Every year, strokes affect 15 million people worldwide. For 5 million of the affected, it is fatal, and for another 5 million, it is disabling. Stroke is the second most costly disease, and we consider it a significant health and social problem in today's society (World Health Organization, 2020). Stroke affect mostly elderly patients. The incidence usually increases with age. Despite the statistics, strokes have become more frequent in younger people. The annual number of cases in the Slovak Republic is about 300 events per every 100,000 inhabitants (Belejová, 2015). The basics of acute care for sudden strokes are urgent diagnosis and quick hospital treatment.
The aim of this work was to compare the success rates in recanalisation treatment (measured by National Institute of Health Stroke Scale [NIHSS]) in patients with/without antithrombotic therapy in anamnesis and to evaluate the change in pharmacotherapy after recanalisation treatment in patients.
The retrospective analysis (2016–2018) of 100 patients with ischaemic stroke at the University Hospital Ladislava Dérera, 2nd Department of Neurology and Comenius University in Bratislava, Faculty of Medicine was performed.
Data collection was performed within MS Excel and subsequent conversion and statistical processing in SPSS v.19.
Males constituted the majority in the analysed group of patients with stroke (59% vs. 41%, n=100). Although stroke is typically related to cardiovascular diseases or complications of the older generation, one third (31 patients) were under the age of 60.
The most common cause of ischaemic stroke (iStroke) in our study group was cerebral artery thrombosis. Altogether, 55% of the patients had iStroke of atherothrombotic origin.
Analysis of the NIHSS results showed that previous antithrombotic treatment did not have a significant effect on the severity of iStroke or recovery from iStroke. We did not observe a significant difference in the mean value of NIHSS in patients without/with antithrombotic treatment on admission, during hospitalization treatment, and on discharge (Figure 1).
The NIHSS score serves as the most commonly used tool to assess the severity of stroke during acute treatment. In the long term, the severity of stroke is assessed by the modified Rankin Scale (mRS) at 3 months after hospitalization. However, a limitation of our work was that we could not evaluate the mRankin scale scores in the patients studied, as they were returning to the medical facility at least 90 days after discharge. This phenomenon is a problem in our country nationwide. The remaining question is how to set up a system to better monitor the treatment success in patients who have had a stroke.
The total time from the first symptoms to the onset of thrombolysis in the medical facility is on average 167.36 minutes, which is 2 hours and 47 minutes.
The longest delay was how long it took to arrive at the hospital, whereas the shortest parameter was the time for CT examination (Figure 2).
As many as 41 patients hospitalised for iStroke received antithrombotic therapy in the anteroom. Overcoming ischaemic stroke led to a significant increase in statins at both hospitalization (87%) and discharge (91%) (Figure 3). Statins reduce the risk of recurrence of stroke regardless of cholesterol levels and therefore play an important role in secondary prevention. After the acute phase of treatment, antithrombotics, hypolipidemics, and antihypertensives along with lifestyle modification as secondary preventatives are the mainstays of overall therapy after iStroke. We identified a significant increase in statin prescriptions. While only 14% were taking statins on admission, up to 91% of patients were taking statins at discharge.
We also identified a significant increase in antiplatelet agent use, with 35% of patients on admission and up to 69% on discharge. Anticoagulants were used on admission by 9.1% of patients, and up to 47.3% of patients were indicated on admission.
With a comprehensive approach to secondary prevention after stroke, we can reduce the risk of recurrence and also influence other cardiovascular risk factors and diseases. An interdisciplinary approach (neurologist, cardiologist, internist, neurosurgeon, radiologist, geriatrician, physiotherapist, etc.) in treatment and care can significantly reduce the primary incidence of stroke and its recurrences. It should also not be forgotten that early rehabilitation of patients after a disabling stroke increases the chances of a full life. Another very important aspect in the overall management of treatment is patient compliance which, in practice, often interferes with the effectiveness of therapy.
Clopidogrel predominated in the treatment. The largest increase was observed between admission and treatment during hospitalisation. As many as 52% of patients received clopidogrel during hospitalisation and 46% of patients were prescribed at the discharge. We also identified a significant increase in new oral anticoagulants (NOACs), which include apixaban, rivaroxaban, and dabigatran (Figure 4). Anticoagulant therapy with novel NOACs is crucial in the secondary prevention of patients with recent iStroke and non-valvular atrial fibrillation. We attribute this increase in apixaban to the fact that 15 patients were diagnosed with non-valvular atrial fibrillation during hospitalization.
Previous antithrombotic use had no significant effect on the incidence of iStroke and NIHSS score. The average total time from the first clinical symptoms to the onset of thrombolysis in a medical facility was 2 hours and 47 minutes. Intravenous thrombolysis by alteplase was administered to all 100 patients in the cohort, and 10 patients also underwent mechanical thrombectomy. Door to needle time was on average 38.46 minutes.
We identified a significant increase in clopidogrel use (15% on admission vs. 52% during hospitalisation, p≤0.05) and NOACs (14% on admission vs. 33% on discharge, p≤0.05) after overcoming iStroke. We identified a significant increase in statin prescriptions (14% on admission vs. 91% on discharge, p≤0.05). Analysing and reviewing data retrospectively is important in identifying weaknesses and solutions so they can be addressed. Long-term follow-up with the mRankin score is important for being able to objectively assess the success of the intervention and identify potential risk characteristics and the severity of consequences in patients.