‘More is better’ for medical management of acute stroke

By Eleanor McDermid, Senior medwireNews Reporter

The outcomes of stroke patients assigned to receive medical therapy in the SAMMPRIS trial were significantly influenced by the experience of the centre in which they were treated, research shows.

Among the 227 patients who received aggressive medical management, 9.8% of those treated at a site that recruited fewer than 12 patients had recurrent stroke or died within 30 days, compared with just 1.8% of those treated at a site that was able to enrol at least 12 patients and therefore had more experience of treating stroke.

The difference was sustained at 2 years, with rates of 20.9% versus 7.3%, report David Chiu (Weill Cornell Medical College, Texas, USA) and co-researchers. And the difference remained when patient enrolment volumes were assessed as three categories or as a continuous variable.

“The current study raises important points that have not received adequate attention despite how intuitive they seem”, write Thomas Jeerakathil (University of Alberta, Edmonton, Canada) and Lars Marquardt (Asklepios Klinik Wandsbek, Hamburg, Germany) in an accompanying editorial.

“If quantity is associated with quality for medical management, then we would be wise to adjust our approach to acknowledge that ‘more is better’ even outside of the operating room or interventional suite.”

The researchers attribute the difference in outcomes to more successful control of risk factors at the high-enrolling centres. For example, patients’ average blood pressure during follow-up was lower at the high-enrolling than the low-enrolling centres, at 131.4 versus 135.2 mmHg, despite patients at the high-enrolling centres having higher baseline blood pressure, at 148.1 versus 146.2 mmHg.

Likewise, 68% of patients at the high-enrolling centres achieved their low-density lipoprotein cholesterol targets, compared with 48% of those at the low-enrolling centres, with average levels at 65.3 versus 74.8 mg/dL.

Jeerakathil and Marquardt note that this relatively modest absolute difference in risk factor control appeared to result in a “substantial” difference in stroke risk.

“The extent of risk reduction may seem implausible, but early aggressive risk factor control in [transient ischaemic attack] patients has a similar magnitude reduction in stroke recurrence”, they say, also noting the possible existence of a threshold effect.

Outcomes of the 213 patients assigned to undergo percutaneous transluminal angioplasty and stenting were not affected by whether they were treated at a low- or high-volume site. However, the SAMMPRIS trial was halted early because of increased stroke and mortality rates among patients in the intervention group.

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