July 11, 2001 By Lisa Ellis
InteliHealth News Service
People who already have had a heart attack or stroke are at high risk for having another one.
But even years later, nearly half of these patients are not managing to control the high cholesterol or high blood pressure that make them more likely to have another event, suggests a study based on data from a large national health survey.
The study, published in the July 11, 2001, issue of the Archives of Internal Medicine, found an "alarming" lack of success in reducing risk factors even among these presumably very motivated patients, says the principal author, Adnan I. Qureshi, M.D., an assistant professor in neurosurgery and co-director of the Toshiba Stroke Research Center at the State University of New York, Buffalo.
The most disturbing aspect of the findings, Dr. Qureshi says, is "the realization that such a high proportion of lack of control exists among so many people with such a high risk of a second event. These people clearly have come to medical attention and clearly had an opportunity for a medical workup and whatever medication was warranted."
Although survey participants reported an average of seven visits to doctors in the year before the survey was taken, hypertension was uncontrolled in 53 percent of the 738 people with known hypertension, and researchers found another 11 percent with previously undetected high blood pressure.
Of the 405 participants with previously diagnosed high cholesterol, 46 percent did not have it under control, and researchers identified high cholesterol levels in another 13 percent of the study group. Of the 289 diabetics, nearly half had poorly controlled glucose levels. Nearly one-fifth of the total group were current smokers.
"This study underscores the importance of targeting high-risk individuals for a secondary prevention," says JoAnn Manson, M.D., who is chief of preventive medicine at Brigham and Women's Hospital in Boston and a professor of medicine at Harvard Medical School. "There are several lifestyle factors as well as medical therapies -- such as low-dose aspirin, statin therapy, beta-blockers and optimal treatment of hypertension -- that can have dramatic benefits in reducing risk of recurrent events."
"A major problem is that this information is not reaching these high-risk individuals and that clinicians may not be particularly targeting this group for the interventions," Dr. Manson says. "And in terms of 'bang for the buck,' this is a group that should receive special and targeted attention."
Dr. Qureshi and his colleagues reached their conclusions by examining data from the Third National Health and Nutrition Examination Survey, a major survey of more than 17,000 U.S. adults that occurred between 1988 and 1994. They identified 1,252 men and women who had survived a heart attack, stroke or both. Heart attacks had occurred an average of 10.6 years and strokes an average of eight years before these participants took the survey.
The New York researchers analyzed cholesterol, blood pressure and other data obtained from physical examinations and questionnaires at the time of the survey. They found that 35 percent of the group with a previous heart attack or stroke had at least two uncontrolled risk factors, and that those with the highest risks were more likely to be middle-aged, female or African American.
Dr. Qureshi, an assistant professor of neurosurgery at the university medical school, says it is unclear from the study to what extent patients did not comply with physicians' instructions or whether physicians did not monitor and treat the diseases aggressively.
He says the study made him, as a speciality physician who has treated patients with strokes, more aware of the need for coordination between specialists and a patient's primary doctor to ensure the best follow-up care.
"We as physicians, I think, don't realize that we may have helped them survive during hospitalization, but these risk factors still exist," he says. "It requires very close monitoring. When people are discharged, there should be a precise plan of how they are going to modify lifestyles and risk factors."
Dr. Qureshi acknowledges that several factors in evaluation and treatment of patients with cardiovascular disease have changed since the survey that provided data for his study.
It is possible, he says, that some patients may have achieved better control of their cholesterol or blood pressure because of the availability of more effective medications or wider use of these medications.
On the other hand, he says, some patients who were identified as having normal cholesterol under the National Institutes of Health guidelines in use at the beginning of the survey would be considered to have high cholesterol under new federal guidelines released in May 2001.
Still, he says, the main point of the study remains valid -- that patients who have had a heart attack or stroke need to be targeted for more intensive prevention efforts. "This has probably the most important impact on the future burden of stroke and heart attack because these patients have the highest risk and this is the population where you can have the greatest impact."
Used with permission of the copyright owner. All rights reserved. This article is not intended to provide advice on personal medical matters or to substitute for consultation with a physician. 
