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Discontinuation of aspirin, warfarin and clopidogrel, and stroke recurrence in Medicaid patients
AJH–May 2005–VOL. 18, NO. 5, PART 2
POSTERS: Cerebrovascular Disease/Stroke
post-baseline measurements for quantitative parameters. All tests were two-tailed, and p value of ⱕ 5% was considered statistically significant. The data was analyzed using the SAS software (SAS Institute, Cary, NC, USA). Blood pressure spontaneously fell more than 15 mmHg systolic and 10 mmHg diastolic a few days following the acute event without significantly changing antihypertensive therapy.While reducing high blood pressure can prevent first and recurrent stroke, aggressive lowering of blood pressure during the acute stage may lead to harmful cerebral hypoperfusion. Caution is recommended in view of the natural tendency of blood pressure to begin falling a few days after stroke onset and to subsequently level off. Results of 24 hour blood pressure monitoring Period 1
SBP, P ⬍ 0.05 DBP, P ⬍ 0.05 Heart Rate, NS
Period 2
Mean ⴞ S.D.
Min
Max
Mean ⴞ S.D.
Min
Max
157 ⫾ 26.9 86.4 ⫾ 17.2 73.1 ⫾ 14.3
114.8 61.3 53.3
198.3 118.0 98.4
139 ⫾ 24.7 76.8 ⫾ 12.0 75.2 ⫾ 15.2
113.1 60.7 53.8
177.1 97.7 96.2
Key Words: 24 Hour Blood Pressure Monitoring, Stroke
P-451 PROGNOSTIC INDEX FOR EVENT ON LATTER THROMBOTIC STROKE IN GREEK POPULATION Spyridon Paximadas, Stamata Pagoni, Georgios Kalokerinos, Penelope Arseni, Panagiota Kefalou, Marios Kosmidis. First Department of Internal Medicine, General Hospital of Athens “ELPIS”, Dimitsanis 7, Ampelokipi, Athens, Greece; Third Department of Internal Medicine, General Hospital of Athens “G.Gennimatas”, Mesogeion 154, Athens, Greece. Epidemiological studies have demonstrated that elevated of blood pressure (B.P.), diabetes mellitus (D.M.) and the lipid profile as increased Total Cholesterol (TC), Triglycerides (TG), LDL, and decreased HDL are associated with significant cardiovascular risk and are predisposing factors for coronary artery disease and stroke. Purpose: The aim of this study was to investigate the basic differences between patients with latter acute thrombolic or embolic stroke episode in Greek population, with progress death or improvement during of nursing. Material and Methods: 826 inpatients aged 76⫾9 (40-100) years with latter acute thrombolic or embolic stroke episodes, 444 females (F) and 382 males (M) were studied during the last three years. Investigated TC, TG, HDL, LDL and Lp(a) and recorded the B.P., and D.M. and results were analyzed in the same laboratory. All patients nursed to our Internal Medicine Clinic and in reference to progress divided between group death (D) and group improvement (I). The proportion of death was 16%. Statistical analysis was performed using a SPSS 11,0. Results: TC 216⫾58 I - 218⫾80 D mg/dl (p⫽0,162), TG 132⫾72 I - 128⫾79 D mg/dl (p⫽0,272), HDL 45⫾13 I - 47⫾15 D mg/dl (p⫽0,946), LDL 141⫾47 I - 140⫾45 D mg/dl (p⫽0,958) and Lp(a) 37⫾36 I - 29⫾14 D mg/dl (p⫽0,256). 61% from all patients had B.P. (52% I - 10% D, p⫽0,398), 41,6 % had D.M. (34,3% I-7,3% D, p⫽0,198). Conclusion: The study shows that lipids, hypertension and D.M., in group with improvement patients from latter thromboembolic stroke versus group death have not difference statistically significant. Key Words: Blood Pressure, Lipids, Stroke
169A
