Adherence to Guidelines at a Stroke Prevention Clinic: A Follow-up Study.

BACKGROUND: In 2010, we published our stroke prevention clinic's performance as compared to Canadian stroke prevention guidelines. We now compare our clinic's adherence with guidelines to our previous results, following the implementation of an electronic documentation form. METHODS: All new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008-2010) regarding vascular risk management and treatment. RESULTS: Three hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04-2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets. CONCLUSIONS: Our study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.

CONTEXTE: En 2010, nous avons rendu publics les résultats de notre clinique de prévention des AVC en ce qui regarde les lignes directrices canadiennes de prévention des AVC. Suite à la mise en place d'un formulaire d'information électronique, nous voulons maintenant comparer l'adhésion actuelle de notre clinique à ces lignes directrices à celle mesurée en 2010. MÉTHODES: Tous les nouveaux patients adressés à notre clinique (Centre universitaire de santé McGill) pour des cas récents d'ischémie cérébrale transitoire (ICT) ou d'AVC ischémique survenus entre 2014 et 2017 ont été inclus dans cette étude. Nous avons ainsi comparé l'adhésion actuelle aux lignes directrices évoquées ci-haut à celle du précédent rapport (N = 408 patients pour la période allant de 2008 à 2010), et ce, en ce qui concerne la prise en charge du risque vasculaire et les traitements nécessaires. RÉSULTATS: Au total, 392 patients ont été inclus; de ce nombre, 36 % d'entre eux avaient été victimes d'ICT tandis que 64 % avaient été victimes d'un AVC ischémique. Leur âge moyen était de 70 ans et 43 % d'entre eux étaient de sexe féminin. Bien que la cohorte la plus récente, à la suite de l'introduction de nouvelles lignes directrices portant sur la surveillance cardiaque prolongée, ait donné à voir une proportion plus élevée d'AVC d'origine cardio-embolique comparativement à la précédente (19,1 % par opposition à 14,7 %), la popularité croissante de l'angiographie par tomodensitométrie ne s'est pas traduite par une proportion plus grande de sous-types d'AVC affectant de grandes artères (26,3 % de 2014 à 2017 par opposition à 26,2 % de 2008 à 2010). Les valeurs cibles fixées en matière de pression artérielle ont été atteintes dans 83 % des cas comparativement à 70 % des cas dans notre rapport précédent (p < 0,01). L'atteinte de la valeur cible en ce qui concerne le taux de LDL-cholestérol (lipoprotéines de faible intensité) a également été améliorée dans notre plus récent rapport (66 % par opposition à 46 %; p < 0,01). Ajoutons aussi qu'aucune différence notable n'a été observée quant à une utilisation constante d'anti-thrombotiques (97,7 % par opposition à 99,8 %; p = 0,08). Fait à souligner, un déclin dans l'abandon du tabagisme a été noté (35 % par opposition à 73%; p = 0,02). Dans l'ensemble, les conditions d'une guérison optimale (optimal therapy status) ont été davantage atteintes dans la cohorte la plus récente comparativement à celle de 2008 à 2010 (52 % par opposition à 22 %; p < 0,01). Le fait d'être de sexe masculin a été associé à de meilleures conditions de guérison optimale (rapport des cotes: 1,61; IC 95 %, 1,04 ­ 2,51). Enfin, mentionnons que le nombre de consultations de suivi et la durée des suivis n'ont pas été associés à l'atteinte de valeurs cibles en matière de prévention des AVC. CONCLUSIONS: Notre étude montre une série d'améliorations dans l'atteinte des objectifs thérapeutiques recommandés par les lignes directrices canadiennes de prévention des AVC. Cela pourrait être en partie attribuable à la mise en place de dossiers médicaux informatisés au sein de notre clinique. Parmi les aspects qui méritent une amélioration, citons l'établissement d'un programme de counseling en ce qui regarde l'abandon du tabagisme et le dépistage du diabète.

Adherence to guidelines: experience of a canadian stroke prevention clinic.

BACKGROUND: Few studies have assessed the performance of stroke prevention clinics. In particular, limited information exists on patient compliance, achievement of therapeutic targets, and related occurrence of vascular events. METHODS: We compared our clinical practice to recommendations from published guidelines in newly referred patients for transient ischemic attack (TIA) or ischemic stroke between 2008 and 2010. We monitored our cohort for at least 1 year and assessed for adequacy of vascular risk factor management, drug adherence, and occurrence of nonlethal vascular outcomes. RESULTS: Of 408 patients, 57.8% had a stroke and 42.2% a TIA. The mean age was 68±13 years, and 52% male. Average follow-up was 15.8 months. During follow-up, 253 patients (70.3%) completely achieved their blood pressure target, 151 (45.5%) achieved their low-density lipoprotein (LDL) cholesterol target, and 407 (99.8%) were on antithrombotics. Eighty-nine patients (21.8%) attained optimal therapy status, defined as reaching targets for LDL cholesterol, blood pressure, and antithrombotic use. Adherence to drug therapy was associated with attainment of optimal therapy status (p=0.01). Diabetes was associated with lower probability of attaining optimal therapy status (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.20-0.66) and blood pressure targets (OR, 0.09; 95% CI, 0.05-0.17). During follow-up, 52 (12.7%) patients had a nonlethal vascular event. CONCLUSION: Our study shows good attainment of therapeutic goals associated with adherence to drug therapy. However, optimal therapy status and blood pressure targets were more difficult to attain in patients with diabetes; therefore, more intensive preventive efforts may be required for these individuals.

