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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3084 — Prevalence of Inadequate Blood Pressure Control among vVterans after Acute Ischemic Stroke Hospitalization: A Retrospective Cohort

Roumie CL (VA-Tennessee Valley Healthcare System), Ofner S (Indiana University School of Medicine), Ross JS (Yale University School of Medicine, Center for Outcomes Research and Evaluation), Arling G (Indiana University Centers for Aging Research, Regenstrief Institute, Indianapolis, IN), Williams LS (HSR&D Stroke Quality Enhancement Research Initiative, VHA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP); Indianapolis VA), Ordin DL (Veterans Affairs Office of Quality and Performance), Bravata DM (HSR&D Stroke Quality Enhancement Research Initiative, VHA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP))

Objectives:
Reducing blood pressure (BP) after stroke improves secondary prevention but this potential benefit has not often been implemented in routine care. We describe 3 measures of hypertension care after hospitalization for acute ischemic stroke: BP control by discharge, antihypertensives prescribed at discharge and BP control within 6 months after stroke.

Methods:
A retrospective cohort utilizing the OQP Stroke Study was assembled including a systematic sample of veterans hospitalized at Veterans Affairs Medical Center (VAMC N = 130) for ischemic stroke in FY2007. The first outcome was proportion with BP control (< 140/90 mmHg) at discharge: we excluded patients who died, enrolled in hospice, or with unknown discharge disposition (N = 3,640 discharge analysis). The second outcome was adequate BP control at the last outpatient visit within 6 months post event; we excluded patients who died/readmitted within 30-days, did not have a follow-up visit or recorded BP at VAMC clinic (N = 2,054 follow-up analysis). We also examined antihypertensive regimens at discharge.

Results:
Patients were white (62.7 %) and male (97.7%); 46.9% were < 65 years of age and 30.7% were > 75 years; 29% and 37% had cerebrovascular or cardiovascular disease history, respectively. Among the 3,640 patients, 43% had their discharge BP > 140/90 mmHg. Black race (adjusted OR 0.77 [95% CI 0.65, 0.91]), diabetes (OR 0.73 [95% CI 0.62, 0.86]) and history of hypertension (OR 0.51 [95% CI 0.42, 0.63]) were associated with lower odds for controlled discharge BP. Of the 2,054 stroke patients in follow-up analysis, 32.8% remained uncontrolled. By 6-months post-event, neither race nor diabetes was associated with BP control; whereas persons with history of hypertension still had lower odds of control. Each 10-point increase in discharge Systolic > 140mmHg was associated with a 12% (95% CI [8%, 18%]) decrease in BP control within 6 months. Fifteen percent of patients were discharged on a combination of ACEI/ thiazide in accordance with JNC 7 recommendations for hypertension management of patients with history of stroke.

Implications:
Uncontrolled BP is common after stroke. Only 15% of veterans hospitalized with acute ischemic stroke were prescribed the two antihypertensives recommended for secondary prevention among stroke patients.

Impacts:
Uncontrolled BP is common after stroke. An organized approach initiated prior to hospital discharge for patients with cardiovascular disease is the mainstay of secondary prevention. Future research is needed to evaluate if a similar approach among stroke patients has the potential to improve adherence to secondary prevention guidelines and quality of care.


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