of 1105 consecutive ischemic stroke patients were prospectively registered. Dyslipidemic ischemic stroke patients were recruited and followed over a 6 months period.

RESULTS

In-hospital lipid testing was performed in 91% of all patients and LLT was initiated in 74% (350/476) of dyslipidemic patients. During the 6 months follow-up period, lipid testing was performed in 77% (266/345) and LLT was maintained in 45% (154/345) of patients. However, the target LDL cholesterol level (<100mg/dL) was achieved in only 30% (78/255) of patients. Older patients had a lower chance to receive LLT.

CONCLUSIONS

The in-hospital initiation of LLT and lipid testing was considered adequate as compared to other studies. However, after discharge from the hospital, many patients, especially older patients remained untreated. Efforts to close treatment gaps in lipid management require sustained quality improvement efforts. More awareness in this area is needed.

Preventing another event: role of the hospitalist in discharge stroke prevention

Only 1 of 8 stroke patients is managed exclusively by a neurologist. Furthermore, many stroke patients harbor other vascular comorbidities and are also at risk for developing general medical complications that can lead to death following stroke. With the growing hospitalist system, it is quite clear that hospitalists are, and will increasingly be, an integral part of the care team for many hospitalized stroke patients. Because prevention remains the mainstay of treatment for ischemic stroke and TIA, it would be useful for practicing hospitalists to know the scientific evidence behind recommended therapeutic approaches to reducing vascular risk following stroke, as well as strategies for bridging the prevailing evidence-practice gap for hospitalized stroke patients, which this review article presents.