Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program

Background: Despite the proven effectiveness of antithrombotic therapy for atrial fibrillation (AF), the treatment remains suboptimal. The aim of this study was to implement and evaluate a system to improve the appropriate use of antithrombotics for stroke prevention in AF utilizing a clinical pharmacist as a stroke risk assessor. Method: Hospital in‐patients with AF were prospectively identified and they received a formal stroke risk assessment from a pharmacist. The patients’ risk of stroke was assessed and documented according to Australian guidelines and a recommendation regarding antithrombotic therapy was made to the medical team on a specially designed stroke risk assessment form. Results: One hundred and thirty‐four stroke risk assessments were performed during the intervention period. For those patients at high risk of stroke and with no contraindication present (warfarin‐eligible patients), 98% were receiving warfarin on discharge from hospital compared to 74% on admission (P < 0·001). Of the 50 (37%) assessments that recommended a change of therapy, 44 (88%) resulted in a change in the patient’s current antithrombotic therapy compared to their admission therapy. Thirty (68%) of the assessments resulted in an ‘upgrade’ to more‐effective treatment options for example from no therapy to any agent or from aspirin to warfarin. Discussion and Conclusion: The pharmacist‐led stroke risk assessment program resulted in a significant increase in the proportion of patients receiving appropriate thromboprophylaxis for stroke prevention in AF. The methods used in this study should be evaluated in a larger trial, in multiple hospitals, with different pharmacists performing the intervention.     

Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans

What is known and background: Unintended bleeds are a common complication of warfarin therapy. We aimed to determine the impact of general practitioner–pharmacist collaborative medication reviews in the practice setting on hospitalization‐associated bleeds in patients on warfarin. Method: We undertook a retrospective cohort study using administrative claims data for the ambulatory veteran and war widow population, Australia. Participants were veterans, war widows and their dependents aged 65 years and over dispensed warfarin. The exposed groups were those exposed to a general practitioner (GP)–pharmacist collaborative home medication review. The service includes GP referral, a home visit by an accredited pharmacist to identify medication‐related problems, a pharmacist report with follow‐up undertaken by the GP. The outcome measure was time to next hospitalization for bleeding. Results: There were 816 veterans exposed to a home medicines review and 16 320 unexposed patients, with an average age of 81·5 years, and six to seven co‐morbidities. Adjusted results showed a 79% reduction in likelihood of hospitalization for bleeding between 2 and 6 months (HR, 0·21 95% CI, 0·05–0·87) amongst those who had received a home medicines reviewed compared to the unexposed patients. No effect was seen in the time period from review to 2 months, nor in the time period 6 to 12 months post a review. What is new and conclusion: Medicines review in the practice setting delays time to next hospitalization for bleeding in those treated with warfarin in the period 2 to 6 months after the review, but is not sustained over time. Six monthly medication reviews may be required for patients on warfarin who are considered at high risk of bleeding.     

Hot off the Press: SGEM #226. I Want a New Drug—One That Doesn't Cause an Adverse Drug Event

Adverse drug events (ADEs) are a significant cause of emergency department (ED) visits in North America and are frequently misdiagnosed. Despite evidence supporting improved health care outcomes for ED patients who have a pharmacist‐led medication review, EDs do not have sufficient clinical pharmacists to perform medication reviews on all patients. The study reviewed in this article aimed to validate clinical decision rules for use by clinical pharmacists and physicians to prioritize ED patients with ADEs.     

Effectiveness of a community pharmacist intervention in diabetes care: a randomized controlled trial

