|Year : 2022 | Volume
| Issue : 2 | Page : 48-52
Assessment of risk factors and management of ischemic stroke at Ibrahim Malik Teaching Hospital in Khartoum, 2018
Ayat A Mohammed1, Ahmed H Arbab2, T Mohammed T. Abdalla3
1 Department of Clinical Pharmacy, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
2 Department of Pharmacognosy, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
3 Department of Pharmacognosy, Faculty of Pharmacy, Omdurman Islamic University, Omdurman, Sudan
|Date of Submission||30-Jan-2021|
|Date of Decision||03-Oct-2021|
|Date of Acceptance||07-Oct-2021|
|Date of Web Publication||12-Apr-2022|
Dr. Ahmed H Arbab
Department of Pharmacognosy, Faculty of Pharmacy, University of Khartoum, Khartoum, P.O. Box 1996
Source of Support: None, Conflict of Interest: None
Context: Ischemic stroke is an acute medical condition with life-threatening complications; therefore, understanding its common risk factors, early management, prevention from recurrent attack, and in our population is necessary. Aim: The aim of this study is to assess common risk factors and management of ischemic stroke at Ibrahim Malik Teaching Hospital (Khartoum, Sudan). Methodology: A retrospective, hospital-based study was conducted at Ibrahim Malik Teaching Hospital Khartoum State. The study included all medical records of patients hospitalized with Ischemic stroke from January 2017 to January 2018. The data were collected using a well-designed data collection form and analyzed with SPSS. Results: Out of 116 participants, ischemic stroke was more frequent in males (59.5%), adults over 65 years (57.8%). Forty-four percent of participants had a history of hypertension. Smoking and family history with ischemic stroke were observed only in 10.3% and 5.2% of participants, respectively. Aspirin (100–300) mg plus atorvastatin 40 mg were the most prescribed regimen of 44.8%. The highest type of drug-drug interaction reported was monitor closely (41.4%) and serious (33.6) type drug-drug interactions. While 74.1% of participants were discharged, the rate of death was significantly higher in females and participants over 65 years' age. Conclusions: Past medical history of hypertension and elderly age were the major risk factors with ischemic stroke. Aspirin plus statin therapy is the most frequently used regimen with nonadherence to the guidelines regarding the use of thrombolytic therapy and anticoagulants. Serious type drug-drug interactions were detected among prescribed medications.
Keywords: Alteplase, drug-drug interaction, ischemic stroke, risk factor, statins, Sudan
|How to cite this article:|
Mohammed AA, Arbab AH, T. Abdalla T M. Assessment of risk factors and management of ischemic stroke at Ibrahim Malik Teaching Hospital in Khartoum, 2018. Matrix Sci Med 2022;6:48-52
|How to cite this URL:|
Mohammed AA, Arbab AH, T. Abdalla T M. Assessment of risk factors and management of ischemic stroke at Ibrahim Malik Teaching Hospital in Khartoum, 2018. Matrix Sci Med [serial online] 2022 [cited 2022 May 20];6:48-52. Available from: https://www.matrixscimed.org/text.asp?2022/6/2/48/343049
| Introduction|| |
Ischemic stroke is the most common type of strokes (85%), and it was ranked as the second leading cause of death after coronary artery disease. By 2020 in developed countries, it is predicted that stroke will be accountable for 6.2% of the total burden of illness. Ischemic stroke is characterized by a sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. The etiology of ischemic strokes is due to either a thrombotic or embolic event that causes a decrease in blood flow to the brain. The symptoms depend upon the affected region of the brain. The common impairments resulting from ischemic stroke include motor impairment, speech, and language, swallowing, vision, sensation, and cognition. Emergent brain imaging is essential for the evaluation of acute ischemic stroke.
The therapeutic window that is needed to prevent reversible ischemia from becoming irreversible infarction is narrow and stresses the phrase “time is brain.” Successful rapid response is crucial to prevent reversible ischemia from becoming irreversible infarction and reversing the neurological symptoms through interventional approaches. Currently, there are many therapeutic and preventive measures for the management of stroke.,,,,, Since the ideal diagnosis and treatment of ischemic stroke is the key in preserving neuronal function and preventing further damage. This study aimed to assess the management of ischemic stroke at Ibrahim Malik Teaching Hospital (Khartoum, Sudan) and to estimate the common risk factors.
| Methodology|| |
Design and Setting
Descriptive retrospective study based on hospital medical records. The study was conducted at Ibrahim Malik Teaching Hospital, which is one of the major hospitals in Khartoum state (Sudan) that provides primary and emergency and medical services to the whole state individuals.
