Ischemic Stroke and Secondary Prevention in Clinical Practice

Risk of Sarcopenia Following Long-Term Statin Use in Community-Dwelling Middle-Aged and Older Adults in Japan

BACKGROUND

Inconsistent results have been reported concerning the association between statin administration and muscle health, specifically its potential to increase the risk of sarcopenia. Given the widespread long-term use of statins among the elderly population, the exploration of this association remains a crucial yet insufficiently examined matter. This study aimed to assess the association between the prolonged administration of statins and the risk of sarcopenia, diminished muscle strength, reduced skeletal muscle mass and impaired physical performance.

METHODS

This population-based cohort study was conducted in Japan utilizing data derived from the National Institute for Longevity Sciences-Longitudinal Study of Aging (NILS-LSA). The study participants, enlisted from the 2nd to the 6th waves (spanning from April 2000 to July 2010) of NILS-LSA, were those who aged 40 years or older and had initiated statin therapy (n = 348, age: 64.1 years, female: 63.5%). Individuals who were not administered statins (n = 2559, age: 55.5 years, female: 48.4%) were arbitrarily chosen using a combined approach of propensity score (PS) matching and risk set sampling to form the control group (with a 1:4 matching ratio). The primary outcome of this study was the occurrence of sarcopenia, as defined by the 2019 consensus of the Asian Working Group for Sarcopenia (AWGS). The secondary outcomes included low muscle mass (< 7.0 kg/m2 for men and below 5.4 kg/m2 for women by DXA), reduced skeletal muscle strength (handgrip strength < 28 kg in men and < 18 kg in women) and subpar physical performance (6-min walking speed < 1.0 m/s). The relationship between the use of statins and the outcomes was estimated using a Cox proportional hazard model with time-varying covariates, which included the status of statin use and other variables (two-tailed p < 0.05 was considered statistically significant). Stratification based on age and sex, along with five sensitivity analyses-including propensity score overlap weighting and a negative control-was conducted.

RESULTS

After applying PS matching, we identified 342 statin initiators and 1294 non-statin users, with well-balanced baseline characteristics between the groups. The use of statins was not associated with an increased risk of incident sarcopenia (adjusted hazard ratio [aHR], 1.43 [95% CI, 0.86, 2.36]), diminished muscle strength (aHR, 1.11 [95% CI, 0.80, 1.54]), reduced muscle mass (aHR, 1.09 [95% CI, 0.66, 1.82]) or impaired physical performance (aHR, 0.73 [95% CI, 0.46, 1.17]). These findings were consistent across age and sex stratifications, as well as all sensitivity analyses.

CONCLUSIONS

Statin use was not associated with an elevated risk of sarcopenia or impaired muscle health among community-dwelling middle-aged and older adults in Japan.

Cost-Minimization Model in Cryptogenic Stroke: ePatch vs Implantable Loop Recorder in Patients from the UK, Netherlands, and Sweden

Background

Patients who have experienced a cryptogenic stroke (CS) may benefit from extended monitoring and possible earlier detection of atrial fibrillation (AF), allowing for the timely initiation of appropriate pharmacotherapy.

Objective

This economic study aimed to evaluate the clinical and cost outcomes of using mid-term cardiac monitors (referred to as "ePatch") versus ILR-only in post-CS patients in the UK, Netherlands (NL) and Sweden.

Methods

An existing cost-minimization model was modified to fit healthcare settings in the UK, Netherlands and Sweden. The model's target population was composed of adult patients who had previously experienced a CS, but had no documented history of AF. The model compares the one-year direct medical costs between two groups: one group receiving wearable ePatch, the other group proceeding directly to ILR.

Results

When applied to a group of 1,000 patients, the ePatch versus ILR approach resulted in cost savings, due to combination of reduced expenses and decreased modelled occurrence of recurrent strokes in all three countries studied. In the base case analysis, the cost savings per patient with detected AF for ePatch ranged from 3.4-6.0 times, depending on the country.

Conclusion

Utilizing ePatch extended wear Holter for mid-term ECG monitoring in CS patients represents a cost-saving alternative to monitoring with ILR. The cost savings were achieved by reducing device expenses and by prevention of recurrent strokes via earlier anticoagulation initiation. Preventing recurrent strokes in this population is highly significant, as it can lead to improved long-term health outcomes and reduced overall healthcare costs.

A nomogram for predicting hemorrhagic transformation in acute ischemic stroke receiving intravenous thrombolysis with extended time window

A recent randomized controlled clinical trial expanded the time window of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) beyond 4.5 hours by applying neuroimaging standards, enabling more patients to benefit from IVT. However, hemorrhagic transformation (HT) after IVT is still a major concern. We aimed to develop a nomogram to predict HT in AIS patients receiving IVT with extended time window. We aimed to develop a nomogram to predict HT in AIS patients receiving IVT with extended time window. Patients with AIS receiving IVT with extended time window from March 2017 to April 2023 were retrospectively reviewed. They were divided into the HT group and the non-HT group based on computed tomography. Logistic regression analysis was used to screen the predictive factors for HT. A nomogram was developed based on the predictive factors. The predictive accuracy of the nomogram was assessed by the area under the curve (AUC) of the receiver operating characteristic curve (ROC). A calibration plot was used to evaluate the calibration of the nomogram. A decision curve analysis (DCA) was used to test the clinical value. A total of 210 patients were enrolled, and 44 patients (21.0%) had HT. Onset to needle time (ONT) (OR = 1.002, 95% CI: 1.000-1.004, P = .016), atrial fibrillation (OR = 2.853, 95% CI: 1.072-7.594, P = .036), and baseline NIHSS (OR = 1.273, 95% CI: 1.159-1.399, P = .000) were predictive factors of HT. The AUC of the nomogram was 0.833 (95% CI: 0.7623-0.9041), with a sensitivity of 78.9% and specificity of 77.3%. The calibration curve indicates that predicted results of the nomogram were in good agreement with the actual observation results. The DCA showed the nomogram had good clinical applicability in predicting HT. We developed an easy-to-use nomogram to predict HT in AIS patients receiving IVT with extended time window. It could be a potential tool to stratify the risk of HT for patients beyond 4.5 hours of onset who may undergo IVT.

Impact of Age on Prescribing Patterns of Cardiovascular Medications in Older Japanese Patients with Non-Dialysis-Dependent Chronic Kidney Disease: A Cross-Sectional Study

AIM

Older patients with chronic kidney disease (CKD) are more likely to be excluded from clinical trials. This exclusion affects the quality of cardiovascular disease (CVD) prevention in this population.

METHODS

Baseline data from the Fukuoka Kidney Disease Registry (FKR) cohort, which included 4476 adult patients with CKD stages G1-G5, were cross-sectionally analyzed to compare the use of recommended drugs for preventing CVD in each age group.

RESULTS

Different prescribing patterns were observed according to age for the cardiovascular drug classes. Older patients with CKD were less likely to receive renin-angiotensin system (RAS) inhibitors and were more likely to receive calcium channel blockers. The proportion of anticoagulation prescriptions for patients with CKD and atrial fibrillation decreased in the older age group (≥ 75 years). However, the proportion of antiplatelet therapy in patients with ischemic CVD increased linearly with age, even in the very old group aged ≥ 85 years. These findings suggest a severe cardiovascular burden in patients with CKD. Notably, RAS inhibitor use was avoided in the older group despite a severe cardiovascular burden, such as a high prevalence of CVD history and massive albuminuria ＞300 mg/g creatinine. This finding indicates that an older age independently contributed to the non-use of RAS inhibitors, even after adjusting for other covariates.

CONCLUSIONS

This study suggests that age is a potential barrier to the treatment of patients with CKD and highlights the need to establish individualized treatment strategies for cardiovascular protection in this population.

Association Between Immigration Status and Ambulatory Secondary Stroke Preventive Care in Ontario, Canada

BACKGROUND AND OBJECTIVES

Secondary stroke preventive care includes evaluation and control of vascular risk factors to prevent stroke recurrence. Our objective was to evaluate the quality of ambulatory stroke preventive care and its variation by immigration status in adult stroke survivors in Ontario, Canada.

