TIA/stroke care: adhering to best practices cuts mortality risk

  • Bravata DM & al.
  • JAMA Netw Open
  • 3 Jul 2019

  • International Clinical Digest
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Takeaway

  • In caring for patients with transient ischemic attack (TIA) or nonsevere ischemic stroke, stringent adherence to certain processes of care is associated with lower mortality but not lower recurrence risk.

Why this matters

  • Many recommendations appear in American Heart Association/American Stroke Association (AHA/ASA) stroke prevention guidelines.
  • Authors assessed which ones specifically correlate with improved hard outcomes.

Key results

  • 9 processes of care correlated with substantially improved 90-day mortality, such as carotid imaging, cholesterol-lowering medication intensification, neurology consultation. 
  • 10 processes correlated with improved 1-year mortality, including the above 9+anticoagulation for Afib. 
  • None correlated with lower recurrent stroke risk at either time point.
  • 15.3% of patients received without-fail care or all guideline-concordant processes of care for which they were eligible.
  • They experienced 31.2% lower 1-year mortality risk: aOR, 0.69 (95% CI, 0.55-0.87).

Study design

  • Cohort study of patients at the Department of Veterans Affairs (VA) with TIA or nonsevere ischemic stroke in 1 year (n=8076).
  • Using multivariate analysis, authors assessed associations between outcomes and:
    • 28 AHA/ASA-recommended processes of care.
    • 6 without-fail processes, such as brain and carotid imaging, hypertension medication intensification, high- or moderate-potency statins.
  • Outcomes: 90-day, 1-year all-cause mortality, recurrent ischemic stroke.
  • Funding: Department of VA.

Limitations

  • Observational; possible confounders.