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Ineffective Secondary Prevention in Survivors of Cardiovascular Events in the US Population
Report From the Third National Health and Nutrition Examination Survey
Adnan I. Qureshi, MD;
M. Fareed K. Suri, MD;
Lee R. Guterman, PhD, MD;
L. Nelson Hopkins, MD
Arch Intern Med. 2001;161:1621-1628.
ABSTRACT
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Background Survivors of myocardial infarction (MI) or stroke are at high risk for
subsequent cardiovascular events. There is limited assessment of the effectiveness
of risk factor modification through current secondary preventive strategies
in the US population. We determined the adequacy of risk factor modification
in 1252 survivors of MI, stroke, or both in a nationally representative sample
of US adults and identified factors related to inadequate control of risk
factors.
Methods The adequacy of control for hypertension, diabetes mellitus, cigarette
smoking, alcohol use, and hypercholesterolemia was assessed by personal interview,
blood pressure measurements, and serum glycosylated hemoglobin and cholesterol
levels in 17 752 US adults who participated in the Third National Health
and Nutrition Examination Survey between 1988 and 1994. We also evaluated
the role of potentially related factors, including age, sex, race/ethnicity,
educational attainment, socioeconomic status, and medical insurance status
using multivariate logistic regression analysis.
Results Of 738 known hypertensive persons, hypertension was uncontrolled in
388 (53%). Previously undiagnosed hypertension was detected in 138 others
(11%). Of 289 diabetic persons, serum glucose control was inadequate in 141.
Of 1252 survivors, 225 (18%) were currently smoking, and heavy alcohol use
was observed in 56 persons. Hypercholesterolemia was poorly controlled in
185 (46%) of 405 persons with known hypercholesterolemia. Undetected hypercholesterolemia
was observed in 160 persons (13%). In the multivariate analysis, high-risk
profiles were more likely to be observed in persons aged 46 to 65 years, women,
and African Americans.
Conclusions High prevalence of inadequate secondary prevention was found in a subset
of the US population at highest risk for stroke and MI. Considerable efforts
are required to effectively implement risk factor modification strategies
after MI or stroke, particularly in middle-aged persons, African Americans,
and women.
INTRODUCTION
CARDIOVASCULAR diseases (CVDs), including myocardial infarction (MI)
and stroke, are a major cause of death and disability in the United States.1 A history of CVD increases the relative risk of subsequent
premature cardiovascular morbidity and mortality by 5 to 7 times.2-3 The survival rate among more than 1
million cases of MI that occur annually is approximately 70% to 80%.4-5 Among survivors of a first MI, the
rate of subsequent MI is increased 3 to 6 times, and the risk of any CVD event
may be as high as 80%.6 Of approximately 500 000
new and recurrent strokes that occur each year in the United States, 80% of
the patients survive the event.7 The risk of
subsequent ischemic stroke is as high as 30%, with a 2-fold increase in subsequent
cardiovascular events.8-10
Because persons with a previous history of cardiovascular events are at high
risk for future MI and stroke, aggressive intervention that includes risk
factor modification is warranted in this population. Despite advances in medical
and surgical management of CVD, long-term survival depends on modification
of underlying disease processes. Considerable evidence exists that a secondary
prevention program to reduce CVD risk factors can favorably impact CVD morbidity
and mortality.4 Survivors of these events are
ideal candidates for secondary prevention efforts because even modest treatment
effects could benefit this large at-risk population. Most survivors receive
medical evaluation regularly, and risk factor modification can be undertaken
in a cost-effective manner. To our knowledge, limited information exists regarding
formal assessment of the magnitude of risk factor modification with current
secondary preventive strategies outside clinical trials. The present study
was undertaken to determine the effectiveness of secondary preventive measures
in survivors of MI and stroke using data from the Third National Health and
Nutrition Examination Survey (NHANES III), a nationally representative sample
of US adults, and to identify factors related to inadequate control of risk
factors.
PARTICIPANTS AND METHODS
The NHANES III was conducted by the Centers for Disease Control and
Prevention between 1988 and 1994 to estimate the prevalence of common chronic
conditions and associated risk factors in a nationally representative sample
of the civilian, noninstitutionalized US population.11
The survey included a household interview; a medical examination in a mobile
examination center, or at home for those unable to travel; and phlebotomy
to measure hematologic factors, including glucose control, cholesterol level,
high-density lipoprotein cholesterol level, triglycerides, and apolipoproteins
A-I and B.12-13 Participants were
considered to have experienced a stroke if they reported a physician diagnosis
of stroke and an MI if they reported a physician diagnosis of heart attack.
