Importance of in-hospital initiation of therapies and therapeutic inertia in secondary stroke prevention: IMplementation of Prevention After a Cerebrovascular evenT (IMPACT) Study.
OBJECTIVE
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) <140/90 mm Hg and low-density lipoprotein (LDL) cholesterol <1 g/L in a collaborative cohort of 240 consecutive patients experiencing stroke/transient ischemic attack (Rankin <4; </=80 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 <140/90 mm Hg and 55% of those with diagnosed hypercholesterolemia had their LDL <1 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 <140/90 mm Hg (OR=2.44; 95% CI: 1.20 to 4.97) and LDL <1 g/L (OR=3.36; 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 >/=140/90 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.


CONCLUSIONS
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.
Touzé
Emmanuel
E
Université Paris Descartes, EA 4055, Department of Neurology, Hôpital Sainte-Anne, 1 rue Cabanis, 75014 Paris, France. e.touze@ch-sainte-anne.fr
Coste
Joël
J
Voicu
Magdalena
M
Kansao
Jamal
J
Masmoudi
Rafik
R
Doumenc
Benoît
B
Durieux
Pierre
P
Mas
Jean-Louis
JL
D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology; D008078:Cholesterol, LDL / Q000037:antagonists & inhibitors / Q000097:blood; D002985:Clinical Protocols; D015897:Comorbidity; D003695:Delivery of Health Care; D005260:Female; D005602:France / Q000453:epidemiology; D006760:Hospitalization / Q000706:statistics & numerical data* / Q000639:trends; D006761:Hospitals / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D006937:Hypercholesterolemia / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control; D006949:Hyperlipidemias / Q000188:drug therapy* / Q000453:epidemiology / Q000503:physiopathology; D006973:Hypertension / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*
D000959:Antihypertensive Agents; D008078:Cholesterol, LDL; D000960:Hypolipidemic Agents; D010975:Platelet Aggregation Inhibitors