Analysis of data from more than a million ischemic-stroke patients in the U.S. revealed that after the American Heart Association and American Stroke Association released their updated guidelines in 2019, 54.5% of stroke patients received monotherapy upon hospital discharge and 44.9% received DAPT, researchers report in JAMA Internal Medicine.
"Although recommendations for appropriate DAPT exist, it appears that they are not closely followed in U.S. clinical practice," said the study's first author, Dr. Ying Xian of UT Southwestern Medical Center, in Dallas.
The study shows that "the publication of national guidelines alone is not sufficient to produce substantial changes in physicians' prescription behavior," Dr. Xian told Reuters Health by email. "There is an opportunity to educate hospitals/physicians to improve their adherence to guidelines. A system-wide stroke quality-improvement initiative is also likely to improve adherence to evidence-based DAPT."
DAPT, aspirin and clopidogrel dual therapy, for secondary prevention in patients with acute ischemic stroke has been proven to be effective when used short-term in patients with minor ischemic stroke to prevent recurrence, Dr. Xian and his colleagues noted.
To take a closer look at the degree to which physicians in routine clinical practice were following the evidence-based guidelines, Dr. Xian and his colleagues analyzed data from more than 1.2 million patients in 2,228 U.S. hospitals in the Get With The Guidelines-Stroke registry who were hospitalized between October 1, 2015, and June 30, 2020, for acute ischemic stroke and prescribed antiplatelet therapy at discharge. Their records included data on race and ethnicity.
The researchers evaluated antiplatelet therapy prescribed at five time periods that were based on clinical trial and guideline publications. The patients had a median age of 68 and 51% were men. Nearly two-thirds were non-Hispanic white, while 21% were non-Hispanic Black, 8% Hispanic, 3% Asian and 4% of another race.
Overall, 54.5% received aspirin monotherapy; 12.4% received clopidogrel monotherapy and 30.8% received DAPT.
The researchers note that use of DAPT increased significantly across the five time periods, from 19.4% before the publication of the CHANCE trial to 23.1% before the 2014 AHA/ASA guideline updates, 27.6% before the POINT trial and the 2018 AHA/ASA guideline updates, 37.2% before the 2019 AHA/ASA guideline updates, and 44.9% after the 2019 AHA/ASA guideline updates.
The new findings did not surprise Dr. Laura Stein, a stroke expert and an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai in New York, who was not involved in the study.
"Unfortunately, in all of medicine, especially in acute stroke, it takes time for people to adopt evidence- based practice even when the guidelines support it strongly," Dr. Stein said. "One of our biggest struggles is trying to promote equitable stroke care. Adoption takes time and there are huge disparities around the country."
"Where you have a stroke matters, even within the same city, not to mention the very rural parts of the country," Dr. Stein told Reuters Health by phone.
It's possible that the numbers are even worse than this study suggests, Dr. Stein said. "These data were taken from the Get With The Guidelines Stroke registry, which is a wonderful hospital-improvement program developed by the American Heart Association. So these are hospitals that have chosen to participate in improving care. You have to wonder what it's like in hospitals that are not participating in this registry."
On the other hand, Dr. Stein said, "we don't know how many patients were not eligible for two blood thinners. Some may have had a risk of bleeding that would prevent them from being on two medications."
Dr. Mitchell S.V. Elkind, who also was not part of the study, agreed that it can take a long time for guidelines to make their way into clinical practice.
"We need to do a better job educating practicing neurologists and others who care for stroke patients about the benefits of DAPT," said Dr. Elkind, a professor of neurology and epidemiology at Columbia University Vagelos College of Physicians and Surgeons, in New York City, and recent past president of the American Heart Association.
"Most physicians tend to practice the medicine they learned in residency," Dr. Elkind told Reuters Health by email. "Particularly when the guidelines evolve and change as quickly as these around antiplatelet agents have over the past five to 10 years, it may be hard for busy practicing physicians to keep up with the new treatment recommendations. Old habits are hard to break."
The solution according to Dr. Elkind: "education, education, education."
SOURCE: https://bit.ly/3wMWrV5 JAMA Internal Medicine, online March 28, 2022.
By Linda Carroll
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