Neal S. Parikh, MD
Some argue that optimizing stroke systems of care may yield more public health gains than scientific advances. This notion does not apply exclusively to acute stroke care. Roughly 20% of strokes in the United States are recurrent; efforts to improve secondary prevention are invaluable.
To this end, Bravata and colleagues sought to compare hypertension, hyperlipidemia, and diabetes treatment success at 1 year after stroke and myocardial infarction (MI) in the Veterans Health Administration (VA) system. Patients with transient ischemic attack (TIA) were included in secondary analyses.
From among 40,230 patients from 75 facilities, they identified 2,127 patients with incident stroke, 4,169 patients with incident MI, and 1,233 patients with TIA hospitalized in 2011. Adequate blood pressure control was defined as <140/90.
Patients with stroke had fewer visits to the doctor’s office, fewer blood pressure measurements recorded, and worse blood pressure control in the 1-year post-stroke period, compared to patients with MI. After adjusting for facility-level and patient-level characteristics, patients with acute MI had 1.39 times the odds (95% confidence interval, 1.21-1.59) of adequate blood pressure control compared to patients with acute stroke. Results were similar for patients with TIA.
Because the results regarding hyperlipidemia and diabetes treatment were less alarming, they are not discussed here.
Several relatively benign factors may explain the findings of this study. As the authors found, patients with stroke also had worse pre-event hypertension than patients with MI. Second, the authors did not adjust for disability. They found that patients with stroke had less healthcare utilization after stroke, and this may reflect the implications of disability on access to care. Similarly, debility and frailty may have influenced stroke neurologists to treat blood pressure less aggressively.
Alternatively, as the authors suggest, neurologists may be less comfortable with hypertension treatment than cardiologists. Efforts to increase post-stroke care and neurologists’ comfort with anti-hypertensives is warranted. Whether these findings are relevant outside of the VA system is unknown. Regardless, let this be a call to action.