Analysis of Prescriptions for Dual Antiplatelet Therapy After Acute Ischemic Stroke.
Analysis of Prescriptions for Dual Antiplatelet Therapy After Acute Ischemic Stroke.
复制标题
急性缺血性中风后双重抗血小板治疗的处方分析。
DOI：
10.1001/jamanetworkopen.2022.24157
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发表时间：
2022-07-01
影响因子：
13.8
通讯作者：
Johnson, Mark
中科院分区：
文献类型：
--
作者：
Xian, Ying;Xu, Haolin;Matsouaka, Roland;Laskowitz, Daniel T.;Maisch, Lesley;Hannah, Deidre;Smith, Eric E.;Fonarow, Gregg C.;Bhatt, Deepak L.;Schwamm, Lee H.;Mac Grory, Brian;Feng, Wuwei;Fosbol, Emil Loldrup;Peterson, Eric D.;Johnson, Mark
在临床试验结果和美国心脏协会/美国卒中协会实践指南更新后，双重抗血小板治疗（DAPT）用于急性缺血性卒中患者二级预防的处方模式是否发生了变化？在这项纳入132817例急性缺血性卒中患者的队列研究中，47.0%的轻度卒中患者在出院时接受了DAPT，如指南所示; 42.6%的非轻度卒中患者在出院时接受了DAPT，其DAPT的风险和获益尚未完全确定，在美国现行实践中存在显著的医院差异。这项研究的结果表明，加强对循证DAPT实践指南的遵守可能是改善缺血性卒中患者治疗质量的目标。在《机会》出版后，（氯吡格雷在急性非致残性脑血管事件高危患者中的应用）和POINT（新发短暂性脑缺血发作和轻度缺血性卒中中的血小板定向抑制）临床试验，美国心脏协会/美国卒中协会（AHA/阿萨）发布了新的1级，证据等级A，推荐双重抗血小板治疗（DAPT;阿司匹林+氯吡格雷）用于轻度缺血性卒中患者的二级预防（美国国立卫生研究院卒中量表[NIHSS]评分≤3）。DAPT处方模式的变化程度以及美国实践模式与循证指南的一致程度尚不清楚。评价新的AHA/阿萨指南发布后出院DAPT处方模式，并评估指南所示轻度卒中患者（NIHSS评分≤3）和非轻度卒中患者（NIHSS评分> 3）使用DAPT进行二级预防的医院水平差异程度，对于非轻度卒中患者，DAPT的风险和获益尚未完全确定。这项多中心回顾性队列研究纳入了来自1890家医院的132817例患者，这些患者参与了AHA/阿萨指南-卒中项目。纳入了2019年10月1日至2020年6月30日期间因急性缺血性卒中住院并在出院时接受抗血小板治疗的患者。轻度缺血性卒中（NIHSS评分≤3）vs非轻度缺血性卒中（NIHSS评分>3）。主要结局为出院时的DAPT处方。通过计算中位比值比（OR）评估了在医院层面解释DAPT使用差异的程度，中位比值比（OR）是使用多变量logistic回归分析得出的，并比较了2家随机选择的医院（1家DAPT使用倾向较高，1家DAPT使用倾向较低）收治的2例具有相同临床特征的患者在出院时接受DAPT的可能性。使用Pearson ρ相关系数评价了轻度与非轻度卒中患者中医院级DAPT使用之间的相关性。在132 817例患者中（中位[IQR]年龄，68 [59-78]岁;男性68 768人[51.8%]，（3.2%）为亚洲人，11 254人（8.5%）是西班牙裔，27 221（20.5%）为非西班牙裔黑人，84 468人（63.6%）为非西班牙裔白色人，5592（4.2%）为其他人种和/或种族（包括美洲印第安人或阿拉斯加原住民、夏威夷原住民或太平洋岛民，无法确定）。总体而言，86551例患者（65.2%）出现轻度缺血性卒中，46266例患者（34.8%）出现非轻度缺血性卒中。在2019年AHA/阿萨指南更新后，40661例（47.0%）轻度卒中患者（NIHSS中位数[IQR]评分，1 [0-2]）和19703例（42.6%）非轻度卒中患者（NIHSS中位数[IQR]评分，6 [5-9]）在出院时接受了DAPT。尽管有指南建议，但45890例（53.0%）轻度卒中患者未接受DAPT。在考虑患者特征后，在轻微卒中患者中使用DAPT时发现了显著的医院水平差异（中位数[IQR]医院级DAPT处方率，44.8% [33.7%-57.7%];范围，0%-91.7%;中位OR，2.03 [95% CI，1.97-2.09]），比较2家随机选择的医院出院的2例具有相同风险因素的患者，1例具有较高的DAPT使用倾向，1例具有较低的DAPT使用倾向。非轻微卒中患者中DAPT的使用也存在显著差异（中位[IQR]医院级DAPT处方率，41.4% [30.0%-53.8%];范围，0%-100%;中位OR，1.90 [95% CI，1.83-1.97]）。总体而言，更可能为轻微卒中开DAPT的医院也更可能为非轻微卒中开DAPT（Pearson ρ = 0.72; P <0.001）。这项队列研究发现，尽管更新了AHA/阿萨指南，但超过50%的轻度急性缺血性卒中患者在出院时未接受DAPT。相比之下，超过40%的非轻微卒中患者接受了DAPT，尽管在这种情况下缺乏证据。这些发现表明，加强对循证DAPT实践指南的遵守可能是改善缺血性卒中患者治疗质量的目标。这项队列研究使用了美国心脏协会/美国卒中协会指南-卒中登记处的数据，以评估轻度和非轻度急性缺血性卒中患者出院时双重抗血小板治疗的处方模式。