Major Adverse Cardiovascular Events Associated With Postoperative Atrial Fibrillation After Noncardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a frequent occurrence after noncardiac surgery. It remains unclear whether POAF is associated with an increased risk of major adverse events. We aimed to elucidate the risk of stroke, myocardial infarction, and death associated with POAF following noncardiac surgery by a meta-analysis of randomized controlled studies and observational studies. METHODS: We searched electronic databases from inception up to August 1, 2019 for all studies that reported stroke or myocardial infarction in adult patients who developed POAF following noncardiac surgery. We used random-effects models to summarize the studies. RESULTS: The final analyses included 28 studies enrolling 2 612 816 patients. At 1-month (10 studies), POAF was associated with an ≈3-fold increase in the risk of stroke (weighted mean 2.1% versus 0.7%; odds ratio [OR], 2.82 [95% CI, 2.15-3.70]; P<0.001). POAF was associated with ≈4-fold increase in the long-term risk of stroke with (weighted mean, 2.0% versus 0.6%; OR, 4.12 [95% CI, 3.32-5.11]; P≤0.001) in 8 studies with ≥12-month follow-up. There was a significant overall increase in the risk of stroke and myocardial infarction associated with POAF (weighted mean, 2.5% versus 0.9%; OR, 3.44 [95% CI, 2.38-4.98]; P<0.001) and (weighted mean, 12.6% versus 2.7%; OR, 4.02 [95% CI, 3.08-5.24]; P<0.001), respectively. Furthermore, POAF was associated with a 3-fold increase in all-cause mortality at 30 days (weighted mean, 15.0% versus 5.4%; OR, 3.36 [95% CI, 2.13-5.31]; P<0.001). CONCLUSIONS: POAF was associated with markedly higher risk of stroke, myocardial infarction, and all-cause mortality following noncardiac surgery. Future studies are needed to evaluate the impact of optimal cardiovascular pharmacotherapies to prevent POAF and to decrease the risk of major adverse events in these high-risk patients.

Meta-analysis of Randomized Controlled Trials Assessing the Impact of Proprotein Convertase Subtilisin/Kexin Type 9 Antibodies on Mortality and Cardiovascular Outcomes.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition by monoclonal antibodies has been shown to reduce low density lipoprotein (LDL-C) but its effects on cardiovascular (CV) outcomes have not been fully described. The aim of this study is to assess the impact of PCSK9 inhibition on mortality and CV outcomes by pooling data from all available randomized clinical trials (RCT) of PCSK9 inhibitors. We conducted a comprehensive search of electronic databases, up to December 1, 2018, for all RCTs comparing PCSK9 inhibition to placebo or ezetimibe in patients with hypercholesterolemia or coronary artery disease receiving maximally tolerated statin for primary or secondary prevention of mortality and cardiovascular outcomes. We used random-effects meta-analyses to summarize the studies. We retained 23 RCTs having included 88,041 patients in primary and secondary prevention. The follow-up ranged from 6 to 36 months. PCSK9 inhibition was not significantly associated with reductions in total mortality (odds ratio [OR] 0.91, 95% confidence interval [CI] 078 to 1.06; p = 0.22) and CV mortality (OR 0.95, 95% CI 0.84 to 1.07; p = 0.37). In contrast, PCSK9 inhibition was associated with reductions in myocardial infarction (OR 0.80, 95% CI 0.71 to 0.91; p <0.0001), stroke (OR 0.75, 95% CI 0.65 to 0.85; p <0.0001), and coronary revascularization (OR 0.82, 95% CI 0.77 to 0.88; p <0.0001). In conclusion, PCSK9 inhibition was associated with reductions in myocardial infarction, stroke, and coronary revascularization. Future analyses may identify high-risk patients who may benefit more from these agents and longer follow-up of current or new trials may show a mortality benefit.

A randomized comparison between ultrasound- and fluoroscopy-guided third occipital nerve block.

BACKGROUND: Third occipital nerve block (TONB) is commonly used in the diagnosis and treatment of upper neck pain and cervicogenic headaches. Although fluoroscopy is the current imaging standard for TONB, ultrasound (US) guidance offers a promising, radiation-free alternative. In this randomized, observer-blinded trial, we compared the 2 imaging modalities. Our research hypothesis was that US guidance would result in a shorter performance time. METHODS: Forty patients undergoing TONB were randomized to fluoroscopy or US guidance. A mixture of local anesthetic and radiographic contrast was injected in both groups. The primary outcome was performance time. Secondary outcomes included success rate, pain levels before and after block, area of sensory hypoesthesia, quality of the block (assessed by electrical perceptual threshold), and procedure-related complications. RESULTS: Ultrasound guidance was associated with a significantly shorter performance time (212.8 vs 396.5 seconds; P = 0.000) and fewer needle passes (2 vs 6; P = 0.000). Both imaging modalities, however, resulted in similar success rates (95%-100%). Furthermore, no intergroup differences were found in preblock and postblock pain scores. In both groups, TONB produced hypoesthesia that was most profound in the suboccipital region. In the fluoroscopy group, C2-C3 intra-articular spread of radiographic contrast and vascular breach were noted in 15% and 10% of patients, respectively. In contrast, no adverse events occurred with US guidance. CONCLUSIONS: Fluoroscopy and US guidance provide similar success rates for TONB. However, ultrasonography is associated with improved efficiency (decreased performance time, fewer needle passes).