Use of Secondary Medical Prophylaxis and Clinical Outcome Among Patients With Ischemic Stroke

Palnum, Kaare Haurvig; Mehnert, Frank; Andersen, Grethe; Ingeman, Annette; Krog, Birgitte Randrup; Bartels, Paul; Johnsen, Søren Paaske

doi:10.1161/strokeaha.111.635342

Cited by 14 publications

(8 citation statements)

References 32 publications

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“…Although our results regarding the deleterious effect of antiplatelet drug discontinuation on the risk of death are highly similar to those reported in previous studies [20,23], including the previously mentioned Danish cohort study [22], we find it unlikely that this finding can be entirely ascribed to pharmacological beneficial effects of antiplatelet drugs. We speculate that part of the observed effect is due to patients near death, that is, those with a conceived dismal prognosis, not using antiplatelet drugs, either because of selective non-prescription by physicians or non-adherence by patients.…”

Section: Discussionsupporting

confidence: 90%

“…This study used the same datasource, DNIP, as employed in our study to identify subjects with stroke and stroke recurrence on a national level, and furthermore utilized a highly similar prescription registry to ascertain drug exposure [22]. A hazard ratio of recurrent stroke of 0.99 (95% CI: 0.89-1.10) in association with antiplatelet discontinuation was reported.…”

Section: Discussionmentioning

confidence: 99%

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Discontinuation of Antiplatelet Treatment and Risk of Recurrent Stroke and All-Cause Death: A Cohort Study

et al. 2014

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Background: We wished to examine the impact of antiplatelet drug discontinuation on recurrent stroke and all-cause mortality. Methods: We identified a cohort of incident ischaemic stroke patients in a Danish stroke registry, 2007-2011. Using population-based registries we assessed subjects' drug use and followed them up for stroke recurrence, or all-cause death. Person-time was classified by antiplatelet drug use into current use, recent use (≤150 days after last use), and non-use (>150 days after last use). Lipid-lowering drug (LLD) use was classified by the same rules. We used Cox proportional hazard models to calculate the adjusted hazard ratio (HR) and corresponding 95% confidence intervals (CIs) for the risk of recurrent stroke or death associated with discontinuation of antiplatelet or LLD drugs. Results: Among 4,670 stroke patients followed up for up a median of 1.5 years, 237 experienced a second stroke and 600 died. Compared with current antiplatelet drug use, both recent use (1.3 (0.8-2.0)), and non-use (1.3 (0.8-1.9)) were associated with increased recurrent stroke risk. The corresponding HRs of death were 1.9 (1.4-2.5) for recent and 1.8 (1.4-2.3) for non-use of antiplatelet drugs. Recent statin use was associated with markedly increased risk of death (2.1 (1.7-2.6)), and only marginally with recurrent stroke (1.2 (0.9-1.6)). Conclusions: Antiplatelet drugdiscontinuation may be associated with an increased recurrent stroke risk. Our results on death risk indicate that non-pharmacological biases, such as ‘sick stopper', may threaten the validity of this risk estimate.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Discontinuation of Antiplatelet Treatment and Risk of Recurrent Stroke and All-Cause Death: A Cohort Study

et al. 2014

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“…An integral part of this is lifestyle changes, emphasizing regular physical activity, a diet low in salt and saturated fat and high in fruit and vegetables, reducing overweight, and quitting smoking and heavy use of alcohol 41. Adequate long-term secondary prevention was associated with a reduced risk of death and recurrent stroke and improved outcome in routine settings 54,55. Hypertension is the single most important vascular risk factor for stroke.…”

Section: Prevention Of Strokes In Young Adultsmentioning

confidence: 99%

Strokes in young adults: epidemiology and prevention

Smajlović

2015

VHRM

307

265

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Strokes in young adults are reported as being uncommon, comprising 10%–15% of all stroke patients. However, compared with stroke in older adults, stroke in the young has a disproportionately large economic impact by leaving victims disabled before their most productive years. Recent publications report an increased incidence of stroke in young adults. This is important given the fact that younger stroke patients have a clearly increased risk of death compared with the general population. The prevalence of standard modifiable vascular risk factors in young stroke patients is different from that in older patients. Modifiable risk factors for stroke, such as dyslipidemia, smoking, and hypertension, are highly prevalent in the young stroke population, with no significant difference in geographic, climatic, nutritional, lifestyle, or genetic diversity. The list of potential stroke etiologies among young adults is extensive. Strokes of undetermined and of other determined etiology are the most common types among young patients according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Prevention is the primary treatment strategy aimed at reducing morbidity and mortality related to stroke. Therefore, primary prevention is very important with regard to stroke in young adults, and aggressive treatment of risk factors for stroke, such as hypertension, smoking, and dyslipidemia, is essential. The best form of secondary stroke prevention is directed toward stroke etiology as well as treatment of additional risk factors. However, there is a lack of specific recommendations and guidelines for stroke management in young adults. In conclusion, strokes in young adults are a major public health problem and further research, with standardized methodology, is needed in order to give us more precise epidemiologic data. Given the increasing incidence of stroke in the young, there is an objective need for more research in order to reduce this burden.

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“…Thus, statins protect against the tPA-mediated neurovascular unit dysfunction, and thereby extend the therapeutic window for stroke. The efficacy of statins in lowering the risk of cerebrovascular events is now well established 103, 104 . However, only a few clinical studies addressed the question of whether statins may improve stroke outcome following thrombolytic therapy, and the results are controversial 105 .…”

Section: Combination Approaches Targeting Neurovascular Unitsmentioning

confidence: 99%

The neurovascular unit and combination treatment strategies for stroke

Zhang

Chopp

2012

Trends in Pharmacological Sciences

125

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Tissue plasminogen activator (tPA) administered within 4.5 hours of symptom onset restores cerebral blood flow and promotes neurological recovery of stroke patients. However, the narrow therapeutic time window and the risk of intracerebral hemorrhage after tPA treatment pose major hurdles to its clinical usage. In light of the failures of neuroprotective therapies in clinical trials, emerging concepts suggest that neuroprotection alone without restoration of tissue perfusion and vascular integrity may not be adequate for treatment of acute stroke. Here we review evidence of the use of adjuvant pharmacological agents to extend the therapeutic window for tPA via targeting the neurovascular unit and the underlying mechanisms of the combination therapy in experimental stroke.

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Use of Secondary Medical Prophylaxis and Clinical Outcome Among Patients With Ischemic Stroke

Abstract: Background and Purpose-Although secondary medical prevention strategies in patients with stroke are well established, only sparse data exist regarding their effectiveness in routine care. We examined the effectiveness in a nationwide, population-based follow-up study.

Cited by 14 publications

References 32 publications

Discontinuation of Antiplatelet Treatment and Risk of Recurrent Stroke and All-Cause Death: A Cohort Study

Discontinuation of Antiplatelet Treatment and Risk of Recurrent Stroke and All-Cause Death: A Cohort Study

Strokes in young adults: epidemiology and prevention

The neurovascular unit and combination treatment strategies for stroke

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