Clinical Topics

Following Guidelines Reduced Mortality in Veterans at High Risk of Recurrent Stroke

by Brenda Mooney

August 12, 2019

Only 15.3% of Eligible Patients Received All Interventions

INDIANAPOLIS—Meticulously following clinical guidelines in VA patients who suffered transient ischemic attack or nonsevere ischemic stroke reduced by nearly one-third their risk of death within a year, according to a new study.

In the cohort study led by researchers at Richard L. Roudebush VAMC, of 8,076 patients with those cardiovascular events from October 2010 until September 2011, only 15.3% were recipients of so-called without-fail care.1

That was defined as receiving all guideline-concordant processes of care for which they were eligible:

  • brain imaging, 
  • carotid artery imaging, 
  • antihypertensive intensification, 
  • high- or moderate-potency statin therapy, 
  • anti-thrombotics, and 
  • anticoagulation for atrial fibrillation.

The study team concluded that receiving all six processes was associated with a 31.2% reduction in mortality at one year. The intensive care did not lower risk of recurrent stroke, however.

“Widespread implementation of these processes should be strongly considered for patients with TIA and non-severe ischemic stroke,” wrote study authors, which also included representatives from VAMCs in Los Angeles, Omaha, NB, and West Haven, CT. “In addition, health care systems should consider routinely measuring key processes of care for patients with TIA in addition to the quality measurement that exists for patients with stroke.”

The research team emphasized, “Clinicians should ensure that patients with transient ischemic attack and non-severe ischemic stroke receive all guideline-concordant processes of care for which they are eligible.”

The study, published online recently by JAMA Network Open, noted that early evaluation and management of patients with TIA and nonsevere ischemic stroke improves outcomes but that there was a need to identify processes of care associated with reduced risk of death or recurrent stroke among those patients. Included in the analysis were all patients with TIA or non-severe ischemic stroke at VA emergency department or inpatient settings during that time period. Data was analyzed from March 2018 to April 2019.

“Patients with transient ischemic attack and nonsevere ischemic stroke are at high risk of recurrent vascular events,” study authors explained. “However, studies have demonstrated that timely delivery of guideline-concordant care can dramatically reduce this risk.47 Studies reporting risk reductions of at least 70% for recurrent events among patients with TIA or nonsevere ischemic stroke have emphasized early evaluation and management; however, these studies differed in terms of the processes of care that were provided.4-8 The American Heart Association/American Stroke Association stroke prevention guidelines recommend a broad range of processes, including diagnostic processes (e.g., brain imaging) and secondary prevention interventions (e.g., hypertension management).”

During review, the authors calculated risk of all-cause mortality and recurrent ischemic stroke at 90 days and one year while also examining 28 processes of care to determine which were essential.

Participants were veterans who had either TIA or nonsevere stroke. Their mean age was 67.8; 96% were male, and 73.4% were white.

Results indicate that 474 of the patients had a recurrent ischemic stroke within 90 days, and 793 (10.7%) had a recurrent ischemic stroke within a year. In terms of mortality, 320 (4.0%) died within 90 days, and 814 (10.1%) died within one year.

Lower Odds of Death

Overall, the study team determined that nine processes were independently associated with lower odds of both 90-day and one-year mortality after adjustment for multiple comparisons. Those were:

  1. Carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72); 
  2. Antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83); 
  3. Lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78); 
  4. Lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85); 
  5. Discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88); 
  6. Cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77); 
  7. Antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87); 
  8. Antithrombotics at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88); and 
  9. Neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). 

In addition, anticoagulation for atrial fibrillation was associated with lower odds of one-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). 

On the other hand, the researchers reported that no processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. 

The goal was to identify the processes of care that were associated with improvements in vascular risk and could be implemented across healthcare systems. “It might not be possible to identify individual processes that confer benefit because patients may receive several processes at the same time or through a shared structure of care (e.g., an admission order set),” the researchers pointed out. “Although the VA system does not use a specific TIA or stroke admission order set or care pathway, we hypothesized that a bundle of processes might be routinely ordered, and therefore, we examined the six processes that were found to be effective in acute TIA management studies (i.e., brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation).”

The study team emphasized that the six without-fail processes should be routinely available, because they do not require advanced structures of care. The issue was more complex when it came to individual process of care, however.

“We were surprised that not more individual processes of care were independently associated with improved outcomes,” the authors wrote. “Our analyses may have been limited by relatively high pass rates on several processes. For example, although antithrombotic medications were associated with lower odds of mortality, they were not associated with recurrent stroke risk. A meta-regression of trials from the 1970s to 1990s indicated that approximately 14% of patients with stroke have a recurrent stroke during 32 months of follow-up, and the recurrent stroke risk can be reduced by 15% (95% CI, 6%-23%) with aspirin. It may be that our cohort of patients with TIA and nonsevere ischemic stroke, who had a one-year recurrent stroke rate of 10.7% and a pass rate of antithrombotics at discharge of 87%, may have included too few eligible patients who did not receive antithrombotics to detect differences in recurrent stroke risk.

“However, among 67 892 patients in the Get With the Guidelines-Stroke cohort, aspirin use was also not statistically associated with a reduction in one-year recurrent stroke risk. Therefore, it may be that the effect of antithrombotics on stroke risk is less robust now than was observed in the clinical trials, many of which were conducted before the advent of high-potency statins.”

The study urged widespread implementation of the six without-fail interventions at the VA and other healthcare system, as well as individual processes of care . 

Researchers from Indiana University, the Regenstrief Institute, Michigan State University, UCLA, Yale University, Purdue University and the University of Maryland also participated in the study.

Bravata DM, Myers LJ, Reeves M, Cheng EM, et. Al. Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke. JAMA Netw Open. 2019 Jul 3;2(7):e196716. doi: 10.1001/jamanetworkopen.2019.6716. PubMed PMID: 31268543.

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