Guideline-directed care after TIA or nonsevere stroke associated with lower mortality risk

Patients who received brain imaging, carotid artery imaging, antihypertensive intensification, statins, antithrombotics, and anticoagulation for atrial fibrillation after transient ischemic attack (TIA) or nonsevere ischemic stroke had lower risk of mortality.


Patients who had a transient ischemic attack (TIA) or nonsevere ischemic stroke had lower risk of mortality, but not recurrent stroke, if they received all recommended care, a study found.

Researchers looked at patients with TIA or nonsevere ischemic stroke who presented at a Department of Veterans Affairs ED or inpatient setting from October 2010 to September 2011. The study analyzed provision of 28 processes of care, but defined six guideline-concordant processes for assessment as without-fail care: brain imaging, carotid artery imaging, antihypertensive intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results were published by JAMA Network Open on July 3.

Among 8,076 patients, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within one year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within one year. Only 1,216 (15.3%) received without-fail care on all six of the processes for which they were eligible. Receiving all six processes was associated with lower risk of death (31.2% reduction at one year, adjusted odds ratio [OR], 0.69; 95% CI, 0.55 to 0.87) but not lower risk of recurrent stroke.

Overall, nine processes were independently associated with lower odds of both 90-day and one-year mortality:

  • carotid artery imaging (adjusted odds ratios [aORs], 0.49 [95% CI, 0.38 to 0.63] and 0.61 [95% CI, 0.52 to 0.72]),
  • antihypertensive medication (aORs, 0.58 [95% CI, 0.45 to 0.74] and 0.70 [95% CI, 0.60 to 0.83]),
  • lipid measurement (aORs, 0.68 [95% CI, 0.51 to 0.90] and 0.64 [95% CI, 0.53 to 0.78]),
  • lipid management (aORs, 0.46 [95% CI, 0.33 to 0.65] and 0.67 [95% CI, 0.53 to 0.85]),
  • discharged with statin medication (aORs, 0.51 [95% CI, 0.36 to 0.73] and 0.70 [95% CI, 0.55 to 0.88]),
  • cholesterol-lowering medication intensification (aORs, 0.47 [95% CI, 0.26 to 0.83] and 0.56 [95% CI, 0.41 to 0.77]),
  • antithrombotics by day 2 (aORs, 0.56 [95% CI, 0.40 to 0.79] and 0.69 [95% CI, 0.55 to 0.87]) or at discharge (aORs, 0.59 [95% CI, 0.41 to 0.86] and 0.69 [95% CI, 0.54 to 0.88]), and
  • neurology consultation (aORs, 0.67 [95% CI, 0.52 to 0.87] and 0.74 [95% CI, 0.63 to 0.87]).

Anticoagulation for atrial fibrillation was associated with lower odds of one-year mortality (aOR, 0.59; 95% CI, 0.40 to 0.85), but not 90-day mortality. None of the processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons.

“The 6 without-fail care processes (ie, brain imaging, carotid artery imaging, antihypertensive intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation) can be provided routinely at diverse medical centers because they do not require specialized structures of care,” the authors wrote. “Given the strength of the prospective trial evidence as well as the current findings supporting the association of these processes with improved outcomes, health care systems should prioritize providing patients with TIA or nonsevere ischemic stroke with the guideline-concordant processes of care for which they are eligible.”