Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Call for attention
- Dr Rajasree Pai Ramachandra Pai (17 April 2009)
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Poor adherence for secondary prevention
- Rizaldy Pinzon (9 May 2009)
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Where's the evidence?
- Paul A Hepple (10 May 2009)
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When can we extrapolate ?
- L Sam Lewis (11 May 2009)
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Dr Rajasree Pai Ramachandra Pai, Resdient University of connecticut
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The article throws light on a much neglected area of modern medicine. It calls for aggressive use of drugs in secondary prevention of stroke in the elderly. In addition to improving the physical quality of life of stroke patients,this measure is likely to bring down the health expenditure for rehabilitating the stroke victims. Competing interests: None declared |
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Rizaldy Pinzon, Neurologist Bethesda hospital Yogyakarta Indonesia 55224
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The article from Dr. Raine, et.al. is very interesting. Patients who have had one stroke are at increased risk of another. Secondary prevention strategies that address medical risk factors and promote healthy lifestyles can reduce the risk. However, concordance with secondary prevention strategies is poor. The clinical evidence is very clear that antithrombotic, statin, and antihypertensive agents are essential to secondary stroke prevention. Many factors have negative effects on medication compliance in stroke patients. Previous study showed income levels, categories of antithrombotic agents and the personal living ability are closely related to compliance. Improvements are needed in management of stroke risk factors especially hypertension, hyperlipidemia, diabetes, atrial fibrillation, and smoking cessation. Competing interests: None declared |
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Paul A Hepple, GP Principal Muirhouse Medical Group, Edinburgh, EH4 4PL
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I am a bit confused by this paper's enthusiasm for lipid lowering in patients over the age of 80. Firstly the Cochrane review of interventions in the management of serum lipids for preventing stroke recurrence state "there is no evidence of benefit or harm from reducing serum cholesterol levels in patients with a history of stroke or transient ischaemic attack". Secondly very few studies on lipid lowering therapy have been done in patients over the age of 80. http://www.cochrane.org/reviews/en/ab002091.html Competing interests: None declared |
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L Sam Lewis, GP Trainer Surgery, Newport, Pembrokeshire, SA42 0TJ
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Raine et al. display how Risk of stroke correlates with Age and Sex, and conclude that "Under-treatment among older people with stroke in routine primary care cannot be justified given the lack of evidence on variations in effectiveness of treatment by age." Paul Hepple rightly challenges with 'where is the evidence' for lipid-lowering in the over-80's. But absence of evidence is not the same thing as Evidence of Absence... Nobody to my knowledge has performed RCT studies on North Pembrokeshire Welshmen, but I extrapolate daily that the Scandinavian 4S or Scottish WOSCOPS studies should apply to my patients. The same challenge was mounted against treating BP in the over-80s. Slowly the evidence emerges that benefits of BP lowering AND Cholesterol lowering are directly correlated with CVD RISK, which as everyone knows, increases with age and varies with gender. The question I would ask is "Why might the over-80s be expected to behave differently ?" The only response I can come up with is that they haven't got long to live, and hence might not prove terribly cost-effective. But is that true ? HPS Cost-Effectiveness studies showed that lipid lowering not only depended on treating high CVD-Risk-patients, but also depended on their expected survival. But that circular and Ageist view might depend on unfair or unreasonable withholding of effective treatments. It should be examined and tested in well-designed trials, directly. Until then , we extrapolate according to our values and interests. Competing interests: None declared |
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