Elsevier

Public Health

Volume 137, August 2016, Pages 64-72
Public Health

Original Research
A comparison of secondary prevention practice in poststroke and coronary heart disease patients

https://doi.org/10.1016/j.puhe.2016.02.003Get rights and content

Highlights

  • Poststroke patients had higher risk of persistent smoking, raised blood pressure and increased LDL than coronary patients.

  • The prescription rate of basic pharmacotherapies (such as antiplatelets, statins, etc) is also substandard in post-stroke patients.

  • 5-year all-cause and cardiovascular mortality rates are substantially higher in post-stroke patients than in coronary patients, even if adjusted for potential covariates.

Abstract

Objectives

It is evident that patients with atherosclerotic vascular disease (AVD) benefit from appropriate secondary prevention. In clinical reality, the secondary prevention in AVD patients other than those with coronary heart disease (CHD) is often overlooked. Therefore, we compared the adherence to secondary prevention principles between poststroke and CHD patients.

Study design

Descriptive (cross-sectional) study with prospective mortality follow-up.

Methods

We examined 1729 chronic patients with AVD (mean age 65.9 (±SD 9.6) years), 964 with CHD, and 765 poststroke (pooled data of Czech samples of EUROASPIRE III, IV, and the ESH stroke survey). The interview was performed 6–36 months after the coronary event/revascularization or the first ischemic stroke, while the mortality follow-up 5 years after this interview.

Results

Poststroke patients had a significantly higher risk of persistent smoking, blood pressure ≥140/90 mmHg and LDL ≥2.5 mmol/L than CHD patients [odds ratios adjusted for age, gender and survey were 1.63 (95% CI: 1.13–2.33), 1.38 (95% CI: 1.13–1.69) and 2.26 (95% CI: 1.84–2.78), respectively]. In contrast, poststroke patients showed a lower risk of inappropriate glucose control and hypertriglyceridemia [0.66 (95%CI: 0.54–0.82) and 0.74 (95%CI: 0.61–0.91), respectively]. The prescription rates of antiplatelets/anticoagulants, antihypertensives and statins were also significantly lower in poststroke than in CHD patients (89.4 vs 93.7, 85.9 vs 97.5, and 57.7 vs 89.8, respectively).

Mortality analysis was performed in a subsample of 815 subjects interviewed in 2006/07. The 5-year all-cause mortality rates were 25.8% and 13.3% in poststroke and coronary patients, respectively (P = 0.0023); the hazard ratio for stroke adjusted for major risk factors was 1.85 (95% CI: 1.31–2.63).

Conclusions

Compared to CHD patients, poststroke patients are strongly handicapped in terms of poor adherence to secondary prevention target, prescription of basic pharmacotherapies and mortality risk.

Introduction

The ultimate goal of treatment of patients with atherosclerotic vascular disease (AVD) is to reduce the case fatality, to reduce risk of recurrent cardiovascular event, to extend life-time, and to improve life quality. Management of patients with coronary heart disease (CHD) was defined extensively by the series of Joint European Societies' Guidelines since 1994.1, 2, 3, 4, 5 Since the third revision of these Guidelines,3 also patients with AVD in non-coronary localisations (including those after ischemic stroke) have been included in the group with highest priority for prevention. To implement secondary prevention measures in poststroke patients in clinical practice, we should adopt similar principles as those applicable to CHD patients, i.e. strictly defined treatment targets for major cardiovascular risk factors, several ‘mandatory’ pharmacotherapies, and necessary lifestyle changes.

To describe clinical reality in secondary prevention of CHD with respect to adherence to these guidelines, the EUROASPIRE (European Action on Secondary Prevention by Intervention to Reduce Events) survey was conducted in 1995/96 (EUROASPIRE I),6 to be subsequently repeated in 1999/2000, 2006/7 and in 2012/13 (i.e. EUROASPIRE II-IV, respectively).7, 8, 9 Data from these surveys demonstrated a high prevalence of inadequately controlled modifiable risk factors and insufficient prescription of basic pharmacotherapies in the secondary prevention of CHD across all European countries included.

Comparable data regarding patients with cerebrovascular disease were virtually non-existent until the stroke-specific module was developed as a voluntary add-on to the EUROASPIRE III survey. The objective of this module was to identify the prevalence of CVD risk factors, lifestyle habits, and medication use among patients after their first ischemic stroke in order to describe the current status of clinical practice against the Third European Guidelines principles. This survey was performed in four European countries (five EUROASPIRE project centres) in 2007,10 including the Czech Republic.11 The Stroke Specific Module of the EUROASPIRE III study highlighted the need for structured disease management and targeted secondary prevention strategies. A second survey in patients with cerebrovascular disease (ESH Stroke Survey) was started in 2012 (and currently analyzed) under the nearly similar protocol12 and in the same Czech centres as the EUROASPIRE III survey in 2007.

The aim of the present analysis is to demonstrate the differences in clinical practice in secondary prevention between poststroke and CHD patients and the corresponding mortality outcomes using data from EUROASPIRE III, IV and ESH stroke survey from 2006/07 and 2012–14.

Section snippets

Study population

The study population consists of Czech patients examined in the framework of well-defined surveys in patients with CHD or in patients after their first ischemic stroke. Patients with CHD represent pooled Czech samples of the EUROASPIRE III (2006/07) and IV (2013/14) surveys, while poststroke patients represent pooled Czech samples of the EUROASPIRE III-stroke survey (2006/07) and ESH stroke survey (2012/13); the selection and standard protocol of examination (nearly similar for all four

Characteristics of participants

A total of 1729 patients, 765 patients after their first verified ischemic stroke and 964 with manifest CHD, with a mean age of 67.8 (±SD 9.9) and 64.3 (±SD 9.0) years, respectively, were compared in the present analysis. After exclusion patients who deceased between the index event and the survey, the overall response rates to interviews by inclusion diagnosis were 76.2% and 86.3%, respectively (for details see flow chart on Fig. 1). The baseline characteristics of interviewed subjects are

Discussion

To our best knowledge, this study is the first to compare directly the adherence to treatment targets between poststroke and CHD patients in secondary prevention. The key finding of our study is that the practical implementation of secondary prevention principles, in terms of appropriate control of conventional cardiovascular risk factor, is markedly poorer in poststroke patients than in CHD patients (despite that these principles are almost the same). Poststroke patients are also at

Acknowledgements

We would like to acknowledge the dedication of all co-investigators, study nurses and laboratory technicians who participated in the EUROASPIRE III, IV, and ESH stroke survey in the Czech Republic.

Ethical statement

The study was carried out according to the guidelines for Good Clinical Practice. The study protocols were approved by the central Ethical Committee of Institute for Clinical and Experimental Medicine, Prague and local Ethical Committee of University Hospital Pilsen. All of the participants gave

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