P-452 DISCONTINUATION OF ASPIRIN, WARFARIN AND CLOPIDOGREL, AND STROKE RECURRENCE IN MEDICAID PATIENTS Fadia T Shaya, Antoine C Elkhoury, Hugh Fatodu, Matthew R Weir. Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD; Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, MD; Johns Hopkins HealthCare LLC Priority Partners, Johns Hopkins University, Baltimore, MD; Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD. This study evaluates the discontinuation of aspirin, warfarin and clopidogrel, and the likelihood of recurrent stroke in Medicaid patients. Little is known about utilization and outcomes in this high risk population. All medical and pharmacy claims of stroke patients (ICD-9 Codes 430-438) between 1/1/01-12/31/03 are obtained from Medicaid. Inclusion: at least one month of follow up. Exclusion (to obtain incident cohort): stroke diagnosis between 1/1-6/30/01. Using Cox proportional hazard models, we compare time dependent discontinuation rates of aspirin, warfarin and clopidogrel for those with or without a recurrence. Logistic regression is used to compare likelihood of recurrence in those on aspirin, warfarin or clopidogrel. We adjust for age, gender, race, urban residence, heart disease, hypertension, diabetes, blood pressure or lipid lowering drugs and persistence. Out of 925 patients, 36% older than 60, 58% African American, 35% males, those with stroke recurrence, versus without, are 73% more likely to discontinue the first drug taken post-stroke (HR⫽1.73, p⫽0.0003, CI 1.29-2.32). Those starting on clopidogrel (HR⫽0.94, NS) or warfarin (HR⫽0.63, p⫽0.02, CI 0.43-0.94) are less likely to discontinue before recurrence or end of follow up, than those starting on aspirin. Out of those who start on aspirin and switch (2%), 71% switch to clopidogrel. The same proportions switch to aspirin or warfarin, from clopidogrel (3%). Out of those who start on clopidogrel and switch (2%), most switch to warfarin (67%). Likelihood of recurrence is not significantly different for aspirin, warfarin or clopidogrel users. Neither use nor persistence on blood pressure or lipid lowering drugs significantly affects results. Medicaid stroke patients who have a recurrence, are more likely to have discontinued their medication post-stroke. Those starting on warfarin, versus aspirin are less likely to discontinue regardless of the number of blood pressure or lipid lowering drugs. Improving adherence may impact stroke recurrence. Key Words: Adherence, Discontinuation and Switch, Aspirin, Warfarin, Clopidogrel, Stroke Recurrence
P-453 HYPERTENSIVE COMPLICATIONS ASSOCIATED WITH METABOLIC SYNDROME Sofia M. Voyaki, Aris D. Efstratopoulos, Athanasios A. Baltas, Leonidas C. Mourgos, Antrea Stavrianou. Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece. Objective of the study was the investigation of the prevalence of cardiac complications in patients suffering from metabolic syndrome (MS) and hypertension. Patients with hypertension followed in our Hypertension Unit and fulfilling at least 3 of the 5 risk criteria of NCEP / ATP-III : abdominal obesity ( waist circumference of ⬎ 102 cm for men, and ⬎ 88 cm in women) , triglycerides ⬎ 150 mg/dl, HDL-C ⬍ 40 mg/dl for men and ⬍
POSTERS: Cerebrovascular Disease/Stroke
post-baseline measurements for quantitative parameters. All tests were two-tailed, and p value of ⱕ 5% was considered statistically significant. The data was analyzed using the SAS software (SAS Institute, Cary, NC, USA). Blood pressure spontaneously fell more than 15 mmHg systolic and 10 mmHg diastolic a few days following the acute event without significantly changing antihypertensive therapy.While reducing high blood pressure can prevent first and recurrent stroke, aggressive lowering of blood pressure during the acute stage may lead to harmful cerebral hypoperfusion. Caution is recommended in view of the natural tendency of blood pressure to begin falling a few days after stroke onset and to subsequently level off. Results of 24 hour blood pressure monitoring Period 1
SBP, P ⬍ 0.05 DBP, P ⬍ 0.05 Heart Rate, NS
Period 2
Mean ⴞ S.D.
Min
Max
Mean ⴞ S.D.
