Under-prescribing of Prevention Drugs and Primary Prevention of Stroke and Transient Ischaemic Attack in UK General Practice: A Retrospective Analysis

Abstract

BackgroundStroke is a leading cause of death and disability; worldwide it is estimated that 16.9 million people have a first stroke each year. Lipid-lowering, anticoagulant, and antihypertensive drugs can prevent strokes, but may be underused.Methods and FindingsWe analysed anonymised electronic primary care records from a United Kingdom (UK) primary care database that covers approximately 6% of the UK population. Patients with first-ever stroke/transient ischaemic attack (TIA), ≥18 y, with diagnosis between 1 January 2009 and 31 December 2013, were included. Drugs were considered under-prescribed when lipid-lowering, anticoagulant, or antihypertensive drugs were clinically indicated but were not prescribed prior to the time of stroke or TIA. The proportions of strokes or TIAs with prevention drugs under-prescribed, when clinically indicated, were calculated.In all, 29,043 stroke/TIA patients met the inclusion criteria; 17,680 had ≥1 prevention drug clinically indicated: 16,028 had lipid-lowering drugs indicated, 3,194 anticoagulant drugs, and 7,008 antihypertensive drugs. At least one prevention drug was not prescribed when clinically indicated in 54% (9,579/17,680) of stroke/TIA patients: 49% (7,836/16,028) were not prescribed lipid-lowering drugs, 52% (1,647/3,194) were not prescribed anticoagulant drugs, and 25% (1,740/7,008) were not prescribed antihypertensive drugs.The limitations of our study are that our definition of under-prescribing of drugs for stroke/TIA prevention did not address patients’ adherence to medication or medication targets, such as blood pressure levels.ConclusionsIn our study, over half of people eligible for lipid-lowering, anticoagulant, or antihypertensive drugs were not prescribed them prior to first stroke/TIA. We estimate that approximately 12,000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs. Improving prescription of lipid-lowering, anticoagulant, and antihypertensive drugs is important to reduce the incidence and burden of stroke and TIA.

Potential prescribing omissions in patients with cardiovascular disease

“…This phenomenon may be explained due to the intention of doctors to prescribe less aggressive therapies to patients who, due to their conditions and comorbidities, are more likely to present with problems related to these medications . However, said patients could benefit from an adequate prescription . The use of ACEI or an ARB‐II was related with a lower probability of presenting a PPO, considering that these medications are one of the fundamental bases in the treatment of various cardiovascular diseases (including hypertension, HF and IHD) and their use impacts several START criteria …”

“…23,36 However, said patients could benefit from an adequate prescription. 11 The use of ACEI or an ARB-II was related with a lower probability of presenting a PPO, considering that these medications are one of the fundamental bases in the treatment of various cardiovascular diseases (including hypertension, HF and IHD) and their use impacts several START criteria. 4 This study had several limitations.…”

“…It is estimated that such omissions have negative consequences on patient morbidity and mortality . The underprescription of effective drugs for cardiovascular disease has been previously described in different populations, especially in patients that are associated with secondary prevention . This is clinically relevant since cardiovascular disease is among the main causes of death in the world …”

“…7,8 The underprescription of effective drugs for cardiovascular disease has been previously described in different populations, especially in patients that are associated with secondary prevention. [9][10][11] This is clinically relevant since cardiovascular disease is among the main causes of death in the world. 12,13 The Colombian Health System offers universal coverage through two types of insurance regimes: contributory, where fees are covered by the worker and employer, and state-subsidised, which has a benefit plan that includes most of the medications that are needed for the prevention and treatment of cardiovascular diseases.…”

Primary Prevention of Cardiovascular Risk in Lithuania—Results from EUROASPIRE V Survey

“…Although controlled clinical studies proved the efficacy of primary prevention with statins in reducing all-cause mortality and the risk of primary cardiovascular events [30,31], other observational studies also reported the undertreatment of patients eligible for preventive lipid-lowering therapy [27,[32][33][34][35][36]. The rates of undertreatment with antihypertensive agents are lower [36][37][38], which can be explained by well-established evidence on efficacy, good safety profiles and the low cost of these drugs [37]. Meanwhile, some controversy regarding the risks and benefits of statins used in primary prevention still exists both in scientific literature [39] and clinical practice.…”