Putting stroke medication guidelines into clinical practice: Is this the best approach for patients?

Problem

Recent changes in guidelines for secondary prevention of cardiovascular disease have potentially wide-reaching implications for primary care. In 2014, NICE recommended atorvastatin 80mg for the secondary prevention of cardiovascular disease and in 2016, the Royal College of Physicians recommended clopidogrel 75mg as first line treatment after TIA/stroke. As a result of these new recommendations, stable compliant patients may potentially be switched from a lower dose statin to atorvastatin 80mg. Additionally, patients on aspirin 75mg or a combination of aspirin and dipyridamole potentially may be switched to clopidogrel 75mg. Our aim was to investigate current uptake by stroke survivors of these medications in practices in the UK, and to assess the clinical impact of these recommendations in general practice.

Approach

We conducted a cross-sectional retrospective study in the West-Midlands and Cambridgeshire of electronic medical records of patients with a history of TIA/stroke from 15 practices in West Midlands and 13 in Cambridgeshire between 2009 and 2012. Prescription data was extracted on all patients coded with TIA or stroke, age ≥ 55 years, including antiplatelet/anticoagulant or lipid lowering medications prescribed in the last 120 days before data collection. We compared these data with the guideline recommendations, and assessed how stroke survivors living in the community may best be helped.

Findings

Of the 3354 stroke survivors in our dataset, only 1% were prescribed atorvastatin 80mg, and about one third of patients were on no statin therapy at all. Looking at the anti-platelets, only 10% of patients were prescribed clopidogrel, and about one quarter did not receive any anti-platelet therapy within our 120-day data window.

Consequences

A significant number of stroke survivors fail to take any secondary prevention medication. A review of those patients on no preventative therapy may present a higher clinical priority than switching stable patients onto a new regimen.