Stroke, statins and depression.

Too busy to read the journals? Let Dr Louise Newson keep you up to date with the latest research

Older patients denied treatment after a stroke BMJ 2009; 338: b1,279

There is plenty of evidence to demonstrate the effectiveness of medication for the secondary prevention of stroke, even in the elderly population.

Secondary prevention of stroke is poor and more attention needs to be paid to appropriate medication

The risk of a recurrent stroke has been quoted to be as high as 30 per cent in some trials.

This UK study analysed data for nearly 13,000 patients aged over 50 who had experienced a stroke over a 10-year period, to determine the extent to which secondary drug prevention in routine primary care varies by sex, age, and socioeconomic circumstances.

The results were disappointing. The rate of secondary prevention for all patients was surprisingly low - only a quarter of men and a fifth of women received treatment following their stroke.

Older patients were less likely to receive treatment, but receipt of secondary prevention did not vary according to socio-economic circumstance or sex.

On average, mortality within the first year was 5.7 per cent for patients receiving treatment compared with 11.1 per cent for those not receiving treatment.

We need to be aware of our stroke patients' medication when they are first discharged to ensure they have been given optimal medication for secondary prevention of stroke.

Higher rate of hypertension in ex-prisoners Arch Intern Med 2009; 169: 687-93
The Coronary Artery Risk Development in Young Adults study examined the association between prior imprisonment and incident hypertension, diabetes and dyslipidemia in patients under 30 years old.

This was a longitudinal study of more than 4,000 young adults who were followed up at intervals for up to 15 years.

The results showed that incident hypertension was more common among previously imprisoned participants; 12 per cent versus 7 per cent of those not incarcerated. This association was independent of age, gender, race and drug and alcohol use.

Those who were black and least educated had the strongest association between prior imprisonment and hypertension. Interestingly, this was the subgroup most likely to be lost to follow up.

Former inmates were also more likely than others to report having no regular source of medical care and also lack of treatment for hypertension at the seven-year follow up and at all subsequent follow-up examinations.

It may be that cardiovascular risk factors are assessed and treated more aggressively in those with a previous prison sentence.

Statins are very effective at reducing risk of stroke Lancet Neurology 2009; 8: 453-63
Although there are many studies demonstrating the effectiveness of statins for the prevention of coronary heart disease, there are few regarding the effectiveness of statins in lowering stroke risk.

This French meta-analysis of the use of statins for secondary prevention of stroke is therefore very interesting.

Although there were only 24 studies used in the analysis, their results showed that for every 1mmol/l reduction in LDL-cholesterol there was a relative risk reduction of stroke of an impressive 21 per cent. Even in secondary prevention of non-cardioembolic stroke, intense reduction of LDL cholesterol by statins significantly reduced the risk of recurrent stroke.

There was no evidence that statin use increased the risk of haemorrhagic stroke, except in patients with prior haemorrhage. Statins are still only considered for prevention of atherothrombotic events.

Postnatal depression and post-traumatic stress BJOG 2009: 116; 672-80
Postnatal depression is very common and unfortunately is still underdiagnosed and undertreated.

There are many risk factors for postnatal depression, including previous history of depression, low social support and obstetric complications.

This Swedish prospective longitudinal study was performed to find risk factors in pregnancy for both post-traumatic stress and depression one month after childbirth.

The relationship between post-traumatic stress and depression was also explored.

In this study, only 1.3 per cent of women had post-traumatic stress and 5.6 per cent had depression. These two conditions were positively related.

The main predictive risk factors for both conditions were depression in early pregnancy and severe fear of childbirth.

The authors suggest that risk factors for post-traumatic stress and depression after childbirth should be assessed, ideally in early pregnancy.

Migraine in recurrent depression Br J Psychiatry 2009: 194; 350-4
There is a clear, established association between depression and headache. However, an association with migraine is still unclear.

This UK study compared patients with recurrent depression with psychiatrically healthy controls to investigate headache, defined according to International Headache Society criteria.

Unsurprisingly, there was a higher rate of all headache types in the depression group compared with controls.

However, the strongest association was between depression and migraine with aura.

Among participants with recurrent headaches, migraine with aura was significantly associated with depression.

The authors conclude that the association is likely to be explained by overlapping aetiological risk factors.

  • Dr Newson is a GP in the West Midlands and a member of our team who regularly review the journals

The quick study

  • Stroke secondary prevention is suboptimal, especially in the elderly.
  • Hypertension is common in former prison inmates.
  • Statins lower stroke risk by about a fifth.
  • Postnatal depression risk factors should be assessed for in early pregnancy.
  • Recurrent depression and migraine are associated.

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