Skip Navigation


Journal of Public Health Advance Access originally published online on June 21, 2007
Journal of Public Health 2007 29(3):251-257; doi:10.1093/pubmed/fdm040
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
29/3/251    most recent
fdm040v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Ramsay, S. E.
Right arrow Articles by Morris, R. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Ramsay, S. E.
Right arrow Articles by Morris, R. W.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Missed opportunities for secondary prevention of cerebrovascular disease in elderly British men from 1999 to 2005: a population-based study



Sheena E. Ramsay, MRC Special Training Fellow in Health of the Public and Health Services Research1,

Peter H. Whincup, Professor of Cardiovascular Epidemiology2

S. G. Wannamethee, Reader in Epidemiology1

Olia Papacosta, Research Statistician1

Lucy Lennon, Research Administrator1

Mary C. Thomas, Research Assistant1

Richard W. Morris, Reader in Medical Statistics and Epidemiology1
1 Department of Primary Care and Population Sciences, Royal Free and University College Medical School, UCL Hampstead Campus, Rowland Hill Street, London NW3 2PF, UK
2 Department of Community Health Sciences, St George's, University of London, London SW17 0RE, UK

Address correspondence to Sheena E. Ramsay, E-mail: s.ramsay{at}pcps.ucl.ac.uk

Objective We examined patterns in medication use for secondary prevention of cerebrovascular disease in older British men from 1999 to 2005, and investigated socio-demographic and disease-related influences on medication use.

Methods Percentage use of antiplatelet drugs, blood pressure-lowering drugs and statins use was calculated in men, aged 65–87 years in 2005, who had been diagnosed with stroke or transient ischaemic attack (TIA) from a population-based cohort based in one general practice in each of 24 British towns.

Results In 1999, most men with cerebrovascular disease received antiplatelet drugs (67%). However, a few received blood pressure-lowering drugs (50%) and statins (13%). By 2005, the use of all drug types had increased; at least half of the patients received each type of drug. However, only one-third of patients received all three medication types and combined blood pressure treatment was limited. Older age, a diagnosis of TIA rather than stroke and absence of co-existing coronary heart disease were associated with lower rates of use of specific medication categories.

Conclusion Despite improvements in secondary prevention medication use, there is scope for achieving the full potential of these medications, particularly by increasing combination blood pressure treatment and statin use and ensuring that older patients receive the benefits of prevention.

Keywords: cerebrovascular disease, medication use, secondary prevention


   Introduction
TOP
 Introduction
Methods
 Results
 Discussion
 Implications and conclusions
 Competing interests
 Acknowledgements
 References
 
Stroke is the third largest cause of death in the UK and worldwide and is the single largest cause of disability.1,2 Patients with a history of transient ischaemic attack (TIA) or stroke are at increased risk of recurrent vascular events.1,3 Since the early nineties, the role of medications in reducing the risk of recurrent vascular events in patients with a history of stroke or TIA has become increasingly clear. Antiplatelet drugs, blood pressure-lowering drugs (particularly in combination) and cholesterol-lowering drugs, particularly statins, independently reduce the risk of recurrent vascular events by about one-quarter among patients with a history of TIA or stroke; these benefits are observed across a wide range of risk factor levels and are not restricted to patients with exceptionally high risk factor profiles.4–7

Several hospital-based studies have reported on the extent to which patients with TIA or stroke receive these medications immediately after the event.8–10 However, there are fewer reports in the population of patients with cerebrovascular disease, which provide better overall estimates of the extent of secondary prevention, including patients with less recent events and those managed in primary care.11 The recent update of the National Service Framework (NSF) for older people and the Chief Medical Officer's report in 2006 emphasized the need for adequate and equitable provision of effective treatments for chronic diseases, with cerebrovascular disease a particular priority.12,13 In this study, we ascertain the use of secondary prevention medication for cerebrovascular disease in a population-based study of older British men studied in primary care settings. We explore whether there were improvements in medication use from 1999 to 2005 and investigate socio-demographic factors and disease characteristics associated with the use of these medications.


