The dimension of preventable stroke in a large representative patient cohort
Abstract
Objective
To analyze the frequency of inadequately treated risk factors in a large representative cohort of patients with acute ischemic stroke or TIA and to estimate the proportion of events potentially avertable by guideline-compliant preventive therapy compared to the status quo.
Methods
A total of 1,730 patients from the Poststroke Disease Management STROKE-CARD trial (NCT02156778) were recruited between 2014 and 2017. We focused on 8 risk conditions amenable to drug therapy and 3 lifestyle risk behaviors and assessed pre-event risk factor control in retrospect.
Results
The proportion of patients with at least 1 inadequately treated risk condition was 79.5% (95% confidence interval [CI] 77.6%–81.4%) and increased to 95.1% (95% CI 94.1%–96.1%) upon consideration of the lifestyle risk behaviors. Risk factor control was worse in patients with recurrent vs first-ever events (p < 0.001), men vs women (p = 0.003), and patients ≤75 vs >75 years of age (p < 0.001). The estimated degree of stroke preventability ranged from 0.4% (95% CI 0.2%–0.6%) to 13.7% (95% CI 12.2%–15.2%) for the individual risk factors. Adequate control of the 5 most relevant risk factors combined (hypertension, hypercholesterolemia, atrial fibrillation, smoking, and overweight) would have averted ≈1 of 2 events or 1 in 4 with a highly conservative computation approach.
Conclusions
Our study confirms the existence of a considerable gap between risk factor control recommended by guidelines and real-world stroke prevention. Our study intends to increase awareness among physicians about stroke preventability and provides a quantitative basis for the emerging discussion on how to best tackle this challenge.
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Information & Authors
Information
Published In
Neurology®
Volume 93 • Number 23 • December 3, 2019
Pages: e2121-e2132
Copyright
© 2019 American Academy of Neurology.
Publication History
Received: October 15, 2018
Accepted: July 22, 2019
Published online: October 31, 2019
Published in print: December 3, 2019
Authors
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Study Funding
This study was supported in part by grant IV-9516/75-2013 from the Tyrolean government. The Medical University of Innsbruck served as the sponsor of this study and received financial or staff support from the university hospital (Tirol Kliniken), Tyrolean Health Insurance, and the Tyrol Health Care Fund and grants from Boehringer Ingelheim, Nstim Services, and Sanofi. Drs. Boehme, Kiechl, and Knoflach are supported by the excellence initiative VASCage (Centre for Promoting Vascular Health in the Ageing Community), an R&D K-Centre (Competence Centers for Excellent Technologies [COMET program]) funded by the Austrian Ministry for Transport, Innovation and Technology, the Austrian Ministry for Digital and Economic Affairs, and the federal states of Tyrol, Salzburg, and Vienna.
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Cited By
- Early Diagnosis of Atrial Fibrillation and Stroke Incidence in Primary Care: Translating Measurements into Actions—A Retrospective Cohort Study, Biomedicines, 11, 4, (1116), (2023).https://doi.org/10.3390/biomedicines11041116
- Author response: The dimension of preventable stroke in a large representative patient cohort, Neurology, 95, 12, (557-557), (2023)./doi/10.1212/WNL.0000000000010594
- Author response: The dimension of preventable stroke in a large representative patient cohort, Neurology, 95, 12, (558-558), (2023)./doi/10.1212/WNL.0000000000010592
- Reader response: The dimension of preventable stroke in a large representative patient cohort, Neurology, 95, 12, (557-558), (2023)./doi/10.1212/WNL.0000000000010591
- Reader response: The dimension of preventable stroke in a large representative patient cohort, Neurology, 95, 12, (556-557), (2023)./doi/10.1212/WNL.0000000000010590
- The structured ambulatory post-stroke care program for outpatient aftercare in patients with ischaemic stroke in Germany (SANO): an open-label, cluster-randomised controlled trial, The Lancet Neurology, (2023).https://doi.org/10.1016/S1474-4422(23)00216-8
- Evaluation of a Newly Developed Smartphone App for Risk Factor Management in Young Patients With Ischemic Stroke: A Pilot Study, Frontiers in Neurology, 12, (2022).https://doi.org/10.3389/fneur.2021.791545
- Long-term outcome of a pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack: study protocol, BMC Cardiovascular Disorders, 22, 1, (2022).https://doi.org/10.1186/s12872-022-02785-5
- Reconstruction of pseudonymized patient-trajectories in Austria’s stroke cohort using medical record-linkage of in-patient routine documentation to establish a nation-wide acute stroke cohort of 102,107 pseudonymized patients between 2015 and 2019, European Stroke Journal, 7, 4, (456-466), (2022).https://doi.org/10.1177/23969873221107619
- Longer term patient management following stroke: A systematic review, International Journal of Stroke, 16, 8, (917-926), (2021).https://doi.org/10.1177/17474930211016963
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Boehme et al.1 examine the burden of untreated risk factors for stroke in 1,730 patients with ischemic stroke/TIA from the Poststroke Disease Management STROKE-CARD trial. They chose to focus on 8 risk factors amenable to drug therapy (hypertension, hypercholesterolemia, atrial fibrillation, previous atherosclerotic cardiovascular disease, diabetes mellitus, carotid stenosis, unrecognized TIA, and the presence of a mechanical heart valve) and 3 lifestyle risk behaviors (smoking, obesity, alcohol excess). An important omission from this list is the presence of chronic kidney disease (CKD). There is a strong association between CKD and stroke2, which is under-recognized and only addressed in current guidelines in terms of its potential to limit or alter otherwise established treatments.3 There is therapeutic nihilism associated with CKD whereby they are less likely to receive important guideline-recommended therapies, particularly oral anti-coagulants.4 It would be interesting to know what the prevalence of CKD was in this patient cohort and whether its presence increased the likelihood of poor risk factor control. There is a need for dedicated stroke prevention trials in this group and for closer collaboration between neurologists and nephrologists to bridge this therapeutic gap.5
Disclosure
The authors report no relevant disclosures. Contact [email protected] for full disclosures.