What is known and Objective: There is little evidence from well‐designed randomized controlled trials of the impact of community pharmacist intervention on the clinical management of patients with type 2 diabetes. It is also not known how sustainable any observed effects on glycaemic control are, over time. This study was initiated to address both these issues. Methods: A 6‐month, randomized, controlled parallel‐group trial in 66 community pharmacies was conducted in Belgium. Patients were randomly assigned to receive usual pharmacist care (n = 135) or a predefined pharmacist intervention (n = 153). The intervention mainly focused on correct medication use, medication adherence and healthy lifestyle promotion. Primary outcome was glycaemic control, as measured by fasting plasma glucose and HbA1c. Sustainability of changes in glycaemic control was assessed by additional glucose measurements 18 months after the end of the study. Results and Discussion: The intervention significantly reduced HbA1c (between‐group difference: 0·5%, P = 0.009). The largest impact on HbA1c was observed when pharmacotherapy changes (i.e., type and/or dose of hypoglycaemic agents) initiated by the physician were sustained with pharmaceutical care: HbA1c was reduced by 1·05% in the intervention group, whose medication was changed, compared with a reduction of 0·02% in the therapy‐modification only, group. It was also found that the diabetes education program resulted in improved self‐management and better knowledge of diabetes. Eighteen months after the end of the formal study period, the mean HbA1c of the intervention group did not differ significantly from the control group (7·4% vs. 7·2%). What is new and Conclusion: This study provides new evidence, from a randomized controlled trial, of the beneficial effect of community pharmacist intervention in the clinical management of type 2 diabetic patients. However, questions remain about the sustainability of the observed improvements.     

The impact of medication therapy management in older oncology patients

Purpose

This project aimed to identify common drug-related problems (DRP) among elderly cancer patients, to determine the effectiveness of medication therapy management (MTM) service in resolving DRP, to determine the clinical significance of pharmacist interventions, and to determine patients’ satisfaction level of MTM service.

Method

Elderly cancer patients (age ≥65) who were at least on one chronic medication would be eligible for the MTM service. Any DRP that was detected would be recorded and steps to resolve it were taken. Pre- and post-service patient satisfaction surveys (PSS) were conducted before and after MTM. All interventions performed by MTM pharmacists were subjected to independent evaluation by a panel of three judges.

Results

One hundred eighteen patients received at least one session of MTM. We identified and attempted to resolve 361 DRPs, and the most common DRPs were drug interactions (117 cases, 32.4 %), adverse effects (114 cases, 31.6 %), and non-adherence (48 cases, 13.3 %). Forty-four interventions were performed by pharmacists and forty cases (91 %) were accepted by physicians. Almost two third of these interventions were deemed significant (or higher) by the judges. Seventy-two patients completed PSS. There was statistically significant improvement in patients’ satisfaction level after the service was provided.

Conclusion

MTM is an important platform in identifying and managing DRPs. Patients are generally satisfied with MTM services.     

Efficacy and safety of a pharmacist-managed inpatient anticoagulation service for warfarin initiation and titration

What is known and Objective: Anticoagulation consultations provided by a pharmacist‐staffed inpatient service, similar to the experience reported in outpatient anticoagulation clinics, can potentially improve anticoagulation control and outcomes. At Tan Tock Seng Hospital, a 1200‐bed acute care teaching hospital in Singapore, pharmacist‐managed anticoagulation clinics have been in place since 1997. Pharmacist‐managed services were extended to inpatient consultations in anticoagulation management from April 2006. Our objective was to assess the effect of implementing a pharmacist‐managed inpatient anticoagulation service. Methods: This was a single‐centre cohort study. Baseline data from 1 January 2006 to 31 March 2006 were collected and compared with post‐implementation data from 1 April 2006 to 31 March 2007. Patients newly started on warfarin for deep vein thrombosis, pulmonary embolism or atrial fibrillation in general medicine and surgery departments were included. The three endpoints were as follows: (i) percentage of international normalized ratios (INRs) achieving therapeutic range within 5 days, (ii) INRs more than 4 during titration and (iii) subtherapeutic INRs on discharge. Results and Discussion: A total of 26 patients in the control period were compared with 144 patients who had received dosing consultations by a pharmacist during the initiation of warfarin. The provision of pharmacist consult resulted in 88% compared to 38% (P < 0·001) of INR values achieving therapeutic range within 5 days. There was a reduction in INR values of more than 4 during titration from 27% to 2% (P < 0·001), and subtherapeutic INR values on discharge without low molecular weight heparin from 15% to 0% (P < 0·001). The mean time to therapeutic INR was reduced from 6·5 to 3·9 days (P < 0·001) and mean length of stay after initiation of warfarin from 11 to 7·7 days (P = 0·004). What is new and Conclusion: Inpatient anticoagulation care and outcomes were significantly improved by a pharmacist‐managed anticoagulation service. The time to therapeutic INR was achieved appropriately and efficiently without compromising patient’s safety.     

Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management

What is known and Objective: Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist‐initiated mailed and face‐to‐face interventions for patients whose asthma may not be well managed. Methods: Seventy‐one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data‐mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face‐to‐face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for ‘usual care’. Results and Discussion: A total of 1483 patients were identified and grouped as follows: 510 (34·4%) mailed intervention, 480 (32·4%) face‐to‐face intervention and 493 (33·2%) controls. Significantly fewer face‐to‐face interventions were offered than mailed interventions (66·6% vs. 89·4%, respectively; χ² = 64·2, P < 0·0001). There were significant improvements in the preventer‐to‐reliever ratio after the intervention period (P < 0·0001) in each group. In a per‐protocol analysis, the magnitude of improvement in the face‐to‐face intervention group was greater than in the mailed intervention group. The reverse was true in an intention‐to‐treat analysis. The improvement in the P : R ratios was mainly due to significant decreases in reliever usage. What is new and Conclusion: Community pharmacy dispensing records can effectively identify patients with suboptimal asthma management, who can then be referred to their GP for review. Time constraints in busy pharmacies may limit the uptake and effectiveness of face‐to‐face interventions in the ‘real world’ setting, making mailed interventions an attractive option.     

The contribution of patient interviews to the identification of drug‐related problems in home medication review

What is known and Objective: To determine to what extent patient interviews contribute to the identification of drug‐related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance. Methods: We performed a cross‐sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home‐dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers’ panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change. Results: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty‐eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1·8 [1·4–2·2]), were more frequently associated with recommendations for drug change (OR = 2·4 [1·9–3·1]) and were implemented recommendations for drug change (OR = 2·8 [2·1–3·7]). What is new and Conclusion: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance.     

Validation of a method for recording pharmaceutical interventions

What is known and objective: The validation of a method for recording pharmaceutical interventions measures the instrument’s ability to provide consistent values when the same analysis is performed several times. Our aim was to validate the inter‐rater reliability of the method used to record pharmaceutical interventions in our hospital. Methods: We recorded interventions in a database, entering variables related to the patient, treatment and impact of the recommendation. We also recorded the type, cause and clinical significance of the negative outcome associated with use of the medicinal product (NOM). Twenty interventions performed during a 3‐year study period (2007–2009) were randomly tested for consistency to analyse the kappa (κ) coefficient statistic of the recommendations as coded by nine senior and junior clinical pharmacists. Results and discussion: There were 87·8% global consistency for NOM cause, 66·1% for intervention impact and 95·0% for NOM type. Agreement was substantial for ‘intervention reasons’, with a κ value of 0·74 (95%CI 0·61–0·87), fair for ‘intervention impact’, with a κ value of 0·24 (95%CI 0·15–0·32) and excellent for ‘NOM type’, with a κ value of 0·87 (95%CI 0·71–1·00), respectively. Our results are globally good, especially with regard to the analysis of intervention reasons and NOM type, which matches other authors’ findings. Furthermore, our validation method is suitable for recording and considering the impact of pharmaceutical interventions. What is new and conclusion: We describe a systematic method for clinical pharmacists to record their activities and assess their value. This methodology should help in the development of clinical pharmacy in Spain and should be translatable to other settings.     

Management of mineral and bone disorders in patients on dialysis: a team approach to improving outcomes

Most patients with mineral and bone disorders do not simultaneously achieve KDOQI target goals for parathyroid hormone, calcium, phosphorus, and the calcium-phosphorus product. A multidisciplinary team composed of the patient, nephrologists, nephrology nurses, renal dietitians, social workers, patient care technicians, clinical pharmacists, and physical therapists can help improve the coordination of care for mineral and bone disorders. The roles of team members are reviewed, with emphasis on nephrology nurses.     

