Guideline-Directed Low-Density Lipoprotein Management in High-Risk Patients With Ischemic Stroke: Findings From Get With The Guidelines-Stroke 2003 to 2012

Oct 21, 2014
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Authors:
Saposnik G, Fonarow GC, Pan W, et al., on behalf of the AHA Get-With-The-Guidelines Stroke.
Citation:
Stroke 2014;Oct 9:[Epub ahead of print].
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What are the differences in the attainment of the contemporary lipid guidelines, based on admission low-density lipoprotein (LDL) testing, among unselected patients with history of transient ischemic attack (TIA), stroke, diabetes mellitus, and coronary artery disease (CAD) admitted with acute ischemic stroke or TIA?

Methods:

This was an observational study, using data from the Get-With-The-Guidelines-Stroke Registry including 913,436 patients with an acute ischemic stroke or TIA from April 2003 to September 2012. Participants were classified as high risk if they had history of TIA, stroke (cardiovascular disease), and CAD. Multivariable logistic regression models were performed to determine the independent predictors of meeting LDL targets.

Results:

Of the 913,436 patients admitted with an acute stroke or TIA, 194,557 (21.3%) had previous stroke/TIA, 148,833 (16.3%) had previous CAD, and 88,605 (9.7%) had concomitant CAD and cardiovascular disease. Overall, only 68% of patients with stroke were at their preadmission National Cholesterol Education Program III guideline-recommended LDL target; 51.3% had LDL <100 mg/dl, and only 19.8% had LDL<70 mg/dl. Among those presenting with a recurrent stroke, >45% had LDL >100 mg/dl. When compared with patients with CAD, patients with previous TIA/stroke were less likely to have LDL <100 or <70 mg/dl. In multivariable analysis, older age, men, white race, lack of major vascular risk factors, previous use of cholesterol-lowering therapy, and care provided in larger hospitals were associated with meeting LDL targets on admission testing.

Conclusions:

The authors concluded that management of dyslipidemia in high-risk patients with pre-existent CAD or stroke continues to be suboptimal.

Perspective:

This study reports that current management of dyslipidemia after a TIA/stroke remains suboptimal, despite a high proportion of individuals being discharged on lipid-lowering agents after their acute hospitalization for ischemic stroke. Quality improvement strategies should be directed to facilitate access to ambulatory care for high-risk patients with pre-existing cardiovascular disease, in particular, for those who are less likely to achieve the recommended targets. Additional work is needed to better understand the reasons for the potential gaps between guideline-recommended therapies and their use in clinical practice and the most appropriate strategies for optimizing care delivery to improve outcomes.

Keywords: Quality Improvement, Dyslipidemias, Stroke, Ischemic Attack, Transient, Cholesterol, LDL, Risk Factors, Ambulatory Care, Hospitalization


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