Relationship between risk factor control and vascular events in the SAMMPRIS trial

Abstract

Objective: The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke inIntracranial Stenosis (SAMMPRIS) study is the first stroke prevention trial to include protocoldriven intensive management of multiple risk factors. In this prespecified analysis, we aimed to investigate the relationship between risk factor control during follow-up and outcome of patients in the medical arm of SAMMPRIS.Methods: Data from SAMMPRIS participants in the medical arm (n 5 227) were analyzed. Risk factors were recorded at baseline, 30 days, 4 months, and then every 4 months for a mean followup of 32 months. For each patient, values for all risk factor measures were averaged and dichotomized as in or out of target.Results: Participants who were out of target for systolic blood pressure and physical activity, as well as those with higher mean low-density lipoprotein cholesterol and non-high-density lipoprotein, were more likely to have a recurrent vascular event (stroke, myocardial infarction, or vascular death) at 3 years compared to those who had good risk factor control. In the multivariable analysis, greater physical activity decreased the likelihood of a recurrent stroke, myocardial infarction, or vascular death (odds ratio 0.6, confidence interval 0.4-0.8).Conclusions: Raised blood pressure, cholesterol, and physical inactivity should be aggressively treated in patients with intracranial atherosclerosis to prevent future vascular events. Physical activity, which has not received attention in stroke prevention trials, was the strongest predictor of a good outcome in the medical arm in SAMMPRIS.ClinicalTrials.gov identifier: NCT00576693. Neurology ® 2017;88:379-385 GLOSSARY BMI 5 body mass index; BP 5 blood pressure; CI 5 confidence interval; HbA1c 5 hemoglobin A1c; HDL-C 5 high-density lipoprotein cholesterol; ICAS 5 intracranial atherosclerotic stenosis; LDL-C 5 low-density lipoprotein cholesterol; MI 5 myocardial infarction; mRS 5 modified Rankin Scale score; NIHSS 5 NIH Stroke Scale; OR 5 odds ratio; PACE 5 Physician-based Assessment and Counseling for Exercise; SAMMPRIS 5 Stenting and Aggressive Medical Management for Prevention of Recurrent Stroke in Intracranial Stenosis; SBP 5 systolic blood pressure; WASID 5 Warfarin Aspirin Symptomatic Intracranial Disease.

Management of intracranial atherosclerotic disease

“…The study named "The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis" (SAMMPRIS) is the first stroke prevention study including tightsupervision of multiple risk factors through protocols, and it was recommended in a preliminary analysis investigating the relationship between risk factor control and patient outcomes in the follow-up of patients in the medical arm of the study, that blood pressure, cholesterol and physical inactivity should be treated aggressively to prevent future vascular events in patients with ICAD. Physical activity was the strongest predictor of good outcome in the medical arm of the SAMMPRIS study [26].…”

Incidence and Etiologies of Stroke Mimics After Incident Stroke or Transient Ischemic Attack

“…blood pressure reduction) may reduce the risk of early recurrence. 247,248 Among factors associated with early recurrence, peripheral artery disease (PAD) was a predictor of early recurrence in the multivariate analysis in paper I. PAD is a common type of atherosclerosis that affects peripheral arteries. Presence of PAD, or low ankle-brachial index which is a measure of arterial stenosis in the lower extremities, is associated with increased risk of recurrent stroke.…”

Impact of Baseline Features and Risk Factor Control on Cognitive Function in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

“…To determine the relationship between risk factor control during follow-up and cognitive impairment, we analyzed patients randomized to the AMM only group and compared the percentage of patients with cognitive impairment that were in versus out of target for the primary risk factor targets (SBP and LDL) and physical activity, since exercise was associated with fewer vascular events during follow-up [7,10,11]. For each patient in the AMM group, values from baseline until the time of the MoCA scores (e.g., 12 months or closeout) were averaged for each risk factor and dichotomized as in-target or out-of-target.…”

“…First, after excluding patients with baseline aphasia or neglect and those with recurrent ischemic stroke, cerebral infarct with temporary signs, or intracerebral hemorrhage during the follow-up period, as well as those with missing MoCA data, there was a small number available to determine the association of risk factor control and cognitive function during follow-up, increasing the chance of Type 2 error. Also, the remaining patients without recurrent events in follow-up may differ from the overall cohort in that patients with recurrent events were more likely to have poorer risk factor control based on prior analyses [10]. However, it was important to exclude those patients so that we could determine the impact of treatment on cognition independent of the impact of a recurrent cerebrovascular event.…”