Impact of European Stroke Organisation secondary prevention guideline for ischaemic stroke / transient ischaemic attack

Abstract

Objectives: We aimed to assess secondary prevention strategies after ischaemic stroke or transient ischaemic attack (TIA).

Materials and methods: We investigated the impact of European Stroke Organisation (ESO) Guideline recommendations for secondary prevention on recurrent events among people with non-cardioembolic ischaemic stroke or TIA. We assessed the following interventions by survival analysis or modelling impacts from clinical trial data: two blood pressure (BP) drugs compared to one drug; LDL-cholesterol target <1.8 mmol/L; and pioglitazone therapy. Outcomes were mortality, major adverse cardiovascular events (MACE) and recurrent stroke or myocardial infarction (MI).

Results: We included 4,037 people admitted between 01/12/2015 to 31/12/2018: mean (SD) age 68.6 (12.9) years; 1984 (49.1 %) female and median (IQR) follow-up 2.2 (1.5-3.1) years. Prescription of two BP drugs was associated with reduced mortality in our sample of 2238 people with hypertension (HR 0.64, 95 %CI 0.51-0.81; P<0.001). We estimate an LDL-cholesterol target <1.8 mmol/L could reduce MACE incidence from 128 to 114 events (95 %CI 103-127) in our sample of 1024 people with LDL-cholesterol 1.8 mmol/L who were not already prescribed intensive lipid-lowering therapy over median (IQR) 2.2 (1.5-2.9) years follow-up (ARR 1.38 %, NNT 73). We estimate pioglitazone therapy could reduce incidence of recurrent stroke or MI from 192 to 169 events (95 %CI 156-185) in our sample of 1587 people with diabetes or insulin resistance over median (IQR) 2.4 (1.7-3.2) years follow-up (ARR 1.45 %, NNT 69).

Conclusions: We estimate that implementing ESO guidelines in a Scottish population after ischaemic stroke or TIA would reduce mortality and recurrent cardiovascular events.

Keywords: Blood pressure; Diabetes mellitus; Ischaemic stroke; Lipids; Secondary prevention; Transient ischaemic attack.