Antiplatelet and anticoagulant medication usage during stroke rehabilitation: the Post-Stroke Rehabilitation Outcomes Project (PSROP).(Post-Stroke Rehabilitation Outcomes Project )

Secondary prevention of strokes is an important issue during the admission to the inpatient rehabilitation facility (IRF). There are many clinical practice guidelines with strong levels of evidence that address the secondary prophylaxis of strokes. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the frequency that antiplatelet and/or anticoagulant medications are prescribed for the secondary prophylaxis of a stroke. Of the 1,161 participants in the PSROP, 890 (76.66%) had nonhemorrhagic strokes. Of the participants with nonhemorrhagic strokes, 169 (18.99%) did not receive any antiplatelet or anticoagulant medication. Of 717 participants who did not have an embolic event, 140 (19.5%) did not receive a salicylate, antiplatelet agent, or warfarin. Of 173 participants who had an embolic event, 29 (16.8%) did not receive a salicylate, antiplatelet agent, or warfarin. Unless patients have any medical contraindications to these medications, they should receive these evidence-based treatments for secondary stroke prophylaxis. As more stroke survivors receive antiplatelet and/or anticoagulant medications, it is more likely that the incidence of recurrent strokes will decrease. Key words: anticoagulants, cerebrovascular accident, cerebrovascular disorders, platelet aggregation inhibitors, rehabilitation

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Behind heart disease and cancer, stroke is the third most common cause of death in the Western world and is a leading cause of adult-onset disability. (1) Each year, 700,000 new cases of stroke are reported, and approximately 5.4 million stroke survivors live in the United States. Comprising more than half of the neurological admissions to community hospitals, it is the second leading cause for admission to inpatient rehabilitation. Stroke is associated with high costs and intensive utilization of rehabilitation resources, (2,3) and it remains a leading cause for placement into nursing homes or extended care facilities. During 2005, the estimated cost of stroke totaled $56.8 billion. The annual cost of hospital-based rehabilitation in the United States totaled $5.7 billion. (4)

Ischemic stroke is a condition with a variety of etiologies and clinical manifestations. Specific stroke pathogenesis and associated clinical features influence the best antithrombotic therapies for treatment and prevention. Atherosclerosis of the proximal aorta, precerebral arteries, and cerebral arteries may be a source of atherogenic brain emboli. Large-artery atherosclerotic infarction occurs when cerebral perfusion is impeded by severe arterial stenosis or occlusion. Frequent causes of subcortical or "lacunar" infarcts include microatheroma, lipohyalinosis, and other occlusive diseases of the small penetrating cerebral arteries. Approximately 20% of ischemic strokes are due to cardiogenic embolism, most commonly from atrial fibrillation. A number of other arterial occlusive disorders may cause or contribute to stroke pathogenesis.

Despite extensive diagnostic evaluations, approximately 30% of ischemic strokes remain idiopathic. Because the specific etiology of stroke in individual patients may be difficult to determine, it is a challenge to find the optimal choice of therapy for secondary prevention of stroke.

Secondary prevention of stroke is an important issue during admissions to inpatient rehabilitation facilities (IRFs). According to Roth and associates, (5) approximately 1.6% of stroke survivors admitted to an IRF experienced a new stroke, and 87.5% of these patients required transfer back to an acute care hospital facility. It is such an important issue that both the Joint Commission on Accreditation of Hospital Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation Facilities (CARF) specifically cite secondary prevention of stroke in their standards for stroke centers. In the primary stroke center accreditation, JCAHO includes the use of antiplatelet medications in two of its standards: "Patients with ischemic stroke or transient ischemic attack (TIA) who receive antithrombotic medication within 48 hours of hospitalization ..."; and "Patients with a transient ischemic attack (TIA) or an ischemic stroke should be prescribed antithrombotic therapy at discharge unless contraindicated ..."(6) The Stroke Subspecialty Program standards from CARF require that health care providers address secondary prevention of stroke. Furthermore, the standards mandate the compilation of a "portable profile" that includes medications and other vital health care information such that the stroke survivor may provide appropriate information at each health care encounter and relay this information to each health care provider involved in the stroke survivor's medical care. (7)

The purpose of this study is to utilize the Post-Stroke Rehabilitation Outcomes Project (PSROP) database to describe the use of antiplatelet agents in the secondary prophylaxis of nonhemorrhagic strokes during admission to IRFs and describe the use of anticoagulants in the secondary prophylaxis of nonhemorrhagic embolic strokes. The types of antiplatelet and anticoagulant medications will be described …