METHODS

We conducted a population-based administrative database-derived retrospective cohort study in Ontario, Canada. Using immigration records, we defined immigrants as those immigrating after 1985 and long-term residents as those arriving before 1985 or those born in Canada. We included community-dwelling stroke survivors 40 years and older with a first-ever stroke between 2011 and 2017. In the year following their stroke, we evaluated the following metrics of stroke prevention: testing for hyperlipidemia and diabetes; among those with the condition, control of diabetes (hemoglobin A1c ≤7%) and hyperlipidemia (low-density lipoprotein <2 mmol/L); medication use to control hypertension, diabetes, and atrial fibrillation; and visit to a family physician and a specialist (neurologist, cardiologist, or geriatrician). We determined age and sex-adjusted absolute prevalence difference (APD) between immigrants and long-term residents for each metric using generalized linear models with binomial distribution and an identity link function.

RESULTS

We included 34,947 stroke survivors (median age 70 years, 46.9% women) of whom 12.4% were immigrants. The receipt of each metric ranged from 68% to 90%. Compared with long-term residents, after adjusting for age and sex, immigrants were slightly more likely to receive screening for hyperlipidemia (APD 5.58%; 95% CI 4.18-6.96) and diabetes (5.49%; 3.76-7.23), have visits to family physicians (1.19%; 0.49-1.90), receive a prescription for antihypertensive (3.12%; 1.76-4.49) and antihyperglycemic medications (9.51%; 6.46-12.57), and achieve control of hyperlipidemia (3.82%; 1.01-6.63). By contrast, they were less likely to achieve diabetes control (-4.79%; -7.86 to -1.72) or have visits to a specialist (-1.68%; -3.12 to -0.24). There was minimal variation by region of origin or time since immigration in immigrants.

DISCUSSION

Compared with long-term residents, many metrics of secondary stroke preventive care were better in immigrants, albeit with small absolute differences. However, future work is needed to identify and mitigate the factors associated with the suboptimal quality of stroke preventive care for all stroke survivors.

Assessing the impact of atrial fibrillation self-care interventions: A systematic review

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population.

Trends in the Use of Medications for Secondary Ischemic Stroke Prevention in Denmark, 2005-2021

BACKGROUND AND OBJECTIVES

Understanding trends in the use of medications for secondary stroke prevention is crucial for identifying areas for improvement in stroke care. We examined the use of lipid-lowering, antihypertensive, glucose-lowering, oral anticoagulant, and antiplatelet medications after ischemic stroke hospitalization, from 2005 to 2021.

METHODS

Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a first-time or recurrent ischemic stroke (N = 150,744). Stratified by calendar year, we ascertained the 180-day probability of filling a prescription for the abovementioned medications after discharge. We further assessed factors associated with medication use.

RESULTS

From 2005 to 2021, lipid-lowering medication use increased from 58.3% to 82.0%; atorvastatin use rose from 2.1% to 64.8% and simvastatin use decreased from 55.7% to 8.6%. Antihypertensive medication use remained stable, at approximately 89%, and various antihypertensive classes were used comparably. Glucose-lowering medication use increased from 71.5% in 2005 to 84.1% in 2021, driven primarily by an increase in metformin use (from 28.0% to 59.5%). Use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors continually increased (from 1.7% to 17.5% and from 0.5% to 17.3%, respectively) between 2015 and 2021. Anticoagulant medication use rose from 45.9% in 2005 to 87.0% in 2021, primarily because of increased use of direct oral anticoagulant medications starting around 2010 and a decline in warfarin use. Antiplatelet use remained consistently high, at approximately 95%. Trends were consistent across subgroups of interest; however, overall medication use was lower in older patients (65 years and older), patients with severe stroke, and patients with neurologic and psychiatric comorbidities.

DISCUSSION

Despite increasing trends in the use of 3 of 5 medication classes, the overall use of lipid-lowering, glucose-lowering, and oral anticoagulant medications was somewhat lower than expected according to clinical guidelines, particularly among older patients with more severe stroke and other comorbidities. The relatively low use in these subgroups may signify appropriate clinical decision making in consideration of frequent contraindications and reduced life expectancy or highlight potential areas of improvement for the care of patients with recent ischemic stroke.

[Mauvais contrôle des facteurs de risque cardiovasculaire modifiables chez les patients congolais en phase aiguë et séquellaire d'un accident vasculaire cérébral : Une étude transversale]

PURPOSE

To assess the level of the control of the cardiovascular risk factors in patients with a history of stroke in the Democratic Republic of the Congo.

METHODS

The level of the control of arterial hypertension, diabetes mellitus, and dyslipidemias was analyzed in two hundred and seventy-four (274) patients followed for stroke.

RESULTS

Among 188 patients with a prior diagnosis of arterial hypertension, only 100 (53.2%) were treated, 27 (27.0%) had their blood pressure well controlled [12.3% in acute stroke vs. 46.5% in sequelae phase; p = 0.0002].  Among 42 (71.2%) diabetics treated, 23 (63.9%) had glycaemia levels > 200 mg/dl, 60.0% in acute phase and 83.3% in sequelae phase (p = 0.28). Finally, 87.0% of the patients had a non-HDL-C > 85 mg/dl.

CONCLUSIONS

This study shows a poor control of modifiable cardiovascular risk factors in patients with very high cardiovascular risk due to stroke. There is a need for an effective program to combat non-communicable diseases in our environment.

'Pill-in-the-pocket' Oral Anticoagulation Guided by Daily Rhythm Monitoring for Stroke Prevention in Patients with AF: A Systematic Review and Meta-analysis

Aims

In patients with a low AF burden and long periods of sinus rhythm, 'pill-in-the-pocket' oral anticoagulation (OAC) may, taken as needed in response to AF episodes, offer the same thromboembolic protection as continuous, life-long OAC, while reducing bleeding complications at the same time. The purpose of this study is to systematically summarise available evidence pertaining to the feasibility, safety and efficacy of pill-in-the-pocket OAC.

Methods

Medline and Embase were searched from inception to July 2022 for studies adopting a pill-in-the-pocket OAC strategy in AF patients guided by daily rhythm monitoring (PROSPERO/CRD42020209564). Outcomes of interest were extracted and event rates per patient-years of follow-up were calculated. A random effects model was used for pooled estimates.

Results

Eight studies were included (711 patients). Daily rhythm monitoring was continuous in six studies and intermittent in two (pulse checks or smartphone single-lead electrocardiograms were used). Anticoagulation criteria varied across studies, reflecting the uncertainty regarding the AF burden that warrants anticoagulation. The mean time from AF meeting OAC criteria to its initiation was not reported. Adopting pill-in-the-pocket OAC led to 390 (54.7%) patients stopping OAC, 85 (12.0%) patients taking pill-in-the-pocket OAC and 237 (33.3%) patients remaining on or returning to continuous OAC. Overall, annualised ischaemic stroke and major bleeding rates per patient-year of follow-up were low at 0.005 (95% CI [0.002-0.012]) and 0.024 (95% CI [0.013-0.043]), respectively.

Conclusion

Current evidence, although encouraging, is insufficient to inform practice. Additional studies are required to improve our understanding of the relationships between AF burden and thromboembolic risk to help define anticoagulation criteria and appropriate monitoring strategies.

Younger age of stroke in low-middle income countries is related to healthcare access and quality

Stroke is the second leading cause of mortality globally with higher burden and younger age in low‐middle income countries (LMICs) than high‐income countries (HICs). However, it is unclear to what extent differences in healthcare access and quality (HAQ) and prevalence of risk factors between LMICs and HICs contribute to younger age of stroke in LMICs. In this systematic review, we conducted meta‐analysis of 67 articles and compared the mean age of stroke between LMICs and HICs, before and after adjusting for HAQ index. We also compared the prevalence of main stroke risk factors between HICs and LMICs. The unadjusted mean age of stroke in LMICs was significantly lower than HICs (63.1 vs. 68.6), regardless of gender (63.9 vs. 66.6 among men, and 65.6 vs. 70.7 among women) and whether data were collected in population‐ (64.7 vs. 69.5) or hospital‐based (62.6 vs. 65.9) studies (all p < 0.01). However, after adjusting for HAQ index, the difference in the mean age of stroke between LMICs and HICs was not significant (p ≥ 0.10), except among women (p = 0.048). In addition, while the median prevalence of hypertension in LMICs was 23.4% higher than HICs, the prevalence of all other risk factors was lower in LMICs than HICs. Our findings suggest a much larger contribution of HAQ to the younger mean age of stroke in LMICs, as compared with other potential factors. Additional studies on stroke care quality and accessibility are needed in LMICs.

Secondary Stroke Prevention in Polish Adults: Results from the LIPIDOGRAM2015 Study

BACKGROUND

The purpose of the study was to evaluate secondary stroke prevention in Poland and its association with sociodemographic factors, place of residence, and concomitant cardiovascular risk factors.

