Clinical Epidemiology (Sep 2021)

Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention

  • Gynnild MN,
  • Hageman SHJ,
  • Dorresteijn JAN,
  • Spigset O,
  • Lydersen S,
  • Wethal T,
  • Saltvedt I,
  • Visseren FLJ,
  • Ellekjær H

Journal volume & issue
Vol. Volume 13
pp. 813 – 823

Abstract

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Mari Nordbø Gynnild,1,2 Steven HJ Hageman,3 Jannick AN Dorresteijn,3 Olav Spigset,4,5 Stian Lydersen,6 Torgeir Wethal,1,2 Ingvild Saltvedt,1,7 Frank LJ Visseren,3 Hanne Ellekjær1,2 1Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU – Norwegian University of Science and Technology, Trondheim, Norway; 2Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; 3Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; 4Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; 5Department of Clinical and Molecular Medicine, NTNU – Norwegian University of Science and Technology, Trondheim, Norway; 6Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, Norway; 7Department of Geriatrics, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, NorwayCorrespondence: Mari Nordbø GynnildDepartment of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, NorwayEmail [email protected]: Suboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets.Patients and Methods: The SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated.Results: In total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55– 0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32– 54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63– 76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2– 3.4) event-free life years if guideline targets were met.Conclusion: Secondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.Keywords: secondary prevention, ischemic stroke, risk factors, risk assessment, risks and benefits, cardiovascular diseases

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