Stroke prevention in the elderly may be excessive, researcher says

Patients more than 80 years old are being “over-treated” for stroke prevention and doctors need to actively rethink their priorities and beliefs about stroke prevention, according to a new study published in Evidence Based Medicine.

Individuals in their 80s are often prescribed drugs to prevent a stroke when the risk of a stroke is not that high and the drugs have other side effects, according to the study’s author Dr. Kit Byatt of the Department of Geriatric Medicine, The County Hospital in Hereford, United Kingdom.

Statins and antihypertensive drugs were the most commonly prescribed cardiovascular drugs in the United Kingdom in 2006. And they are widely prescribed to patients in their 80s to ward off stroke.

Dr. Byatt pointed out that the largest trials of antihypertensive therapy and statins for people in this age group have shown only a marginal reduction in stroke and very modest reductions in other cardiovascular events.

“Careful scrutiny of relevant large trials suggest that the risks of hypertension and hypercholesterolemia in the over 80s, and the benefit of antihypertensives and statins in the same population have been greatly exaggerated,” Dr. Byatt said.

Older patients have diverse views on the relative importance of stroke and death as end points, which differ from clinicians’ beliefs, he argued.

When looked at in terms of absolute benefit; underestimated side effects; and above-average health in study subjects, “the findings are relatively very modest, and really hardly applicable to the vast majority of patients I see in my secondary care clinical practice,” Dr. Byatt said. “Without this information, how can doctors help patients reach informed judgments about what are their preferred management strategies?”

Millions of dollars per year are spent on medications to prevent stroke and significant savings can be made-both prescribing costs and on costs for office visits, blood tests, consumables, etc., according to Dr. Byatt. “The hidden impact of large pharmaceutical companies in influencing prescribing guidelines by the way they selectively release and present trial data perhaps needs to be made more explicit in order to inform this discussion,” he said. “Perhaps most importantly, we need to educate and empower patients to make more informed choices about their healthcare, taking into account the context of their values, priorities. and preferences in order to put any trial data into perspective.”

Most older patients would probably reject the modest potential benefit conferred by these medicines, in favor of taking fewer drugs every day and not having to manage their possible side effects, he suggested.

Dr. Byatt advised physicians to perform an individualized risk/benefit assessment for each patient; express risks and benefits in an absolute form (eg, using NNTs, ideally with the help of a visual-decision aid);
allow the patient to make the decision, or at least empower them to discontinue the medication if they experience significant (significant to them, not to the prescriber) side effects;
consider the possibility that trial data might be open to different interpretations when deciding guidelines.