Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-28T22:07:31.681Z Has data issue: false hasContentIssue false
  • English
  • Français

Secondary Stroke Prevention: Practice Patterns in a Tertiary Care Stroke Service

Published online by Cambridge University Press:  02 December 2014

Janice C. Fan ,
Tania M. Mysak ,
Thomas J. Jeerakathil  and
Glen J. Pearson
Janice C. Fan*
Affiliation:
Pharmacy Department, North York General Hospital, Toronto, Ontario
Tania M. Mysak
Affiliation:
Pharmacy Services, Alberta Health Services
Thomas J. Jeerakathil
Affiliation:
Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
Glen J. Pearson
Affiliation:
Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
*
North York General Hospital, Pharmacy Department, 4001 Leslie Street, Toronto, Ontario, M2K 1E1, Canada.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

Stroke and transient ischemic attack (TIA) have a high personal and financial cost to society and prevention is critical. Outside of registries in Ontario, there has been little effort to determine whether care gaps exist for secondary preventative care within Canada. The objective of this study was to evaluate inpatient medical team compliance to four secondary stroke prevention interventions: antithrombotic therapy, antihypertensive therapy, lipid lowering therapy and smoking cessation.

Methods:

Adults admitted to the University of Alberta Hospital stroke service with a diagnosis of stroke or TIA between August 1st, 2005 and July 31st, 2006 were identified using International Classification of Diseases (10th Revision) codes. Two hundred charts were randomly selected for retrospective review. Compliance, defined as achievement of therapeutic targets or appropriate therapy for subtherapeutic targets, was assessed.

Results:

Among 190 eligible patients (mean age 67 years, 55 % male), 147 (77.4%) had a non-cardioembolic cerebral event while 43 (22.6%) had a cardioembolic cerebral event. We found high compliance for antithrombotic (92% [174/190]) and antihypertensive (95% [136/143]) agents, but suboptimal compliance for lipid lowering agents (68% [107/158]) and smoking cessation (27% [17/64]).

Conclusions:

There is room for improvement in early risk factor management for secondary prevention, even in specialized stroke centres. To optimize stroke preventative care, more interdisciplinary collaboration, investigation of reasons for suboptimal care, development of strategies to minimize care gaps and ongoing stroke care audits for quality improvement are needed.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 37 , Issue 2 , March 2010 , pp. 245 - 251
Copyright
Copyright © The Canadian Journal of Neurological 2010