   Methods
TOP
 Introduction
 Methods
Results
 Discussion
 Implications and conclusions
 Competing interests
 Acknowledgements
 References
 
The British Regional Heart Study (BRHS) is a prospective study of cardiovascular disease which includes a socially and geographically representative sample of men recruited from one general practice in each of 24 towns representing all major British regions.14,15 Participants were enrolled in 1978–80 and have been followed up through the National Health Service Central Register (Southport and Edinburgh), general practice records and questionnaires to study participants. More details of BRHS methods are reported elsewhere.15

Regular two-yearly reviews of general practitioner's records were carried out to identify subjects with stroke and TIA; information on coronary heart disease (CHD) diagnoses (particularly myocardial infarction and angina) was also obtained.15 Standard WHO definitions were used to define stroke and TIA, which were considered as two separate categories. Subjects with both diagnoses were included as stroke cases. Reports of current medication are based on questionnaires completed by study participants in 1998–2000 (referred to as the mid-year 1999 in this paper), 2003 and 2005. Details of all current medications including non-prescription medications were sought on each occasion.

The use of different medications (antiplatelet drugs, blood pressure-lowering drugs and statins) individually and in combination was calculated in percentages at the three time points for stroke and TIA patients. Use of medication in all cerebrovascular disease patients (both stroke and TIA) in 2005 was examined in relation to age, social class, region, time since last diagnosis, presence of disability, type of vascular event (stroke or TIA) and previous CHD event. The age of the subjects in 2005 was 65–87 years. Subjects were divided into two approximately equal age groups, 65–75 and 76–87 years. Social class was derived from the longest held occupation recorded at the time of baseline questionnaire using the Registrar General's classification of occupations, with categories grouped as non-manual (I, II and III non-manual) and manual (III, IV and V manual). Men in the armed forces at baseline were excluded from this analysis. Regions were divided into north and south depending on whether the town of residence was north or south of a line joining Bristol and the Wash. Presence of disability was ascertained by self-report of any long-standing illness, disability or infirmity in the questionnaire in 2005. Time since diagnosis was ascertained using the date of last (most recent) diagnosis of stroke or TIA before 2005. The ‘time since diagnosis’ variable was categorized into three groups of less than 5 years, 5–10 years and greater than 10 years. Information on previous event of CHD was collected from general practitioner's records. Prevalence ratios were calculated with 95% confidence intervals (CIs) using Clinstat software and were expressed as percentage reductions or increases in medication use according to different variables mentioned above.


   Results
TOP
 Introduction
 Methods
 Results
Discussion
 Implications and conclusions
 Competing interests
 Acknowledgements
 References
 
Response rates for questionnaires were 77% in 1999 and 80% in both 2003 and 2005. In 1999, 2003 and 2005 there were 141, 186 and 159 subjects with a history of stroke and 171, 213 and 190 with a history of TIA. Table 1 shows the use of different secondary prevention medications at the three time points in stroke and TIA subjects. In 1999, the highest levels of medication use were seen for antiplatelet drugs (67–73%) followed by blood pressure-lowering drugs (51–61%); use of statin was very low. Use of all medications increased between 1999 and 2005; the relative increase was particularly marked for statins, which were now received by more than 50% of patients. Three-quarters of subjects were receiving antiplatelet and blood pressure-lowering drugs. However, fewer than half the subjects were receiving two or more blood pressure-lowering drugs and only a third were receiving a combination of treatment with antiplatelet, blood pressure lowering and statin drugs. Among patients not receiving antiplatelet drugs, an appreciable proportion was receiving anticoagulant treatment (44% of stroke patients and 53% of TIA patients in 2005).