Sleep health awareness in pharmacy undergraduates and practising community pharmacists

Background and objectives: Pharmacists are in an optimal position to provide health care to patients with sleep disorders, however, at present their involvement in sleep services is limited. This study aimed to (i) establish an understanding of baseline levels of sleep health awareness, and attitudes towards sleep health in pharmacists and pharmacy undergraduate students in comparison with sleep physicians and (ii) collate the expressed preferences for sleep health training by final year pharmacy undergraduate students and practising community pharmacists. Methods: Two previously validated instruments, the Dartmouth sleep knowledge survey and the ASKME (attitudes section) were used to construct a self‐report style questionnaire. Data from respondents were collated and analysed to evaluate differences in responses and test scores between the groups, using the statistical software package‐spss 14·0. Results and discussion: Responses from 14 specialized sleep pharmacists, 14 general community pharmacists, 134 final‐year undergraduate pharmacy students and 26 sleep physicians were obtained. The mean knowledge score per cent (35·5 ± 14·0% for students, 48·2 ± 19·5% for general and 50·6 ± 16·6% for specialized sleep pharmacists, 86·7 ± 9·3% for sleep physicians) and attitudes scores (37·3 ± 4·0 for students, 37·2 ± 5·4 for general and 40·3 ± 5·3 for sleep specialist pharmacists, 42·6 ± 4·7 for sleep physicians, expressed as a score out of 50) were significantly different between groups (Kruskal–Wallis test, P < 0·001). All groups reported slightly different preferences for future training formats and topics. There is a need to improve practising pharmacists’ as well as undergraduate students’ knowledge of sleep health. The positive attitude reported by the respondents indicates a high level of interest in acquiring knowledge and suggests that a tailored educational programme would be well received and timely. Conclusion: These results provide a valid indication of the pharmacy profession’s expressed and actual training needs, and should be used to inform the design, implementation and evaluation of a sleep health educational strategy, which targets practising community pharmacists and students.     

Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all‐cause emergency department revisits

What is known and objective: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug‐related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post‐discharge hospital revisits or death. Methods: This prospective, controlled study included all patients hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n = 1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n = 2758) attended the wards before implementation of the intervention. Results and Discussion: No impact of medication reconciliation and reviews on ED revisits [hazard ratio (HR), 0·95; 95% confidence interval (CI), 0·86–1·04]or event‐free survival (HR, 0·96; 95% CI, 0·88–1·04) was demonstrated. In the intervention group, 594 patients (48·8%) visited the ED, compared with 1416 (51·3%) control patients. In total, 716 intervention (58·9%) and 1688 (61·2%) control patients experienced any event (ED visit, hospitalization or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (P < 0·05), we re‐examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (P = 0·608). What is new and conclusion: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, re‐hospitalizations or mortality over 6‐month follow‐up.     

Clinical impact of a pharmacist–physician co-managed programme on hyperlipidaemia management in Hong Kong

Objective: The study aimed to investigate the clinical impact of pharmacist–physician co‐managed programme on the management of hyperlipidaemia. Methods: The study was a prospective randomized controlled trial. Adult patients were selected if: (i) they were taking one or more lipid‐lowering agents with a valid lipid panel before their next follow up; (ii) had a baseline lipid profile within the previous 6 months; (iii) their lipid panel did not reach the targeted low‐density lipoprotein‐cholesterol (LDL‐C) goal based on the National Cholesterol Education Programme Adult Treatment Panel III. Pharmacists interviewed patients in the intervention group for 15–30 min to provide consultation on the drug regimen and lifestyle modifications. A telephone follow‐up every 4 weeks and a follow‐up interview on the date of the physician visit were scheduled. Patients in the control group received routine conventional care. The primary outcome measurement was the change in lipid panel between baseline and at the end of study. Results: One hundred and eighteen patients were recruited to the study [58 patients in intervention group (mean age 63 ± 10 years old) and 60 in control group (mean age 61 ± 12 years old)]. Starting with similar baseline levels, the end of study LDL‐C and total cholesterol levels for the intervention and control groups were LDL‐C: 2·80 ± 0·89 mmol/L and total cholesterol 4·75 ± 1·08 mmol/L vs. LDL‐C: 3·24 ± 0·78 mmol/L and total cholesterol 5·18 ± 0·93 mmol/L, respectively. The differences were statistically significant (P < 0·0015). Conclusion: The study showed that a pharmacist–physician co‐managed programme for hyperlipidaemic patient was effective in getting more patients to reach their target lipid levels.     

