Bahar M. Beaver, MD

Bravata DM, Daggy J, Brosch J, Sico JJ, Baye F, Myers LJ, et al. “Comparison of Risk Factor Control in the Year After Discharge for Ischemic Stroke Versus Acute Myocardial Infarction.” Stroke. 2018

Stroke patients universally receive stroke education as part of their inpatient stay following their stroke. This education typically covers risk factors of stroke and expected outcomes, and emphasizes post-stroke lifestyle modifications (medication compliance, diet, and exercise) for secondary prevention. Once patients leave the hospital, compliance with these measures varies greatly. Current literature supports continued close follow-up in order to support patients as they implement these lifestyle modifications. One simple modification with which physician office staff can assist patients is medication compliance. More diligent medication compliance and close follow-up can lead to tighter control of vascular risk factors.

In this article, Bravata et al followed patients in the post-hospitalization period and evaluated quality of control of the following risk factors: hypertension, hyperlipidemia, and diabetes mellitus. They evaluated data from the U.S. Veterans Health Administration (VHA), which analyzed control of vascular risk factors. Their study included a total of 40,230 patients across 75 facilities. The primary analysis was risk factor control following stroke or acute myocardial infarction (AMI). They also evaluated outpatient resource use in the year prior to the incident and in the year following.

Analysis of the data on hypertension showed that patients who had an AMI had better control of their blood pressure than those who had a stroke. Lipid control was similar between patients who had an AMI versus patients who had a stroke. Diabetes control was better in patients with stroke versus in patients with AMI. This data showed no difference among facilities when adjusted for variability in resources at each location.

Regarding outpatient resource use post-hospitalization, AMI patients had more outpatient follow-up visits than stroke patients. Risk factor control was analyzed across three separate specialty visits: primary care (PCP), cardiology, and neurology. The study found that blood pressure control was better in patients who saw a cardiologist. Patients who followed up with their PCP did not have a change in their blood pressure. Those who followed up with a neurologist had worse blood pressure control. This was similar for diabetes control. Interestingly, patients who visited a cardiologist and neurologist post-hospitalization had better LDL control.

The authors concluded that patients who had a stroke had worse blood pressure control in the year following hospitalization than those who had an AMI. They offered several explanations as to why this difference in outcomes exists — including higher level of comfort treating blood pressure in cardiologists versus neurologists, patients on multiple anti-hypertensives (beta blockers prescribed to most AMI patients), and tighter follow-up schedules in cardiology versus neurology. They acknowledged the limitations of their study, namely that stroke etiology was not specified, anti-hypertensives were not individually identified, and the homogenous nature of their large sample size from the VHA.

Though the study does not identify specific reasons for the discrepancy in risk factor control between the two groups (stroke patients versus AMI patients), it does serve an important purpose in drawing attention to this difference. Stroke neurologists should be mindful of this and play a more active role in controlling patients’ risk factors instead of deferring to their PCP or cardiologist for further management.