We evaluated the frequency and characteristics of the defined risk factors
of hypertension, diabetes mellitus, hypercholesterolemia, alcohol use, and
cigarette smoking in stroke and MI survivors. The prevalence of uncontrolled
hypertension (defined as average blood pressure >140/90 mm Hg from 3 consecutive
readings) in persons with diagnosed hypertension was estimated. The prevalence
of undiagnosed hypertension (defined as average blood pressure >140/90 mm
Hg from 3 consecutive readings) in persons with no previous diagnosis of hypertension
was also determined. Diabetes mellitus was defined as either a physician diagnosis
of diabetes mellitus or sugar diabetes or current use of insulin or oral hypoglycemic
agents. Control of diabetes was determined according to serum glycosylated
hemoglobin levels. Levels greater than 7.0 were considered indicative of poor
control. Current smoking status was categorized as active, previous, or never.
Alcohol use was categorized as heavy if the persons reported having more than
9 drinks per day at least 7 days per year or more than 5 drinks per day at
least 14 days per year. Uncontrolled hypercholesterolemia, defined as a serum
cholesterol level greater than 6.21 mmol/L (>240 mg/dL), was estimated separately
for participants with diagnosed hypercholesterolemia. Previously undiagnosed
hypercholesterolemia was defined as a serum cholesterol level greater than
6.21 mmol/L (>240 mg/dL). The diagnosis of hypercholesterolemia was based
on the guidelines of the National Cholesterol Education Program I (NCEP I),
which were available in 1988 at initiation of the study.14
The updated guidelines (NCEP II) were not used because they were not available
until the end of the survey.15 Physical activity
was graded using the response to the question, "Compared with most men/women
of your age, would you say that you are more active, less active, or about
the same?" Overweight status was defined by a body mass index (calculated
as weight in kilograms divided by the square of height in meters) of 27.3
or greater in women and 27.8 or greater in men.16
As part of the interview, participants were asked whether their physicians
prescribed any medication for treatment of hypertension or hypercholesterolemia.
Participants were also questioned regarding whether they took the medication
as prescribed by their physician to determine the status of compliance with
treatment. As a separate analysis, individual components of the dietary intake
of survivors were compared with the NCEP I guidelines to determine the adequacy
of dietary habits.14
Another analysis was performed to identify the strata of high-risk persons
who might benefit most from secondary prevention. High-risk profile was defined
by the presence of 2 or more of the following characteristics: poorly controlled
or undiagnosed hypertension, poorly controlled diabetes mellitus, active smoking,
heavy alcohol use, or uncontrolled or undiagnosed hypercholesterolemia. The
association of a high-risk profile with age, sex, race/ethnicity, medical
insurance status, and educational attainment was evaluated using logistic
regression analysis. Age was categorized in 3 groups before entry into the
model: younger than 46 years, 46 to 65 years, and older than 65 years. Race/ethnicity
was grouped as white, African American, or other. Other variables were dichotomized
based on presence or absence. To estimate the extent of medical follow-up
and evaluation in participants with and without a high-risk profile, we compared
the number of visits to the physician's office within the past year for each
group. We also compared the frequency with which participants with and without
high-risk profiles had seen a physician or health professional within the
past 6 months.
Economic status was estimated for 948 persons as poverty index. Poverty
index was computed as a ratio of 2 components. The numerator was the midpoint
of the observed family income category. The denominator was the poverty threshold,
the age of the family reference person, and the calendar year in which the
family was interviewed. The poverty index allowed income data to be analyzed
in a comparable manner across the 6 years of the survey and with previous
surveys. A higher poverty index suggests higher income and economic status.
A separate logistic regression analysis was performed in participants in whom
poverty index was available to analyze the effect of economic status on the
presence of multiple uncontrolled risk factors. Poverty index was categorized
based on quartiles.
RESULTS
Of 17 752 adults older than 18 years who underwent complete interview
and examination in the NHANES III, 1252 survivors of MI, stroke, or both were
identified. A total of 828 participants reported a physician diagnosis of
MI, 560 reported a previous diagnosis of stroke, and 136 reported a history
of both. The mean ± SD interval between the event and the present NHANES
III evaluation was 10.6 ± 9.4 years for MI and 8.0 ± 9.6 years
for stroke.
