中風之後 預防性藥物的使用迅速減少
作者：Pam Harrison
出處：WebMD醫學新聞
January 19, 2010 — 根據瑞典的研究者指出，中風之後2年，次級預防藥物(例如抗高血壓與抗血小板製劑、statins類藥物與warfarin)的持續使
用情況迅速減少，需發展一些改善持續服藥的方法。
他們的研究結果線上登載於1月14日以及將發表於2月發行的Stroke期刊。
瑞典Umea大學醫院的Eva-Lotta Glader博士與多家中心的研究者發現，瑞典中風登記資料庫、Riks-Stroke有74.2%的病患在中風之後2年會繼續服用抗高血壓藥物，63.7%仍接受抗血小板治療，56.1%繼續服用一種statin類藥物，只有45%繼續服用warfarin。
Glader博士向Medscape Neurology表示，我認為你可以將這個研究和其他國家比較，因為整個西方世界採用的是相同的中風照護原則，在最初幾週和幾個月有健康照護專業人員密切服務，之後，病患返回社區後就比較少了。我們需要中風病患的特殊介入計畫，因為有些介入計畫在
涉及復發事件時才有較佳的持續率與較佳的結果。
【觀察型研究】
這篇前瞻觀察型研究是根據來自Riks-Stroke資料庫的1年世代，涵蓋了該國所有急性中風事件的80%- 90%。在2005年9月1日至2006年8月30
日之間，有24,024名中風病患納入該資料庫，21,077人存活出院。登記案件中有9.5%是腦出血，有86.5%的病患是缺血性中風，4%的中風原
因未確定。
出院後4個月的維持率還不錯，抗高血壓藥物有95.5%、warfarin有89.1%，不過，這些比率隨著時間降低，特別是warfarin。有趣的是，研究者
觀察發現，不同抗高血壓藥物的維持率差不多。阿斯匹靈的持續率比其他抗血小板製劑佳，2年後繼續服用阿斯匹靈的病患比其他抗血小板製
劑多。
表. 出院時與2年後的中風預防治療持續率 [table][tr][td=1,1,183]
[/td][td=1,1,95][align=center]1 – 4 個月(%) [/align][/td][td=1,1,100]<P
align="center">1 – 24 個月(%) [/td][/tr][tr][td][align=center]所有病患 [/align][/td][td]<P
align="center"> [/td][td]
[/td][/tr][tr][td][align=center]任何抗高血壓
藥物 [/align][/td][td][align=center]95.5 [/align][/td][td][align=center]74.2 [/align][/td][/tr][tr][td]<P
align="center">缺血性中風病患 [/td][td]
[/td][td][align=center]
[/align][/td][/tr][tr][td][align=center]Statin 類藥物 [/align][/td][td][align=center]91.7 [/align][/td][td]56.1
[/td][/tr][tr][td][align=center]任何抗血小板藥物 [/align][/td][td]
[/td][td][align=center]63.1 [/align][/td][/tr][tr][td][align=center]阿斯匹靈
[/align][/td][td][align=center]93.2 [/align][/td][td][align=center]61.5 [/align][/td][/tr][tr][td]<P
align="center">Dipyridamole [/td][td][align=center]87.3 [/align][/td][td][align=center]46.5
[/align][/td][/tr][tr][td][align=center]Clopidogrel [/align][/td][td][align=center]81.9 [/align][/td][td]39.4
[/td][/tr][tr][td][align=center]缺血性中風與心房纖維顫動病患 [/align][/td][td][/td][td]
[/td][/tr][tr][td]<P
align="center">Warfarin [/td][td][align=center]89.1 [/align][/td][td][align=center]45.0
[/align][/td][/tr][/table]
多元邏輯回歸模式中，居住於養護機構與持續使用藥物有強烈關聯，與病患繼續使用抗高血壓藥物、抗血小板藥物與statin類藥物的可能性增加有關(所有的P < .001)。
相對的，居住於養護機構與病患繼續服用warfarin的可能性降低有關(P = .004)。Glader博士表示，Warfarin是最難服用的藥物，該藥的持續率不只依賴服藥順從性，也和醫師有關，醫師可能會因為副作用風險而決定病患不必繼續使用該藥。
其他與2年時的高持續率無關的因素包括男性、之前的中風史、有共病症(包括糖尿病與心房纖維顫動)、曾經在中風病房接受照護、由直系親屬扶養。
研究作者指出，年紀增加與抗血小板藥物的持續率高有關，但是warfarin的持續率低，而自我認知的健康狀況不佳與情緒低落，傾向會降低持續用藥的機會。
【該研究的特徵】
加州大學洛杉磯分校的Bruce Ovbiagele醫師向Medscape Neurology表示，這個來自特定登記資料庫的研究特徵之一是，追蹤期間夠長。他表示，我們有的資料大多是3個月到1年左右，所以追蹤病患更久、到他們幾乎忘記中風這件事情時，才可以發現實際上會發生的事情。如同瑞
典研究者所提及的，需建立一個結構性的中風計畫(例如由UCLA建立的美國的第一個這類計畫)來確保中風病患繼續服用他們的藥物。
Ovbiagele醫師解釋，首先，我們得讓病患使用正確的藥物，之後，一旦開始使用，我們必須維持他們用藥，因此，他們系統性地建構了醫院
流程，以確保中風病患在出院時服用所有必須使用的藥物；至於在社區中，持續用藥需依賴病患和醫師合作，病患和有些醫師不確定他們在出院後是否須繼續服用所有的藥物。
Ovbiagele醫師觀察發現，經常發生的是，病患不是十分清楚他們需要做的事情與必須服用的藥物，所以，我們每一次面對病患時，都必須再
