Deintensification or No Statin Treatment Is Associated With Higher Mortality in Patients With Ischemic Stroke or Transient Ischemic Attack

Background and Purpose: Practice guidelines recommend that most patients receive moderate- or high-potency statins after ischemic stroke or transient ischemic attack (TIA) of atherosclerotic origin. We tested the association of different patterns of potency for prescribed statin therapy—assessed before admission and at hospital discharge for ischemic stroke or TIA—on mortality in a large, nationwide sample of US Veterans. Methods: The study population included patients with an ischemic stroke or TIA occurring during 2011 at any of the 134 Veterans Health Administration facilities. We used electronic outpatient pharmacy files to identify statin dose at hospital admission and within 7 days after hospital discharge. We categorized statin dosing as low, moderate, or high potency; moderate or high potency was considered at goal. We created 6 mutually exclusive groups to reflect patterns of statin potency from hospital admission to discharge: goal to goal, low to goal, goal to low or goal to none (deintensification), none to none, none to low, and low to low. We used logistic regression to compare 30-day and 1-year mortality across statin potency groups. Results: The population included 9380 predominately White (71.1%) men (96.3%) who were hospitalized for stroke or TIA. In this sample, 34.1% of patients (n=3194) were discharged off a statin medication. Deintensification occurred in 14.0% of patients (n=1312) and none to none in 20.5% (n=1924). Deintensification and none to none were associated with a higher odds of mortality as compared with goal to goal (adjusted odds ratio 1-year mortality: deintensification versus goal to goal, 1.26 [95% CI, 1.02–1.57]; none to none versus goal to goal, 1.59 [95% CI, 1.30–1.93]). Adjustments for differences in baseline characteristics using propensity weighted scores demonstrated similar results. Conclusions: Underutilization of statins, including no treatment or underdosing after stroke (deintensification), was observed in approximately one-third of veterans with ischemic stroke or TIA and was associated with higher mortality when compared with patients who were at goal for statin prescription dosing.

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Abstract WP361: Temporal Variation in Facility Performance of Process Measures After Transient Ischemic Attack in the Veterans Health Administration: Predictors and Association With Ischemic Stroke Incidence

Stroke ◽

10.1161/str.50.suppl_1.wp361 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Deborah A Levine ◽

Anthony J Perkins ◽

Jason J Sico ◽

Laura Myers ◽

Michael S Phipps ◽

...

Keyword(s):

Ischemic Stroke ◽

Temporal Variation ◽

Transient Ischemic Attack ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Process Measures ◽

Stroke Incidence ◽

Ischemic Attack

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Abstract TP175: Intensification of Statin Treatment is Associated With Improved Mortality Among Patients With TIA and Ischemic Stroke

Stroke ◽

10.1161/str.47.suppl_1.tp175 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Jason J Sico ◽

Susan Ofner ◽

Fitsum Baye ◽

John Concato ◽

Alan J Zillich ◽

...

Keyword(s):

Ischemic Stroke ◽

Treatment Guidelines ◽

Care Facility ◽

Statin Treatment ◽

Fiscal Year ◽

Cerebrovascular Event ◽

Veterans Health ◽

Health Administration ◽

Treatment Intensification ◽

High Potency

Introduction: Current guidelines for hyperlipidemia among patients with cerebrovascular disease recommend prescribing moderate/high potency statins rather than intensifying (low/moderate) treatment, but whether this treatment approach confers mortality benefits is unclear. Hypothesis: Intensification of statin therapy will be associated with improved outcomes within a given potency strata. Methods: Administrative data were analyzed from a sample of 11,306 Veterans admitted to 134 Veterans Health Administration (VHA) facilities with a TIA or ischemic stroke in fiscal year 2011. Patients who: were transferred to another non-VHA acute care facility or hospice, died in the emergency room/hospital, left against medical advice, had a documented statin allergy were excluded (n=1538). Treatment intensification was defined as an increase in potency class within 7-days of discharge. Multivariable logistic regression models were used to determine whether treatment intensification (vs. none) was associated with differences in 30-day and 1-year mortality. Results: Among 9,768 eligible patients, 66.5 % (n=6494) were prescribed statins at discharge; a majority (90.4%) were prescribed moderate/high potency statins. Treatment intensification occurred among 51.7% and 57.1% of patients in the moderate/high potency and low potency strata, respectively. Compared with patients receiving moderate/high potency statins without intensification, intensification was associated with lower 1-year (odds ratio [OR]=0.51; confidence Interval [CI] 95 :0.33, 0.80) but not 30-day (OR=2.10; CI 95 :0.66, 6.68) mortality. Compared with patients receiving low potency statins without intensification, intensification was associated with lower 1-year (OR=0.79 CI 95 :0.67, 0.93) and thirty-day (OR=0.72; CI 95 :0.52, 0.99) mortality. Conclusion: Treatment intensification for patients receiving moderate/high or low potency statins was associated with improved mortality after a cerebrovascular event, with potential implications for future treatment guidelines.

