Greater Adherence to Secondary Prevention Medications Improves Survival After Stroke or Transient Ischemic Attack: A Linked Registry Study
Lachlan L. DalliJoosup KimDominique A. CadilhacMelanie GreenlandFrank SanfilippoNadine E. AndrewAmanda G. ThriftRohan GrimleyRichard I. LindleyVijaya SundararajanDouglas E. CromptonNatasha A. LanninCraig S. AndersonLeanne WhileyMonique F. Kilkenny
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Background and Purpose: Although a target of 80% medication adherence is commonly cited, it is unclear whether greater adherence improves survival after stroke or transient ischemic attack (TIA). We investigated associations between medication adherence during the first year postdischarge, and mortality up to 3 years, to provide evidence-based targets for medication adherence. Methods: Retrospective cohort study of 1-year survivors of first-ever stroke or TIA, aged ≥18 years, from the Australian Stroke Clinical Registry (July 2010–June 2014) linked with nationwide prescription refill and mortality data (until August 2017). Adherence to antihypertensive agents, statins, and nonaspirin antithrombotic medications was based on the proportion of days covered from discharge until 1 year. Cox regression with restricted cubic splines was used to investigate nonlinear relationships between medication adherence and all-cause mortality (to 3 years postdischarge). Models were adjusted for age, sex, socioeconomic position, stroke factors, primary care factors, and concomitant medication use. Results: Among 8363 one-year survivors of first-ever stroke or TIA (44% aged ≥75 years, 44% female, 18% TIA), 75% were supplied antihypertensive agents. In patients without intracerebral hemorrhage (N=7446), 84% were supplied statins, and 65% were supplied nonaspirin antithrombotic medications. Median adherence was ≈90% for each medication group. Between 1% and 100% adherence, greater adherence to statins or antihypertensive agents, but not nonaspirin antithrombotic agents, was associated with improved survival. When restricted to linear regions above 60% adherence, each 10% increase in adherence was associated with a reduction in all-cause mortality of 13% for antihypertensive agents (hazard ratio, 0.87 [95% CI, 0.81–0.95]), 13% for statins (hazard ratio, 0.87 [95% CI, 0.80–0.95]), and 15% for nonaspirin antithrombotic agents (hazard ratio, 0.85 [95% CI, 0.79–0.93]). Conclusions: Greater levels of medication adherence after stroke or TIA are associated with improved survival, even among patients with near-perfect adherence. Interventions to improve medication adherence are needed to maximize survival poststroke.Keywords:
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The relation between hospitalization timing and risk of clinical outcomes among patients with atrial fibrillation (AF) with and without stroke remained undetermined.Rehospitalization due to AF, cardiovascular (CV) death and all-cause mortality were the outcomes of interest in this study. Multivariable Cox proportional hazard model was applied to estimate the adjusted hazard ratio (HR) and 95% confidence interval (CI).While considering patients with AF hospitalized during weekdays without stroke as the reference group, patients with AF hospitalized during weekends with stroke had the risk of AF rehospitalization, CV death and all-cause death by 1.48 (95% CI 1.44 to 1.51), 1.77 (95% CI 1.71 to 1.83) and 1.17 (95% CI 1.15 to 1.19) times, respectively.Patients with AF hospitalized during weekends with stroke had the worst clinical outcomes.
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Approximately 85 percent of strokes are caused by infarction, with the remainder due to subarachnoid or intracerebral hemorrhage. Eighty percent of ischemic strokes are attributed to cerebrovascular disease, 15 percent to cardiogenic embolism and 5 percent to more unusual causes. Risk factors for stroke include hypertension and lifestyle choices. Recommendations for anticoagulant prophylaxis, treatment and dosage are provided.
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Hypertension is associated with stroke-related mortality. However, the long-term association of blood pressure (BP) and the risk of stroke-related mortality and the influence path of BP on stroke-related death remain unknown. The current study aimed to estimate the long-term causal associations between BP and stroke-related mortality and the potential mediating and moderated mediating model of the associations.This is a 45-year follow-up cohort study and a total of 1696 subjects were enrolled in 1976 and 1081 participants died by the latest follow-up in 2020. COX proportional hazard model was used to explore the associations of stroke-related death with baseline systolic blood pressure (SBP)/diastolic blood pressure (DBP) categories and BP changes from 1976 to 1994. The mediating and moderated mediating effects were performed to detect the possible influencing path from BP to stroke-related deaths. E value was calculated in the sensitivity analysis.Among 1696 participants, the average age was 44.38 ± 6.10 years, and 1124 were men (66.3%). After a 45-year follow-up, a total of 201 (11.9%) stroke-related deaths occurred. After the adjustment, the COX proportional hazard model showed that among the participants with SBP ≥ 160 mmHg or DBP ≥ 100 mmHg in 1976, the risk of stroke-related death increased by 217.5% (hazard ratio [HR] = 3.175, 95% confidence interval [CI]: 2.297-4.388), and the adjusted HRs were higher in male participants. Among the participants with hypertension in 1976 and 1994, the risk of stroke-related death increased by 110.4% (HR = 2.104, 95% CI: 1.632-2.713), and the adjusted HRs of the BP changes were higher in male participants. Body mass index (BMI) significantly mediated the association of SBP and stroke-related deaths and this mediating effect was moderated by gender.In a 45-year follow-up, high BP and persistent hypertension are associated with stroke-related death, and these associations were even more pronounced in male participants. The paths of association are mediated by BMI and moderated by gender.