Min
Max
157 ⫾ 26.9 86.4 ⫾ 17.2 73.1 ⫾ 14.3
114.8 61.3 53.3
198.3 118.0 98.4
139 ⫾ 24.7 76.8 ⫾ 12.0 75.2 ⫾ 15.2
113.1 60.7 53.8
177.1 97.7 96.2
Key Words: 24 Hour Blood Pressure Monitoring, Stroke
P-451 PROGNOSTIC INDEX FOR EVENT ON LATTER THROMBOTIC STROKE IN GREEK POPULATION Spyridon Paximadas, Stamata Pagoni, Georgios Kalokerinos, Penelope Arseni, Panagiota Kefalou, Marios Kosmidis. First Department of Internal Medicine, General Hospital of Athens “ELPIS”, Dimitsanis 7, Ampelokipi, Athens, Greece; Third Department of Internal Medicine, General Hospital of Athens “G.Gennimatas”, Mesogeion 154, Athens, Greece. Epidemiological studies have demonstrated that elevated of blood pressure (B.P.), diabetes mellitus (D.M.) and the lipid profile as increased Total Cholesterol (TC), Triglycerides (TG), LDL, and decreased HDL are associated with significant cardiovascular risk and are predisposing factors for coronary artery disease and stroke. Purpose: The aim of this study was to investigate the basic differences between patients with latter acute thrombolic or embolic stroke episode in Greek population, with progress death or improvement during of nursing. Material and Methods: 826 inpatients aged 76⫾9 (40-100) years with latter acute thrombolic or embolic stroke episodes, 444 females (F) and 382 males (M) were studied during the last three years. Investigated TC, TG, HDL, LDL and Lp(a) and recorded the B.P., and D.M. and results were analyzed in the same laboratory. All patients nursed to our Internal Medicine Clinic and in reference to progress divided between group death (D) and group improvement (I). The proportion of death was 16%. Statistical analysis was performed using a SPSS 11,0. Results: TC 216⫾58 I - 218⫾80 D mg/dl (p⫽0,162), TG 132⫾72 I - 128⫾79 D mg/dl (p⫽0,272), HDL 45⫾13 I - 47⫾15 D mg/dl (p⫽0,946), LDL 141⫾47 I - 140⫾45 D mg/dl (p⫽0,958) and Lp(a) 37⫾36 I - 29⫾14 D mg/dl (p⫽0,256). 61% from all patients had B.P. (52% I - 10% D, p⫽0,398), 41,6 % had D.M. (34,3% I-7,3% D, p⫽0,198). Conclusion: The study shows that lipids, hypertension and D.M., in group with improvement patients from latter thromboembolic stroke versus group death have not difference statistically significant. Key Words: Blood Pressure, Lipids, Stroke
169A
P-452 DISCONTINUATION OF ASPIRIN, WARFARIN AND CLOPIDOGREL, AND STROKE RECURRENCE IN MEDICAID PATIENTS Fadia T Shaya, Antoine C Elkhoury, Hugh Fatodu, Matthew R Weir. Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD; Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, MD; Johns Hopkins HealthCare LLC Priority Partners, Johns Hopkins University, Baltimore, MD; Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD. This study evaluates the discontinuation of aspirin, warfarin and clopidogrel, and the likelihood of recurrent stroke in Medicaid patients. Little is known about utilization and outcomes in this high risk population. All medical and pharmacy claims of stroke patients (ICD-9 Codes 430-438) between 1/1/01-12/31/03 are obtained from Medicaid. Inclusion: at least one month of follow up. Exclusion (to obtain incident cohort): stroke diagnosis between 1/1-6/30/01. Using Cox proportional hazard models, we compare time dependent discontinuation rates of aspirin, warfarin and clopidogrel for those with or without a recurrence. Logistic regression is used to compare likelihood of recurrence in those on aspirin, warfarin or clopidogrel. We adjust for age, gender, race, urban residence, heart disease, hypertension, diabetes, blood pressure or lipid lowering drugs and persistence. Out of 925 patients, 36% older than 60, 58% African American, 35% males, those with stroke recurrence, versus without, are 73% more likely to discontinue the first drug taken post-stroke (HR⫽1.73, p⫽0.0003, CI 1.29-2.32). Those starting on clopidogrel (HR⫽0.94, NS) or warfarin (HR⫽0.63, p⫽0.02, CI 0.43-0.94) are less likely to discontinue before recurrence or end of follow up, than those starting on aspirin. Out of those who start on aspirin and switch (2%), 71% switch to clopidogrel. The same proportions switch to aspirin or warfarin, from clopidogrel (3%). Out of those who start on clopidogrel and switch (2%), most switch to warfarin (67%). Likelihood of recurrence is not significantly different for aspirin, warfarin or clopidogrel users. Neither use nor persistence on blood pressure or lipid lowering drugs significantly affects results. Medicaid stroke patients who have a recurrence, are more likely to have discontinued their medication post-stroke. Those starting on warfarin, versus aspirin are less likely to discontinue regardless of the number of blood pressure or lipid lowering drugs. Improving adherence may impact stroke recurrence. Key Words: Adherence, Discontinuation and Switch, Aspirin, Warfarin, Clopidogrel, Stroke Recurrence
P-453 HYPERTENSIVE COMPLICATIONS ASSOCIATED WITH METABOLIC SYNDROME Sofia M. Voyaki, Aris D. Efstratopoulos, Athanasios A. Baltas, Leonidas C. Mourgos, Antrea Stavrianou. Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece; Hypertension Unit, General Hospital of Athens “ G. Gennimatas”, Athens, Attica, Greece. Objective of the study was the investigation of the prevalence of cardiac complications in patients suffering from metabolic syndrome (MS) and hypertension. Patients with hypertension followed in our Hypertension Unit and fulfilling at least 3 of the 5 risk criteria of NCEP / ATP-III : abdominal obesity ( waist circumference of ⬎ 102 cm for men, and ⬎ 88 cm in women) , triglycerides ⬎ 150 mg/dl, HDL-C ⬍ 40 mg/dl for men and ⬍