Hypertension had been previously diagnosed in 738 persons (59%). According
to our criteria, hypertension was controlled in 280 participants (38%) and
uncontrolled in 388 (53%). Blood pressure readings were not available for
70 persons (9%). The distribution of systolic and diastolic blood pressures
among survivors of MI and stroke is shown in Figure 1 and Figure 2,
respectively. Most participants with elevated systolic blood pressure had
readings between 140 and 180 mm Hg. Critical analysis of the data for 388
persons with uncontrolled hypertension revealed that noncompliance (n = 49)
and lack of prescribed medication or treatment advice (n = 7) contributed
minimally to poor control. Of the 388 participants, 350 reported evaluation
by a medical physician or other health professional within the past 6 months.
Previously undiagnosed hypertension was detected in 138 survivors, of whom
117 reported evaluation by a physician or other health professional within
the past 6 months. A total of 289 participants were known diabetics; 110 required
insulin treatment, 128 used oral hypoglycemic agents, 16 used both, and 67
were not using any medication. Serum glucose control, as reflected by glycosylated
hemoglobin levels, was adequate in 136 persons with diabetes (47%) and inadequate
in 141 (49%). Levels were not available for 12 persons (4%). Of 1252 survivors,
225 (18%) were currently smoking and 530 (42%) reported a past history of
smoking. Heavy alcohol use was observed in 56 persons (4%). Hypercholesterolemia
previously diagnosed in 405 survivors (32%) was considered to be adequately
controlled in 199 (49%) and poorly controlled in 185 (46%) based on our criteria.
Cholesterol levels were not available for 21 persons. Distribution of serum
total cholesterol levels in survivors of MI and stroke is shown in Figure 3. Most participants with elevated
concentrations of cholesterol had levels between 6.21 and 7.24 mmol/L (240
and 280 mg/dL). Of 185 persons with poorly controlled hypercholesterolemia,
noncompliance to medication was reported by 23 and no prescribed treatment
was reported by 12; 176 had seen a medical professional in the past 6 months.
Previously undiagnosed hypercholesterolemia was detected in 160 persons, of
which 133 reported a recent (<6 months) evaluation by a health professional.
Low-density lipoprotein cholesterol level was evaluated in 417 participants
(Figure 4); 236 (57%) had levels
greater than 3.36 mmol/L (>130 mg/dL). Physical activity compared with their
peers was graded as more active by 28% of respondents, about the same by 38%,
and as less active by 34%. A total of 543 participants (43%) were considered
overweight.
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Figure 1. Distribution of systolic blood
pressures in survivors of myocardial infarction and stroke in the Third National
Health and Nutrition Examination Survey population. The gray and black bars
represent levels below and above the cutoff value for defining inadequate
control, respectively.
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Figure 2. Distribution of diastolic blood
pressures in survivors of myocardial infarction and stroke in the Third National
Health and Nutrition Examination Survey population. The gray and black bars
represent levels below and above the cutoff value for defining inadequate
control, respectively.
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Figure 3. Distribution of serum total cholesterol
levels in survivors of myocardial infarction and stroke in the Third National
Health and Nutrition Examination Survey population. The gray and black bars
represent levels below and above the cutoff value for defining inadequate
control, respectively. To convert cholesterol from millimoles per liter to
milligrams per deciliter, divide by 0.02586.
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Figure 4. Distribution of serum low-density
lipoprotein cholesterol (LDL-C) levels in a subset of the survivors of myocardial
infarction and stroke in the Third National Health and Nutrition Examination
Survey population. The gray and black bars represent levels below and above
the cutoff value for defining inadequate control, respectively. To convert
cholesterol from millimoles per liter to milligrams per deciliter, divide
by 0.02586.
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Table 1 compares inadequately
controlled risk factors in persons with vs without previous stroke or MI in
the NHANES III. The group with previous MI or stroke was older and had a higher
proportion of men and whites. The frequency of participants with inadequately
controlled hypertension, hypercholesterolemia, and diabetes mellitus was higher
in persons with previous stroke or MI. The proportions of current smokers
and heavy alcohol users were lower in persons with previous stroke or MI.
The comparison does not adjust for demographic differences between the 2 groups.