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Hypertension is associated with stroke-related mortality. However, the long-term association of blood pressure (BP) and the risk of stroke-related mortality and the influence path of BP on stroke-related death remain unknown. The current study aimed to estimate the long-term causal associations between BP and stroke-related mortality and the potential mediating and moderated mediating model of the associations.This is a 45-year follow-up cohort study and a total of 1696 subjects were enrolled in 1976 and 1081 participants died by the latest follow-up in 2020. COX proportional hazard model was used to explore the associations of stroke-related death with baseline systolic blood pressure (SBP)/diastolic blood pressure (DBP) categories and BP changes from 1976 to 1994. The mediating and moderated mediating effects were performed to detect the possible influencing path from BP to stroke-related deaths. E value was calculated in the sensitivity analysis.Among 1696 participants, the average age was 44.38 ± 6.10 years, and 1124 were men (66.3%). After a 45-year follow-up, a total of 201 (11.9%) stroke-related deaths occurred. After the adjustment, the COX proportional hazard model showed that among the participants with SBP ≥ 160 mmHg or DBP ≥ 100 mmHg in 1976, the risk of stroke-related death increased by 217.5% (hazard ratio [HR] = 3.175, 95% confidence interval [CI]: 2.297-4.388), and the adjusted HRs were higher in male participants. Among the participants with hypertension in 1976 and 1994, the risk of stroke-related death increased by 110.4% (HR = 2.104, 95% CI: 1.632-2.713), and the adjusted HRs of the BP changes were higher in male participants. Body mass index (BMI) significantly mediated the association of SBP and stroke-related deaths and this mediating effect was moderated by gender.In a 45-year follow-up, high BP and persistent hypertension are associated with stroke-related death, and these associations were even more pronounced in male participants. The paths of association are mediated by BMI and moderated by gender.
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Hypertension is associated with stroke-related mortality. However, the long-term association of blood pressure (BP) and the risk of stroke-related mortality and the influence path of BP on stroke-related death remain unknown. The current study aimed to estimate the long-term causal associations between BP and stroke-related mortality and the potential mediating and moderated mediating model of the associations.This is a 45-year follow-up cohort study and a total of 1696 subjects were enrolled in 1976 and 1081 participants died by the latest follow-up in 2020. COX proportional hazard model was used to explore the associations of stroke-related death with baseline systolic blood pressure (SBP)/diastolic blood pressure (DBP) categories and BP changes from 1976 to 1994. The mediating and moderated mediating effects were performed to detect the possible influencing path from BP to stroke-related deaths. E value was calculated in the sensitivity analysis.Among 1696 participants, the average age was 44.38 ± 6.10 years, and 1124 were men (66.3%). After a 45-year follow-up, a total of 201 (11.9%) stroke-related deaths occurred. After the adjustment, the COX proportional hazard model showed that among the participants with SBP ≥ 160 mmHg or DBP ≥ 100 mmHg in 1976, the risk of stroke-related death increased by 217.5% (hazard ratio [HR] = 3.175, 95% confidence interval [CI]: 2.297-4.388), and the adjusted HRs were higher in male participants. Among the participants with hypertension in 1976 and 1994, the risk of stroke-related death increased by 110.4% (HR = 2.104, 95% CI: 1.632-2.713), and the adjusted HRs of the BP changes were higher in male participants. Body mass index (BMI) significantly mediated the association of SBP and stroke-related deaths and this mediating effect was moderated by gender.In a 45-year follow-up, high BP and persistent hypertension are associated with stroke-related death, and these associations were even more pronounced in male participants. The paths of association are mediated by BMI and moderated by gender.
