CV Risk Prevention Profiles Significantly Worse Following Stroke vs MI in 2 Large National Cohorts

Among individuals with prior stroke new research identified significant deficiencies in risk factor control compared with individuals with previous myocardial infarction (MI).

Those with prior stroke were far less likely to have met targets for LDL-C and blood pressure, among other vascular measures, and were less adherent with guideline-directed therapies, including statin and antiplatelet drugs. The analysis, which drew on data from large national databases in the US and the UK, found that race and ethnicity as well as neighborhood deprivation levels, were all significantly associated with the odds of having a favorable CV prevention score.

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“There are significant public health implications for the inadequate management and control of vascular risk in stroke survivors and a missed opportunity for individual patients,” study authors wrote in the Journal of the American Heart Association. The findings underscore significant gaps in secondary prevention for stroke survivors, they continued. “Furthermore, we must understand the root causes that explain diminished use of secondary prevention strategies in stroke survivors compared with those with MI.”

Senior author Kevin N Sheth, MD, Professor of Neurology and Neurosurgery at Yale School of Medicine and director of the Yale Center for Brain & Mind Health, and colleagues point to the increasing prevalence of stroke and thus of survivors requiring effective secondary prevention strategies but also to limited knowledge of how widely and consistently those interventions are in use, particularly compared with aftercare for “other large populations who carry similar vascular risk.” Given the similar CV risk profiles between individuals with history of stroke and of MI, the secondary preventive care should ideally be similar, they wrote.

Sheth and fellow researchers set out to compare the quality of that care among participants in 2 large national cohorts – the UK Biobank and the US All of Us (AoU) Research Program.

From the UK Biobank, they identified 14 760 adults (mean age, 61.2 years; 62% men) with history of either stroke (5567) or MI (9193) and from the AoU, 7315 adults (mean age 64.24 years; 49.2% men) with history of stroke (2948) or MI (4367).

For the study outcomes of interest, the researchers evaluated 4 variables related to adherence to CV prevention guidelines: LDL control (<100 mg d/L), blood pressure control (<140/90 mm Hg), statin use and antiplatelet use. A fifth, an overall CV prevention score (CPS), was a composite of the 4 other variables. A binary metric, the CPS categorized individuals who met standards for 3 or 4 CV prevention variables as having "good" CPS and those who met fewer than 3 as having "insufficient” prevention profiles. Sheth et al used tertiles of the Deprivation Index to create categories of neighborhood deprivation in order to assess the potential effect on CPS and separately analyzed the effects of age, sex, race and ethnicity.

FINDINGS

UK Biobank. Overall, after adjusting for covariates, UK Biobank participants with a history of stroke had 58% lower odds of having all risk factors at target control levels compared with those who had a history of MI (OR, 0.42, 95% CI, 0.39-0.45; P < .001).

History of stroke was also consistently associated with reduced odds of meeting criteria for all 4 preventive variables. After adjustment for age, sex, race/ethnicity differences, stroke history vs MI history was linked to:

• 27% lower odds of having LDL-C levels controlled (OR, 0.73, 95% CI, 0.68–0.78; P < .001)
• 37% lower odds of blood pressure control (OR, 0.63, 95% CI, 0.59–0.68; P < .001)
• 55% lower odds of being on a statin medication (OR, 0.45, 95% CI, 0.42–0.48; P < .001)
• 72% lower odds of being on an antiplatelet medication (when also considering anticoagulant use) (OR, 0.28, 95% CI, 0.26–0.31; P < .001)

All of Us. Analysis of data from the AoU cohort returned similar patterns with participants with a history of stroke being overall 43% less likely to have good control across all 4 CV prevention variables than peers with a history of MI, after adjusting for covariates (OR, 0.57, 95% CI, 0.50–0.65; P < .001; P < .05 for all individual variables). 

Subgroup analyses in the more diverse AoU cohort revealed significant racial and ethnic disparities in risk factor control, according to the results. White participants with MI had higher rates of control vs Black participants with MI (65% vs. 43%), but for those with stroke, the difference was much less, at 47% vs 45%, respectively.

The researchers also found a more pronounced difference in odds of achieving a favorable CV prevention score between White participants with stroke vs MI (49%; OR, 0.51, 95% CI, 0.45–0.58; P < .001) compared with Black participants with stroke vs MI (28%; OR 0.72; 95% CI, 0.59-0.88; P < .001).

“There are significant public health implications for the inadequate management and control of vascular risk in stroke survivors and a missed opportunity for individual patients. Furthermore, we must understand the root causes that explain diminished use of secondary prevention strategies in stroke survivors compared with those with MI."

Using the Deprivation Index, the researchers compared composite CV prevention scores based on participants’ neighborhood deprivation level, which was based on mean income and the prevalence of vacant housing, poverty, high school education, health insurance coverage and assisted income.

Overall, researchers found that neighborhood deprivation “was suggestive of having an influence” on the likelihood of having good composite CPS for participants with stroke vs MI. Specifically, in privileged neighborhoods, those with a history of stroke had 56% (OR, 0.44. 95% CI, 0.36–0.53; P < .001) reduced odds of achieving favorable CPS vs those with MI while in deprived neighborhoods the odds were reduced by 36% (OR, 0.64; 95% CI, 0.53-0.77; P < .001).

“In summary, our study, using 2 large and diverse datasets, highlights a clear discrepancy in care between patients with stroke and MI, observed consistently in populations from both the United Kingdom and the United States, across several races, ethnicities, and deprivation levels,” Sheth and colleagues wrote. This disparity in care, as evidenced by our findings, suggests fundamental differences in the care systems for these 2 conditions.”

"There may be opportunities to understand facilitating elements that are helpful for survivors of myocardial infarction that may not be present for stroke survivors," they concluded.

Reference

Rivier CA, Acosta JN, Leasure AC, et al. Secondary prevention in patients with stroke versus myocardial infarction: analysis of 2 national cohorts. J Am Heart Assoc. Published online April 19, 2024. doi:10.1161/JAHA.123.033322