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Table 1. Comparison of Inadequately Controlled Risk Factors in Participants
With vs Without Previous Stroke or MI in NHANES III (1988-1994)*
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Analysis of dietary consumption revealed that the following components
were not in accordance with NCEP I guidelines: total fat greater than 30%
of total calories (n = 646), saturated fatty acid greater than 10% of total
calories (n = 580), polyunsaturated fatty acid greater than 10% of total calories
(n = 181), monounsaturated fatty acid greater than 15% of total calories (n
= 278), cholesterol level greater than 7.76 mmol/L (>300 mg/dL) (n = 328),
and carbohydrates greater than 60% of total calories (n = 228).
Of 1060 survivors with complete data for multivariate analysis, 366
(35%) had a high-risk profile, defined as the presence of 2 or more poorly
controlled risk factors. In the multivariate analysis, those aged 46 to 65
years (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.8), women
(OR, 1.6; 95% CI, 1.3-2.1), and African Americans (OR, 1.4; 95% CI, 1.0-1.9)
were at significantly higher risk for having a high-risk profile (Table 2). The probability of having a high-risk
profile was not affected by educational attainment or medical insurance status.
In a separate analysis, poverty index was not associated with a high-risk
profile. The mean ± SD number of evaluations by health professionals
within the past year was similar in the high-risk group (6.9 ± 7.5)
and the group with 1 or no uncontrolled risk factors (6.9 ± 8.6). Among
the 366 high-risk persons, 326 (89%) reported a consultation with a medical
professional within the past 6 months.
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Table 2. Relationship Between Demographic and Social Factors and the
Presence of Inadequate Risk Factor Control (High-Risk Profile) in 1060 Survivors
of Myocardial Infarction and Stroke in NHANES III (1988-1994)*
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COMMENT
SALIENT FINDINGS OF THE STUDY
Efforts aimed at secondary prevention in survivors of MI, stroke, or
both are inadequate. The NHANES III represents one of the largest recent national
population-based assessments of CVD risk factors in the United States.11 Therefore, these data afford a unique opportunity
to evaluate the status of various socioeconomic, clinical, and hematologic
factors in a representative population. Our results call for major efforts
directed toward secondary prevention in a subset of the population at highest
risk for CVD events. The magnitude of inadequate risk factor control was high,
with almost half of persons with hypertension, diabetes mellitus, and hypercholesterolemia
having inadequate risk factor control. One fifth of MI and stroke survivors
were currently smoking. This ineffectiveness was in part the result of patient
attitudes toward risk factor modification, as evident from medication noncompliance
and active cigarette smoking. However, a large proportion of undetected hypertension
and hypercholesterolemia also suggests the inadequacy of regular medical evaluation
regarding secondary prevention in this population. Almost 90% of the high-risk
group reported that they had seen a physician or other health professional
in the past 6 months. Participants reported an average of 7 consultations
with physicians or other health professionals within the past year.
COMPARISON WITH OTHER STUDIES
Table 3 compares our results
with those of similar studies conducted within and outside the United States.17-20 The
proportion of uncontrolled hypertension and current smoking was similar among
studies. The hyperlipidemia profile varies in studies depending on the age
and sex distributions. The higher proportion of inadequately controlled hyperlipidemia
in the Heart and Estrogen/Progestin Replacement Study and the Health Education
and Research Trial might also be attributed to use of low-density lipoprotein
cholesterol level to define hyperlipidemia. Some data for secondary prevention
are also available from recent trials evaluating the effect of cholesterol
lowering in patients with coronary heart disease and high or average cholesterol
levels in the Scandinavian Simvastatin Survival Study,21
the Cholesterol and Recurrent Events trial,22
and the Long-term Intervention With Pravastatin in Ischaemic Disease Study.23 However, study inclusion criteria limit the extrapolation
of these data to reflect the secondary prevention status in the general population.
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Table 3. Comparison of Studies Evaluating the Cardiovascular Risk Factor
Status in Survivors of Cardiovascular Disease*
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RISK REDUCTION WITH SECONDARY PREVENTION
Uncontrolled hypertension (systemic blood pressure >140/90 mm Hg) was
observed in 53% of participants with previously diagnosed hypertension. An
additional 138 survivors (11%) had hypertension that was previously undetected.
