Significant Stroke Risk Disparities Reduced Following Intensive Medical Intervention

Eyad Almallouhi, MD

Recently published in Stroke, findings from a retrospective analysis showed that significant stroke risk disparities between Black and nonBlack stroke survivors were reduced after 1 year of intensive medical intervention.¹ These findings suggest that that intensive risk factor management may have an important role in ameliorating disparities in these risk factors between Black and nonBlack patients.²

Overall, investigators observed significant differences at baseline between the 2 groups in age (Black: 57.5 vs nonBlack: 61.0 years; P = .004), hypertension (95.2% vs 87.5%; P = .027), and diabetes (52.9% vs 39.7%; P=0.017). At the same time, there were significant differences observed among Black and nonBlack patients in mean diastolic blood pressure (82.4 vs 79.5 mm Hg; P = .035), as well as mean physician-based assessment and counseling for exercise score (2.7 vs 3.3; P = .002).

“Modifiable stroke risk factor differences between Black and nonBlack adults were found at enrollment; however, our study found these disparities may be resolved by tailoring care to include lifestyle coaching, medication alterations or additions if appropriate, access to routine health care support and regular physician follow-up,” coauthor Ashley M. Nelson, DO, neurology resident at the Medical University of South Carolina said in a statement.¹ “Intense risk factor management has an important role in improving or eliminating these risk factor disparities in Black adults.”

Led by Eyad Almallouhi, MD, a neurointerventionalist at Sarasota Memorial Health Care System, investigators assessed data from the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis study (SAMMPRIS), specifically looking at medication use and vascular risk factors, such as systolic blood pressure, diastolic blood pressure, low-density lipoprotein, blood glucose levels and physical activity among both Black and nonBlack adults who had a recent stroke. In addition, physical activity was measured by the Physician-based Assessment and Counseling for Exercise (PACE) score, in which a score of 4 or above would be considered moderately active and in the target range.

“We tend to focus on systolic blood pressure, yet diastolic blood pressure is also a good marker for cardiovascular health and the integrity of the blood vessels,” Nelson said in a statement.¹ “Using a tailored approach resulted in better risk factor control for the participants.”

READ MORE: Study Identifies Significant Link Between Hypertensive Disorders of Pregnancy and Stroke in Black Women

After 1 year of intensive intervention, the disparity in diastolic blood pressure had dropped to 74.7 mm Hg compared with 75.5 mm Hg in all other participants (P = .575). At the same time, the average PACE score increased among Black adults from 2.7 to 4.2 compared with an average PACE score among nonBlack adults, which was 4.1 (P = .593). During the 1 year of aggressive medical management, diuretic medication use doubled in Black adults, which researchers speculated may explain the notable decrease in average diastolic blood pressure. “Many different approaches are needed to reduce and eliminate these disparities in Black adults. Access to health care, lifestyle coaching, early follow-up and administration of appropriate medications after stroke may help to resolve it, but not wholly in terms of overall risk and all of the baseline disparities,” Nelson said in a statement.1

The authors noted that this research raises questions about other factors beyond physiology, medications and regular follow-up that may further reduce these disparities in stroke. It was noted in a statement that this analysis did not compare Black adults to any other specific racial subgroup because of insufficient numbers of each race in the nonBlack group which included White, Asian and Hispanic adults. The study compared Black and nonBlack patients in the United States and had a disproportionate enrollment of people from all ethnicities, therefore, these results may not be generalizable to a broader geographic population.

SAMMPRIS was a randomized controlled trial conducted between 2008 and 2011 at 50 sites in the U.S. which compared medical management with stenting as a way to prevent recurrent stroke caused by severe intracranial atherosclerotic stenosis. Among 451 adults with stroke, the trial reported that a second stroke was less likely in adults treated with aggressive medical management alone in comparison with adults who received an intracranial stent and aggressive medical care. Notably, the 30-day rate of recurrent stroke or mortality was 14.7% in the group that received stents in comparison with 5.8% for the medical management group.

In the SAMMPRIS follow-up analysis, researchers compared data on the cardiovascular risk factors of 104 Black and 347 nonBlack adults over a 1 year period after aggressive medical management intervention. The intervention comprised of initiation of dual antiplatelet therapy and intensive medical control of blood pressure, cholesterol, type 2 diabetes, smoking and physical activity levels, and included regular follow-up visits with the health care team and lifestyle coaching.

REFERENCES
1. Disparities in Black adults’ stroke risk factors persist; risk factor control reduced gap. News Release. American Heart Association. Published August 3, 2023. Accessed September 13, 2023. https://newsroom.heart.org/news/disparities-in-black-adults-stroke-risk-factors-persist-risk-factor-control-reduced-gap
2. Almallouhi E, Nelson AM, Cotsonis G, Harris W, Chimowitz MI, Turan TN. Ameliorating Racial Disparities in Vascular Risk Factor Management With Aggressive Medical Management in the SAMMPRIS Trial. Stroke. 2023;54(9):2235-2240. doi:10.1161/STROKEAHA.122.042055