MATERIAL AND METHODS

From all patients in LIPIDOGRAM2015 Study (n = 13,724), 268 subjects had a history of ischaemic stroke and were included.

RESULTS

165 subjects (61.6%) used at least one preventive medication. Oral antiplatelet and anticoagulation agents were used by 116 (43.3%) and 70 (26.1%) patients, respectively. Only 157 (58.6%) participants used lipid-lowering drugs, and 205 (76.5%) were treated with antihypertensive drugs. Coronary heart disease (CHD) and dyslipidaemia were associated with antiplatelet treatment (p = 0.047 and p = 0.012, respectively). A history of atrial fibrillation, CHD, and previous myocardial infarction correlated with anticoagulant treatment (p = 0.001, p = 0.011, and p < 0.0001, respectively). Age, gender, time from stroke onset, place of residence, and level of education were not associated with antiplatelet or anticoagulant treatment. Only 31.7% of patients were engaged in regular physical activity, 62% used appropriate diet, and 13.6% were current smokers.

CONCLUSIONS

In Poland drugs and lifestyle modification for secondary stroke prevention are not commonly adhered to. Educational programmes for physicians and patients should be developed to improve application of effective secondary prevention of stroke.

Cost-effectiveness of insertable cardiac monitors for diagnosis of atrial fibrillation in cryptogenic stroke in Australia

INTRODUCTION

Detection of atrial fibrillation (AF) is required to initiate oral anticoagulation (OAC) after cryptogenic stroke (CS). However, paroxysmal AF can be difficult to diagnose with short term cardiac monitoring. Taking an Australian payer perspective, we evaluated whether long-term continuous monitoring for 3 years with an insertable cardiac monitor (ICM) is cost-effective for preventing recurrent stroke in patients with CS.

METHODS

A lifetime Markov model was developed to simulate the follow-up of patients, comparing long-term continuous monitoring with an ICM to monitoring by conventional care. We used a linked evidence approach to estimate the rates of recurrent stroke when AF detection leads to initiation of OAC, as detected using ICM during the lifetime of the device or as detected using usual care. All diagnostic and patient management costs were modeled. Other model inputs were determined by literature review. Probabilistic sensitivity analysis (PSA) was undertaken to explore the effect of parameter uncertainty according to CHADS2 score and OAC treatment effect.

RESULTS

In the base-case analysis, the model predicted an incremental cost-effectiveness ratio (ICER) of A$29 570 per quality-adjusted life year (QALY). Among CHADS2 subgroups analyses, the ICER ranged from A$26 342/QALY (CHADS2 = 6) to A$42 967/QALY (CHADS2 = 2). PSA suggested that the probabilities of ICM strategy being cost-effective were 53.4% and 78.7%, at thresholds of $30 000 (highly cost-effective) and $50 000 per QALY (cost-effective), respectively.

CONCLUSIONS

Long-term continuous monitoring with an ICM is a cost-effective intervention to prevent recurrent stroke in patients following CS in the Australian context.

Sex Differences in Stroke Care and Outcome 2005-2018: Observations From the Swedish Stroke Register

BACKGROUND AND PURPOSE

Previous studies of stroke management and outcome in Sweden have revealed differences between men and women. We aimed to analyze if differences in stroke incidence, care, and outcome have altered over time.

METHODS

All stroke events registered in the Swedish Stroke Register 2005 to 2018 were included. Background variables and treatment were collected during the acute hospital stay. Survival data were obtained from the national cause of death register by individual linkage. We used unadjusted proportions and estimated age-adjusted marginal means, using a generalized linear model, to present outcome.

RESULTS

We identified 335 183 stroke events and a decreasing incidence in men and women 2005 to 2018. Men were on average younger than women (73.3 versus 78.1 years) at stroke onset. The age-adjusted proportion of reperfusion therapy 2005 to 2018 increased more rapidly in women than in men (2.3%-15.1% in men versus 1.4%-16.9% in women), but in 2018, women still had a lower probability of receiving thrombolysis within 30 minutes. Among patients with atrial fibrillation, oral anticoagulants at discharge increased more rapidly in women (31.2%-78.6% in men versus 26.7%-81.9% in women). Statins remained higher in men (36.9%-83.7% in men versus 32.3%-81.2% in women). Men had better functional outcome and survival after stroke. After adjustment for women's higher age, more severe strokes, and background characteristics, the absolute difference in functional outcome was <1% and survival did not differ.

CONCLUSIONS

Stroke incidence, care, and outcome show continuous improvements in Sweden, and previously reported differences between men and women become less evident. More severe strokes and older age in women at stroke onset are explanations to persisting differences.

Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke

Stroke is a leading cause of morbidity and mortality worldwide. Although the majority of strokes affect the elderly, the incidence of stroke in young patients is on the rise. Prompt recognition of stroke symptoms and time critical therapies play a key role in management and prognosis of this condition. This is especially critical in young stroke patients, for whom delays in early recognition and treatment can result in many years of disability with associated social and financial burden. Misdiagnosis and unwarranted variation in treatment of stroke in young patients is problematic. Clinician implicit bias, the unconscious and unintentional process of judgement in healthcare decision-making, is a contributor to the short-falls in outcomes in this population. Interventions in this process have been shown to improve clinical outcomes in young stroke patients and represent an active area of study.

Trends in Atrial Fibrillation Incidence Rates Within an Integrated Health Care Delivery System, 2006 to 2018

IMPORTANCE

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and multiple studies have reported increasing AF incidence rates over time, although the underlying explanations remain unclear.

OBJECTIVES

To estimate AF incidence rates from 2006 to 2018 in a community-based setting and to investigate possible explanations for increasing AF by evaluating the changing features of incident AF cases and the pool of patients at risk for AF over time.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 500 684 patients who received primary care and other health care services for more than 2 years through a single integrated health care delivery network in Pennsylvania. Data collection was conducted from January 2003 to December 2018. The base study population had no documentation of AF in the electronic medical record for at least 2 years prior to baseline. Data analysis was conducted from May to December 2019.

MAIN OUTCOMES AND MEASURES

Incident AF cases were identified through diagnostic codes recorded at inpatient or outpatient encounters. Age- and sex-adjusted AF incidence rates were estimated by calendar year from 2006 to 2018 both overall and across subgroups, including according to diagnostic setting (inpatient vs outpatient) and priority (primary vs secondary diagnosis).

RESULTS

Among 514 293 patients meeting criteria for the base study population, the mean (SD) age at baseline was 47 (18) years and 282 103 (54.9%) were women; 13 609 (2.6%) met AF diagnostic criteria on or prior to the baseline date and were excluded. Among 500 684 patients free of AF at baseline, standardized AF incidence rates from 2006 to 2018 increased from 4.74 (95% CI, 4.58-4.90) to 6.82 (95% CI, 6.65-7.00) cases per 1000 person-years, increasing significantly over time (P < .001). Incidence rates increased in all age and sex subgroups, although absolute rate increases were largest among those aged 85 years or older. The fraction of incident AF cases among individuals aged 85 years or older increased from 135 of 1075 (12.6%) in 2006 to 451 of 2427 (18.6%) in 2017. Patients with incident AF were more likely over time to have high body mass index (1351 of 3389 patients [39.9%] in 2006-2008 vs 4504 of 9214 [48.9%] in 2015-2018; P < .001), hypertension (2764 [81.6%] in 2006-2008 vs 7937 [86.1%] in 2015-2018; P < .001), and ischemic stroke (328 [9.7%] in 2006-2008 vs 1455 [15.8%] in 2015-2018; P < .001), but less likely to have coronary artery disease (1533 [45.2%] in 2006-2008 vs 3810 [41.4%] in 2015-2018; P < .001). Among 22 077 new cases of AF, 9146 (41.4%) were diagnosed as inpatients and 5731 (26.0%) as the primary diagnosis. Incidence rates of AF increased significantly in all diagnostic setting and priority pairings (eg, inpatient, primary: rate ratio, 1.07; 95% CI, 1.06-1.08; P < .001). Among patients at risk for AF, high BMI and hypertension increased over time (BMI: 71 433 of 198 245 [36.0%] in 2007 to 130 218 of 282 270 [46.1%] in 2017; hypertension: 79 977 [40.3%] in 2007 to 134 404 [47.6%] in 2017). Documentation of short-term ECG increased over time (23 297 of 207 349 [11.2%] in 2008 to 45 027 [16.0%] in 2017); however, long-term ECG monitoring showed no change (1871 [0.9%] in 2007 to 4036 [1.4%] in 2017).

