Are Neurologists More Likely to Prescribe Antithrombotic Therapy After Stroke?
To the Editor:
Volpato et al1 in their recent work have highlighted the lack of antithrombotic treatment prescription at discharge from hospitals in a large proportion of patients after an ischemic brain attack. Although the rate of prescription was increased in the late 90s, 30% of patients did not receive antithrombotic treatment for secondary prevention. In the Neurology department of our hospital, there is a strong interest in stroke, so a stroke outpatient clinic was set up and has been running since early 2000. We, therefore, looked at our stroke register to find out the attitude of neurologists compared with that of the physicians in prescribing antithrombotic treatment after stroke.
During an 18-month period commencing in 2000, 278 patients (mean age 68.4±12.5, female 42%) with an acute ischemic stroke were discharged from Neurology and General Medicine wards of the University Hospital of Patras, Greece. The catchment area of our hospital is the city of Patras, which is the third largest city in Greece, and the smaller towns and villages of northwest Peloponnese. All patients were invited at discharge to attend the stroke outpatient clinic at regular intervals (1, 3, 6 and 12 months from onset).
Antithrombotic treatment was prescribed in 223 (80%) of the 278 patients (13% aspirin alone, 75% ticlopidine, clopidogrel, or slow release dipyridamole with aspirin, and 12% oral anticoagulants). Of the 198 patients (mean age 63.8±11.3), who were discharged from the Neurology wards, 16 (8%) were not taking any antithrombotic treatment, compared with 39 (49%) of the 80 patients (mean age 79.7±7.2) discharged from the General Medicine wards (P<0.0001). Aspirin alone was prescribed in 5% and 50% of the patients on antithrombotic treatment in the Neurology and General Medicine wards respectively. Logistic regression analysis showed that among age, sex, residence (rural versus urban), discharge ward, vascular risk factors and cognitive impairment (Mini Mental State Examination score at discharge), only discharge ward was independently associated with not prescribing antithrombotic treatment (OR, 13.0; 95% CI, 5.4 to 31.2).
During the first year post-stroke, 197 patients attended the stroke clinic (81% of the first year survivors). Of these, 173 patients, who were discharged on antithrombotic therapy, showed excellent compliance with treatment throughout the first year of follow up. Of the 24 patients who were not on any antithrombotic treatment at discharge, 15 (63%) commenced treatment, whereas in the remaining antithrombotic treatment was contraindicated.
Our data show that a larger proportion of patients are prescribed antithrombotic treatment after stroke compared with that reported by Volpato et al. However, neurologists prescribed antithrombotic treatment at discharge significantly more often than internists, and this is independent of other confounding factors. Whether this is because of the special interest our neurologists have in stroke, to their greater exposure to the results of the multicenter randomized control trials and overviews, or to a targeted promotion of the newer antiplatelet drugs, is not clear. The stroke outpatient clinic at the University Hospital of Patras helps to maximize the proportion of patients on preventive treatments, and possibly also helps to maintain the compliance with treatments, although, it is not possible with our data to tell whether the patients who did not attend the clinic complied with therapy. We are currently examining the prescription and compliance of preventive treatments for other modifiable stroke risk factors.
Volpato S, Maraldi C, Ble A, Ranzini M, Rita Atti A, Dominguez L J, Barbagallo M, Fellin R, and Zuliani G. Prescription of antithrombotic therapy in older patients hospitalized for transient ischemic attack and ischemic stroke: the GIFA study. Stroke. 2004; 35 (4): 913–917.
We appreciate the interest of Drs Ellul, Talelli, and Papapetropoulos in our article on antithrombotic prescription in older Italian patients with ischemic brain events.1 We found a substantial rate of patients (≈40%) discharged from internal medicine and geriatrics departments without antithrombotic therapy prescription. We also found that presence of physical and cognitive impairment was the most important independent factor related to the likelihood of having the antithrombotic prescription.
In their work, Ellul and coauthors reported a higher prevalence rate of antithrombotic prescription (80%) in a sample of 278 patients discharged with an ischemic stroke from neurology and general medicine wards. They also pointed out that patients discharged from neurology departments were more likely to receive antithrombotic treatment as compared with patients from general medicine wards. This difference was independent of age, gender, vascular risk factors, and cognitive impairment. The authors therefore concluded that neurologists are more prone than general physicians to adhere to international guidelines for ischemic stroke secondary prevention.
This hypothesis is interesting and certainly plausible; however, other potential explanations should be considered. Although the authors did account for important confounders, including age and cognitive status, other major clinical characteristics, potentially related to both drug prescription pattern and patient setting allocation, were not included in the analysis. Indeed, in our clinical experience, the more complex patients, characterized by older age, higher comorbidity level, physical disability, and polypharmacotherapy, are more likely to be admitted to a geriatric or internal medicine ward. In these complex patients, systematic application of guidelines is often challenging and not always feasible. Therefore, the lower antithrombotic prescription rate recorded in the general medicine department may be, at least in part, the result of a careful clinical evaluation and not the consequence of lack of adherence to evidence-based medicine. In keeping with this interpretation, a recent article reported a different prescription rate of statins according to age and cardiovascular risk profile with the oldest patients with the highest risk profile having the lowest probability of statins prescription.2