According to national guidelines, patients with ischemic stroke or transient ischemic attack (TIA) should be put on lipid-lowering therapies such as statins during hospitalization. They should continue this treatment even after they are discharged, along with plans for proper diet and exercise. This is a top tier recommendation because studies have shown that lipid-lowering medications and statins, in particular, can dramatically lower the rates of subsequent heart attacks, strokes, and the need for procedures to reopen clogged arteries.

Statin Usage Following Acute Stroke

Cholesterol-lowering targets have been established by recommendations from the National Cholesterol Education Project Adult Treatment Panel III for patients with documented coronary heart disease and those that have had an ischemic stroke or TIA. For patients who have no other manifestations of atherosclerosis (other than cerebrovascular disease), the latest American Heart Association (AHA)/American Stroke Association (ASA) guidelines recommend intensive lipid-lowering therapy. “We know from prior experience that medications started at the time of discharge are much more likely to be continued by patients in the year after the event,” explains Lee H. Schwamm, MD. “Starting lipid-lowering medications, especially statins, at discharge in appropriately selected patients hospitalized for ischemic stroke or TIA makes good sense and should be considered good clinical practice.

“Starting lipid-lowering medications, especially statins, at discharge in appropriately selected patients hospitalized for ischemic stroke or TIA makes good sense and should be considered good clinical practice.”

Cholesterol-lowering targets have been established by recommendations from the National Cholesterol Education Project Adult Treatment Panel III for patients with documented coronary heart disease and those that have had an ischemic stroke or TIA. For patients who have no other manifestations of atherosclerosis (other than cerebrovascular disease), the latest American Heart Association (AHA)/American Stroke Association (ASA) guidelines recommend intensive lipid-lowering therapy. “We know from prior experience that medications started at the time of discharge are much more likely to be continued by patients in the year after the event,” explains Lee H. Schwamm, MD. “Starting lipid-lowering medications, especially statins, at discharge in appropriately selected patients hospitalized for ischemic stroke or TIA makes good sense and should be considered good clinical practice.”

Important New Data & Findings

To determine if the national trends in statin use at discharge following an acute stroke were increasing over the last few years, Dr. Schwamm and colleagues reviewed and evaluated patient data from 2005 through 2007 in institutions that were part of the AHA/ASA’s Get With The Guidelines–Stroke (GWTG–Stroke) initiative, a nationwide quality improvement registry. The study, published in the July 2010 issue of Stroke, used data from eligible stroke and TIA patients and assessed discharge statin use over time and in relation to dissemination of results from the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. SPARCL demonstrated that statins appear to reduce vascular risk among patients with atherosclerotic stroke or TIA.

Researchers analyzed data on 173,284 hospitalized stroke patients that were involved in GWTG–Stroke throughout the United States. The overall discharge rate of statin treatment was 83.5% in the investigation. The frequency of discharge statin prescription climbed steadily but modestly over the 2-year study period, increasing from 75.7% to 84.8%. There was a non-significant increase during reporting of the SPARCL trial but a return to prior levels thereafter (Figure).

Risk Factors for Poor Statin Prescription at Discharge

In the study published in Stroke, Dr. Schwamm and colleagues identified multiple patient and hospital level factors that were associated with lower rates of statin prescription at discharge (Table). Being female or a non-Caucasian patient reduced the likelihood of receiving treatment. Other factors identified as lowering the likelihood of receiving statins included:

Suffering a TIA instead of a stroke.

Atrial fibrillation.

Ownership of a prosthetic heart valve.

Patients taking a cholesterol medication prior to admission were eight times more likely to leave the hospital with a prescription for the therapy when compared with patients who were not on cholesterol medication before admission. Smaller hospitals and those located in the southern region of the United States were less likely to issue statin prescriptions than larger hospitals and those in other areas of the country. A surprising finding was that academic hospitals were also less likely to comply with providing stroke patients with a statin at discharge. Dr. Schwamm notes that this may be due to high rates of trainees and staff turnover at these institutions.

It should be noted that GWTG–Stroke is a voluntary program. “Because hospital participation is voluntary, hospitals in GWTG-Stroke may have higher compliance with preventive recommendations than those that don’t participate in the program,” Dr. Schwamm explains. “We have limited information on the performance of hospitals not participating. Therefore, efforts should be made to get as many hospitals as possible to participate in national stroke quality improvement programs such as GWTG-Stroke. It is becoming quite clear that these programs can improve delivery of care over time.”

The Time is Now

According to Dr. Schwamm, physicians and nurses who care for stroke or TIA patients should familiarize themselves with the latest stroke prevention and treatment guidelines, which are available at www.heart.org. “It’s important that the entire stroke care management team be up to date so that all stroke symptoms can be recognized. A keen awareness of the appropriate steps in hospital-based secondary prevention efforts for stroke is also paramount. Statin therapy or secondary stroke prevention is an important element in the stroke treatment tool kit, equally as important as the use of aspirin or cessation of smoking.”

In hospitals already partaking in quality improvement efforts like GWTG–Stroke, Dr. Schwamm says physicians providing care in these facilities should understand the key achievement and quality measures. “These programs enable hospitals to measure compliance with evidence-based care so that better outcomes can be achieved. Even high-performing hospitals can benefit from such programs.”

 

References

Ovbiagele B, Schwamm LH, Smith EE, et al. Recent nationwide trends in discharge statin treatment of hospitalized patients with stroke. Stroke. 2010;41:1508-1513.

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.

Amarenco P, Bogousslavsky J, Callahan A III, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355:549-559.

Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647-1652.