CONCLUSIONS AND RELEVANCE

In this community-based study, AF incidence rates increased significantly during the study period. Concurrent increases were observed in AF risk factors in the at-risk population and short-term ECG use.

Use of Statins After Ischemic Stroke in Young Adults and Its Association With Long-Term Outcome

Background and Purpose—

Knowledge of the use of secondary preventive medication in young adults is limited. We studied the use of statins and its association with subsequent vascular events in young adults with ischemic stroke—a patient group with a known low burden of atherosclerosis.

Methods—

The study population included 935 first-ever 30-day ischemic stroke survivors aged 15 to 49 years from the Helsinki Young Stroke Registry, 1994 to 2007. Follow-up data until 2012 were obtained from the Social Insurance Institution of Finland (Drug Prescription Register), the Finnish Care Register, and Statistics Finland. The association of the use of statins (defined as at least 2 purchases) with all-cause mortality, recurrent stroke, and other recurrent vascular events was assessed through adjusted Cox regression analyses. We further compared propensity score–matched statin users with nonusers.

Results—

Of our 935 patients, 46.8% used statins at some point during follow-up. Higher age, dyslipidemia, heavy alcohol use, and hypertension were significantly associated with purchasing statins. Statin users exhibited lower risk of all-cause mortality (hazard ratio, 0.38 [95% CI, 0.25–0.58]) and recurrent stroke (hazard ratio, 0.29 [95% CI, 0.19–0.44]) than nonusers, after adjustment for dyslipidemia, stroke subtype, and other confounders. These results remained unchanged after propensity score–matched comparison.

Conclusions—

Less than half of young ischemic stroke patients used statins; use was affected by age and risk factor profile. Statin use was independently associated with lower risk of all-cause mortality and recurrent stroke.

Treatment with Statins in Elderly Patients

Elderly patients are a special category of patients, due to the physiological changes induced by age, the great number of comorbidities and drug treatment and last, but not least, to the cognitive dysfunction frequently encountered in this population. Cardiovascular disease is the most important cause of morbidity and mortality in elderly individuals worldwide. The rate of cardiovascular events increases after 65 years in men and after 75 years in women. Myocardial infarction and stroke are the leading disorders caused by atherosclerosis, that lead to death or functional incapacity. Elderly people have a greater risk to develop atherosclerotic cardiovascular disease. The incidence and prevalence of atherosclerosis increase with age and the number of cardiovascular events is higher in elderly patients. The most efficient treatment against atherosclerosis is the treatment with statins, that has been shown to decrease the risk both of stroke and coronary artery disease in all age groups. The advantages of the treatment become evident after at least one year of treatment. Primary prevention is the most important way of preventing cardiovascular disease in elderly individuals, by promoting a healthy lifestyle and reducing the risk factors. Secondary prevention after a stroke or myocardial infarction includes mandatory a statin, to diminish the risk of a recurrent cardiovascular event. The possible side effects of statin therapy are diabetes mellitus, myopathy, and rhabdomyolysis, hepatotoxicity. The side effects of the treatment are more likely to occur in elderly patients, due to their multiple associated comorbidities and drugs that may interact with statins. In elderly people, the benefits and disadvantages of the treatment with statins should be put in balance, especially in those receiving high doses of statins.

Statin use and high-dose statin use after ischemic stroke in the UK: a retrospective cohort study

Background: Trial evidence supports statin use after ischemic stroke and recent American, European and British guidelines recommend high-intensity statins for this indication. Limited data are available describing current statin use among these patients in unselected settings. We conducted a cohort study to examine secular trends and factors associated with statin use and dose following ischemic stroke. Methods: A retrospective cohort study of patients with first ischemic stroke between 2000 and 2014 was conducted using the Clinical Practice Research Datalink (CPRD). Proportions of statin users and high-intensity statin users within 2 years after stroke were estimated for each calendar year. We used Cox regression models to explore potential factors associated with statin use and Poisson regression models to calculate risk ratios for the use of a high-intensity statin. Results: A total of 80,442 patients with first stroke were analyzed. The proportion using statins within 2 years after stroke increased from 25% in 2000 to 70% in 2006 and remained at about 75% through 2014. Among post-stroke statin users, high-intensity use accounted for approximately 15% between 2004 and 2011 and then increased to almost 35% in 2014. Older patients (aged ≥75 years), younger patients (<45 years), patients with no prior statin treatment, dementia, underweight, or absence of cardiovascular factors (coronary heart disease, smoking, obesity, diabetes, hypertension, or transient ischemic attack) were less likely to use statins and less likely to receive a high-intensity statin. Conclusion: There has been an increase over time in both statin use and dose, but many patients with ischemic stroke continue to be under-treated. Clinical trials and policy interventions to improve appropriate post-stroke statin use should focus on younger and older patients, patients with no pre-stroke statin treatment, and patients without additional cardiovascular risk factors.

Impact of age on cardiovascular drug use in patients with chronic kidney disease

Background

Elderly patients with chronic kidney disease (CKD) are often excluded from clinical trials; this may affect their use of essential drugs for cardiovascular complications. We sought to assess the impact of age on cardiovascular drug use in elderly patients with CKD.

Methods

We used baseline data from the Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort including 3033 adult patients with CKD Stages 3 and 4. We studied the use of recommended drugs for coronary artery disease (CAD), stroke and atrial fibrillation by age, after adjusting for socio-demographic and clinical conditions.

Results

The patients’ mean age was 66.8 years (mean estimated glomerular filtration rate 32.9 mL/min/1.73 m²). The prevalence of CAD was 24.5% [81.3% receiving antiplatelet agents, 75.6% renin–angiotensin system (RAS) blockers, 65.4% β-blockers and 81.3% lipid-lowering therapy], that of stroke 10.0% (88.8% receiving antithrombotic drugs) and that of atrial fibrillation 11.1% (69.5% receiving oral anticoagulants). Compared with patients aged <65 years, older age (≥65 years) was associated with greater use of antithrombotic drugs in stroke [adjusted odds ratio (aOR) (95% confidence interval) = 2.83 (1.04–7.73) for patients aged (75–84 years)] and less use of RAS blockers [aOR = 0.39 (0.16–0.89) for patients aged ≥85 years], β-blockers [aOR = 0.31 (0.19–0.53) for patients aged 75–84 years] and lipid-lowering therapy [aOR = 0.39 (0.15–1.02) for patients aged ≥85 years, P for trend = 0.01] in CAD. Older age was not associated with less use of antiplatelet agents in CAD or oral anticoagulants in atrial fibrillation.

Conclusions

In patients with CKD, older age per se was not associated with the underuse of antithrombotic drugs but was for other major drugs, with a potential impact on cardiovascular outcomes.

[Association of atrial fibrillation with hemorrhagic transformation after intravenous thrombolysis in patients with ischemic stroke]

OBJECTIVE

To investigate the association of atrial fibrillation (AF) with hemorrhagic transformation (HT) in patients with ischemic stroke treated by intravenous thrombolysis.

METHODS

Clinical data of 3272 patients treated by intravenous thrombolysis from 71 hospitals in Zhejiang Province during June 2017 and December 2018 were retrospectively reviewed. Intracranial HT was defined as intracranial hemorrhage suggested by imaging examination 24 hours after intravenous thrombolysis. Patients were dichotomized into HT group (n=533) and non-HT group (n=2739). The association of AF and HT was analyzed by univariate analysis and binary logistic regression.

RESULTS

Compared with the non-HT group, the HT group were older, had longer onset to needle time (ONT), higher baseline National Institute of Health Stroke Scale (NIHSS) score, higher baseline glucose level, and higher AF rate (P<0.05 or P<0.01). Binary logistic regression analysis revealed that AF was independently associated with HT (OR=2.527, 95%CI:2.030-3.146, P<0.01).

CONCLUSIONS

AF is independently associated with the occurrence of HT in ischemic stroke patients treated with intravenous thrombolysis.

Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis

OBJECTIVE

Whether statins increase the risk of intracerebral haemorrhage (ICH) in patients with a previous stroke remains uncertain. This study addresses the evidence of statin therapy on ICH and other clinical outcomes in patients with previous ischaemic stroke (IS) or ICH.

METHODS

A systematic literature review and meta-analysis was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess observational and randomised studies comparing statin therapy with control (placebo or no treatment) in patients with a previous ICH or IS. The risk ratios (RR) for the primary outcome (ICH) and secondary outcomes (IS, any stroke, mortality and function) were pooled using random effects meta-analysis according to stroke subtype.

