Patients with 'bleeding' strokes less likely to receive medications and counseling to prevent recurrent strokes

May 11 2007

Patients with a hemorrhagic ("bleeding") stroke are significantly less likely to receive medications and counseling to prevent recurrent strokes compared to patients with an ischemic (clot-caused) stroke, researchers reported at the American Heart Association's 8th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

These findings are the result of a three-year study conducted by members of the American Heart Association's Get With The Guidelines Steering Committee and investigators. The project involved 662 hospitals with entries for 149,089 ischemic strokes or transient ischemic attacks (a "mini-stroke"), 17,195 intracerebral hemorrhages (ICH) and 5,503 subarachnoid hemorrhages (SAH).

An intracerebral hemorrhage occurs when a defective artery in the brain bursts, flooding the surrounding tissue with blood. A subarachnoid hemorrhage occurs when a blood vessel on the brain's surface ruptures and bleeds into the space between the brain and the skull (but not into the brain itself). Bleeding strokes have a much higher fatality rate than strokes caused by clots.

Get With The Guidelines, Stroke is an American Heart Association quality improvement program in which hospitals establish teams to ensure that stroke patients are treated and discharged appropriately according to guideline-based performance measures.

The researchers looked for the proportion of patients who received cholesterol-reducing medications, diabetes medications and weight-reduction management and smoking cessation therapy at discharge. High cholesterol, diabetes, overweight/obesity and cigarette smoking are risk factors for heart disease and stroke. Smoking, in particular, is a known risk factor for both bleeding strokes and ischemic strokes.

They found that 77 percent of ischemic stroke patients received cholesterol-lowering medications at discharge, compared with 67 percent of ICH patients and 62 percent of those with SAH.

"It is uncertain whether prescription patterns were influenced by the known association between low cholesterol levels and an increased risk for ICH," said Eric E. Smith, M.D., M.P.H., lead author of the report and associate director of acute stroke services at Massachusetts General Hospital in Boston.

The association between ICH and low cholesterol, as well as some cholesterol-lowering drugs, is a relatively established risk, Smith said. By contrast, having a low cholesterol level is protective against heart attacks and ischemic strokes. "For people with high cholesterol who are at risk for heart attacks and ischemic stroke, physicians have to weigh whether the benefit of cholesterol-lowering outweighs the potential increased risk for hemorrhagic stroke."

The numbers were a little closer with diabetes medications or treatment at discharge, with 81 percent of ischemic stroke patients, 77 percent of those with ICH and 73 percent of those with SAH receiving them. Researchers also found less disparity in weight-loss management, with 36 percent of those with ischemic stroke, 33 percent of those with ICH and 27 percent with SAH receiving some kind of intervention.

The biggest difference was in smoking cessation therapy. While 71 percent of patients with ischemic stroke received it, 63 percent of those with ICH and only 55 percent of SAH patients were counseled about the risk of stroke associated with cigarette smoking.

SAH patients were the most likely to be current smokers but the least likely to receive smoking cessation therapy in the study.

"We're not clear why these patients were less likely to receive smoking cessation therapy," said Smith, who is also assistant professor of neurology at Harvard Medical School in Boston. "It could be influenced by variations in hospital practice, availability of smoking cessation counseling, patient characteristics or socioeconomic factors, for example. The study didn't collect detailed data on the reasons for not offering intervention."

"The Get With The Guidelines, Stroke program was developed to improve quality of ischemic stroke care, but many of the risk factors for ischemic stroke are the same for hemorrhagic stroke. The system is also set up to receive data about hemorrhagic strokes. Ideally, all of these measures should be 100 percent because patients with contraindications to treatment should have been left out of the statistics. The data suggest it may be time to develop performance measures specifically for treating hemorrhagic stroke."