Prevalence of Cerebrovascular Events in Indigent Systolic Heart Failure Patients Receiving Optimum M

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Prevalence of Cerebrovascular Events in Indigent
Systolic Heart Failure Patients Receiving Optimum
Medical Therapy Followed in a Disease Management
Program
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• Dale Leleaux 1, Michael Odinet 2, MD, Lee
  Arcement 1 MD, MPH, Ron Horswell 3, PhD, Zaza
  Katsarava 4, MD, PhD, MSc, Kathy Hebert 1 MD,
  MMM.
• Chabert Medical Center, Houma, Louisiana, LSU
  School of Medicine, New Orleans, Louisiana, LSU
  School of Public Health, New Orleans, Louisiana,
  University of Essen, Essen, Germany.

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Introduction
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What Is the Impact of Stroke?

• Stroke is the third leading cause of death in the
  United States
  
• On average, someone suffers a stroke every 45
  seconds
  
• About 700,000 Americans suffer strokes each
  year
  
• About every 3 minutes, someone dies of a stroke

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What Is the Impact of Stroke? (Continued)

• Stroke is a leading cause of serious,
  long-term disability
  
• About 4 million Americans are stroke survivors
• Americans will pay about 51 billion in 2003
  for stroke-related medical costs

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What Are the Types of Stroke ?

• Ischemic Stroke (Blockage)
• Caused when there is a blockage in the blood
  vessels to the brain
  
• Hemorrhagic Stroke (Bleeding)
• Caused by burst or leaking blood vessels in the
  brain

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What Are the Causes of Ischemic Stroke ?

• Begins with the development of fatty deposits
  lining the blood vessel wall
  
• Thrombus Development of blood clot at the
  fatty deposit
  
• Embolus Traveling particle too large to pass
  through a small vessel

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Stroke Risk FactorsThat Can Be Treated

• Hypertension/High Blood Pressure
• Heart Disease
• Cigarette Smoking
• Transient Ischemic Attacks

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Stroke Risk FactorsThat Can Be Treated
(continued)

• Diabetes
• Elevated Blood Cholesterol/Lipids
• Asymptomatic Carotid Bruits

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Stroke Warning Signs

• Sudden weakness or numbness of the face, arm or
  leg, especially on one side of the body
  
• Sudden confusion, trouble speaking or
  understanding
  
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of
  balance or coordination
  
• Sudden, severe headaches with no known cause (for
  hemorrhagic stroke)

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Transient Ischemic Attacks (TIAs)

• TIAs are warning strokes that can happen
  before a major stroke
  
• They occur when blood flow through a brain artery
  is blocked or reduced for a short time

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Prevention of Stroke

• Control High Blood Pressure
• Prevent heart disease
• Stop cigarette smoking

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Background

• Systolic heart failure-second most common cause
  for CVE in US after atrial fibrillation
  
• Framingham study- RR 4.1 males, 2.8 females risk
  for CVA with CHF
  
• HOPE trial- protective effect of Ace inhibitors
  for CVE in pts with CV risk

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Aim of Study

• Determine prevalence of CVE in heart failure
  population receiving optimal medical therapy for
  heart failure and to ascertain magnitude of the
  effect of these and other clinical variables on
  the association of CVE

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Methods

• 455 SHF pts in disease management program
  screened for history of CVE(CVA or TIA) using the
  National Institute of Neurological Disorders and
  Stroke 5 questionnaire
• SHF defined as EF
• CART analysis

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Results

• Total 55 patients CVE
• CVA 40(9) , TIA 16(4)
• 13 of total heart failure population
• 60 of patients did not know any signs or
  symptoms of a stroke

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• CVE (n 47 CVA,16 TIA ) No CVE (n
  404)
  
• Mean Age 59.5
  57.6
  
• African-American 28.6
  39.8
  
• Female 39.7
  33.6
  
• Ejection Fraction 31.7
  33
  
• NYHA I/II 52.4
  66.2
  
• NYHA III/IV 47.6
  33.3
  
• SBP 129.8 mmHg
  130.9mmHg
  
• Diabetes 30
  21.7
  
• BMI 30.7
  33
  
• Atrial Fibrillation 15.9
  13
  
• Aspirin 55.6
  51.4
  
• Ace inhibitor 88.9
  93.5
  
• Beta Blocker 93.7
  96.3
  
• Median Income 11,850
  11,800
  
• Maximum grade attained 50

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CART Analysis
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Cart Analysis Risk factors Identified

• Mean arterial blood pressure
• Non-use of Ace Inhibitor p.083
• Age p.008

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Conclusion

• Prevalence of CVE is common in an indigent heart
  failure population followed in a disease
  management program receiving optimal medical
  therapy

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Limitations

• Patients could have had a CVA prior to developing
  heart failure
  
• Objective CT scan imaging was not obtained
• Differentiating embolic, thrombotic or
  hemorrhagic stroke was not obtained
  
• Retrospective analysis assuming patient survived
  the CVE
  

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Clinical Implications

• Because of the significant prevalence of CVE in
  this high risk group, both primary and secondary
  CVE prevention is highly warranted
  
• Patient education on the recognition of the 5
  established warning signs of CVE is needed and
  should be incorporated into the heart failure
  disease management program

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2005 Outcome Goals

• Primary and secondary CVE prevention
• Educational Stroke handouts to all patients
• Coumadin for atrial fibrillation or
  contraindication documented
  
• Decrease Emergency Room visits by implementing
  outpatient IVP lasix in clinic