Importance of in-hospital initiation of therapies and therapeutic inertia in secondary stroke prevention: IMplementation of Prevention After a Cerebrovascular evenT (IMPACT) Study.

ABSTRACT

BACKGROUND AND PURPOSE: Many patients do not receive prevention consistent with recommendations after stroke, but the relative importance of patient- and physician-related factors is uncertain. METHODS: We prospectively assessed factors associated with blood pressure (BP) <140/90 mm Hg and low-density lipoprotein (LDL) cholesterol <1 g/L in a collaborative cohort of 240 consecutive patients experiencing stroke/transient ischemic attack (Rankin <4; comorbidity) from a stroke unit and 3 emergency departments. A standardized assessment of risk factors was performed 6 and 12 months after the initial event by an investigator who was not involved in the usual follow-up of patients. RESULTS: At 6 months, 41% of patients with diagnosed hypertension at inclusion had their BP <140/90 mm Hg and 55% of those with diagnosed hypercholesterolemia had their LDL <1 g/L. Adherence to treatment was excellent in 81% of patients. In univariate and multivariate analyses, initiation or reinforcement of appropriate treatments during hospitalization were the main factors associated with BP <140/90 mm Hg (OR=2.44; 95% CI 1.20 to 4.97) and LDL <1 g/L (OR=3.36; 1.27 to 8.89) or with decrease in BP and LDL. Patients' sociodemographic characteristics, education, income, knowledge of disease, and risk factors were not associated with control of BP or LDL. Among patients with BP >/=140/90 mm Hg, approximately 40% received either no treatment or one drug only, and treatment was reinforced in 20% of them only. Results were similar at 12 months with no improvement in the rate of control of risk factors. CONCLUSIONS: Therapeutic inertia is an important impediment to achieve BP and LDL control goals after stroke, even in fairly motivated/adherent patients. In-hospital initiation of preventive therapies could improve quality of secondary stroke prevention in the long term.