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Is prestroke use of angiotensin-converting enzyme inhibitors associated with better outcome?

From the National Stroke Research Institute, Austin Health, Heidelberg Heights, Victoria, Australia (N.C., M.B.N., D.C.P., A.G.T.); Department of Medicine, University of Melbourne, Victoria, Australia (H.M.D., M.B.N., D.L.H., A.G.T.); Neurology Department, Austin Health, Heidelberg, Victoria, Australia (H.M.D., A.G.T.); and Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia (A.G.T.).

Address correspondence and reprint requests to Dr. Helen M. Dewey, National Stroke Research Institute, Level 1, Neurosciences Building, Repatriation Hospital Heidelberg, Austin Health, 300 Waterdale Road, Heidelberg Heights, Victoria 3081, Australia deweyhm{at}unimelb.edu.au

Background: There is evidence that angiotensin-converting enzyme inhibitors (ACEIs) reduce the risk of stroke. However, it is unclear whether ACEI use before stroke provides a vasoprotective effect resulting in less severe stroke.

Methods: We ascertained all strokes occurring in a defined population in Melbourne, Australia. Prestroke use of ACEIs and concomitant medications was obtained from medical records. Initial neurologic deficit was dichotomized according to a NIH Stroke Scale (NIHSS) score < 8 (less severe deficit) or 8 (severe deficit). Logistic regression was used to assess the association between prestroke use of ACEIs and stroke severity (measured by severity of neurologic deficits and death at 28 days).

Results: Seven hundred sixteen first-ever ischemic stroke patients were included. Previous use of ACEIs was independently associated with a reduced risk of severe neurologic deficits (odds ratio [OR] 0.56; 95% CI 0.35 to 0.91) and death within 28 days (OR 0.46; 95% CI 0.24 to 0.87). Diuretics were associated with an increased risk of severe neurologic deficits (OR 1.81; 95% CI 1.13 to 2.90). Factors associated with a greater NIHSS score were older age, atrial fibrillation, heart failure, and use of diuretics. These factors and claudication were associated with an increased risk of 28-day mortality, whereas use of anticoagulants was associated with a reduced risk of severe neurologic deficits and death.

Conclusion: Within this large community-based cohort, prestroke use of angiotensin-converting enzyme inhibitors was associated with a reduced risk of severe stroke.

Supplemental data at www.neurology.org

Supported by grants from the National Health and Medical Research Foundation Council, Victorian Health Promotion Foundation, and Foundation for High Blood Pressure Research.

Disclosure: The authors report no conflicts of interest.

Received March 22, 2006. Accepted in final form January 10, 2007.