RESULTS

Forty-three studies with a combined total of 317 291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled RR for recurrent ICH (1.04, 95% CI 0.86 to 1.25; n=23 695); however, statins were associated with significant reductions in mortality (RR 0.49, 95% CI 0.36 to 0.67; n=89 976) and poor functional outcome (RR 0.71, 95% CI 0.67 to 0.75; n=9113). In patients with previous IS, statins were associated with a non-significant increase in ICH (RR 1.36, 95% CI 0.96 to 1.91; n=103 525), but significantly lower risks of recurrent IS (RR 0.74, 95% CI 0.66 to 0.83; n=53 162), any stroke (RR 0.82, 95% CI 0.67 to 0.99; n=55 260), mortality (RR 0.68, 95% CI 0.50 to 0.92; n=74 648) and poor functional outcome (RR 0.83, 95% CI 0.76 to 0.91; n=34 700).

CONCLUSIONS

Irrespective of stroke subtype, there were non-significant trends towards future ICH with statins. However, this risk was overshadowed by substantial and significant improvements in mortality and functional outcome among statin users.

TRIAL REGISTRATION NUMBER

CRD42017079863.

Secondary prevention and lifestyle indices after stroke in a long-term perspective

OBJECTIVES

To describe the long-term perspective regarding prevalence of risk factors, secondary stroke prevention, and lifestyle indices after stroke.

METHODS

From a population-based one-year cohort (n = 416), we performed an observational study of 145 survivors at 16 months and 10 years after stroke (age 27-97 years) regarding secondary prevention including reaching acceptable treatment goals; nutritional status with focus on underweight; and the lifestyle indices: living situation, level of dependence, and self-assessed health condition.

RESULTS

Ten years after stroke, 50% of the subjects with hypertension diagnosis and 55% of those without hypertension diagnosis were within the blood pressure goal <140/90 compared with 32% (P = .008) and 37% (N.S.) at 16 months. Acceptable HbA1c levels among subjects with diabetes mellitus diagnosis increased from 35% to 45% (N.S.). Among those without diabetes diagnosis, satisfactory HbA1c levels decreased from 98% to 79% (P < .001). Underweight increased from 9% to 17% (P = .019). Among patients with cerebral infarction, the prevalence of atrial fibrillation increased from 22% to 29% (P = .004), and treatment with oral anticoagulants from 75% to 78% (N.S.). Acceptable LDL cholesterol levels increased from 59% to 80% (P = .033) among subjects on lipid lowering treatment, and from 18% to 40% among untreated (P = .010). At 10 years, 90% still lived in their own home. Health condition was reported as good/very good/excellent by 65%. Age, female sex, and living situation were associated with intensity of secondary prevention measures and underweight.

CONCLUSIONS

The proportion of individuals within treatment goals improved over time, but secondary prevention still needed additional consideration 10 years after stroke.

Timing of oral anticoagulant therapy in acute ischemic stroke with atrial fibrillation: study protocol for a registry-based randomised controlled trial

Background

Oral anticoagulation therapy is recommended for the prevention of recurrent ischemic stroke in patients with atrial fibrillation (AF). Current guidelines do not provide evidence-based recommendations on optimal time-point to start anticoagulation therapy after an acute ischemic stroke. Non-vitamin K antagonist oral anticoagulants (NOACs) may offer advantages compared to warfarin because of faster and more predictable onset of action and potentially a lower risk of intracerebral haemorrhage also in the acute phase after an ischemic stroke. The TIMING study aims to establish the efficacy and safety of early vs delayed initiation of NOACs in patients with acute ischemic stroke and AF.

Methods/Design

The TIMING study is a national, investigator-led, registry-based, multicentre, open-label, randomised controlled study. The Swedish Stroke Register is used for enrolment, randomisation and follow-up of 3000 patients, who are randomised (1:1) within 72 h from ischemic stroke onset to either early (≤ 4 days) or delayed (≥ 5–10 days) start of NOAC therapy. The primary outcome is the composite of recurrent ischemic stroke, symptomatic intracerebral haemorrhage, or all-cause mortality within 90 days after randomisation. Secondary outcomes include: individual components of the primary outcome at 90 and 365 days; major haemorrhagic events; functional outcome by the modified Rankin Scale at 90 days; and health economics. In an optional biomarker sub-study, blood samples will be collected after randomisation from approximately half of the patients for central analysis of cardiovascular biomarkers after study completion. The study is funded by the Swedish Medical Research Council. Enrolment of patients started in April 2017.

Conclusion

The TIMING study addresses the ongoing clinical dilemma of when to start NOAC after an acute ischemic stroke in patients with AF. By the inclusion of a randomisation module within the Swedish Stroke Register, the advantages of a prospective randomised study design are combined with the strengths of a national clinical quality register in allowing simplified enrolment and follow-up of study patients. In addition, the register adds the possibility of directly assessing the external validity of the study findings.

Trial registration

ClinicalTrials.gov, NCT02961348. Registered on 8 November 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2313-9) contains supplementary material, which is available to authorized users.

Prescription of secondary preventive drugs after ischemic stroke: results from the Malaysian National Stroke Registry

BACKGROUND

Evaluation of secondary stroke prevention in low and middle-income countries remains limited. This study assessed the prescription of secondary preventive drugs among ischemic stroke patients upon hospital discharge in Malaysia and identified factors related to the prescribing decisions.

METHODS

From Malaysian National Stroke Registry, we included patients with non-fatal ischemic stroke. Prescriptions of antiplatelet, anticoagulants, antihypertensive drugs and lipid-lowering drugs were assessed. Multi-level logistic regressions were performed to determine the relation between potential factors and drug prescriptions.

RESULTS

Of 5292 patients, 48% received antihypertensive drugs, 88.9% antiplatelet and 88.7% lipid-lowering drugs upon discharge. Thirty-three percent of patients with an indication for anticoagulants (n = 391) received it. Compared to patients <=50 years, patients above 70 years were less likely to receive antiplatelet (OR: 0.72, 95% CI: 0.50-1.03), lipid-lowering drugs (OR: 0.66, 95% CI: 0.45-0.95) and anticoagulants (OR: 0.27, 95% CI: 0.09-0.83). Patients with moderate to severe disability upon discharge had less odds of receiving secondary preventive drugs; an odds ratio of 0.57 (95% CI: 0.45-0.71) for antiplatelet, 0.86 (95% CI: 0.75-0.98) for antihypertensive drugs and 0.78 (95% CI: 0.63-0.97) for lipid-lowering drugs in comparison to those with minor disability. Having prior specific comorbidities and drug prescriptions significantly increased the odds of receiving these drugs. No differences were found between sexes and ethnicities.

CONCLUSIONS

Prescription of antihypertensive drugs and anticoagulants among ischemic stroke patients in Malaysia were suboptimal. Efforts to initiate regular clinical audits to evaluate the uptake and effectiveness of secondary preventive strategies are timely in low and middle-income settings.

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose

Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes.

Method

We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up.

Findings

We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit.

Discussion

Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke.

Conclusion

Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.

Antiplatelet and anticoagulant therapy in elderly people with type 2 diabetes mellitus in Poland (based on the PolSenior Study)

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is an important and common cardiovascular risk factor. The purpose of the study was to evaluate the frequency of use of oral antiplatelet drugs (OAPs) and oral anticoagulant drugs (OACs) among the elderly with T2DM in Poland.

MATERIAL AND METHODS

The study was based on the data collected in the Polish national PolSenior study.

RESULTS

Among 4979 PolSenior participants aged 65 and over, 883 (17.8%) had previously diagnosed T2DM. Among them, 441 (49.9%) used at least one drug in pharmacological cardiovascular prevention, i.e. OAPs (mostly ASA) in 405 (45.9%) cases and OACs in 38 (4.3%). The use of these drugs significantly depended on the sex (p = 0.02) and personal income (p = 0.05). Age, place of residence and level of education did not affect the prevalence of pharmacological prevention. Previous stroke and myocardial infarction were mostly associated with OAPs, whereas a history of atrial fibrillation (AF) was related to OAC treatment. Among participants treated with OAPs, therapy was applied as secondary cardiovascular prevention in 211 (52.1%) subjects, and as primary prevention in 194 (47.9%) subjects. Among participants treated with OACs, 24 (64.9%) persons had a history of AF. Secondary cardiovascular pharmacological prevention should be considered in 45 untreated participants (12.5%), and primary cardiovascular pharmacological prevention (SCORE ≥ 10 and/or AF) in 154 participants (42.7%).