References

1. Stroke, statistics. Ottawa (ON): Heart and Stroke Foundation of Canada; [no date, cited April 10th, 2008]. Available from: http://www.heartandstroke.ab.ca/site/c.lqIRL1PJJtH/b.3651251/k.BD66/stroke_statistics.htm Google Scholar
2. Canadian Institute for Health Information. The burden of neurological diseases, disorders and injuries in Canada. Ottawa (ON): CIHI; 2007.Google Scholar
3. Coull, AJ, Lovett, JK, Rothwell, PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ. 2004;328:326.Google Scholar
4. Vickrey, BG, Rector, TS, Wickstrom, SL, Guzy, PM, Sloss, EM, Gorelick, PB, et al. Occurrence of secondary ischemic events among persons with atherosclerotic vascular disease. Stroke. 2002;33:901–6.Google Scholar
5. Antithrombotic Trialists’ Collaboration. Collaborative metaanalysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.CrossRefGoogle Scholar
6. Diener, HC, Cunha, L, Forbes, C, Sivenius, J, Smets, P, Lowenthal, A. European Stroke Prevention Study 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci. 1996;143:1–13.Google Scholar
7. The ESPRIT Study Group. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet. 2006;367:1665–73.Google Scholar
8. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:1329–39.Google Scholar
9. Diener, HC, Bogousslavsky, J, Brass, LM, Cimminiello, C, Csiba, L, Kaste, M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364:331–7.CrossRefGoogle ScholarPubMed
10. EAFT (European Atrial Fibrillation Trial) Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet. 1993;342:1255–62.CrossRefGoogle Scholar
11. Albers, GW, Amarenco, P, Easton, JD, Sacco, RL, Teal, P. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest. 2004;126(3)Suppl:S483S–512.CrossRefGoogle ScholarPubMed
12. Sacco, RL, Adams, R, Albers, G, Alberts, MJ, Benavente, O, Furie, K, et al. Guidelines for the prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006;37:577–617.Google Scholar
13. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033–41.CrossRefGoogle Scholar
14. Rashid, P, Leonardi-Bee, J, Bath, P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke. 2003;34:2741–9.CrossRefGoogle ScholarPubMed
15. Semplicini, A, Calo, L. Administering antihypertensive drugs after acute ischemic stroke: timing is everything. CMAJ. 2005;172(5):625–6.Google Scholar
16. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med. 1998;339(19):1349–57.Google Scholar
17. Plehn, JF, Davis, BR, Sacks, FM, Rouleau, JL, Pfeffer, MA, Bernstein, V, et al. Reduction of stroke incidence after myocardial infarction with pravastatin: the Cholesterol and Recurrent Events (CARE) study. Circulation. 1999;99:216–23.CrossRefGoogle ScholarPubMed
18. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355(6):549–59.Google Scholar
19. Law, MR, Wald, NJ, Rudnicka, AR. Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ. 2003;326:1423–7.Google Scholar
20. Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective metaanalysis of data from 90056 participants in 14 randomised trials of statins. Lancet. 2005;366:1267–78.CrossRefGoogle Scholar
21. Graham, ID, Beardall, S, Carter, AO, Glennie, J, Hébert, PC, Tetroe, JM, et al. What is the quality of drug therapy clinical practice guidelines in Canada? CMAJ. 2001;165(2):157–63.Google Scholar
22. Cabana, MD, Rand, CS, Powe, NR, Wu, AW, Wilson, MH, Abboud, PC, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–65.Google Scholar
23. Schwamm, LH, Fonarow, GC, Reeves, MJ, Pan, W, Frankel, MR, Smith, EE, et al. Get With the Guidelines Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119:107–15.CrossRefGoogle ScholarPubMed
24. Kapral, MK, Laupacis, A, Phillips, SJ, Silver, FL, Hill, MD, Fang, J, et al. Stroke care delivery in institutions participating in the Registry of the Canadian Stroke Network. Stroke. 2004;35:1756–62.CrossRefGoogle ScholarPubMed
25. Mouradian, MS, Majumdar, SR, Senthilselvan, A, Khan, K, Shuaib, A. How well are hypertension, hyperlipidemia, diabetes, and smoking managed after a stroke or transient ischemic attack? Stroke. 2002;33:1656–9.CrossRefGoogle ScholarPubMed
26. Mouradian, MS, Hussain, MS, Lari, H, Salam, A, Senthilselvan, A, Dean, N, et al. The impact of a stroke prevention clinic in diagnosing modifiable risk factors for stroke. Can J Neurol Sci. 2005;32:496–500.CrossRefGoogle ScholarPubMed
27. Capital Health programs and services: acute stroke. Edmonton (AB): Capital Health; [no date, cited December 15th, 2006]. Available from: www.capitalhealth.ca/ProgramsAndServices/BrowseServicesByAlpha/Content?IA_ID=5988 Google Scholar
28. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, enhanced Canadian version (ICD-10-CA). Ottawa (ON): Canadian Institute of Health Information; [no date; cited January 5th, 2007]. Available from: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=codingclass_icd10_e Google Scholar
29. Research, Randomizer. Middletown (CT): Urbaniak GC, Plous S; [no date; cited March 4th, 2007]. Available from: www.randomizer.org/form.htm Google Scholar
30. Canadian Hypertension Education Program recommendations for the management of hypertension 2006. Ottawa (ON): Canadian Hypertension Education Program; [no date, cited October 25th, 2006]. Available from: www.hypertension.ca Google Scholar
31. Genest, J, Frohlich, J, Fodor, G, McPherson, R. Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. CMAJ. 2003;169(9):921–4.Google ScholarPubMed
32. Adams, RJ, Albers, G, Alberts, MJ, Benavente, O, Furie, K, Goldstein, LB, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647–52.Google Scholar
33. Diener, HC, Sacco, RL, Yusuf, S, Cotton, D, Ôunpuu, S, Lawton, WA, et al. Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebocontrolled study. Lancet Neurol. 2008;7:875–84.Google Scholar
34. Cannon, CP, Braunwald, E, McCabe, CH, Rader, DJ, Rouleau, JL, Belder, R. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. New Engl J Med. 2004;350:1495–504.CrossRefGoogle ScholarPubMed
35. California Acute Stroke Pilot Registry (CASPR) Investigators. The impact of standardized stroke orders on adherence to best practices. Neurology. 2005;65:360–5.CrossRefGoogle Scholar
36. Ovbiagele, B, Saver, JL, Fredieu, A, Suzuki, S, McNair, N, Dandekar, A, et al. PROTECT: a coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217–22.CrossRefGoogle ScholarPubMed