A Failing Grade in Stroke Prevention
A third of the patients had a history of stroke or TIA. In this group, almost 40% of patients had no documented anti-clotting therapy. Medication use revealed in the records consisted of aspirin in just four out of 10 of the patients, and no more than 15% were on any other kind of blood-thinning agent.
The researchers then looked at people with a history of heart attack or angina (chest pain) as well as other conditions that put patients at high risk of having a stroke, such as the heart rhythm problem known as atrial fibrillation and a history of blood vessel disease in the legs. All these conditions are felt to benefit from stroke prevention with blood-thinning drugs. These patients showed a similar pattern of medication use. About 40% were on no anti-clotting therapy prior to their strokes, said Lichtman.
"We might have expected a gap of 10% or so between what should be done and what in fact is being done. The magnitude of the difference we found was really alarming to us," says Lichtman.
The patient chart review showed a consistent disregard for preventive treatment across most subgroups. No evidence of gender, age, or race bias emerged from the data, according to Lichtman. In fact, those in the most elderly subgroup (75 and older) were more likely to receive anti-clotting therapy than were patients younger than 65.
"If anything, there was a bias against preventive therapy in younger people," says Lichtman. "The patient, the treating physician, or both might have assumed there was no reason to be concerned about stroke because of the person's younger age."
More than 80% of the study population had some evidence of stroke risk, said Lawrence Brass, MD, a professor of neurology at Yale. All of them should have been on some form of preventive therapy, he said.
"The real issue is why -- why were these patients not receiving preventive therapy?" says Brass. "We know from other work by our group that the answer is probably multifactorial."
"The take-home message from this study is that everybody needs to be involved in stroke prevention," Brass says. "The take-home message is that everybody can be involved in enhancement of stroke prevention. Some of the information and education needs to be directed toward patients and some toward physicians."