Noncompliance and lack of prescribed medication or treatment advice contributed
minimally to poor control. Participants in the Hypertension Detection and
Follow-up Program who had a previous history of MI had a 20% reduction in
the total mortality rate.24 Uncontrolled hypertension
in survivors of stroke is associated with poor prognosis.25-26
Direct evidence suggesting a link between stroke recurrence reduction and
blood pressure reduction is lacking. A study27
comparing aggressive antihypertensive treatment with standard care demonstrated
a 20% stroke reduction in patients with previous evidence of end-organ damage,
including stroke. Poor control of diabetes mellitus was observed in 49% of
participants with diabetes. Stroke survivors with diabetes have a 2-fold higher
risk of subsequent stroke and MI than do those without diabetes.28
Whether aggressive glucose control reduces the risk of CVD events is debated.29 Reduction of CVD risk might depend more on control
of other coexisting risk factors, such as obesity, hypertension, and lipid
abnormalities.29 However, poor glycemic control
can exacerbate or cause dyslipidemia.4 Smoking
remains the most modifiable risk factor for MI and stroke survivors.30-31 Cessation of smoking after MI results
in a 50% reduction in subsequent CVD events (compared with those who continue
to smoke) independent of other factors.32 A
70% reduction in MI and death was reported in men and women older than 55
years with angiographically demonstrated coronary artery disease who quit
smoking.33
A high frequency of uncontrolled hypercholesterolemia was also observed
in survivors. Cholesterol lowering for secondary prevention after MI has been
shown to reduce the risk of subsequent MI.21-23
In the Coronary Drug Project, the mortality rate over a 15-year period was
11% lower in the niacin therapy group than in the placebo group.34
The maximum benefit was observed after 12 years of follow-up. In the West
of Scotland Coronary Prevention Study, participants with or without previous
coronary heart disease were randomized to receive pravastatin or placebo.35 The study concluded that the absolute benefit of
pravastatin treatment for hypercholesterolemia was most prominent when used
for secondary prevention of MI. The role of hypercholesterolemia is less well
defined for secondary prevention of stroke. An overview analysis of 16 trials
evaluating antilipidemic medications demonstrated a significant reduction
in cardiovascular events and death and stroke.36
The beneficial effect was seen in patients with or without previous coronary
artery disease.
IMPACT OF RECENT CLINICAL TRIALS AND GUIDELINES
In recognition of the importance of this issue, the NCEP has carried
out a variety of educational activities to develop and implement guidelines
for treatment of elevated cholesterol levels.37
The first guidelines were available in 1988 at initiation of the study.14 The guidelines were updated in 1993 before completion
of the present survey.15 Recent studies38-39 have also documented the benefits
of antihypertensive treatment in patients with isolated systolic hypertension
and diabetes mellitus. The physicians' practices might have been affected
by these studies since data collection in the NHANES III. Therefore, the effect
of the updated guidelines and recent clinical trials might be undermined in
the present study. More recent studies still continue to demonstrate the inadequacy
of secondary prevention (Table 3).
Frolkis et al40 reported that 36% of hospitalized
patients and 46% of patients who should be treated for hyperlipidemia at discharge
from coronary care units according to NCEP II guidelines were not treated.
The study concluded that physicians are poorly compliant with NCEP guidelines.
INADEQUATE DIETARY INTAKE
In our study, a large proportion of participants had dietary habits
that were not in accordance with NCEP I guidelines. This observation might
have important implications as accumulating evidence suggests the role of
diet in modification of hypertension and hypercholesterolemia.41-42
In the Lyon Diet Heart Study, the risk of cardiac death or nonfatal MI was
lower in the Mediterranean dietary group than in the prudent Western-type
dietary group.43 The protective effect was
maintained for 4 years after the first MI.
FACTORS RELATED TO INADEQUATE SECONDARY PREVENTION
Our analysis suggests that attitudes toward risk factor modification,
as seen in participants who were noncompliant with medications or continued
to smoke, were a determinant of inadequate secondary prevention. Patient education
and awareness efforts might favorably impact this issue. However, the analysis
also suggests that a substantial proportion of survivors had hypertension
or hypercholesterolemia that was not previously diagnosed. This observation
highlights the importance of regular medical evaluation and follow-up in survivors
of MI or stroke. Three population subsets were more likely to have an inadequately
controlled CVD risk factor profile: middle-aged persons (46-65 years), African
Americans, and women. The present study was not designed to determine the
underlying reasons behind the association of age or sex with poor control
of risk factors. However, the analysis identifies persons who might benefit
most from risk factor modification efforts. Educational attainment and access
to medical care as reflected by medical insurance status were not related
to risk factor status. Furthermore, almost 90% of persons with poorly controlled
risk factors had seen a medical professional in the past 6 months. Persons
with high-risk profiles reported an average of 7 visits to the physician's
office within the past year. These observations emphasize the lack of implementation
of secondary preventive strategies despite frequent medical evaluations.