References
We thank Dr. Goldstein for the valuable comment on our article.1 Diabetes is a major risk factor for ischemic stroke and every fifth patient with diabetes dies of stroke.2 Guidelines recommend target control for hypertension and use of statins, whereas the benefit of prophylactic antiplatelet therapy remains controversial.3,4 In our cohort of ischemic stroke and TIA patients, 321 (18.6%) had diabetes and 60 of them were newly diagnosed (3.5% of all stroke/TIA patients). Among diabetic patients, 47.6% had undertreated hypertension, which is similar to the situation in patients without diabetes (45.3%). However, the proportion of patients not receiving adequate antithrombotic therapy—based on previous cardiovascular disease or carotid stenosis—was higher among diabetics (34.6% vs. 7.3%, p<0.001) as was the proportion of inadequately treated hypercholesterolemia (63.6% vs. 51.1%, p=0.002). Overall, risk factor control in diabetic patients was even worse than in non-diabetic patients—the proportions of patients with at least one untreated or inadequately treated risk condition at the time of the index event: 93.8% vs. 76.2%, p<0.001. Substantial improvement in primary prevention is one of the over-arching goals in the Action Plan for Stroke in Europe 2018–2030,5 and concerted actions are required to reduce the worrisome proportion of preventable strokes.
Disclosure
The authors report no relevant disclosures. Contact [email protected] for full disclosures.
References
We thank Dr. Kelly for the thoughtful comment on our article,1 which allows us to highlight important aspects regarding chronic kidney disease (CKD) in our work. In fact, CKD is an underrecognized important risk factor for ischemic stroke, potentially affecting safety and efficacy of cardiovascular prevention therapy. In our large cohort of patients with ischemic stroke or TIA, no less than 27.6% (95% CI, 25.5–29.7%) had a glomerular filtration rate (GFR) of less than 60ml/min/1.73m² upon hospital admission. The frequency of GFR categories G4 (GFR 15-29) and G5 (GFR<15) were rather low at 1.4% (0.9–2.0%) and 0.3% (0.2–0.4%). These proportions must be interpreted such that the most severe strokes with permanent severe disability (mRS=5 at hospital discharge) were excluded and proportions of severely decreased GFR and kidney failure are presumably higher in this latter group. Patients with a GFR less versus greater or equal 60ml/min/1.73m² showed similar proportions of at least one untreated or inadequately treated cardiovascular risk factor (80.7% vs. 79.0%).
Disclosure
The authors report no relevant disclosures. Contact [email protected] for full disclosures.
References
In their report of data from the Poststroke Disease Management (STROKE-CARD) trial,1 and consistent with other studies,2,3 Boehme et al. found that a high proportion of stroke is associated with potentially modifiable risk factors that are incompletely addressed, representing an important opportunity for effective prevention. Boehme et al., however, list the impact of risk factor management on stroke among those with diabetes as being unclear because of the lack of data showing that tight glycemic control reduces stroke incidence. As a result, diabetes mellitus was not separately considered in their calculation that 79.5% (95% CI 77.6%–81.4%) of their cohort had at least one untreated risk condition. Although likely reflected in other intervention categories in their analysis, it needs to be stressed that the risk of stroke in persons with diabetes can be reduced with antihypertensives and statins.4,5 Use of these approaches—in addition to general risk factor modification and the use of aspirin in those at high risk—are proven strategies for reducing stroke and cardiovascular risk in this population.
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References