Welcome to the WSC 2021 Interactive Program

Background and Aims

Lipid-lowering medications (LLMs) are recommended for secondary prevention of stroke. Little is known about the association between their ongoing use post-discharge and outcomes. We investigated the use and adherence to LLMs within the first 90 days post-discharge for ischaemic stroke and associated 12-month outcomes.

Methods

Retrospective cohort study of 90-day survivors of ischaemic stroke from hospitals (n=45) in two Australian states participating in the Australian Stroke Clinical Registry (2012-2016). Person-level data were linked with Pharmaceutical Benefits Scheme (PBS), hospital and death datasets. LLM use within 90 days post-discharge was determined from PBS dispensing records. Among users, adherence was assessed using the proportion of days covered (PDC: <80% vs. ≥80%) within 90 days post-discharge. Outcomes during the subsequent year (91-455 days) included all-cause mortality and hospital readmissions (cardiovascular disease, all-cause). Associations between use/adherence and outcomes were determined using propensity score adjusted-multivariable Cox regression models.

Results

Of 11,217 eligible patients (median age 72 years, 42% female), 9,294 (83%) used LLMs within 90 days post-discharge, including 5,938 (64%) with PDC ≥80%. Compared to users, non-users, had greater rates of mortality [hazard ratio (HR) 2.35, 95% CI 1.89-2.93] or all-cause readmissions (HR 1.16, CI 1.09-1.22). Among users, those with PDC <80% had greater rates of mortality (HR 1.31, CI 1.14-1.51) or all-cause readmissions (HR 1.05, CI 1.00-1.09) than those with PDC ≥80%. There were no associations between use/adherence and cardiovascular disease readmissions.

Conclusions

Use and greater adherence to LLMs (90-days) for ischaemic stroke is associated with reduced all-cause mortality and readmissions.

Background and Aims

High-intensity statins are recommended as tertiary prevention after ischemic stroke, but evidence on different statin intensities and the risk of recurrence remains inconclusive. We examined the association between statin intensity and the risk of recurrent ischemic stroke.

Methods

In this Danish nationwide, population-based, new-user, active comparator cohort study, we used the Danish Stroke Registry to identify patients with a first-time ischemic stroke during 2004-2018. Patients who redeemed a statin prescription within 7 days after discharge were assigned to cohorts according to international guidelines on statin intensity. We used competing risk methods to compute 10-year risk differences (RDs) and Cox regression to compute adjusted hazard ratios (aHRs) of ischemic stroke recurrence and all-cause mortality, adjusting for age, sex, calendar period, stroke severity, and other risk factors.

Results

Low (n=305), moderate (n=29,325), and high (n=6,115) intensity statin users were followed for a median of 4.2 years. The risk of recurrence was largely similar among high-intensity users compared with moderate-intensity (RD: -0.3% [95% CI: -3.7; 3.0], aHR: 1.09 [95% CI: 0.95; 1.24]) and low-intensity users (RD: -2.8% [95% CI: -6.2; 0.6], aHR: 0.78 [95% CI: 0.56; 1.08]). The risk of all-cause mortality was lower among high-intensity users compared with low-intensity (RD: -21.8% [95% CI: -26.5; -17.0], aHR: 0.65 [95% CI: 0.53; 0.79]) and moderate-intensity users (RD: -12.4% [95% CI: -17.1; -7.6], aHR: 0.79 [95% CI: 0.71; 0.87]).

Conclusions

High-intensity statin use was not associated with a reduced risk of recurrent ischemic stroke. All-cause mortality was lowered in a possible dose-dependent manner.

Background and Aims

Background and aims: Knowledge on the risk and prognosis of stroke recurrence is limited. We examined risks of stroke recurrence and mortality after first and recurrent stroke.

Methods

Methods: Danish patients (≥18 years) with a first-time ischemic stroke (IS; n = 105,527) or intracerebral hemorrhage (ICH; n = 13,387) during 2004–2018 were identified from the Danish Stroke Registry and the Danish National Patient Registry. Using competing risk methods, we computed absolute risks, risk differences, and odds ratios of stroke recurrence separately for each stroke subtype and within patient subgroups. Mortality was assessed with the Kaplan-Meier estimator.

Results

Results: The 1-year and 10-year risks of recurrence were 4% and 13% for IS and 2% and 7% for ICH. For IS, the risk increased marginally with age and was higher for men than for women, for milder first-time stroke than for more severe, and for obese than for normal weight patients. Essen risk scores predicted recurrence in a dose-response manner. For ICH, risks were similar between sexes and did not increase with body mass index and Essen risk score. For IS, the 1-year and 10-year risks of mortality were 17% and 56% after first-time stroke and 22% and 69% after recurrent stroke; corresponding estimates for ICH were 37% and 69% after a first-time event and 41% and 82% after a recurrent event.

Conclusions

Conclusions: The risk of stroke recurrence was substantial, especially after IS, but the risk varied among subgroups. The risk of mortality was higher after a recurrent than first-time stroke.

Background and Aims

In patients with the loss-of-function (LOF) allele CYP2C19*2 or CYP2C19*3, dual antiplatelet therapy (DAPT) with the prodrug clopidogrel has reduced effectiveness. Our aim was to evaluate cost-effectiveness of genotype-guided DAPT with point of care testing.