All patients medical records from the previously hospitalized ischemic stroke patients at Ibrahim Malik Teaching Hospital from January 2017 to January 2018, which were 116 patient's medical records.
Inclusion and exclusion c criteria
All medical records of male and female adults over 18 years diagnosed with ischemic stroke were included in the study. Medical records of patients with transient ischemic attack and incomplete medical records were omitted from the study.
The data were collected from the medical records using a data collection form designed in accordance with the objectives of the study. The data collection form was reformulated after pilot study. Data collection form was containing the following variables: demographic data of participants, clinical data (past medical history, family history, and lifestyle), concomitant drug(s) used, and the fate of the patient.
Medscape application: drug interaction checker was used for checking drug-drug interactions.
The data were analyzed using the International Business Machines (IBM). Statistical Package for Social Sciences (SPSS) for Windows, Version 23.0 software (Armonk, NY, USA: IBM Corp). Data were represented as frequencies and percentages; the Chi-square test was used to describe the correlation between variables under study. P ≤0.05 was used to consider the relationship is significant. Data were represented as tables and figures.
Ethical clearance and approval to conduct the research were taken from the Ministry of Health and Ibrahim Malik hospital administrators. Confidentiality of all data collected was ensured, and remaining information from the sample will not be reused for other purposes.
| Results|| |
From the findings of 116 participants, ischemic stroke has a higher frequency in males, elderly patients over 65 years, and it was slightly higher in participant from the rural areas (55.2%) than the urban one [Table 1].
Regarding the lifestyle of participants, it was found that about 89.7% of ischemic stroke patients were a nonsmoker and only 10.3% were smokers. Moreover, while 94.8% of participants had no family history of the disease, only 5.2% of them had a family history of ischemic stroke. Analysis of the past medical history of participants is summarized in [Table 2], hypertension was found to be the most frequent factor; alone (21.6%) or in addition to another factor as diabetes mellitus (11.2%) or previous ischemic attack (11.2%). On the other hand, 25% of participants have no past medical history.
|Table 2: Distribution of the participants according to the past medical history (n=116)|
Click here to view
Medscape drug interaction checker was applied to detect potential drug-drug interaction. Out of 116 participants, drug-drug interaction was detected in 89 (76.7%) of participants, and monitor closely was the most frequent drug-drug interaction (41.4%) between concomitant drugs used and prescribed medications [Table 3].
|Table 3: Categories of drug-drug interaction checked in medications used for participants|
Click here to view
As summarized in [Table 4], the Chi-square test showed significant association between gender and outcomes (P = 0.004). Furthermore, there was a significant relationship between the age of patients and outcome (P = 0.034), where the rate of death was higher in elder individuals.
|Table 4: Association between demographic variables and fade of the participant|
Click here to view
Aspirin at low dose (100-300 mg) once daily and atorvastatin 40 mg once daily was the most frequent regimen prescribed for the management of ischemic stroke patients (44.8%), followed by (low dose aspirin + atorvastatin 40 mg + Enoxaparin 40 mg) once daily [Table 5]. 74.1% of participants were discharged, whereas 25.9% were died [Figure 1]. Importantly, there was no significant relationship between prescribed regimens for the management of patients and outcomes (P = 0.329).
|Table 5: Association between prescribed regimen and fade of the participant (n=116)|
Click here to view
| Discussion|| |
This study attempted to investigate the risk common factors and management of ischemic stroke at Ibrahim Malik Teaching Hospital. According to the findings of this study, ischemic stroke is more frequent in males (59.5%) than females. This finding is in concordance with Forster. A., et al. study which revealed that slight gender difference in acute ischemic stroke due to difference in etiology and risk factors profiles. The frequency of the disease is moderately higher for older patients (>65 years old), in line with Rojas et al. findings who noted that stroke rates doubling every decade after the age of 55 years which mainly due to increased thromboembolic risk factors and comorbidities. The study also showed a higher distribution of the disease in rural areas than urban ones, this may be due to differences in lifestyle, diet, and nutrition.