度強調繼續服用藥物的必要性，因為他們的風險絕對不會消失。醫師們也須對病患出現情緒低落或憂鬱有所警覺，特別是中風之後的6個月內，許多病患在這段期間會出現憂鬱，在瑞典的研究中，也可因此預測不佳的藥物持續率。
Ovbiagele醫師重申，我們需尋找原因並且加以解決，這會影響病患在追蹤期間的利益，醫師應幫助他們重新開立處方。
研究作者接受等Apoteket AB、瑞典心臟與肺臟基金會、Vasterbotten郡議會等資金支持而進行本研究。他們宣告沒有相關財務關係。
Ovbiagele醫師宣告沒有相關財務關係。
Stroke. 線上發表於2010年1月14日。
[b][font=Arial][size=4]Use of Preventive Medications Declines Rapidly After Stroke[/size][/font][/b][font=Arial][size=2]
[/size][/font][size=2][font=Arial][i]By Pam Harrison
Medscape Medical News[/i]
January 19, 2010 — Persistent use of secondary prevention medications, including antihypertensive and antiplatelet agents, statins, and warfarin, quickly declines during the first 2 years after a stroke, and measures to improve persistence need to be developed, according to Swedish investigators.
Their results were published online January 14 and will appear in the February issue of [i]Stroke[/i].
Eva-Lotta Glader, MD, PhD, from Umea University Hospital in Umea, Sweden, and multicenter colleagues found that 74.2% of patients in Riks-Stroke, the Swedish Stroke Register, were still taking antihypertensive medication 2 years after a stroke, 63.7% were still undergoing antiplatelet therapy, 56.1% were still taking a statin, and only 45% were still taking warfarin.
“I think you can make a parallel from this study to other countries as well because stroke care is built on the same principles in the whole western world, with a tight connection to healthcare professionals in the first weeks and months, and then much less so once patients are out in the community,” Dr. Glader told [i]Medscape Neurology. [/i]“We need to have special intervention programs for stroke patients because some intervention programs have been shown to lead to better persistence rates and better outcomes when it comes to recurrent events.”
[b]Observational Study[/b]
The prospective observational study was based on a 1-year cohort from the Riks-Stroke, which covers 80% to 90% of all acute stroke events in the country. Between September 1, 2005, and August 30, 2006, 24,024 stroke patients were included in the registry — 21,077 having been discharged alive. Cerebral hemorrhage occurred in 9.5% of registrants, whereas 86.5% of patients had an ischemic stroke. Four percent of the strokes remained undefined.
Persistence rates during the first 4 months after discharge were very good at 95.5% for antihypertensive drugs and 89.1% for warfarin. However, over time, these rates fell, especially for warfarin. Interestingly, persistence rates were similar for different types of antihypertensive drugs, as the investigators observed. Persistence with aspirin was also better than with other antiplatelets because more patients were still taking aspirin after 2 years than comparable agents.