View this table:
[in this window]
[in a new window]

  		Table 1 Use of medications for secondary prevention of cerebrovascular disease in patients with stroke and TIA

 
Table 2 shows the influence of socio-demographic factors and disease characteristics on the use of medications in all patients with cerebrovascular disease (stroke and TIA) in 2005. The use of all medications was lower in older subjects compared with younger subjects. This age difference was particularly marked in the use of statin (64% in younger patients, 41% in older patients). There was no systematic variation in medication use by social class or region. TIA patients had a lower use of blood pressure-lowering drugs than stroke patients, though there was no appreciable difference in the use of other drugs. Subjects with cerebrovascular disease who also had a history of CHD were appreciably more likely to receive blood pressure-lowering drugs and statins than those without previous CHD. Though the use of antiplatelet drugs and statin tended to decrease with increasing time since diagnosis of a vascular event, this difference was not statistically significant. There was no appreciable relation between physical disability and the use of secondary prevention.


View this table:
[in this window]
[in a new window]

  		Table 2 Determinants of medication use in cerebrovascular disease (stroke and TIA) patients in 2005

 

   Discussion
TOP
 Introduction
 Methods
 Results
 Discussion
Implications and conclusions
 Competing interests
 Acknowledgements
 References
 
Main findings of this study
Our results show that the use of secondary prevention medication in older British men with stroke and TIA in primary care settings has increased from 1999 to 2005. There still, however, remains room for further improving the completeness of medication use in older subjects. In 2005, three-quarters of stroke patients were taking antiplatelet drugs and blood pressure-lowering treatment and about half were on statins. However, fewer than half were receiving the benefits of combined blood pressure treatment and only one-third of all patients were receiving a combination of antiplatelet, blood pressure lowering and statin treatment. Patients at particular risk of not receiving secondary prevention included older patients (less likely to receive statins), those with TIA rather than stroke (less likely to receive blood pressure-lowering drugs) and those without concurrent CHD (less likely to receive blood pressure-lowering treatment and statins).

What is already known about this topic
Medications form an important part of the secondary prevention programme in stroke and TIA patients to prevent recurrence of these events. The effectiveness of antiplatelet drugs, blood pressure-lowering drugs (particularly in combination) and cholesterol-lowering drugs in reducing the risk of recurrent vascular events in patients with cerebrovascular disease is now well established1,5–7,16,17 even in older people (these reports had subjects aged over 65 and up to 75 or 80 years in some trials5,16 ). The use of these medications in preventing recurring strokes has been shown to also be cost effective.17–20 Given the higher risk of stroke in older people,1 the need for secondary prevention is even greater. Deficiencies in the use of secondary prevention medication for vascular disease have been reported by other studies in the UK.9,21–23 However, most studies on secondary prevention of cerebrovascular or cardiovascular disease in the UK and elsewhere have been hospital-based or with patients in acute care.8–10,23

What this study adds
Our study is based on a highly representative sample of British men and is likely to reflect closely the current uptake of secondary prevention medications for cerebrovascular disease. The increase in medication use in our study appears to have followed the publication of key reports such as Antiplatelet Trialists Collaboration, Heart Protection Study and progress trial,4–6 and policy initiatives like the NSF for Older People24 and the Quality and Outcomes Framework (QOF).25 However, it is difficult to comment on how much of the observed increase in medication use in our study was a results of these initiatives. It is likely that the increased evidence-base and the NSF may have had more of an influence on our findings than the QOF since this came into effect much later in the period of our study, but it could be useful for further improvement in secondary prevention.

The lower rates of medication use observed in our study, when compared with some previous studies of patients in acute care,8,9,23 probably reflect the population setting of our study, which included patients followed-up for a longer period beyond acute care. The use of antiplatelet drug was very high; an appreciable proportion of those not taking antiplatelet treatment were receiving anticoagulants. The use of blood pressure-lowering drug was also reasonably high overall. However, blood pressure treatment use was less prevalent among TIA patients, and the use of combined blood pressure-lowering treatment (shown in the progress trial to be particularly effective in reducing recurrent vascular events)6 was limited. Appreciable opportunities also remain for increasing the uptake of statin use. Because the actions of antiplatelet, blood pressure lowering and cholesterol-lowering treatment are independent, increasing use of the combination of these treatments would provide considerable gains in reduction of recurrent cerebrovascular disease.

