Evaluation of Adherence to Prescription Guidelines for Secondary Prevention at Discharge Following Ischemic Stroke
Keywords:
Antihypertensive treatment, guidelines, ischemic stroke, secondary prevention, statins
Abstract
Stroke is a significant public health issue. It represents the second cause of death globally and the third cause of death and disability combined. This study aims to evaluate stroke secondary prevention therapy prescribed at discharge. A retrospective analysis of patients admitted to Al-Yarmouk Teaching Hospital from the 15th of September 2023 to the 15th of January 2024. The prescription of secondary prevention therapy at discharge was evaluated according to American Heart Association/American Stroke Association guidelines which recommends the prescription of antiplatelet therapy and high-intensity statins to all patients and antihypertensive treatment to patients with hypertension. Researchers reviewed 180 medical records, of those 164 were eligible who were aged 33-101 years (mean=65.5), and of those, 97 (55.7%) were male. Overall, 70.1% received appropriate secondary prevention therapy; 92.1% received antiplatelet therapy and statins; 78.0% received antihypertensive treatment. In contrast, 16.8% received high-intensity statins and only 11.1% of patients with atrial fibrillation received anticoagulants. There was no statistically significant difference between receivers and non-receivers of appropriate secondary prevention therapy with the exception of systolic blood pressure on admission (P: 0.038). In addition, the male patients (odd ratio (OR): 0.404; 95% CI 0.164, 0.995) were less likely to receive antihypertensive therapy. Our findings highlight the need for education programs to ensure optimal statin dosing and improve prescribing of antihypertensive medications, and anticoagulants on follow-up to reduce stroke-related morbidity and mortality.
References
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Nassr, O. A., & Forsyth, P. (2019). Evaluation of Blood Pressure Control and Associated Factors among Patients with Hypertension in Iraq: A Prospective Cross-sectional Study. Journal of Pharmacy & Bioallied Sciences, 11(3), 232–239. https://doi.org/10.4103/jpbs.JPBS_82_19
PROGRESS Collaborative Group. (2001). Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet (London, England), 358(9287), 1033–1041. https://doi.org/10.1016/S0140-6736(01)06178-5
Sandset, E. C., Bath, P. M. W., Boysen, G., Jatuzis, D., Kõrv, J., Lüders, S., Murray, G. D., Richter, P. S., Roine, R. O., Terént, A., Thijs, V., Berge, E., & SCAST Study Group. (2011). The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): A randomised, placebo-controlled, double-blind trial. Lancet (London, England), 377(9767), 741–750. https://doi.org/10.1016/S0140-6736(11)60104-9
Sawalha, A. (2009). Characterization of hospitalized ischemic stroke patients in palestine. The Libyan Journal of Medicine, 4(1), 37–40. https://doi.org/10.4176/080920
Shah, J., Liu, S., & Yu, W. (2022). Contemporary antiplatelet therapy for secondary stroke prevention: A narrative review of current literature and guidelines. Stroke and Vascular Neurology, 7(5). https://doi.org/10.1136/svn-2021-001166