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The use of neurovascular ultrasound versus digital subtraction angiography in acute ischemic stroke

Arquivos de Neuro-Psiquiatria ◽

10.1590/0004-282x20140231 ◽

2015 ◽

Vol 73 (3) ◽

pp. 218-222 ◽

Cited By ~ 1

Author(s):

Marcos C. Lange ◽

Tatiana P. Bruch ◽

Jeff C. Pedrozo ◽

Luana Maranha ◽

Thiago Mamôru Sakae ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Admission ◽

Acute Ischemic Stroke ◽

Digital Subtraction Angiography ◽

Sensitivity And Specificity ◽

Transient Ischemic Attack ◽

Ultrasound Examination ◽

High Sensitivity ◽

Digital Subtraction ◽

Ischemic Attack

Cervical and intracranial arterial evaluation is an important issue for acute ischemic stroke (IS). Objective Compare the use of the neurovascular ultrasound examination (NVUE) to digital subtraction angiography (DSA) in acute IS patients for diagnosing significant extracranial and intracranial arteriopathy. Method Nonconsecutive patients with IS or transient ischemic attack admitted within 12 hours of the onset of symptoms were evaluated retrospectively. Standardized NVUE and DSA were done in all patients within the first 120 hours of hospital admission. Results Twenty-four patients were included in the study. Compared to DSA, the NVUE demonstrated 94.7% sensitivity and 100% specificity for identifying symptomatic extracranial and/or intracranial arteriopathy. Conclusion The standardized NVUE technique demonstrated high sensitivity and specificity compared to DSA for diagnosing arterial abnormalities in acute IS patients.

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Stroke Epidemiology, Patterns of Management, and Outcomes in Fortaleza, Brazil

Stroke ◽

10.1161/strokeaha.111.626523 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3341-3346 ◽

Cited By ~ 58

Author(s):

João José Freitas de Carvalho ◽

Monique Bueno Alves ◽

Georgiana Álvares Andrade Viana ◽

Cícera Borges Machado ◽

Bento Fortunato Cardoso dos Santos ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Hospital Admission ◽

Median Time ◽

Transient Ischemic Attack ◽

Stroke Risk Factors ◽

Level Of Consciousness ◽

Ischemic Attack ◽

Stroke Epidemiology

Background and Purpose— Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil. Methods— Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010. Results— We evaluated 2407 consecutive patients (mean age, 67.7±14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8–32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2–26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score ≤2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome. Conclusions— The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series. Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality.

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Abstract P388: Trends in Cardiac Monitoring After Ischemic Stroke and Transient Ischemic Attack: The Florida Puerto Rico Atrial Fibrillation Stroke Study

Stroke ◽

10.1161/str.52.suppl_1.p388 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Nicole B Sur ◽

Kefeng Wang ◽

Sebastian Koch ◽

Marco Di Tullio ◽

Carolina M Gutierrez ◽

...

Keyword(s):

Puerto Rico ◽

Ischemic Stroke ◽

Hospital Admission ◽

Transient Ischemic Attack ◽

Cardiac Monitoring ◽

Stroke Severity ◽

Ecg Monitoring ◽

Extended Surface ◽

Surface Monitoring ◽

Ischemic Attack

Introduction: Prolonged cardiac monitoring after cryptogenic stroke reveals a cardiac cause in up to 30% of patients; however, practice patterns for monitoring vary widely. We sought to evaluate overall and race/ethnic trends in the rate of ECG monitoring and types of cardiac monitoring performed after ischemic stroke and transient ischemic attack (TIA) across a network of hospitals in Florida and Puerto Rico(PR). Methods: We identified 46,878 ischemic stroke and TIA cases with data on ECG monitoring in the Florida Stroke Registry from 2016-18. Univariate analysis was performed to determine the overall rate of ECG monitoring and the characteristics of patients who received cardiac surface monitoring ≤7days and >7days, and implantable cardiac monitoring. Multivariate logistic regression was performed to identify factors associated with the types of monitoring. Results: Overall, 39,333 (84%) patients admitted for stroke/TIA received ECG monitoring during hospital admission (mean age 71±14 years; 49% female; 63% white, 18% black, 15% FL-Hispanic, 4% PR-Hispanic). Compared to patients who received ECG monitoring, patients who did not were more likely to be younger (mean age 70±15 years), PR-Hispanic (24% vs 4.3%), and have TIA (13% vs 8%), Medicare (42% vs 35%), large vessel disease (14% vs 9%) and greater admission NIHSS (median score 5 vs 4). After adjustment, smokers and patients >80years were less likely to receive ECG monitoring overall (OR 0.95, 95% CI 0.9-0.99 for both). Black race was associated with receiving extended surface monitoring >7 days (OR 1.15, 95%CI 1.04-1.26), but negatively associated with implantable cardiac monitoring (OR 0.81, 95%CI 0.68-0.96). Patients with moderate/severe stroke had higher odds of extended surface monitoring >7days (OR 2.29, 95%CI 1.89-2.77), yet lower odds of implantable cardiac monitoring (OR 0.80, 95%CI 0.71-0.89). Conclusion: The majority of patients received ECG monitoring during hospital admission for stroke/TIA; however, significant differences were found with respect to age, race/ethnicity and stroke severity across the various types and duration of cardiac monitoring. Further research is needed to understand and address the underlying drivers of these differences.

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