Regarding the lifestyle of the participants revealed that only (10.3%) of the patients were smokers which indicates a weak association between smoking and ischemic stroke in contrast to a meta-analysis review conducted to analyze the relation between cigarette smoking and stroke. This may be attributed to the limited sample size in the current study. Furthermore, the study revealed weak association between previous ischemic stroke history and the disease, only (5.2%) of participants had a family history of ischemic stroke. Our finding is contradictory to a previous study conducted in the United States and included a total of 1886 participants. This difference may be due to the differences in the study population size and genetic variables. Unfortunately, in this study, there was not sufficient data documented in the medical records about physical activity and obesity and other possible risk factors. Investigation of the past medical history of the participants revealed that hypertension was the most common history. This finding is in agreement with Benjamin et al. heart disease and stroke statistics 2018 update. It is well-known that controlling blood pressure decreases the risk of ischemic stroke.
From medication point of view, this study utilized Medscape drug interaction checker to detect different categories of inappropriate practice in the utilization and monitoring of drugs. Medscape is a trusted website from the WebMD Health Professional Network. The most frequent type of drug-drug interactions was “monitor closely” (41.4%), followed by serious type of interaction checked between concomitant drugs used (33.6%). In serious type of drug-drug interaction, the use of the alternative drug is recommended. The detected irrational use of drugs in this study indicates deficiencies in utilization practices at Ibrahim Malik Teaching Hospital, where the study was conducted and maybe in the other hospitals in Sudan. Therefore, this high frequency of drug-drug interactions enforces the need for drug utilization risk prevention measures. Also, further studies are needed to detect drugs involved in drug-drug interaction between medications used for ischemic stroke or between ischemic stroke medications and drugs for co-morbid conditions.
Regarding adherence to guidelines, the followed thrombolytic therapy for the early management of acute ischemic stroke is not in line with American Heart Association/American Stroke Association (AHA/ASA) guidelines, which state that intravenous Alteplase (0.9 mg/kg, maximum dose 90 mg over 60 min with initial 10% of the dose given as a bolus over 1 min) should be used for patients who may be treated within 3 hours of symptoms onset unless the patient is not eligible for Alteplase therapy. Nonadherence to this guideline can be attributed to the nonavailability of intravenous Alteplase in Sudan, and the late diagnosis with brain imaging to exclude the existence of any intracranial hemorrhage, so all regimens prescribed used for the prevention of recurrent attack. In the current study, the regimen of aspirin low dose (100–300 mg) plus atorvastatin 40 mg once daily was the most frequently used regimen for the secondary prevention of ischemic stroke which is in line with international randomized stroke trial which highly recommended aspirin over anticoagulants due to its safety and efficacy, also a systematic review conducted by Manktelow and Potter reported the beneficial value of high dose of atorvastatin after ischemic stroke. Unfortunately, all the remaining prescribed regimens used for the secondary prevention except for the regimen of atorvastatin plus aspirin are nonadherent to AHA/ASA guidelines neither regarding the use of anticoagulant (low-molecular-weight heparins and unfractionated heparin) nor regarding use of a combination of clopidogrel and aspirin. For anticoagulant use, AHA/ASA states that urgent anticoagulation, to prevent early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke, is not recommended for treatment of patients with acute ischemic stroke. Furthermore, the benefit of prophylactic-dose of subcutaneous heparin in immobile patients with acute ischemic stroke is not well established for deep-venous thrombosis prophylaxis in ischemic stroke patients. For the use of a combination of aspirin and clopidogrel, AHA/ASA states that combination use must be restricted for secondary prevention after transient ischemic attack.
In terms of outcome, in the current study, out of 116 participants, 86 (74.1%) were discharged, this finding is in line with Xu et al., 2016 study. Moreover, in concordance with Seshadri et al., 2006 study findings, a statistically significant relationship (P = 0.044) was found gender and outcome, in both studies, a higher percentage of death was observed among female participants. The death rate was also significantly associated with age (P = 0.034). However, there was a nonsignificant relationship between different prescribed regimens for the management and fate of the participant.
| Conclusions|| |
The major risk factors with ischemic stroke are the past medical history of hypertension and the elderly age. Aspirin plus statin therapy was the most frequently used regimen (44.8%) with nonadherence to guidelines, especially regarding the use of thrombolytic therapy and anticoagulants. Besides, “monitor closely” type and serious type drug-drug interactions among prescribed medications were around 41.40% and 33.6%, respectively. While 74.1% of participants were discharged, the fate of the participates was significantly associated with the gender and age of the participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Patel RA, White CJ. Acute ischemic stroke treatment: State of the art. Vasc Med 2010;1619-28.