CONCLUSIONS

Cardiovascular pharmacological prevention in the elderly with T2DM in Poland seems to be unsatisfactory. Educational programmes concerning current recommendations for pharmacological cardiovascular prevention should be developed among general practitioners.

Integrated sensor-augmented pump therapy systems [the MiniMed® Paradigm™ Veo system and the Vibe™ and G4® PLATINUM CGM (continuous glucose monitoring) system] for managing blood glucose levels in type 1 diabetes: a systematic review and economic evaluation

BACKGROUND

In recent years, meters for continuous monitoring of interstitial fluid glucose have been introduced to help people with type 1 diabetes mellitus (T1DM) to achieve better control of their disease.

OBJECTIVE

The objective of this project was to summarise the evidence on the clinical effectiveness and cost-effectiveness of the MiniMed(®) Paradigm™ Veo system (Medtronic Inc., Northridge, CA, USA) and the Vibe™ (Animas(®) Corporation, West Chester, PA, USA) and G4(®) PLATINUM CGM (continuous glucose monitoring) system (Dexcom Inc., San Diego, CA, USA) in comparison with multiple daily insulin injections (MDIs) or continuous subcutaneous insulin infusion (CSII), both with either self-monitoring of blood glucose (SMBG) or CGM, for the management of T1DM in adults and children.

DATA SOURCES

A systematic review was conducted in accordance with the principles of the Centre for Reviews and Dissemination guidance and the National Institute for Health and Care Excellence Diagnostic Assessment Programme manual. We searched 14 databases, three trial registries and two conference proceedings from study inception up to September 2014. In addition, reference lists of relevant systematic reviews were checked. In the absence of randomised controlled trials directly comparing Veo or an integrated CSII + CGM system, such as Vibe, with comparator interventions, indirect treatment comparisons were performed if possible.

METHODS

A commercially available cost-effectiveness model, the IMS Centre for Outcomes Research and Effectiveness diabetes model version 8.5 (IMS Health, Danbury, CT, USA), was used for this assessment. This model is an internet-based, interactive simulation model that predicts the long-term health outcomes and costs associated with the management of T1DM and type 2 diabetes. The model consists of 15 submodels designed to simulate diabetes-related complications, non-specific mortality and costs over time. As the model simulates individual patients over time, it updates risk factors and complications to account for disease progression.

RESULTS

Fifty-four publications resulting from 19 studies were included in the review. Overall, the evidence suggests that the Veo system reduces hypoglycaemic events more than other treatments, without any differences in other outcomes, including glycated haemoglobin (HbA1c) levels. We also found significant results in favour of the integrated CSII + CGM system over MDIs with SMBG with regard to HbA1c levels and quality of life. However, the evidence base was poor. The quality of the included studies was generally low, often with only one study comparing treatments in a specific population at a specific follow-up time. In particular, there was only one study comparing Veo with an integrated CSII + CGM system and only one study comparing Veo with a CSII + SMBG system in a mixed population. Cost-effectiveness analyses indicated that MDI + SMBG is the option most likely to be cost-effective, given the current threshold of £30,000 per quality-adjusted life-year gained, whereas integrated CSII + CGM systems and Veo are dominated and extendedly dominated, respectively, by stand-alone, non-integrated CSII with CGM. Scenario analyses did not alter these conclusions. No cost-effectiveness modelling was conducted for children or pregnant women.

CONCLUSIONS

The Veo system does appear to be better than the other systems considered at reducing hypoglycaemic events. However, in adults, it is unlikely to be cost-effective. Integrated systems are also generally unlikely to be cost-effective given that stand-alone systems are cheaper and, possibly, no less effective. However, evidence in this regard is generally lacking, in particular for children. Future trials in specific child, adolescent and adult populations should include longer term follow-up and ratings on the European Quality of Life-5 Dimensions scale at various time points with a view to informing improved cost-effectiveness modelling.

STUDY REGISTRATION

PROSPERO Registration Number CRD42014013764.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Atrial Fibrillation in Transient Ischemic Attack Versus Ischemic Stroke

Background and Purpose—

Compared with ischemic stroke (IS), the association of atrial fibrillation (AF) with transient ischemic attack (TIA) is less well established. We aimed to assess the proportion of AF in patients with TIA, and these patients’ characteristics and secondary preventive treatment in comparison to patients with IS.

Methods—

Hospital-based data on TIA and IS events, registered from July 2011 to June 2013, were obtained from the Swedish Stroke Register (Riksstroke). A time-based TIA definition (duration of symptoms <24 hours) was applied. AF was registered as present when previously known or diagnosed at the time of assessment.

Results—

AF was present in 2779 of 14 980 (18.6%) patients with TIA and 13 258 of 44 173 (30.0%) patients with IS. The proportion of AF increased with age, reaching 32.9% in TIA and 46.6% in IS patients ≥85 years. Both in TIA and IS, age, hypertension, a history of stroke, and TIA, and being a nonsmoker were associated with the presence of AF. In contrast to IS, AF was less common in female than in male patients with TIA. At discharge, 64.2% of TIA and 50.0% of IS patients with AF were treated with oral anticoagulants. Proportions of AF patients treated with oral anticoagulants decreased substantially with increasing age.

Conclusions—

AF is highly prevalent not only in IS but also in TIA patients, with proportions steeply increasing with age. In both TIA and IS, a substantial proportion of patients with AF were discharged without anticoagulant therapy.

Factors Associated with Thrombolysis Outcome in Ischemic Stroke Patients with Atrial Fibrillation

The outcome of early intravenous thrombolysis for ischemic stroke in patients with atrial fibrillation (AF) is worse than that without thrombosis. How to increase the efficacy of intravenous thrombolysis for AF-related ischemic stroke remains largely unknown. In this study, we investigated factors that influence the effect of intravenous thrombolysis in these patients. Our results showed that thrombolysis was independently associated with a favorable outcome (P < 0.001) and did not influence the mortality of AF-related ischemic stroke, although it increased the risk of hemorrhage within 24 h after treatment. Risk factors for a poor outcome at admission were: heart failure (P = 0.045); high systolic pressure (P = 0.039); high blood glucose (P = 0.030); and a high National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001). Moreover, high systolic pressure at admission (P = 0.007), high blood glucose (P = 0.027), and a high NIHSS score (P < 0.001) were independent risk factors for mortality at 3 months. Besides thrombolysis, a high NIHSS score (P = 0.006) and warfarin taken within 48 h before stroke onset (P = 0.032) were also independent risk factors for symptomatic hemorrhage within 24 h after treatment. Ischemic stroke patients with AF benefited from intravenous thrombolysis with recombinant tissue plasminogen activator within 4.5 h after stroke.

Risk of Recurrent Stroke and Death After First Stroke in Long-Distance Ski Race Participants

BACKGROUND

Physical activity is of benefit for primary prevention of cardiovascular diseases, but it appears to increase the risk for atrial fibrillation. We aimed to study a cohort of patients following a first stroke in individuals with previous high physical activity, compare them to the general population with respect to recurrent stroke and death, and relate these to atrial fibrillation.

METHODS AND RESULTS

From the participants of the Vasaloppet, the world's largest ski-race, and matched individuals from the general population (n=708,604), we identified 5964 patients hospitalized with a first-time stroke between 1994 and 2010. Individuals with severe diseases were excluded. One half percent of skiers and 1% of nonskiers were hospitalized due to stroke. The incidence rate was 8.3 per 100 person-years among skiers and 11.1 among nonskiers. The hazard ratio (HR) for recurrent stroke or death between the 2 groups was 0.76 (95% CI 0.67 to 0.86). The result was consistent in subgroups. The HR for death was 0.66 (95% CI 0.56 to 0.78) and for recurrent stroke 0.82 (95% CI 0.70 to 0.96). After adjustment for smoking and socioeconomic factors, the HR for death was consistent at 0.70 (95% CI 0.56 to 0.87) while the HR for recurrent stroke was not statistically significant. Outcomes for skiers with atrial fibrillation tended to show a lower risk than for nonskiers.

CONCLUSIONS

This large cohort study supports the hypothesis that patients with a stroke and with prior regular physical activity have a lower risk of death, while their risk for recurrent stroke is similar to that of nonskiers. The skiers had a higher incidence of atrial fibrillation, but still no increased risk of recurring stroke.

