Prevalence of Inadequate Blood Pressure Control Among Veterans After Acute Ischemic Stroke Hospitalization

Abstract

Background Reducing blood pressure (BP) after stroke reduces risk for recurrent events. Our aim was to describe hypertension care among veterans with ischemic stroke including BP control by discharge and over the 6 months post stroke event. Methods and Results The Office of Quality and Performance Stroke Special Study included a systematic sample of veterans hospitalized for ischemic stroke in 2007. We examined BP control (<140/90 mmHg) at discharge excluding those who died, enrolled in hospice, or had unknown discharge disposition (N=3640, 3382 adjusted analysis). The second outcome was BP control (<140/90 mmHg) within 6-months post-stroke, excluding patients who died /readmitted within 30 days, lost to follow-up or did not have a BP recorded (N=2054, 1915 adjusted analysis). The population was white (62.7 %) and male (97.7%); 46.9% were <65 years of age; 29% and 37% had a history of cerebrovascular or cardiovascular disease, respectively. Among the 3640 stroke patients 1573(43%) had their last documented BP prior to discharge >140/90 mmHg. Black race (adjusted OR 0.77 [95% CI 0.65, 0.91]), diabetes (OR 0.73 [95% CI 0.62, 0.86]) and hypertension history (OR 0.51 [95% CI 0.42, 0.63]) were associated with lower odds for controlled BP at discharge. Of the 2054 stroke patients seen within 6 months from their index event, 673 (32.8%) remained uncontrolled. By 6 months post event, neither race nor diabetes was associated with BP control; whereas history of hypertension continued to have lower odds of BP control. For each 10 point increase in systolic BP > 140 mmHg at discharge, odds of BP control within 6 months post discharge decreased by 12% (95% CI (8%, 18%)). Conclusions BP values in excess of national guidelines are common after stroke. Forty three percent of patients were discharged with an elevated BP and 33% remained uncontrolled by 6 months.

Hypertension Treatment Intensification Among Stroke Survivors With Uncontrolled Blood Pressure

“…At particular risk are those with resistant hypertension or black patients who are both more likely to be uncontrolled in the post stroke period, and may not have their medications changed or titrated. 8, 23 The lack of treatment intensification which we report are similar to those reported by Heisler et al 11 These investigators studied 38, 327 Veterans with hypertension; treatment intensification occurred at 30% of 68,610 elevated BP visits. While we observed higher proportion of intensifications (58-65%), these investigators also found no relationship between intensification and medication adherence.…”

“…6-8 A systematic sample of 5000 records that included all ischemic stroke patients at hospitals with less than 55 stroke hospitalizations and an 80% random sample of patients at hospitals with more than 55 stroke hospitalizations were selected for abstraction. Because of this sampling, the number of patients per hospital ranged from 1 to 198 (mean=38 and standard deviation [SD] =28).…”

Post‐stroke hypertension control and receipt of health care services among veterans

“…However, the results of this study show those patients with elevated BP at the time of discharge from an ischemic stroke hospitalization continue with poorly controlled BP in the year post‐discharge. These findings are similar to a previous retrospective study conducted in 2054 stroke patients, seen within a 6‐month period from their index event, among which 673 (32.8%) remained with uncontrolled BP …”

Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

“…However, our study setting closely resembles the United Kingdom National Health Service and integrated managed care organizations in the United States, and the clinical profiles of our participants were similar to recent reports of stroke survivors from other Canadian provinces, the US, the UK and Europe. 1,2,10,20,24,25,28 When considering the external validity of our results, the under-treatment of vascular risk factors is a nearly universal phenomenon and has been documented in many other settings and for other atherosclerotic conditions.…”