French BR, Boddepalli RS, Govindarajan R. Acute ischemic stroke: Current status and future directions. Mo Med 2016;113:480-6.
Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al.
An updated definition of stroke for the 21st
century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:2064-89.
Ntaios G. Embolic stroke of undetermined source: JACC review topic of the week. J Am Coll Cardiol 2020;75:333-40.
Musuka TD, Wilton SB, Traboulsi M, Hill MD. Diagnosis and management of acute ischemic stroke: Speed is critical. CMAJ 2015;187:887-93.
Adams HP Jr., del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al.
Guidelines for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation 2007;115:181486.
Broussalis E, Killer M, McCoy M, Harrer A, Trinka E, Kraus J. Current therapies in ischemic stroke. Part A. Recent developments in acute stroke treatment and in stroke prevention. Drug Discov Today 2012;17:296-309.
Ojaghihaghighi S, Vahdati SS, Mikaeilpour A, Ramouz A. Comparison of neurological clinical manifestation in patients with hemorrhagic and ischemic stroke. World J Emerg Med 2017;8:34-8.
Schwamm LH, Ali SF, Reeves MJ, Smith EE, Saver JL, Messe S, et al.
Temporal trends in patient characteristics and treatment with intravenous thrombolysis among acute ischemic stroke patients at Get With The Guidelines-Stroke hospitals. Circ Cardiovasc Qual Outcomes 2013;6:543-9.
Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al.
Guidelines for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-711.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al.
2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018;49:e46-99.
Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, et al.
Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013;369:11-9.
Manktelow BN, Potter JF. Interventions in the management of serum lipids for preventing stroke recurrence. Cochrane Database Syst Rev 2009; 2009(3):CD00209.
Amarenco P, Bogousslavsky J, Callahan A 3rd
, Goldstein LB, Hennerici M, Rudolph AE, et al.
High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006;355:549-59.
Förster A, Gass A, Kern R, Wolf ME, Ottomeyer C, Zohsel K, et al.
Gender differences in acute ischemic stroke: Etiology, stroke patterns and response to thrombolysis. Stroke 2009;40:2428-32.
Rojas JI, Zurrú MC, Romano M, Patrucco L, Cristiano E. Acute ischemic stroke and transient ischemic attack in the very old--risk factor profile and stroke subtype between patients older than 80 years and patients aged less than 80 years. Eur J Neurol 2007;14:895-9.
Shinton R, Beevers G. Meta-analysis of relation between cigarette smoking and stroke. BMJ 1989;298:789-94.
Fox CS, Polak JF, Chazaro I, Cupples A, Wolf PA, D'Agostino RA, et al.
Genetic and environmental contributions to atherosclerosis phenotypes in men and women: Heritability of carotid intima-media thickness in the Framingham heart study. Stroke 2003;34:397-401.
Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al.
Heart disease and stroke statistics-2018 update: A report from the American Heart Association. Circulation 2018;137:e67-492.
O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al
. Risk factors for ischaemic and intracerebral hemorrhagic stroke in 22 countries (the interstroke study): A case-control study. Lancet 2010;376:112-23.
Group IS. The International Stroke Trial (IST): A randomized trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997;349:1569-81.
Whiteley WN, Adams HP Jr., Bath PM, Berge E, Sandset PM, Dennis M, et al.
Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: An individual patient data meta-analysis of randomised controlled trials. Lancet Neurol 2013;12:539-45.
Dennis M, Sandercock P, Graham C, Forbes J; CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration, Smith J. The clots in legs or stockings after stroke (CLOTS) 3 trial: A randomised controlled trial to determine whether or not intermittent pneumatic compression reduces the risk of post-stroke deep vein thrombosis and to estimate its cost-effectiveness. Health Technol Assess 2015;19:1-90.
Xu J, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS Data Brief 2016;(267):1-8.
Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Au R, Kannel WB, et al.
The lifetime risk of stroke: Estimates from the Framingham Study. Stroke 2006;37:345-50.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]