Have prescribing patterns in dual antiplatelet therapy (DAPT) for secondary prevention among patients with acute ischemic stroke changed after clinical trial findings and American Heart Association/American Stroke Association practice guideline updates? In this cohort study of 132 817 patients with acute ischemic stroke, 47.0% of patients with minor stroke received DAPT at discharge, as indicated by guidelines; 42.6% patients with nonminor stroke, for whom the risks and benefits of DAPT have not been fully established, received DAPT at discharge, with substantial hospital variation across current US practice. This study’s findings suggest that enhancing adherence to evidence-based DAPT practice guidelines may be a target for quality improvement in the treatment of patients with ischemic stroke. After the publication of the CHANCE (Clopidogrel in High Risk Patients With Acute Nondisabling Cerebrovascular Events) and POINT (Platelet-Oriented Inhibition in New Transient Ischemic Attack and Minor Ischemic Stroke) clinical trials, the American Heart Association/American Stroke Association (AHA/ASA) issued a new class 1, level of evidence A, recommendation for dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) for secondary prevention in patients with minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤3). The extent to which variations in DAPT prescribing patterns remain and the extent to which practice patterns in the US are consistent with evidence-based guidelines are unknown. To evaluate the discharge DAPT prescribing patterns after publication of the new AHA/ASA guidelines and assess the extent of hospital-level variation in the use of DAPT for secondary prevention in patients with minor stroke (NIHSS score ≤3), as indicated by guidelines, and in patients with nonminor stroke (NIHSS score >3), for whom the risks and benefits of DAPT have not been fully established. This multicenter retrospective cohort study involved 132 817 patients from 1890 hospitals participating in the AHA/ASA Get With The Guidelines–Stroke program. Patients who were hospitalized for acute ischemic stroke and prescribed antiplatelet therapy at discharge between October 1, 2019, and June 30, 2020, were included. Minor ischemic stroke (NIHSS score ≤3) vs nonminor ischemic stroke (NIHSS score >3). The primary outcome was DAPT prescription at discharge. The extent to which variations in DAPT use were explained at the hospital level was assessed by calculating the median odds ratio (OR), which was derived using multivariable logistic regression analysis and compared the likelihood that 2 patients with identical clinical features admitted to 2 randomly selected hospitals (1 with higher propensity and 1 with lower propensity for DAPT use) would receive DAPT at discharge. Associations between hospital-level DAPT use among patients with minor vs nonminor stroke were evaluated using Pearson ρ correlation coefficients. Among 132 817 patients (median [IQR] age, 68 [59-78] years; 68 768 men [51.8%]), 4282 (3.2%) were Asian, 11 254 (8.5%) were Hispanic, 27 221 (20.5%) were non-Hispanic Black, 84 468 (63.6%) were non-Hispanic White, and 