[b]Table. Persistence Rates With Stroke Preventive Treatments at Discharge and After 2 Years [/b]
[/font][/size][table][tr][td][b]Drug [/b][/td][td][b]1 – 4 Months, %[/b] [/td][td][b]1 – 24 Months, %[/b] [/td][/tr][tr][td][b]All patients [/b][/td][td]?[/td][td]?[/td][/tr][tr][td]Any antihypertensive drug[/td][td]95.5[/td][td]74.2[/td][/tr][tr][td][b]Patients with ischemic stroke [/b][/td][td]?[/td][td]?[/td][/tr][tr][td]Statin[/td][td]91.7[/td][td]56.1[/td][/tr][tr][td]Any antiplatelet drug[/td][td]96.4[/td][td]63.1[/td][/tr][tr][td]Aspirin[/td][td]93.2[/td][td]61.5[/td][/tr][tr][td]Dipyridamole[/td][td]87.3[/td][td]46.5[/td][/tr][tr][td]Clopidogrel[/td][td]81.9[/td][td]39.4[/td][/tr][tr][td][b]Patients with ischemic stroke and atrial fibrillation[/b] [/td][td]?[/td][td]?[/td][/tr][tr][td]Warfarin[/td][td]89.1[/td][td]45.0[/td][/tr][/table]In a multiple logistic regression model, living in an institution most strongly correlated with persistent drug use and was associated with an increased likelihood of patients continuing to use antihypertensive medication, antiplatelet therapy, and a statin (all [i]P[/i] < .001).
In contrast, living in an institution was associated with a reduced likelihood of patients continuing to take warfarin ([i]P[/i] = .004). "Warfarin is the most difficult drug to take," as Dr. Glader observes, "and persistence with the drug depends not just on compliance but also on the physician, who may decide that the patient should not continue on the drug because of the risk for adverse events."
Other factors that were independently associated with high persistence rates at 2 years were female sex, a history of previous stroke, the presence of comorbid disorders (including diabetes and atrial fibrillation), having been cared for in a stroke unit, and support by next of kin.
"Advanced age was associated with high persistence of antiplatelet drugs but low persistence of warfarin," the study authors add, "[whereas] poor self-perceived general health and low mood tended to reduce the chance of being a persistent medication user."
[b]Unique Aspect of the Study[/b]
Bruce Ovbiagele, MD, University of California, Los Angeles, told [i]Medscape Neurology [/i]that one of the unique aspects of this particular registry study was its long-term follow-up.
"Most of the data we have go out to about 3 months or maybe a year, so we are really seeing what happens when you follow patients out a lot further, when they tend to have forgotten about the event," he says. As the Swedish authors allude to, a structured stroke program such as that at UCLA — one of the first of its kind in the country, he points out — was established precisely to ensure that stroke patients continue to take their medications.
"We first wanted to get patients started on the right medication and then once they were started, we wanted to maintain them on the medication," Dr. Ovbiagele explains. To do this, they systematically structured hospital procedures to ensure stroke patients were taking all necessary medications at discharge. In the community, persistence with medication depends on both patients and physicians, he adds, with both patients and occasionally physicians not being certain if patients need to continue taking all medications indefinitely after their discharge.
"What often happens is that patients are not as clear as they need to be that they have to take these medications indefinitely," Dr. Ovbiagele observes, "so each time we see the patient, we need to reemphasize the need for them to be on their medications indefinitely because their risk never goes away." Physicians also need to be alert to the presence of low or depressed mood, especially within the first 6 months after a stroke, when many patients are depressed, because this was also predictive of poor persistence in the Swedish experience.
"We need to look for it and treat it, as this will also influence patient interest in follow-up with their physicians and help them to refill their prescription," Dr. Ovbiagele reaffirms.
[i]The study authors received grant support from Apoteket AB, the Swedish Heart and Lung Foundation, and Vasterbotten County Council to carry out the study. They have disclosed no relevant financial relationships. Dr. Ovbiagele has disclosed no relevant financial relationships. [/i]
[i]Stroke[/i]. Published online January 14, 2009.