We observed systematic variations in the use of these medications within our study population in 2005. The lower rates of statin use observed in older patients and the lower rates of use of all medications in those without CHD are consistent with the findings of other studies.9,26–29 The overall use of medications in our cerebrovascular patients was lower than in CHD patients of our cohort, which we have previously reported.11 We did not find a social class difference in medication use in our study; this has also not been observed in earlier papers on CHD patients.30,31 There was also no variation in medication use by region or presence of disability.

The reasons for the apparent ‘treatment-paradox’27 seen in the under-use of secondary prevention medications, despite substantial evidence for the usefulness of these medications in reducing recurrence of vascular disease, are not clear. This may to some extent reflect the delay in implementation of medical evidence; the benefits of statin treatment and blood pressure reduction specifically after stroke have been demonstrated relatively recently. To a large extent, the low rates of medication use are likely to reflect a failure to initiate treatment;32 there is little evidence from patients with cerebrovascular disease studied repeatedly that cessation of medication use is the underlying problem. Compliance rates to antithrombotic and antihypertensive medications in other studies have generally been reported to be good.33,34 The low rates of medication in this context do not appear to reflect concerns about quality of life and disability among patients; presence of disability did not influence prevalence of medication use, which was in any case lower among patients with transient TIA than in subjects with established stroke. Overall, it appears that implementation of secondary prevention for cerebrovascular disease is less advanced than that for CHD, the presence of CHD had a strong influence in the present population on the likelihood of receiving treatment.

Strengths and limitations of this study
The results of our study provide current data on medication use in a socio-economically representative sample of older British men with stroke and TIA. As the study is based on primary care, it provides a population-wide view of patients and is not restricted to recent cases; we were able to include patients whose event had been as early as 10 years previously. Thus, these results give a picture of the long-term use of medication in the community and not just in acute care after an event of stroke or TIA. Our cases were ascertained by a thorough two-yearly review of general practice records. Medication use is based on current reporting by study subjects, and does not rely on general practice records of medication use, which might be a poor reflection of actual use. While our results are limited to men, previous studies suggest that secondary prevention may be less complete in women.35,36 A limitation of the present investigation was the lack of systematic information on type of stroke (infarct or haemorrhage). Almost all the strokes seen in this population are likely to have been infarcts rather than haemorrhage as has been reported in previous studies;9,37 this presumption is also reflected in the high rates of antiplatelet treatment observed in our study. However, the use of blood pressure lowering and statin treatment would have been applicable both to infarct and haemorrhagic disease.


   Implications and conclusions
TOP
 Introduction
 Methods
 Results
 Discussion
 Implications and conclusions
Competing interests
 Acknowledgements
 References
 
Given the high risk of recurrent vascular events and death after stroke/TIA,1,3,38 there should be a greater focus on ensuring that patients obtain the full benefits of secondary prevention; the treatment deficiencies observed in our study suggest that this is not currently being achieved. This evidence-treatment gap needs to be narrowed with a greater consensus on use of blood pressure lowering and antiplatelet drugs and also combination treatments that are shown to produce greater risk reductions in secondary prevention. Studies have shown that an early initiation of medication during hospitalization influences the long-term use of medication.32,39–41 The transition from acute care to primary or community-based care is crucial and will improve long-term use of medication by patients. Nevertheless, there is a need to target and focus efforts on improving both prescription rates and patient compliance. Primary care services play a special role in ensuring that benefits of recent advances in treatment are obtained by patients with a history of stroke or TIA in the community thus achieving the full potential of these medications. Greater uptake of secondary prevention medications has important implications both for health services and patients.


   Competing interests
TOP
 Introduction
 Methods
 Results
 Discussion
 Implications and conclusions
 Competing interests
Acknowledgements
 References
 
All authors declare that there are no competing interests.


   Acknowledgements
TOP
 Introduction
 Methods
 Results
 Discussion
 Implications and conclusions
 Competing interests
 Acknowledgements
References
 
The BRHS is a British Heart Foundation Research Group and also received funding from the Department of Health, England. SR is funded by a UK MRC Special Training Fellowship in Health Services Research and Health of the Public. The views expressed in this study are those of the authors and not necessarily those of the funding bodies.