5592 (4.2%) were of other races and/or ethnicities (including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and unable to determine). Overall, 86 551 patients (65.2%) presented with minor ischemic stroke, and 46 266 patients (34.8%) presented with nonminor ischemic stroke. After the 2019 AHA/ASA guideline updates, 40 661 patients (47.0%) with minor stroke (NIHSS median [IQR] score, 1 [0-2]) and 19 703 patients (42.6%) with nonminor stroke (NIHSS median [IQR] score, 6 [5-9]) received DAPT at discharge. Despite guideline recommendations, 45 890 patients (53.0%) with minor stroke did not receive DAPT. After accounting for patient characteristics, substantial hospital-level variations were found in the use of DAPT in those with minor stroke (median [IQR] hospital-level DAPT prescription rate, 44.8% [33.7%-57.7%]; range, 0%-91.7%; median OR, 2.03 [95% CI, 1.97-2.09]) when comparing 2 patients with identical risk factors discharged from 2 randomly selected hospitals, 1 with higher propensity and 1 with lower propensity for DAPT use. The use of DAPT in patients with nonminor stroke also varied significantly (median [IQR] hospital-level DAPT prescription rate, 41.4% [30.0%-53.8%]; range, 0%-100%; median OR, 1.90 [95% CI, 1.83-1.97]). Overall, hospitals that were more likely to prescribe DAPT for minor strokes were also more likely to prescribe DAPT for nonminor strokes (Pearson ρ = 0.72; P < .001). This cohort study found that despite updated AHA/ASA guidelines, more than 50% of patients with minor acute ischemic stroke did not receive DAPT at discharge. In contrast, more than 40% of patients with nonminor stroke received DAPT despite lack of evidence in this setting. These findings suggest that enhancing adherence to evidence-based DAPT practice guidelines may be a target for quality improvement in the treatment of patients with ischemic stroke. This cohort study used data from the American Heart Association/American Stroke Association Get With The Guidelines–Stroke registry to assess prescribing patterns for dual antiplatelet therapy at discharge among patients with minor and nonminor acute ischemic stroke.
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DOI：
10.1161/circoutcomes.109.921858
发表时间：
2010-05-01
影响因子：
6.9
作者：
Fonarow, Gregg C.;Reeves, Mathew J.;Schwamm, Lee H.
通讯作者：
Schwamm, Lee H.
影响因子：
168.9
作者：
Diener, HC;Bogousslavsky, J;Rupprecht, HJ
通讯作者：
Rupprecht, HJ
影响因子：
8.3
作者：
Menon, Bijoy K.;Frankel, Michael R.;Smith, Eric E.
通讯作者：
Smith, Eric E.
DOI：
10.1056/nejmoa1204133
发表时间：
2012-08-30
期刊：
The New England journal of medicine
影响因子：
--
作者：
SPS3 Investigators;Benavente OR;Hart RG;McClure LA;Szychowski JM;Coffey CS;Pearce LA
通讯作者：
Pearce LA
影响因子：
8.3
作者：
Lusk JB;Xu H;Peterson ED;Bhatt DL;Fonarow GC;Smith EE;Matsouaka R;Schwamm LH;Xian Y
通讯作者：
Xian Y