Methods

Genotype-guided therapy with aspirin monotherapy (gASA), prasugrel (gPRASU) or aspirin-dipyridamole (gASA-DP) in patients with the LOF allele was compared to usual therapy with clopidogrel and aspirin without testing (uCLOPI), but also with universal aspirin monotherapy (uASA), aspirin-dipyridamole (uASADP) and prasugrel (uPRASU). Estimates of recurrent ischemic events and bleeding complications were based on published studies. A lifetime Markov state-transition microsimulation model with 1-year cycle length was developed to estimate the incremental cost-effectiveness ratio (ICER) in a sample of 100.000 individuals in a West-European stroke population. Outcomes were measured in quality-adjusted life years (QALY). Probabilistic sensitivity analysis was performed to assess precision.

Results

Both uPRASU and gPRASU were cost-saving compared to clopidogrel treatment, with uPRASU being more cost-effective than gPRASU. uPRASU resulted in an incremental cost-saving of €976 and a gain of 0.037 QALYs per patient. gPRASU resulted in a cost-saving of €584 and a gain of 0.017 QALYs per patient. gASADP was more costly than clopidogrel treatment, with an ICER of €209,436.

Conclusions

Genotype-guided antiplatelet therapy and universal prasugrel therapy for prevention of recurrent events after stroke should be considered. These strategies are cost-effective for reducing long-term risk of recurrent events and death in patients with ischemic stroke or TIA. There is still uncertainty about the effect size of prasugrel treatment, which should be further investigated.

Background and Aims

Atrial Fibrillation is the most important cause of ESUS. Implantable Loop Recorder demonstrated the highest sensitivity for detecting it.

This register was created to confirm the high prevalence of AF in patients after ESUS and to verify possible benefits on clinical outcomes such as TIA/stroke recurrence and death using ILR.

Methods

278 patients admitted to “Molinette” Hospital in Stroke Unit department between 2011 and 2019, diagnosed with ESUS, underwent ILR implantation if they had at least one risk factor for AF.

165 patients admitted in other departments in the same center for the same pathology, without ILR rapresented the control group.

We used propensity score to select 132 patients from each group (matching age, sex, CHADS-VASC, and HAS-BLEED baseline characteristics).

Risk and protective factors were estimated for clinical outcomes (deaths and TIA/stroke recurrence) and were evaluated with logistic regression univariate/multivariate analysis.

Results

The detection rate of AF episodes was significantly higher in the ILR group (41.7% vs 15.9%, p<0.001)

On univariate analysis, we didn't find a significant association between ILR and clinical outcomes, although a relevant protective trend for TIA/stroke recurrence and mortality has been pointed out (p=0.06).

On multivariate analysis, we detected a protective role of ILR in terms of TIA/stroke recurrence.

Conclusions

With our statistical models we identified for the first time in a real-world population a significant clinical benefit from ILR monitoring, evidenced by a trend of less death and TIA/stroke recurrence in univariate analysis and relevant ILR protection in multivariate models for prediction of TIA/stroke recurrence

Background and Aims

Sub-Saharan Africa (SSA) is gradually becoming the epicentre of stroke worldwide, but continental-wide data alluding to the significance of diets in stroke risk among indigenous Africans are scarce. This study determined the association between dietary patterns (DP) and odds of stroke among Africans.

Methods

3684 strokes patients matched for 3684 controls were recruited across multiple SIREN sites and communities in Nigeria and Ghana. Diet histories (servings and frequency of consumption) were summarized using principal component analysis to identify DP. Stroke was defined using predefined criteria primarily on clinical evaluation following standard operating procedures. Logistic regressions were applied to compute odds ratio (OR) and 95% confidence interval (CI) for stroke risk by tertile distribution of DP at P<0.05.

Results

Mean age was 59.0±13.9years, 45.8% were females, 8.1% and 29.4% reported tobacco and alcohol use respectively. Seven DP (vegetable-dense-diet, poultry&fish-dense-diet, whole grains-diet, fried&sweetened-foods, red-meaty-diet, pickled/processed-foods and fruit-dense-diet) were identified in this sample. Multivariable-adjusted OR (95%CI) for odds of stroke across tertile distribution (lowest tertile as reference) of DP were; 2nd tertile – 0.82 (0.73, 0.92), 3rd – 0.61 (0.54, 0.69) for vegetable-dense-diet, 1.36 (1.22, 1.53), 1.54 (1.37, 1.73) for poultry&fish-dense-diet, 0.77 (0.69, 0.87), 0.81 (0.73, 0.91) for whole-grains-diet, 1.56 (1.39, 1.75), 1.46 (1.30, 1.64) for red-meaty-diet, 1.02 (0.91, 1.14), 1.12 (1.00, 1.26) for pickled/processed-foods, and 0.91 (0.82, 1.02), 0.84 (0.74, 0.94) for fruit-dense diet.

Conclusions

There is a complex association between dietary patterns and odds of stroke, but regular consumption of a vegetable-dense diet was independently associated with reduced odds of stroke.