Shahbandi, A., Shobeiri, P., Azadnajafabad, S., Saeedi Moghaddam, S., Sharifnejad Tehrani, Y., Ebrahimi, N., Rezaei, N., Rashidi, M.-M., Ghamari, S.-H., Abbasi-Kangevari, M., Koolaji, S., Haghshenas, R., Rezaei, N., Larijani, B., & Farzadfar, F. (2022). Burden of stroke in North Africa and Middle East, 1990 to 2019: A systematic analysis for the global burden of disease study 2019. BMC Neurology, 22(1), 279. https://doi.org/10.1186/s12883-022-02793-0
Thrift, A. G., Kim, J., Douzmanian, V., Gall, S. L., Arabshahi, S., Loh, M., & Evans, R. G. (2014). Discharge is a critical time to influence 10-year use of secondary prevention therapies for stroke. Stroke, 45(2), 539–544. https://doi.org/10.1161/STROKEAHA.113.003368
Toffali, M., Carbone, F., Fainardi, E., Morotti, A., Montecucco, F., Liberale, L., & Padovani, A. (2023). Secondary prevention after intracerebral haemorrhage. European Journal of Clinical Investigation, 53(6), e13962. https://doi.org/10.1111/eci.13962
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Al Banna, M., Baldawi, H., Kadhim, A., Humaidan, H., & Whitford, D. L. (2015). Stroke in Bahrain: Rising incidence, multiple risk factors, and suboptimal care. International Journal of Stroke: Official Journal of the International Stroke Society, 10(4), 615–618. https://doi.org/10.1111/ijs.12513
Al-Obaidi, H., Khidhair, Z., Jirjees, F., Barakat, M., AlSalamat, H., Kharaba, Z., Alfoteih, Y., Haddad, C., Mansour, S., Hallit, S., Malaeb, D., & Hosseini, H. (2023). Factors associated with knowledge and awareness of stroke in the Iraqi population: A cross-sectional study. Frontiers in Neurology, 14, 1144481. https://doi.org/10.3389/fneur.2023.1144481
Arima, H., Chalmers, J., Woodward, M., Anderson, C., Rodgers, A., Davis, S., Macmahon, S., Neal, B., & PROGRESS Collaborative Group. (2006). Lower target blood pressures are safe and effective for the prevention of recurrent stroke: The PROGRESS trial. Journal of Hypertension, 24(6), 1201–1208. https://doi.org/10.1097/01.hjh.0000226212.34055.86
Awad, S. M., Al-Jumaily, H. F., Al-Dulaimi, K. M., & Abdulghafoor, R. H. (2010). Assessment of major risk factors among stroke patients. Saudi Medical Journal, 31(9), 1028–1031.
Bangad, A., Abbasi, M., & de Havenon, A. (2023). Secondary Ischemic Stroke Prevention. Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics, 20(3), 721–731. https://doi.org/10.1007/s13311-023-01352-w
Biffi, A., Teo, K.-C., Castello, J. P., Abramson, J. R., Leung, I. Y. H., Leung, W. C. Y., Wang, Y., Kourkoulis, C., Myserlis, E. P., Warren, A. D., Henry, J., Chan, K.-H., Cheung, R. T. F., Ho, S.-L., Anderson, C. D., Gurol, M. E., Viswanathan, A., Greenberg, S. M., Lau, K.-K., & Rosand, J. (2021). Impact of Uncontrolled Hypertension at 3 Months After Intracerebral Hemorrhage. Journal of the American Heart Association, 10(11), e020392. https://doi.org/10.1161/JAHA.120.020392
Campbell, B. C. V., De Silva, D. A., Macleod, M. R., Coutts, S. B., Schwamm, L. H., Davis, S. M., & Donnan, G. A. (2019). Ischaemic stroke. Nature Reviews. Disease Primers, 5(1), 70. https://doi.org/10.1038/s41572-019-0118-8
Chen, Y., Wright, N., Guo, Y., Turnbull, I., Kartsonaki, C., Yang, L., Bian, Z., Pei, P., Pan, D., Zhang, Y., Qin, H., Wang, Y., Lv, J., Liu, M., Hao, Z., Wang, Y., Yu, C., Peto, R., Collins, R., … China Kadoorie Biobank Collaborative Group. (2020). Mortality and recurrent vascular events after first incident stroke: A 9-year community-based study of 0•5 million Chinese adults. The Lancet. Global Health, 8(4), e580–e590. https://doi.org/10.1016/S2214-109X(20)30069-3
Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., Jones, D. W., Materson, B. J., Oparil, S., Wright, J. T., Roccella, E. J., Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute, & National High Blood Pressure Education Program Coordinating Committee. (2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension (Dallas, Tex.: 1979), 42(6), 1206–1252.https://doi.org/10.1161/01.HYP.0000107251.49515.c2
Connelly, P. J., Currie, G., & Delles, C. (2022). Sex Differences in the Prevalence, Outcomes and Management of Hypertension. Current Hypertension Reports, 24(6), 185–192. https://doi.org/10.1007/s11906-022-01183-8
Cuschieri, S. (2019). The STROBE guidelines. Saudi Journal of Anaesthesia, 13(Suppl 1), S31–S34. https://doi.org/10.4103/sja.SJA_543_18
El-Hajj, M., Salameh, P., Rachidi, S., & Hosseini, H. (2016). The epidemiology of stroke in the Middle East. European Stroke Journal, 1(3), 180–198. https://doi.org/10.1177/2396987316654338
GBD 2019 Stroke Collaborators. (2021). Global, regional, and national burden of stroke and its risk factors, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet. Neurology, 20(10), 795–820. https://doi.org/10.1016/S1474-4422(21)00252-0
Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C., Johnson, R., Keigher, K. M., Mack, W. J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., Sunnerhagen, K. S., & American Heart Association/American Stroke Association. (2022). 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke, 53(7), e282–e361. https://doi.org/10.1161/STR.0000000000000407
Hwong, W. Y., Abdul Aziz, Z., Sidek, N. N., Bots, M. L., Selvarajah, S., Kappelle, L. J., Sivasampu, S., & Vaartjes, I. (2017). Prescription of secondary preventive drugs after ischemic stroke: Results from the Malaysian National Stroke Registry. BMC Neurology, 17, 203. https://doi.org/10.1186/s12883-017-0984-1
Jaberinezhad, M., Farhoudi, M., Nejadghaderi, S. A., Alizadeh, M., Sullman, M. J. M., Carson-Chahhoud, K., Collins, G. S., & Safiri, S. (2022). The burden of stroke and its attributable risk factors in the Middle East and North Africa region, 1990-2019. Scientific Reports, 12(1), 2700. https://doi.org/10.1038/s41598-022-06418-x
Kamel, H., & Healey, J. S. (2017). Cardioembolic Stroke. Circulation Research, 120(3), 514–526. https://doi.org/10.1161/CIRCRESAHA.116.308407
Kleindorfer, D. O., Towfighi, A., Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., Kamel, H., Kernan, W. N., Kittner, S. J., Leira, E. C., Lennon, O., Meschia, J. F., Nguyen, T. N., Pollak, P. M., Santangeli, P., Sharrief, A. Z., Smith, S. C., Turan, T. N., & Williams, L. S. (2021). 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke, 52(7), e364–e467. https://doi.org/10.1161/STR.0000000000000375
Ko, D., Lin, K. J., Bessette, L. G., Lee, S. B., Walkey, A. J., Cheng, S., Kim, E., Glynn, R. J., & Kim, D. H. (2022). Trends in Use of Oral Anticoagulants in Older Adults With Newly Diagnosed Atrial Fibrillation, 2010-2020. JAMA Network Open, 5(11), e2242964. https://doi.org/10.1001/jamanetworkopen.2022.42964
Law, M. R., Morris, J. K., & Wald, N. J. (2009). Use of blood pressure lowering drugs in the prevention of cardiovascular disease: Meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ, 338, b1665. https://doi.org/10.1136/bmj.b1665
Lee, S., Shafe, A. C. E., & Cowie, M. R. (2011). UK stroke incidence, mortality and cardiovascular risk management 1999-2008: Time-trend analysis from the General Practice Research Database. BMJ Open, 1(2), e000269. https://doi.org/10.1136/bmjopen-2011-000269
