Abstract
Background: The burden of stroke weighs heavily in developing countries where recurrence rates clearly exceed that of developed countries. The impact of nonadherence to antithrombotic treatment within this context has been poorly investigated. Objective: The objective of this study was to evaluate patients with recurrent ischemic stroke in Egypt and Germany with focus on stroke subtype distribution and adherence to antithrombotic therapy. Methods: We conducted a comparative cross-sectional retrospective cohort study enrolling consecutive patients hospitalized for recurrent ischemic stroke in 2017 in 2 academic centers. Data were collected on demographics, risk factors, stroke subtypes, and medication adherence. Nonadherence to antithrombotic agents was analyzed at the time point of index stroke (recurrent stroke). Predictors of nonadherence were analyzed using logistic regression. Results: A total of 373 Egyptian and 468 German patients with ischemic stroke were included. The proportion of recurrent ischemic stroke among all patients was higher in the Egyptian cohort compared to the German cohort (33 vs. 10%, p < 0.05). Small-vessel occlusion stroke was the most frequent subtype in Egyptians, with a significantly greater proportion than in Germans (45 vs. 26%, p < 0.05). Nonadherence to antiplatelets at the time point of the recurrent stroke was higher in Egyptians than in Germans (82 vs. 19%, p < 0.001). Low educational attainment among Egyptians (OR 0.14, 95% CI [0.00–0.19], p < 0.01) and high comorbidity scores among Germans (OR 2.45, 95% CI [1.06–5.66], p < 0.05) were found to be predictors of nonadherence to antithrombotic treatment. Conclusions: The large stroke recurrence burden in Egypt may be partly explained by differing adherence to secondary preventative antithrombotic pharmacotherapy. Predictors of medication nonadherence have to be addressed to reduce stroke recurrence disparities.
References
1.
Owens Johnsen
C
, Nguyen
M
, Roth
GA
, Nichols
E
, Alam
T
, Abate
D
, et al. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
. Lancet Neurol
. 2019 May
;18
(5
):439
–58
.2.
Feigin
VL
, Norrving
B
, Mensah
GA
. Global burden of stroke
. Circ Res
. 2017 Feb
;120
(3
):439
–48
. .3.
Benjamin
EJ
, Virani
SS
, Callaway
CW
, Chamberlain
AM
, Chang
AR
, Chenget
S
, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association
. Circulation
. 2018 Mar
;137
(12
):e67
–492
.4.
Engel-Nitz
NM
, Sander
SD
, Harley
C
, Rey
GG
, Shah
H
. Costs and outcomes of noncardioembolic ischemic stroke in a managed care population
. Vasc Health Risk Manag
. 2010 Oct
;6
:905
–13
. .5.
El-Hajj
M
, Salameh
P
, Rachidi
S
, Hosseini
H
. The epidemiology of stroke in the Middle East
. Eur Stroke J
. 2016 Sep
;1
(3
):180
–98
. .6.
Abd-Allah
F
, Moustafa
RR
. Burden of stroke in Egypt: current status and opportunities
. Int J Stroke
. 2014 Dec
;9
(8
):1105
–8
. .7.
Stahmeyer
JT
, Stubenrauch
S
, Geyer
S
, Weissenborn
K
, Eberhard
S
. The frequency and timing of recurrent stroke: an analysis of routine health insurance data
. Dtsch Arztebl Int
. 2019
;116
(42
):711
–7
. .8.
Shah
R
, Wilkins
E
, Nichols
M
, Kelly
P
, El-Sadi
F
, Wright
F
, et al. Epidemiology report: trends in sex-specific cerebrovascular disease mortality in Europe based on WHO mortality data
. Eur Heart J
. 2019 Mar
;40
(9
):755
–64
. .9.
Kolominsky-Rabas
PL
, Weber
M
, Gefeller
O
, Neundoerfer
B
, Heuschmann
PU
. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study
. Stroke
. 2001 Dec
;32
(12
):2735
–40
. .10.
Hillen
T
, Coshall
C
, Tilling
K
, Rudd
AG
, McGovern
R
, Wolfe
CD
, et al. Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register
. Stroke
. 2003 Jun
;34
(6
):1457
–63
. .11.
Broderick
JP
, Bonomo
JB
, Kissela
BM
, Khoury
JC
, Moomaw
CJ
, Alwell
K
, et al. Withdrawal of antithrombotic agents and its impact on ischemic stroke occurrence
. Stroke
. 2011 Sep
;42
(9
):2509
–14
. .12.
Weimar
C
, Cotton
D
, Sha
N
, Sacco
RL
, Bath
PM
, Weber
R
, et al. Discontinuation of antiplatelet study medication and risk of recurrent stroke and cardiovascular events: results from the PRoFESS study
. Cerebrovasc Dis
. 2013 Jun
;35
(6
):538
–43
. .13.
Del Brutto
VJ
, Chaturvedi
S
, Diener
HC
, Romano
JG
, Sacco
RL
. Antithrombotic therapy to prevent recurrent strokes in ischemic cerebrovascular disease: JACC scientific expert panel
. J Am Coll Cardiol
. 2019 Aug
;74
(6
):786
–803
. .14.
Yeo
SH
, Toh
MPHS
, Lee
SH
, Seet
RCS
, Wong
LY
, Yau
WP
. Impact of medication nonadherence on stroke recurrence and mortality in patients after first-ever ischemic stroke: insights from registry data in Singapore
. Pharmacoepidemiol Drug Saf
. 2020 Mar
;29
(5
):538
–49
. .15.