   References
TOP
 Introduction
 Methods
 Results
 Discussion
 Implications and conclusions
 Competing interests
 Acknowledgements
 References
 

  1. Warlow C, Sudlow C, Dennis M, et al. Stroke. Lancet (2003) 362(9391):1211–24.[CrossRef][Web of Science][Medline]
  2. Department of Health. Stroke. Department of Health [ 2006 [cited 2006 Feb. 27]. Available from.
  3. Clark TG, Murphy MFG, Rothwell PM. Long term risks of stroke, myocardial infarction, and vascular death in "low risk" patients with a non-recent transient ischaemic attack. J Neurol Neurosurg Psychiatry (2003) 74(5):577–80.[Abstract/Free Full Text]
  4. Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ (2002) 324(7329):71–86.[Abstract/Free Full Text]
  5. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo-controlled trial. Lancet (2002) 360:7–22.[CrossRef][Web of Science][Medline]
  6. PROGRESS Collaborative G. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet (2001) 358(9287):1033–41.[CrossRef][Web of Science][Medline]
  7. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med (2000) 342(3):145–53.[Abstract/Free Full Text]
  8. Ovbiagele B, Hills NK, Saver JL, et al. Antihypertensive medications prescribed at discharge after an acute ischemic cerebrovascular event. Stroke (2005) 36(9):1944–7.[Abstract/Free Full Text]
  9. Rudd AG, Lowe D, Hoffman A, et al. Secondary prevention for stroke in the United Kingdom: results from the National Sentinel Audit of Stroke. Age Ageing (2004) 33(3):280–6.[Abstract]
  10. Volpato S, Maraldi C, Ble A, et al. Prescription of antithrombotic therapy in older patients hospitalized for transient ischemic attack and ischemic stroke: the GIFA study. Stroke (2004) 35(4):913–7.[Abstract/Free Full Text]
  11. Ramsay SE, Whincup PH, Lawlor DA, et al. Secondary prevention of coronary heart disease in older patients after the national service framework: population based study. BMJ (2006) 332(7534):144–5.[Abstract/Free Full Text]
  12. Department of Health CMO. The Chief Medical Officer on the State of Public Health (2006) London: Department of Health.
  13. Philp I. A New Ambition for Old Age: Next Steps in Implementing the National Service Framework for Older People (2006) London: Department of Health.
  14. Shaper AG, Pocock SJ, Walker M, et al. British Regional Heart Study: cardiovascular risk factors in middle-aged men in 24 towns. Br Med J (1981) 283:179–93.[Abstract/Free Full Text]
  15. Walker M, Whincup PH, Shaper AG. The British Regional Heart Study 1975–2004. Int J Epidemiol (2004) 33(6):1185–92.[Free Full Text]
  16. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Br Med J (1994) 308(6921):81–106.[Abstract/Free Full Text]
  17. Ward S, Lloyd Jones M, Pandor A, et al. A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technol Assess (2007) 11((14).).
  18. Ebrahim S. Cost-effectiveness of stroke prevention. Br Med Bull (2000) 56(2):557–70.[Abstract/Free Full Text]
  19. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet (1999) 354(9188):1457–63.[CrossRef][Web of Science][Medline]
  20. Sarasin FP, Gaspoz JM, Bounameaux H. Cost-effectiveness of New Antiplatelet Regimens Used as Secondary Prevention of Stroke or Transient Ischemic Attack. Arch Intern Med (2000) 160(18):2773–8.[Abstract/Free Full Text]
  21. Coppola WGT, Whincup PH, Walker M, et al. Identification and management of stroke risk in older people: a national survey of current practice in primary care. J Hum Hypertens (1997) 11(3):185–91.[CrossRef][Web of Science][Medline]
  22. McKevitt C, Coshall C, Tilling K, et al. Are there inequalities in the provision of stroke care? Analysis of an Inner-City Stroke Register. Stroke (2005) 36(2):315–20.[Abstract/Free Full Text]
