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Adherence to guidelines: Are ischemic stroke patients receiving guideline-concordant cardiac stress testing?
Sico JJ, Bravata DM. Adherence to guidelines: Are ischemic stroke patients receiving guideline-concordant cardiac stress testing? Presented at: American Neurological Association Annual Meeting; 2014 Oct 12; Baltimore, MD.
Summary: Ischemic stroke and ischemic heart disease (IHD) share many of the same vascular risk factors, especially such atherosclerotic risk factors as hypertension, diabetes, hyperlipidemia, and cigarette smoking. An estimated 20% to 30% of stroke patients have symptomatic IHD, whereas 40% are thought to have silent ischemia. Cardiovascular disease is a common cause of adverse events in the first three months post-stroke, with 2% to 6% of stroke patients dying from vascular causes and 4 to 6% being readmitted with myocardial infarction. While cardiac evaluation in the acute and subacute stroke patients largely focuses on discerning whether a stroke was caused by a cardioembolic source, the American Heart Association/American Stroke Association has advocated that cardiac screening for asymptomatic IHD based on a 'high risk' Framingham Cardiac Risk Score (FCRS 20%) be considered after discharge.[1,2] The FCRS uses age, gender, cholesterol and blood pressure values, and cigarette smoking, and diabetes status to determine 10-year risk of cardiovascular disease. Stroke patients are more likely to have a 'high risk' FCRS compared to demographically matched controls. Previous studies have demonstrated that the FCRS can be reliably calculated from administrative data and the recommendation can feasibly be implemented at discharge for patients with TIA and ischemic stroke. Adherence to cardiac screening among recently discharged 'high risk' stroke patients occurs in a minority of patients, with providers citing lack of outcomes data to support the guideline as a reason for not ordering testing. Researchers concluded that guideline concordant cardiac screening is underutilized among ischemic stroke patients without evidence of previous cardiac stress testing. Patients at the highest risk of future cardiac events were not more likely to receive cardiac stress testing than patients with lower risk. Furthermore, those at highest risk were likely to have lower mortality when screening was performed. Additional research is required to identify potential barriers to CHD screening, and to determine reasons behind a potential mortality benefit when guideline concordant cardiac screening is performed.
-Researchers examined medical records that were abstracted for a sample of 3965 Veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007).
-Patients with a history of IHD, receipt of cardiac stress testing within 18-months prior to stroke event, and patients who died during the index hospitalization were excluded (n = 1628).
-Administrative data were used to calculate FRS and to determine whether or not cardiac stress testing was performed within 6-months following discharge from the index stroke hospitalization.
-Among 2337 stroke patients, 28% (n = 664) had FCRS 20, and a total of 6% (n = 140) had cardiac stress testing within 6-months of discharge.
-Cardiac stress testing was not more frequently performed among those with 'high risk' (5.6%) than those with 'low risk' (6.2%) FRS.
-High risk patients were as likely to have received cardiac stress testing as those with low FCRS (OR = 0.90; CI: 95: 0.61-1.32).
-High-risk patients that received screening also had lower one-year all-cause mortality compared with those that did not receive screening (5% vs 19%; P = 0.018).
1. Adams RJ, et al. Stroke. 2003;34:2310-2322.
2. Morris JG, et al. Stroke. 2009;40:2893-2898.
3. Ekundayo OJ, et al. Stroke. 2011;42:1982-1987.
4. Ovbiagele B, et al. Stroke. 2009;40:3407-3409.