Gebreyohannes
EA
, Bhagavathula
AS
, Tegegn
HG
. Poor outcomes associated with antithrombotic undertreatment in patients with atrial fibrillation attending Gondar University Hospital: a retrospective cohort study
. Thromb J
. 2018 Sep
;16
:22
. .16.
Negm
M
, Abd El-Razek
R
. Role of aspirin discontinuation in recurrence of ischemic cerebrovascular stroke
. Egypt J Neurol Psychiatry Neurosurg
. 2019 Feb
;55
(1
):14
. .17.
Sacco
RL
, Kasner
SE
, Broderick
JP
, Caplan
LR
, Connors
JJ
, Culebras
A
, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association
. Stroke
. 2013 Jul
;44
(7
):2064
–89
. .18.
Adams
HP
Jr, Bendixen
BH
, Kappelle
LJ
, Biller
J
, Love
BB
, Gordon
DL
, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment
. Stroke
. 1993 Jan
;24
(1
):35
–41
. .19.
Charlson
ME
, Pompei
P
, Ales
KL
, MacKenzie
CR
. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
. J Chronic Dis
. 1987
;40
(5
):373
–83
. .20.
Al AlShaikh
S
, Quinn
T
, Dunn
W
, Walters
M
, Dawson
J
. Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischemic attack: a systematic review and meta-analyses
. Eur Stroke J
. 2016 Jun
;1
(2
):65
–5
.21.
Abd-Allah
F
, Khedr
E
, Oraby
MI
, Bedair
AS
, Georgy
SS
, Moustafa
RR
. Stroke burden in Egypt: data from five epidemiological studies
. Int J Neurosci
. 2018 Aug
;128
(8
):765
–71
. .22.
Markus
HS
, Khan
U
, Birns
J
, Evans
A
, Kalra
L
, Rudd
AG
, et al. Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study
. Circulation
. 2007 Nov
;116
(19
):2157
–64
. .23.
White
H
, Boden-Albala
B
, Wang
C
, Elkind
MS
, Rundek
T
, Wright
CB
, et al. Ischemic stroke subtype incidence among whites, blacks, and hispanics: the northern Manhattan study
. Circulation
. 2005 Mar
;111
(10
):1327
–31
. .24.
Kaptoge
S
, Pennells
L
, De Bacquer
D
, Cooney
MT
, Kavousi
M
, Stevens
G
, et al. World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions
. Lancet Glob Health
. 2019 Oct
;7
(10
):e1332
–45
. .25.
Rolnick
SJ
, Pawloski
PA
, Hedblom
BD
, Asche
SE
, Bruzek
RJ
. Patient characteristics associated with medication adherence
. Clin Med Res
. 2013 Jun
;11
(2
):54
–65
. .26.
Hassanein
M
. Adherence to antihypertensive fixed-dose combination among Egyptian patients presenting with essential hypertension
. Egypt Heart J
. 2020 Mar
;72
(1
):10
. .27.
Shams
ME
, Barakat
EA
. Measuring the rate of therapeutic adherence among outpatients with T2DM in Egypt
. Saudi Pharm J
. 2010 Oct
;18
(4
):225
. .28.
Rücker
V
, Heuschmann
PU
, O’Flaherty
M
, Weingärtner
M
, Hess
M
, Sedlak
C
, et al. Twenty-year time trends in long-term case-fatality and recurrence rates after ischemic stroke stratified by etiology
. Stroke
. 2020 Sep
;51
(9
):2778
–85
. .29.
Wilke
T
, Groth
A
, Mueller
S
, Pfannkuche
M
, Verheyen
F
, Linder
R
, et al. Incidence and prevalence of atrial fibrillation: an analysis based on 8.3 million patients
. Europace
. 2013 Apr
;15
(4
):486
–93
. .30.
Paciaroni
M
, Agnelli
G
, Falocci
N
, Caso
V
, Becattini
C
, Marcheselli
S
, et al. Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation: effect of anticoagulation and its timing: the RAF study
. Stroke
. 2015 Aug
;46
(8
):2175
–82
. .31.
Rohla
M
, Weiss
TW
, Pecen
L
, Patti
G
, Siller-Matula
JM
, Schnabel
RB
, et al. Risk factors for thromboembolic and bleeding events in anticoagulated patients with atrial fibrillation: the prospective, multicentre observational PREvention oF thromboembolic events: European Registry in Atrial Fibrillation (PREFER in AF)
. BMJ Open
. 2019 Mar
;9
(3
):e022478
. .32.
Kini
V
, Ho
PM
. Interventions to improve medication adherence: a review
. JAMA
. 2018 Dec
;320
(23
):2461
–73
. .33.
Xu
J
, Ju
Y
, Wang
C
, Wang
Y
, Liu
L
, Zhao
X
, et al. Patterns and predictors of antihypertensive medication used 1 year after ischemic stroke or TIA in urban China
. Patient Prefer Adherence
. 2013 Jan
;7
:71
–9
. .34.
Lin
CS
, Khan
H
, Chang
RY
, Liao
WC
, Chen
YH
, Siao
SY
, et al. A study on the impact of poor medication adherence on health status and medical expense for diabetes mellitus patients in Taiwan: a longitudinal panel data analysis
. Medicine
. 2020 Jun
;99
(26
):e20800
. .© 2021 S. Karger AG, Basel
2021
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.
