A. Kaleel, MD, MSc

Saposnik G, Fonarow GC, Pan W, Liang L, Hernandez AF, Schwamm LH, et al. Guideline-Directed Low-Density Lipoprotein Management in High-Risk Patients With Ischemic Stroke: Findings From Get With The Guidelines-Stroke 2003 to 2012. Stroke. 2014

As secondary prevention management guidelines have proven effective at reducing the risk of recurrent vascular events, there remains concern that there is lack of adherence to these guidelines. This study sought to assess the “real world” success of achieving NCEP-ATP III LDL guideline goals in high risk stroke patients with prior cardiovascular or cerebrovascular disease. In particular, this observational study focused on LDL levels at the new index event of TIA or stroke in the following categories: patients with pre-existing TIA/stroke, pre-existing CAD, pre-existing concomitant CVD and CAD, and no pre-existing CAD/CVD. 

Among the 913,436 patients evaluated from the Get With The Guidelines (GWTG)-Stroke Program between April 2003 to September 2012 within the 1246 participating institutions, 21.3% had a pre-existing TIA/stroke, 16.3% had a pre-existing CAD, 9.7% had concomitant CAD and CVD, and 52.7% had no known documented history of CVD or CAD.

It was discovered at the index event that the mean LDL was 100.9 in those with pre-existing CVD, 95.1 in those with pre-existing CAD, 93.5 in those with both CAD and CVD, and 111 in those without pre-existing CAD/CVD. To put this into perspective, only 21.4% of patients with pre-existing TIA/stroke with a new stroke achieved an LDL <70 and this was also true for only 28.5% of pre-existing CAD patients. 

Overall, only 68% of stroke patients were at their pre-admission NCEP III guideline-recommended LDL target and among those who presented with recurrent stroke, more than 45% had LDL >100.

Encouragingly, the data revealed a temporal shift in LDL management, with improved LDL control over time. This study particularly highlights the disparity between the guidelines and actual realization among these patients. In multivariable analysis, older age, male, white race, lack of major vascular risk factors, prior use of cholesterol-lowering therapy, and care provided in larger hospitals were associated with meeting LDL targets on admission testing.