1 in 5 at-risk stroke patients meet low LDL targets

Efforts to bring low-density lipoprotein (LDL) cholesterol levels within guideline parameters fall short with stroke. Only one in five patients at high risk for recurrent stroke met recommendations for LDL cholesterol levels below 70 mg/dL, according to results published online Oct. 9 in Stroke.

More than 45 percent of these patients had LDL higher than 100 mg/dL at admission for a subsequent stroke.

The research team led by Gustavo Saposnik, MD, MSc, of St. Michael’s Hospital in Toronto, looked at adherence to guideline goals such as those by the National Cholesterol Education Program-Adult Treatment Panel III, the American Heart Association (AHA), American Stroke Association and the American College of Cardiology (ACC). Although AHA/ACC guidelines released in 2013 move away from a focus on LDL targets, Saposnik et al wrote that the pooled cohort equations used by the guidelines still factor in cholesterol levels.

Utilizing the Get with the Guidelines-Stroke (GWTG-Stroke) database, Saposnik et al reviewed patient cases between April 2003 and September 2012. LDL cholesterol, as one of seven core performance measures, was collected by all institutions participating in the GWTG-Stroke database.

They found that of the 913,436 patients presenting with acute stroke, 21.3 percent had a pre-existing stroke or transit ischemic attack. Pre-existing coronary artery disease occurred in 16.3 percent of patients and 9.7 percent had both pre-existing coronary artery disease and cardiovascular disease. Lipid lowering therapies were used by 41.8 percent of patients.

In patients with pre-existing transit ischemic attacks or stroke, 47.6 percent were receiving medication to lower lipid levels. Of those, 54.5 percent had LDL below 100 mg/dL and 21.4 percent had less than 70 mg/dl. Saposnik et al wrote that the same could be said for patients with stroke and pre-existing coronary artery disease: 59.7 percent of patients were on lipid lowering therapy, however 62.3 percent had LDL below 100 mg/dL and 28.5 percent had LDL of less than 70 mg/dL.

They found that in patients who had no prior history of stroke, cardiovascular disease or coronary artery disease, 41.6 percent had LDL below 100 mg/dL and only 12.4 percent had LDL below 70 mg/dL. About half of patients with diabetes but no prior stroke, coronary artery disease or MI had cholesterol below 100 mg/dL.

In total, 81 percent of patients were discharged on statins.

Saposnik et al found trends for meeting LDL targets seemed to have a correlation to sex, ethnicity and socioeconomic factors. White men were more likely than Hispanic, blacks or women to attain LDL goals, they found. They suggested that the proportion of patients seen that meet targets below 100 or 70 mg/dL may reflect less aggressive prevention care or lower access to care.

“These results suggest that clinicians may be more aggressive when facing older men with pre-existing CVD [cardiovascular disease] or CAD [coronary artery disease] with no vascular risk factors,” they wrote.  

“Alternatively, socioeconomic, lifestyle behavior, and genetic factors may explain why ethnic groups other than whites, patients living in the northeast or south regions, or patients cared for in smaller hospitals were less likely to meet the LDL targets. Economic factors have also been documented in previous studies using hierarchical models.”

They suggested new strategies be developed to allow all patients equal access to prevention clinics with careful patient monitoring by physicians on outpatient adherence.