ECONOMIC IMPACT OF SECONDARY PREVENTION
The economic burden of CVD in the United States is estimated to be $286.5
billion dollars annually.44 Lightwood and Glantz45 estimated that a 1% reduction per year in the prevalence
of smoking could result in savings of $3.2 billion over 7 years. Grover et
al46 estimated that treatment of hypercholesterolemia
in persons with CVD could result in an estimated 4.65 years of life saved.
Similarly, treatment of hypertension could increase life expectancy by approximately
1.26 years. In their analysis, the forecasted benefits were prominent in primary
prevention only when persons had multiple risk factors. However, the forecasted
benefit was observed in secondary prevention in persons with single or multiple
risk factors. We hope that our analysis encourages policymakers to increase
funding to support secondary preventive efforts. At the individual physician
level, a more thorough effort toward ensuring patient understanding of the
importance of risk factor modification and regular medical evaluation might
ensure compliance and early detection of new-onset hypertension or hypercholesterolemia.
ISSUE RELATED TO DATA INTERPRETATION
There are certain potential limitations to this study. The definitions
of MI and stroke used to identify participants with previous CVDs were based
on self-reported physician diagnoses. Previous studies have suggested that
self-reported MI in the NHANES surveys is reasonably accurate to justify its
use in assessment of risk factor and prevalence studies. A study47
was conducted in the early years of the National Health Survey to measure
the accuracy and completeness of health interviews that concluded that the
frequency of underreporting or overreporting was low for heart diseases. Bergmann
et al48 compared interview reports with hospitalization
records for 10 523 participants from NHANES I. The interview consisted
of the same question for MI as used in NHANES III with a similar study population.
A true-positive rate of 83% (95% CI, 78%-87%) was observed for the 294 self-reported
MIs. O'Mahony et al49 validated the accuracy
of assessing lifetime history of stroke in a random sample of 2000 persons
aged 45 years and older in a mailed questionnaire. Participants were asked
whether they ever had a stroke. Response accuracy was confirmed by review
of medical records. The question had a sensitivity of 95% and a specificity
of 96%. Similarly, high sensitivity (74%-100%) and specificity (94%-99%) have
been reported for estimation of prevalent MI by means of mailed questionnaires.50-51 The status of certain risk factors
such as smoking and compliance to medication was based on self-report without
independent confirmation, which might undermine the prevalence of current
smoking and compliance to medication. Similarly, the definition of undetected
hypertension and hypercholesterolemia based on self-report is affected by
participants' awareness of such a diagnosis in addition to detection by a
physician. Because the study was not longitudinal, there is a possibility
that control of risk factors might have improved after the event compared
with risk factor status before the event but might not have achieved the optimal
level defined in our study. The number of participants available for analysis
was relatively small (n = 1252) but was comparable to that in other studies
(Table 3).
CONCLUSIONS
Our analysis shows a high prevalence of inadequate secondary prevention
in a subset of the US population at highest risk for stroke and MI. Strong
motivation and regular access to medical care make MI and stroke survivors
ideal candidates for education programs and medical treatment. Secondary prevention
strategies are cost-effective because high-risk individuals are already identified
by the medical system, and small efforts can make a large impact on outcome
because of the large number of expected events. Most efforts need to be focused
on African Americans, women, and persons aged 46 to 65 years. Unless risk
factor modification efforts in survivors of MI and stroke are more effective,
the high incidence of CVD and related mortality will continue.
AUTHOR INFORMATION
Accepted for publication November 7, 2000.
Presented in part (abstract) at the 26th International Stroke Conference,
American Stroke Association, Fort Lauderdale, Fla, February 14, 2001 (Stroke. 2001;32:320[abstract]).
Corresponding author and reprints: Adnan I. Qureshi, MD, Department
of Neurosurgery, Millard Fillmore Hospital, 3 Gates Cir, Buffalo, NY 14209-1194
(e-mail: aiqureshi{at}hotmail.com).
From the Department of Neurosurgery and the Toshiba Stroke Research
Center, School of Medicine and Biomedical Sciences, The State University of
New York, Buffalo.
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