  23. Hillen T, Dundas R, Lawrence E, et al. Antithrombotic and antihypertensive management 3 months after ischemic stroke: a prospective study in an inner city population. Stroke (2000) 31(2):469–75.[Abstract/Free Full Text]
  24. Department of Health. National Service Framework for Older People (2001) London.
  25. Quality and Outcomes Framework Guidance – Updated August 2004. (2005) Department of Health. 11-5.
  26. Ramsay SE, Morris RW, Papacosta O, et al. Secondary prevention of coronary heart disease in older British men: extent of inequalities before and after implementation of the National Service Framework. J Public Health (2005) 27(4):338–43.[CrossRef]
  27. Ko DT, Mamdani M, Alter DA. Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. J Am Med Assoc (2004) 291(15):1864–70.[Abstract/Free Full Text]
  28. Cheng E, Chen A, Vassar S, et al. Comparison of secondary prevention care after myocardial infarction and stroke. Cerebrovasc Dis (2006) 21(4):235–41.[Web of Science][Medline]
  29. Amar J, Cambou JP, Touze E, et al. Comparison of hypertension management after stroke and myocardial infarction: results from ECLAT1—A French Nationwide Study. Stroke (2004) 35(7):1579–83.[Abstract/Free Full Text]
  30. Reid FDA, Cook DG, Whincup PH. Use of statins in the secondary prevention of coronary heart disease: is treatment equitable? Heart (2002) 88(1):15–9.[Abstract/Free Full Text]
  31. Whincup PH, Emberson JR, Lennon L, et al. Low prevalence of lipid lowering drug use in older men with established coronary heart disease. Heart (2002) 88(1):25–9.[Abstract/Free Full Text]
  32. Aronow HD, Novaro GM, Lauer MS, et al. In-hospital initiation of lipid-lowering therapy after coronary intervention as a predictor of long-term utilization: a propensity analysis. Arch Intern Med (2003) 163(21):2576–82.[Abstract/Free Full Text]
  33. Marini C, Totaro R, Carolei A. Long-term prognosis of cerebral ischemia in young adults. Stroke (1999) 30(11):2320–5.[Abstract/Free Full Text]
  34. Sappok T, Faulstich A, Stuckert E, et al. Compliance with secondary prevention of ischemic stroke: a prospective evaluation. Stroke (2001) 32(8):1884–9.[Abstract/Free Full Text]
  35. Hippisley-Cox J, Pringle M, Crown N, et al. Sex inequalities in ischaemic heart disease in general practice: cross sectional survey. BMJ (2001) 322(7290):832.[Abstract/Free Full Text]
  36. Primatesta P, Poulter NR. Lipid concentrations and the use of lipid lowering drugs: evidence from a national cross sectional survey. BMJ (2000) 321(7272):1322–5.[Abstract/Free Full Text]
  37. Bamford J, Sandercock P, Dennis M, et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project–1981–86. 2. J Neurol Neurosurg Psychiatry (1990) 53(1):16–22. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage.[Abstract/Free Full Text]
  38. Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ (2004) 328(7435):326.[Abstract/Free Full Text]
  39. Ovbiagele B, Saver JL, Fredieu A, et al. In-hospital initiation of secondary stroke prevention therapies yields high rates of adherence at follow-up. Stroke (2004) 35(12):2879–83.[Abstract/Free Full Text]
  40. Muhlestein JB, Horne BD, Bair TL, et al. Usefulness of in-hospital prescription of statin agents after angiographic diagnosis of coronary artery disease in improving continued compliance and reduced mortality. Am J Cardiol (2001) 87(3):257–61.[CrossRef][Web of Science][Medline]
  41. Fonarow GC, Gawlinski A, Moughrabi S, et al. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol (2001) 87(7):819–22.[CrossRef][Web of Science][Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
29/3/251    most recent
fdm040v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Ramsay, S. E.
Right arrow Articles by Morris, R. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Ramsay, S. E.
Right arrow Articles by Morris, R. W.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?