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Published on: February 16, 2011
Comparison of Risk Factor Control in the Year After Discharge for Ischemic Stroke Versus Acute Myocardial Infarction
Dawn M Bravata1, Joanne Daggy2, Jared Brosch2
1From the VHA Health Services Research and Development (HSR&D), Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, IN (D.M.B., J.D., F.B., L.J.M., G.A.); VHA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VHA Medical Center, Indianapolis, IN (D.M.B., J.D., L.J.M., J.C.); Department of Medicine (D.M.B., L.J.M.), Department of Neurology (D.M.B., J.B.), and Department of Biostatistics (J.D., F.B.), Indiana University School of Medicine, Indianapolis; Department of Sociology, Indiana University School of Liberal Arts, Indiana University, Purdue University Indianapolis (G.A.); Regenstrief Institute, Indianapolis, IN (D.M.B., G.A.); Department of Neurology, Department of Internal Medicine, and Center for Neuroepidemiological and Clinical Neurological Research, Yale University School of Medicine, New Haven, CT (J.J.S.); HSR&D, GRECC, and Clinical Research Training Center of Excellence, Veterans Affairs-Tennessee Valley Healthcare System, Nashville, TN (C.L.R.); Institute of Medicine and Public Health, Vanderbilt University, Nashville, TN (C.L.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); and Department of Neurology, University of California at Los Angeles (E.C.). Dawn.Bravata2@va.gov.
Insights
Vascular risk factor control, including blood pressure, lipids, and glycemic control, was examined one year after hospitalization for acute ischemic stroke or myocardial infarction (AMI). AMI patients had better blood pressure control than stroke patients, but stroke patients had better glycemic control.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Public Health
Background:
- The Veterans Health Administration (VHA) implemented quality improvement initiatives to enhance vascular risk factor management.
- Vascular risk factors, including blood pressure, lipids, and glycemic control, are critical for secondary prevention after major cardiovascular and cerebrovascular events.
Purpose of the Study:
- To compare the control of blood pressure, low-density lipoprotein (LDL) cholesterol, and hemoglobin A1c (HbA1c) in patients one year post-hospitalization for acute ischemic stroke versus acute myocardial infarction (AMI).
Main Methods:
- A cohort of 40,230 patients hospitalized in fiscal year 2011 across 75 VHA facilities was analyzed.
- Patients hospitalized with incident ischemic stroke (n=2127) or AMI (n=4169) were included in the primary analysis.
- A generalized linear mixed model was used to compare risk factor control, adjusting for patient and facility-level factors.
Main Results:
- Fewer ischemic stroke patients achieved blood pressure control (64%) compared to AMI patients (77%) (P<0.0001).
- After adjustment, AMI patients had higher odds of blood pressure control (OR, 1.39; 95% CI, 1.21-1.51).
- No significant differences in hyperlipidemia control were observed between AMI and stroke patients (P=0.534).
- Among patients with diabetes, AMI patients had lower odds of glycemic control (OR, 0.72; 95% CI, 0.54-0.96) compared to stroke patients.
Conclusions:
- Hypertension control is crucial for secondary stroke prevention.
- Interventions are needed to improve post-stroke hypertension management.
- Further research should explore strategies to optimize vascular risk factor control in high-risk patient populations.
Background And Purpose:
The Veterans Health Administration has engaged in quality improvement to improve vascular risk factor control. We sought to examine blood pressure (<140/90 mm Hg), lipid (LDL [low-density lipoprotein] cholesterol <100 mg/dL), and glycemic control (hemoglobin A1c <9%), in the year post-hospitalization for acute ischemic stroke or acute myocardial infarction (AMI).
Methods:
We identified patients who were hospitalized (fiscal year 2011) with ischemic stroke, AMI, congestive heart failure, transient ischemic attack, or pneumonia/chronic obstructive pulmonary disease. The primary analysis compared risk factor control after incident ischemic stroke versus AMI. Facilities were included if they cared for ≥25 ischemic stroke and ≥25 AMI patients. A generalized linear mixed model including patient- and facility-level covariates compared risk factor control across diagnoses.
Results:
Forty thousand two hundred thirty patients were hospitalized (n=75 facilities): 2127 with incident ischemic stroke and 4169 with incident AMI. Fewer stroke patients achieved blood pressure control than AMI patients (64%; 95% confidence interval, 0.62-0.67 versus 77%; 95% confidence interval, 0.75-0.78; P<0.0001). After adjusting for patient and facility covariates, the odds of blood pressure control were still higher for AMI than ischemic stroke patients (odds ratio, 1.39; 95% confidence interval, 1.21-1.51). There were no statistical differences for AMI versus stroke patients in hyperlipidemia (P=0.534). Among patients with diabetes mellitus, the odds of glycemic control were lower for AMI than ischemic stroke patients (odds ratio, 0.72; 95% confidence interval, 0.54-0.96).
Conclusions:
Given that hypertension control is a cornerstone of stroke prevention, interventions to improve poststroke hypertension management are needed.
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