Liu, L., Xie, X., Pan, Y., Wang, A., Wei, Y., Liu, J., Nie, X., Liu, D., Zhao, Z., Wang, P., Shen, S., Zhong, C., Xu, T., Wang, D., Wang, G.-C., Song, D., Ma, Y., Zhao, J., Jiang, Y., … CATIS-2 Investigators. (2023). Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: Multicentre, open label, randomised, controlled trial. BMJ (Clinical Research Ed.), 383, e076448. https://doi.org/10.1136/bmj-2023-076448
Nassr, O. A., & Forsyth, P. (2019). Evaluation of Blood Pressure Control and Associated Factors among Patients with Hypertension in Iraq: A Prospective Cross-sectional Study. Journal of Pharmacy & Bioallied Sciences, 11(3), 232–239. https://doi.org/10.4103/jpbs.JPBS_82_19
PROGRESS Collaborative Group. (2001). Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet (London, England), 358(9287), 1033–1041. https://doi.org/10.1016/S0140-6736(01)06178-5
Sandset, E. C., Bath, P. M. W., Boysen, G., Jatuzis, D., Kõrv, J., Lüders, S., Murray, G. D., Richter, P. S., Roine, R. O., Terént, A., Thijs, V., Berge, E., & SCAST Study Group. (2011). The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): A randomised, placebo-controlled, double-blind trial. Lancet (London, England), 377(9767), 741–750. https://doi.org/10.1016/S0140-6736(11)60104-9
Sawalha, A. (2009). Characterization of hospitalized ischemic stroke patients in palestine. The Libyan Journal of Medicine, 4(1), 37–40. https://doi.org/10.4176/080920
Shah, J., Liu, S., & Yu, W. (2022). Contemporary antiplatelet therapy for secondary stroke prevention: A narrative review of current literature and guidelines. Stroke and Vascular Neurology, 7(5). https://doi.org/10.1136/svn-2021-001166
Shahbandi, A., Shobeiri, P., Azadnajafabad, S., Saeedi Moghaddam, S., Sharifnejad Tehrani, Y., Ebrahimi, N., Rezaei, N., Rashidi, M.-M., Ghamari, S.-H., Abbasi-Kangevari, M., Koolaji, S., Haghshenas, R., Rezaei, N., Larijani, B., & Farzadfar, F. (2022). Burden of stroke in North Africa and Middle East, 1990 to 2019: A systematic analysis for the global burden of disease study 2019. BMC Neurology, 22(1), 279. https://doi.org/10.1186/s12883-022-02793-0
Thrift, A. G., Kim, J., Douzmanian, V., Gall, S. L., Arabshahi, S., Loh, M., & Evans, R. G. (2014). Discharge is a critical time to influence 10-year use of secondary prevention therapies for stroke. Stroke, 45(2), 539–544. https://doi.org/10.1161/STROKEAHA.113.003368
Toffali, M., Carbone, F., Fainardi, E., Morotti, A., Montecucco, F., Liberale, L., & Padovani, A. (2023). Secondary prevention after intracerebral haemorrhage. European Journal of Clinical Investigation, 53(6), e13962. https://doi.org/10.1111/eci.13962
Wang, Y., Wang, Y., Zhao, X., Liu, L., Wang, D., Wang, C., Wang, C., Li, H., Meng, X., Cui, L., Jia, J., Dong, Q., Xu, A., Zeng, J., Li, Y., Wang, Z., Xia, H., Johnston, S. C., & CHANCE Investigators. (2013). Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. The New England Journal of Medicine, 369(1), 11–19. https://doi.org/10.1056/NEJMoa1215340
Published
2025-12-08
How to Cite
Nassr, O. A., Forsyth, P., Muzher, H. M., Wadeea, R. F., Sara Delman Najim, Mustafa, A. M., & Tarish, M. S. (2025). Evaluation of Adherence to Prescription Guidelines for Secondary Prevention at Discharge Following Ischemic Stroke. Indonesian Journal of Pharmacy, 36(4), 709-719. https://doi.org/10.22146/ijp.17778
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Research Article