Prescription of "ineffective neuroprotective" drugs to stroke patients: a cross sectional study in North Indian population

In a developing country, where patient access to tertiary care is limited and most patients have to pay out of pocket, it is imperative for the physicians to practice evidence-based medicine. Reports on prescription details and surveys are not available. The aim of this study is to describe the prescribing patterns for various medications used in the treatment of stroke among the first contact physicians in North India; to estimate the proportion of patients being prescribed the non-recommended drugs and to determine any relationship between the economic status of the patient and the prescription pattern. Details of economic status, education level, type of stroke, type of hospital, qualification of treating physician and the number and nature of medications were noted from the prescriptions and patients. Two hundred and sixteen patients with ischemic stroke (71.3% males, average age 51.5 years) were included. Among poor patients, N = (36.8%) received any of the neuroprotective drugs including citicoline 19 (27.5%), piracetam 11(15.9%) and edaravone 2(2.9%). Both specialist and private hospitals are associated with higher prescription of "ineffective neuroprotective" drugs in both poor and rich patients. Reasons for overprescribing neuroprotective medications need to be studied and remedial measures need to be taken to practice evidence-based medicine.

Strokes in young adults: epidemiology and prevention

Strokes in young adults are reported as being uncommon, comprising 10%-15% of all stroke patients. However, compared with stroke in older adults, stroke in the young has a disproportionately large economic impact by leaving victims disabled before their most productive years. Recent publications report an increased incidence of stroke in young adults. This is important given the fact that younger stroke patients have a clearly increased risk of death compared with the general population. The prevalence of standard modifiable vascular risk factors in young stroke patients is different from that in older patients. Modifiable risk factors for stroke, such as dyslipidemia, smoking, and hypertension, are highly prevalent in the young stroke population, with no significant difference in geographic, climatic, nutritional, lifestyle, or genetic diversity. The list of potential stroke etiologies among young adults is extensive. Strokes of undetermined and of other determined etiology are the most common types among young patients according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Prevention is the primary treatment strategy aimed at reducing morbidity and mortality related to stroke. Therefore, primary prevention is very important with regard to stroke in young adults, and aggressive treatment of risk factors for stroke, such as hypertension, smoking, and dyslipidemia, is essential. The best form of secondary stroke prevention is directed toward stroke etiology as well as treatment of additional risk factors. However, there is a lack of specific recommendations and guidelines for stroke management in young adults. In conclusion, strokes in young adults are a major public health problem and further research, with standardized methodology, is needed in order to give us more precise epidemiologic data. Given the increasing incidence of stroke in the young, there is an objective need for more research in order to reduce this burden.

High Prevalence of Atrial Fibrillation Among Patients With Ischemic Stroke

Background and Purpose—

Atrial fibrillation (AF) is a common cause of devastating but potentially preventable stroke. Estimates of the prevalence of AF among patients with stroke vary considerably because of difficulties in detection of intermittent, silent AF. Better recognition of AF in this patient group may help to identify and offer protection to individuals at risk. Our aim was to determine the nationwide prevalence of AF among patients with ischemic stroke, as well as their use of oral anticoagulation.

Methods—

Cross-sectional study of unselected patients in cross-linked nationwide Swedish health registers. All 94 083 patients with a diagnosis of ischemic stroke in the nationwide stroke register Riks-Stroke between 2005 and 2010 were studied. Information about previously diagnosed AF, and comorbidity, was obtained from the nationwide Patient Register and cross-referenced with the national Drug Register containing data on all dispensed pharmacological prescriptions in Sweden.

Results—

Combination of data from Riks-Stroke and from the Patient Register showed that 31 428 (33.4%) patients with ischemic stroke had previously known, or newly diagnosed, AF. Of those, only 16.2% had received warfarin in a pharmacy within 6 months before stroke onset. After hospital discharge, only 35.0% of the survivors received warfarin within the first 3 months after discharge. The likelihood for underlying AF was strongly correlated to the CHA 2 DS 2 -VASC score, which is a point based scheme for assessment of stroke risk in AF but which also predicts likelihood of AF. In this scheme points are given for age, previous stroke or transient ischemic attack, hypertension, heart failure, diabetes, vascular disease and female sex.

Conclusions—

Access to nationwide register data shows that AF is more common among patients with ischemic stroke than those previously reported. Few patients with stroke and AF had anticoagulant treatment before the event, and few got it after the event. CHA 2 DS 2 -VASc could be a useful monitoring tool to intensify efforts to diagnose AF among patients with cryptogenic stroke.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack

BACKGROUND

This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA).

METHODS

A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated.

RESULTS

There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively.

CONCLUSION

Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.

Evidence-to-practice gaps in post-stroke management: a focus on care in a stroke unit and anticoagulation to prevent death, disability and recurrent stroke

ABSTRACT: 

The global burden of stroke is large. Over the last 15 years significant advances have been made to improve acute stroke care and prevention management providing the ability to mitigate much of this burden. In this article, we describe the importance of two main elements of stroke care: stroke units to reduce death and disability and anticoagulation therapy to prevent recurrent, often fatal or disabling, cardioembolic stroke. We also describe the issues related to translating these interventions into practice and the related economic implications. Despite the proven effectiveness and cost–effectiveness of these and other interventions, many people experiencing stroke are not receiving these interventions. Effective evidence translation initiatives and routine monitoring of healthcare is needed to address important gaps in stroke management in promoting societal well-being.

Ischemic stroke in patients older and younger than 80 years

OBJECTIVES

To compare short-term outcome and long-term mortality in old and younger patients with ischemic stroke. We hypothesized that short-term outcomes in patients≥80 and <80 years with no neurological worsening are similar.

METHODS

The National Institute of Health Stroke Scale (NIHSS) was used to assess stroke severity. Short-term outcome was determined by the NIHSS score 7 days after stroke onset. Neurological worsening was defined as NIHSS score worsening >3 points. Risk factors, prior diseases, complications, and long-term mortality were registered.

RESULTS

The study includes 592 patients≥80 years and 1275 patients<80 years. High NIHSS score on admission and day 7, neurological worsening, and complications were significantly more frequent among patients≥80 years. In patients with no neurological worsening, improvement in NIHSS score on day 7 was not associated with age≥80 years (P=0.75). Long-term mortality was associated with the number of risk factors in both age groups (P<0.05).

CONCLUSION

Avoiding neurological worsening may have a large potential for reducing the difference in short-term outcome between old and young stroke patients by preventing treatable complications including pneumonia. Risk factor burden is important for long-term survival in both stroke patients≥80 years and <80 years.

Evaluating stroke patients' awareness of risk factors and readiness to change stroke risk-related behaviors in a randomized controlled trial

PURPOSE

To identify the effects of a brief educational intervention on stroke patients' recall and recognition of risk factors and performance of and stage of change for stroke risk-related behaviors.

METHODS

Sixty-six patients with stroke participated in a multisite randomized controlled trial. The intervention group (n = 35) received a brief education intervention (tailored written stroke information, verbal reinforcement of information for 3 months after discharge, and provision of a telephone number). The control group (n = 31) received usual care. Unprompted recall (personal and general), prompted recognition of risk factors (0-13), and performance of (0-10) and stage of change for up to 7 stroke risk-related behaviors were assessed before and 3 months after discharge.

RESULTS

No significant between-group differences were found. For all participants over time, there were significant improvements for personal (mean difference [MD], 0.3; 95% CI, 0.004-0.69; P = .05) and general (MD, 0.6; 95% CI, 0.09-1.16; P = .02) risk factor recall; performance of stroke risk-related behaviors (MD, 0.8; 95% CI, 0.28-1.26; P < .01); and progression from a nonaction to an action stage of change for 4 of 7 behaviors over time. There was a significant decline in total risk factor recognition scores (MD, -0.8; 95% CI, 0.39-1.13; P < .01).

CONCLUSION

Stroke patients' unprompted recall of risk factors and performance of risk-related behaviors improved over time; readiness to change risk-related behaviors progressed for some behaviors. A brief educational intervention did not improve risk factor awareness or behavior change more than usual care.

Clinical factors associated with statins prescription in acute ischemic stroke patients: findings from the Lombardia Stroke Registry

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Secondary prevention of stroke in elderly people in Poland--results of PolSenior study

BACKGROUND AND PURPOSE

The purpose of the study was to evaluate the frequency of use of oral antiplatelet (OAP) and anticoagulant (OAC) drugs as secondary stroke prevention among older people in Poland and its association with sociodemographic factors, place of residence, and concomitant cardiovascular risk factors.