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Background We investigated the longitudinal association of herpes zoster (HZ), commonly known as "shingles," and long-term risk of stroke or coronary heart disease (CHD) among participants in 3 large US cohorts, the NHS (Nurses' Health Study), NHS II (Nurses' Health Study II), and HPFS (Health Professionals Follow-Up Study). Methods and Results Participants were 79 658 women in the NHS (2000-2016), 93 932 women in the NHS II (2001-2017), and 31 440 men in the HPFS (2004-2016), without prior stroke or CHD. Information on HZ, stroke, and CHD was collected on biennial questionnaires and confirmed by medical record review. Cox proportional hazards regression models were used to estimate multivariable-adjusted hazard ratios for stroke and for CHD according to years since HZ compared with never HZ. During >2 million person-years of follow-up, 3603 incident stroke and 8620 incident CHD cases were documented. History of HZ was significantly and independently associated with higher long-term risk of stroke and CHD. In pooled analyses, compared with individuals with no history of HZ, the multivariable-adjusted hazard ratios (95% CIs) for stroke were 1.05 (0.88-1.25) among those with 1 to 4 years since HZ, 1.38 (1.10-1.74) for among those with 5 to 8 years since HZ, 1.28 (1.03-1.59) among those with for 9 to 12 years since HZ, and 1.19 (0.90-1.56) among those with ≥13 years since HZ. For CHD, the corresponding multivariable-adjusted hazard ratios (95% CIs) were 1.13 (1.01-1.27) for 1 to 4 years, 1.16 (1.02-1.32) for 5 to 8 years, 1.25 (1.07-1.46) for 9 to 12 years, and 1.00 (0.83-1.21) for ≥13 years. Conclusions HZ is associated with higher long-term risk of a major cardiovascular event. These findings suggest there are long-term implications of HZ and underscore the importance of prevention.
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The relation between hospitalization timing and risk of clinical outcomes among patients with atrial fibrillation (AF) with and without stroke remained undetermined.Rehospitalization due to AF, cardiovascular (CV) death and all-cause mortality were the outcomes of interest in this study. Multivariable Cox proportional hazard model was applied to estimate the adjusted hazard ratio (HR) and 95% confidence interval (CI).While considering patients with AF hospitalized during weekdays without stroke as the reference group, patients with AF hospitalized during weekends with stroke had the risk of AF rehospitalization, CV death and all-cause death by 1.48 (95% CI 1.44 to 1.51), 1.77 (95% CI 1.71 to 1.83) and 1.17 (95% CI 1.15 to 1.19) times, respectively.Patients with AF hospitalized during weekends with stroke had the worst clinical outcomes.
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The association of physical activity (PA) before stroke (prestroke PA) with long-term prognosis after stroke is still unclear. We examined the association of prestroke PA with adverse health outcomes in the ARIC study (Atherosclerosis Risk in Communities).
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Background and Purpose: To date, large studies comparing mortality and functional outcome of intracerebral hemorrhage (ICH) during oral anticoagulant (OAC), antiplatelet, and nonantithrombotic use are few and show discrepant results. Methods: We used data on 13 291 patients with ICH registered in Riksstroke between 2012 and 2016 to compare 90-day mortality and functional outcome following OAC-related ICH (n=2300), antiplatelet-related ICH (n=3637), and nonantithrombotic ICH (n=7354). Univariable and multivariable Cox regression analyses, with adjustment for relevant confounders, were used to compare 90-day mortality. Early (≤24 hours and 1–7 days) and late (8–90 days) mortality was also studied in subgroup analyses. Univariable and multivariable 90-day functional outcome, based on self-reported modified Rankin Scale, was determined using logistic regression. Results: Patients with antithrombotic treatment were more often prestroke dependent, older, and had a larger comorbidity burden compared with patients without antithrombotic treatment. At 90 days, antiplatelet and OAC were associated with an increased death rate in multivariable analysis (antiplatelet ICH: hazard ratio, 1.23 [95% CI, 1.14–1.33]; OAC ICH: hazard ratio, 1.40 [95% CI, 1.26–1.57]) compared with nonantithrombotic ICH (reference). OAC ICH and antiplatelet ICH were associated with higher risk of early mortality (≤24 hours: OAC ICH: hazard ratio, 1.93 [95% CI, 1.57–2.38]; antiplatelet ICH: hazard ratio, 1.32 [95% CI, 1.13–1.54]). In multivariable analysis, the odds ratios for the association of antiplatelet and OAC treatment on functional dependency (modified Rankin Scale score, 3–5) at 90 days were nonsignificant (antiplatelet: odds ratio, 1.07 [95% CI, 0.92–1.24]; OAC: odds ratio, 0.96 [95% CI, 0.76–1.22]). Conclusions: In this large observational study, we found that 90-day mortality outcome was worse not only in OAC ICH but also in antiplatelet ICH, compared with patients with nonantithrombotic ICH. Antiplatelet ICH is common and is a serious condition with poor clinical outcome. Further studies are, therefore, warranted in determining the appropriate clinical management of these patients.
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