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Underutilization of Guideline-Concordant Cardiac Screening among Patients with Cerebrovascular Disease

Sico J, Baye F, Myers L, Concato J, Williams LS, Bravata DM. Underutilization of Guideline-Concordant Cardiac Screening among Patients with Cerebrovascular Disease. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2015 Apr 1; 46(4):AWP158.

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Introduction: Guidelines recommend the use of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with TIA and ischemic stroke who have a 'high risk' Framingham Risk score (FRS). It is unclear whether TIA/stroke patients regularly receive guideline-concordant cardiac stress testing. Methods: Administrative data from a sample of 10,923 Veterans from admitted to Veterans Health Administration (VHA) facilities with a TIA or mild stroke in fiscal year 2011 were analyzed. Patients were excluded (n = 6947) on the basis of a history of CHD, receipt of cardiac stress testing within 18-months prior to cerebrovascular event, patients who died within 90 days of discharge or were discharged to hospice, and those with missing/unknown race. A FRS was calculated for each patient based on: age, gender, race, systolic blood pressure, blood pressure treatment (yes/no), diabetes, smoking status (smoker/non-smoker), and cholesterol (total and high-density lipoprotein). Patients with an FRS 20 were classified as 'high risk' of having CHD. Administrative data were used to identify whether cardiac stress testing was performed within 6-months after the cerebrovascular event. Results: Of the 3976 TIA/mild stroke patients, 53.9% (2322) had FRS 20. A higher proportion of patients with FRS 20 that received cardiac screening were younger, white men with diabetes and without a history of cancer, compared with patients with a FRS 20 that did not receive testing. Cardiac stress testing was not performed more frequently for 'high risk' (4.5%; 104/2322) versus 'low/intermediate risk' (4.7%; 77/1654) FRS (OR = 0.96; CI95:071-1.30). Conclusions: Guideline concordant cardiac screening is underutilized among patients with TIA and minor ischemic stroke. Additional research is required to: 1) better understand clinicians' understanding of and approach to cardiac screening for patients with cerebrovascular disease at high risk for CHD; and 2) determine whether cardiac screening improves post-TIA/stroke outcomes.

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