MATERIAL AND METHODS

The study group consisted of 426 subjects with a history of a previous stroke (mean age of 81.5±8.2 years), participants of multicentre, population-based PolSenior study.

RESULTS

Among the study group, 261 people (61.3%) used at least one drug as a secondary prevention. OAPs were regularly used by 237 people (55.6%), and OACs-by 25 people (5.9%). The most often used drug was acetylsalicylic acid. Ticlopidine was more frequently used than clopidogrel, and acenocoumarol was used more often than warfarin. Among all of the concomitant cardiovascular risk factors, congestive heart failure was mostly associated with OAP treatment, and a history of atrial fibrillation-with OAC treatment. Use of drugs did not depend on age, sex, place of residence (rural or urban), level of education and personal income, but it was associated with the region where the respondents lived.

CONCLUSIONS

Secondary cardiovascular preventive therapy in Poland is used too rarely in older people after stroke, and it especially concerns anticoagulant therapy in those with a history of atrial fibrillation. Structured educational programmes should be developed in Poland to improve usage of secondary preventive therapy in the elderly.

NT-proBNP best predictor of cardiovascular events and cardiovascular mortality in secondary prevention in very old age: the Leiden 85-plus Study

BACKGROUND

In the aging population cardiovascular disease (CVD) is highly prevalent. Identification of very old persons at high risk of recurrent CVD is difficult, since traditional risk markers loose predictive value with age.

METHODS

In a population-based sample of 282 85-year old participants with established CVD from the Leiden 85-plus Study, we studied predictive values of traditional cardiovascular risk markers, a history of major CVD (myocardial infarction, stroke or arterial surgery), and new cardiovascular biomarkers (estimated glomerular filtration rate (MDRD), C-reactive protein (CRP), homocysteine and N-terminal pro B-type natriuretic peptide (NT-proBNP)) regarding 5-year risk of recurrent cardiovascular events and mortality (composite endpoint).

RESULTS

During complete 5-year follow-up 157 (56%) participants died. 109 (39%) had a cardiovascular event or died from cardiovascular causes. Individually related to the composite endpoint were: a history of major CVD (HR 1.5 (95%CI 1.03-2.3)), CRP (HR 1.3 (95%CI 1.03-1.5)), homocysteine (HR 1.4 (95%CI 1.2-2.6)) and NT-proBNP (HR 1.7 (95%CI 1.4-2.1)). A prediction model including all traditional risk markers yielded a C-statistic of 0.59 (95%CI 0.52-0.66). Of all five new markers only addition of NT-proBNP improved the C-statistic (0.67 (95%CI 0.61-0.74, p=0.023)). The categoryless net reclassification improvement for NT-proBNP was 39% (p=0.001), for a history of major CVD 27.2% (p=0.03) and for homocysteine 24.7% (p=0.04).

CONCLUSIONS

Among very old subjects with established CVD, NT-proBNP was the strongest risk marker for cardiovascular events and cardiovascular mortality. When estimating risk in secondary prevention in very old age, use of NT-proBNP should be considered.

Predictive role of C reactive protein in stroke recurrence after cardioembolic stroke: the Fukuoka Stroke Registry

OBJECTIVES

We investigated the clinical characteristics of patients with stroke recurrence in the first year after cardioembolic stroke, and determined the predictors associated with recurrence.

DESIGN

A prospective cohort study.

SETTING

Multicentre study at the Fukuoka prefecture in Japan.

PARTICIPANTS

We enroled 2084 consecutive patients who were hospitalised in stroke centres within 7 days of onset from June 2007 to October 2009. The clinical characteristics of patients were assessed on admission, and the clinical course of all patients was followed for 1 year.

RESULTS

Of all patients, 425 (234 men, 76±11 years of age) had cardioembolic stroke and were included in this study. Fifty-one patients (12%) suffered a recurrence during the follow-up period. Age (HR 1.04, 95% CI 1.01 to 1.06, p=0.014), and level of C reactive protein (HR 1.01, 95% CI 1.00 to 1.02, p=0.018) on admission were significantly associated with recurrence in the univariate analyses. Male gender (HR 0.61, 95% CI 0.35 to 1.05, p=0.076), body mass index (HR 0.94, 95% CI 0.87 to 1.01, p=0.093), hypertension (HR 0.59, 95% CI 0.33 to 1.06, p=0.079), diastolic blood pressure (HR 0.99, 95% CI 0.97 to 1.00, p=0.087) and haematocrit (HR 0.95, 95% CI 0.91 to 1.00, p=0.052) were marginally significant in the univariate Cox analyses. Multivariate Cox proportional hazards analysis showed that age (HR 1.03, 95% CI 1.00 to 1.06, p=0.031, per 1-year increase), and C reactive protein (HR 1.01, 95% CI 1.00 to 1.02, p=0.022, per 1 mg/L increase) were independent predictors of a recurrence in the first year after cardioembolic stroke.

CONCLUSIONS

In patients with cardioembolic ischaemic stroke, age and C reactive protein are independent risk factors for recurrence in the first year after onset.

Adherence to secondary prevention medications and four-year outcomes in outpatients with atherosclerosis

BACKGROUND

Although nonadherence with evidence-based secondary prevention medications is common in patients with established atherothrombotic disease, long-term outcomes studies are scant. We assessed the prevalence and long-term outcomes of nonadherence to secondary prevention (antiplatelet agents, statins, and antihypertensive agents) medications in stable outpatients with established atherothrombosis (coronary, cerebrovascular, or peripheral artery disease) enrolled in the international REduction of Atherothrombosis for Continued Health registry.

METHODS

Adherence with these medications in eligible patients at baseline and 1-year follow-up was assessed. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke at 4 years.

RESULTS

A total of 37,154 patients with established atherothrombotic disease were included. Adherence rates with all evidence-based medications at baseline and 1 year were 46.7% and 48.2%, respectively. Nonadherence with any medication at baseline (hazard ratio, 1.18; 95% confidence interval, 1.11-1.25) and at 1 year (hazard ratio, 1.19; 95% confidence interval, 1.11-1.28) were both significantly associated with an increased risk of the primary end point. The risk of all-cause mortality was similarly elevated. Corresponding numbers needed to treat were 31 and 25 patients for the composite end point and total mortality, respectively. This also was true for each disease-specific subgroup. Patients who were fully adherent at both time points had the lowest incidence of adverse outcomes, whereas patients who were nonadherent at both time points had the worst outcomes (P < .01).

CONCLUSIONS

Our analysis of a large international registry demonstrates that nonadherence with evidence-based secondary prevention therapies in patients with established atherothrombosis is associated with a significant increase in long-term adverse events, including mortality.

Prognostic value of cardiovascular disease status: the Leiden 85-plus study

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.

Evaluation on the compliance with secondary prevention and influence factors of ischemic stroke in Hainan province, China

Survivors of ischemic stroke are still at a significant risk for recurrence. Numerous effective strategies for the secondary prevention of ischemic stroke have now been established; however, these guidelines are not widely known. In this retrospective, a multicenter study was conducted from January 2011 to February 2012 in 10 general hospitals, which included 1300 elderly patients who had previously been diagnosed with ischemic stroke and re-admitted to hospitals. Logistic regression models were fitted to determine the relationship between compliance with secondary prevention therapy and each variable of interest. The treatment rates of antihypertensive, antiplatelet and lipid-lowering therapy were only 56.3%, 48.9% and 19.6%, respectively. Multivariate analysis presented that cardiovascular risk factors would motivate patients with hypertension and hyperlipidemia to receive corresponding treatments. However, it is worth noting that they did not influence the use of antiplatelet therapy. In addition, high education, health education and insurance promote the use of secondary prevention in patients. In conclusion, the importance of antiplatelet therapy should not be ignored any more. Besides, health education will raise patients’ attention to ischemic stroke.

Real-effectiveness medicine--pursuing the best effectiveness in the ordinary care of patients

Clinical know-how and skills as well as up-to-date scientific evidence are cornerstones for providing effective treatment for patients. However, in order to improve the effectiveness of treatment in ordinary practice, also appropriate documentation of care at the health care units and benchmarking based on this documentation are needed. This article presents the new concept of real-effectiveness medicine (REM) which pursues the best effectiveness of patient care in the real-world setting. In order to reach the goal, four layers of information are utilized: 1) good medical know-how and skills combined with the patient view, 2) up-to-date scientific evidence, 3) continuous documentation of performance in ordinary settings, and 4) benchmarking between providers. The new framework is suggested for clinicians, organizations, policy-makers, and researchers.