Importance of In-Hospital Initiation of Therapies and Therapeutic Inertia in Secondary Stroke Prevention

Abstract

Background and Purpose-Many patients do not receive prevention consistent with recommendations after stroke, but the relative importance of patient-and physician-related factors is uncertain. Methods-We prospectively assessed factors associated with blood pressure (BP) Ͻ140/90 mm Hg and low-density lipoprotein (LDL) cholesterol Ͻ1 g/L in a collaborative cohort of 240 consecutive patients experiencing stroke/transient ischemic attack (Rankin Ͻ4; Յ80 years; no major comorbidity) from a stroke unit and 3 emergency departments. A standardized assessment of risk factors was performed 6 and 12 months after the initial event by an investigator who was not involved in the usual follow-up of patients. Results-At 6 months, 41% of patients with diagnosed hypertension at inclusion had their BP Ͻ140/90 mm Hg and 55% of those with diagnosed hypercholesterolemia had their LDL Ͻ1 g/L. Adherence to treatment was excellent in 81% of patients. In univariate and multivariate analyses, initiation or reinforcement of appropriate treatments during hospitalization were the main factors associated with BP Ͻ140/90 mm Hg (ORϭ2.44; 95% CI: 1.20 to 4.97) and LDL Ͻ1 g/L (ORϭ3.36; 1.27 to 8.89) or with decrease in BP and LDL. Patients' sociodemographic characteristics, education, income, knowledge of disease, and risk factors were not associated with control of BP or LDL. Among patients with BP Ն140/90 mm Hg, approximately 40% received either no treatment or one drug only, and treatment was reinforced in 20% of them only. Results were similar at 12 months with no improvement in the rate of control of risk factors. Conclusion-Therapeutic inertia is an important impediment to achieve BP and LDL control goals after stroke, even in fairly motivated/adherent patients. In-hospital initiation of preventive therapies could improve quality of secondary stroke prevention in the long term. (Stroke. 2008;39:1834-1843.)

Adherence to Guidelines: Experience of a Canadian Stroke Prevention Clinic

“…1,[3][4][5][6] The identification and control of modifiable vascular risk factors (MRFs) is one of the main goals of stroke prevention clinics (SPCs) in addition to appropriate use of antithrombotics and selective surgical interventions as suggested by current practice guidelines. 1,6,7 Unfortunately, a relatively high proportion of patients fail to achieve the recommended therapeutic objectives. [8][9][10] Recent evidence in the literature suggests that improving outpatient care through referral to SPCs may decrease risk of adverse outcomes.…”

Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease

“…Reasons for this gap between guideline recommendations and current practise are not well known. The most commonly cited factors include patient nonadherence to prescribed treatment, therapeutic inertia (defined as the lack of initiating or intensifying treatment despite failure to achieve therapeutic goals) and lack of access to care [11,[15][16][17][18][19].…”

“We're Almost Guests in Their Clinical Care”: Inpatient Provider Attitudes Toward Chronic Disease Management

“…17 The true benefit is likely from improved processes of care in the short term that lead to long-term improvement in outcomes. 4,5,18 Thus, the advantage of starting a patient hospitalized for a stroke on blood pressure medication is the increased likelihood that the patient will continue the medication as an outpatient, which may reduce long-term mortality.…”

“…Studies have suggested that intervening in chronic diseases during hospitalizations can lead to long-term improvement in treatment; [4][5][6] for instance, stroke patients who were started on antihypertensive therapy at discharge were more likely to have their blood pressure controlled in the next year. 5 However, some authors have argued that aggressive hypertension management by inpatient providers may result in patient harm. 7 One case-based survey suggested that hospitalists were mixed in their interest in participating in chronic disease management in the hospital.…”