Societal perceptions of community pharmaceutical services in Malta

Objective: To assess the views of the Maltese general public on services provided by community pharmacies in Malta and their opinions on the proposed extended role for pharmacies Method: An interviewer-administered structured questionnaire was used to interview 912 members of the public (395 males, 517 females) Results: The majority of respondents (70·8%) visited a pharmacy at least once a month, with females visiting more frequently than males ( P< 0·01). Almost 31% stated that the main reason for visiting a pharmacy was to purchase prescribed medication, while 23·3% said that it was to obtain over-the-counter products. Women were more likely than men to be influenced by the pharmacist's advice when selecting an over-the-counter product ( P< 0·05). The majority of respondents (62·8%) said that they usually bought their medicines from the same pharmacy and loyalty to a particular pharmacy increased with age. When treating minor ailments, respondents were more likely to consult their doctor or self-treat rather than seek advice from the pharmacist. The proposed extended role of the community pharmacist found support with the public, e.g. 90·2% felt that the pharmacist should promote health education, with the preferred method suggested being through individual advice; 85·7% were in favour of screening and monitoring services and 85·6% felt that the keeping of patient medication records would be useful. Almost three-quarters (74·6%) of respondents said that they would be willing to participate in pharmaceutical care programmes. When asked to suggest new activities for community pharmacy, respondents were most in favour of the pharmacist offering more advice on the treatment of minor ailments Conclusion: Overall, the results obtained are encouraging and Maltese pharmacists should plan to provide new services to the community in the future     

High risk of cross-reactivity between vancomycin and sequential teicoplanin therapy

What is known and Objective: Teicoplanin and vancomycin show similar clinical and bacteriological efficacy in clinical trials. Teicoplanin has been reported to have a lower adverse drug reaction (ADR) rate than vancomycin. Cross‐reactivity between these two glycopeptides is controversial. Our aim was to study the cross‐reactivity between teicoplanin and vancomycin through an assessment of all the reported ADRs of these drugs in our University hospital. Methods: Over a period of 2 years, 170 cases of vancomycin therapy, which were closely monitored by doctors and clinical pharmacists, were used to analyse ADRs. Teicoplanin therapy was used as an alternative in cases of vancomycin intolerance. When an ADR related to vancomycin or teicoplanin was suspected, specialists were consulted to confirm if these were true ADR and to determine whether the implicated drug should be stopped. All ADRs for the two glycopeptides were assessed for causality using the Naranjo probability scale. Results and Discussion: Thirty‐eight of 170 patients (22·4%) treated with vancomycin developed ADRs. Twenty‐four patients were switched to teicoplanin. However, 14 of those 24 patients (58·3%) developed ADRs. The time of onset of ADRs involving vancomycin was 12·7 ± 10·9 days (range, 1–46 days). The time of onset of sequential teicoplanin‐induced ADRs was 11·7 ± 4·7 days (range, 2–20 days). Of the 14 patients with ADRs related to sequential teicoplanin therapy, six showed cross‐reactivity between vancomycin and teicoplanin. The incidence of vancomycin‐induced neutropenia was 4·7% (8/170), whereas the incidence of teicoplanin‐induced neutropenia subsequent to vancomycin intolerance was as high as 33·3% (8/24). Furthermore, 71·4% (10/14) of the teicoplanin‐induced ADRs were associated with haematological abnormalities such as neutropenia, thrombocytopenia or leucopenia. What is new and Conclusion: Teicoplanin, used as an alternative in cases of vancomycin intolerance, was associated with a high incidence of ADRs and haematological reactions, most notably neutropenia. This high rate of ADRs suggests cross‐reactivity between the two glycopeptides.     

Comparison of SSRIs and SNRIs in major depressive disorder: a meta‐analysis of head‐to‐head randomized clinical trials

Context: Controversy exists whether serotonin–norepinephrine reuptake inhibitors (SNRIs) have improved efficacy compared with selective serotonin reuptake inhibitors (SSRIs). Objective: To compare clinical outcomes of adults treated with SSRIs or SNRIs for major depressive disorder (MDD) under ideal clinical condition, research design, and outcome measure. Data sources: Electronic databases searched were Medline, Embase and Cochrane Library from inception to July 2007. Study selection: Included studies were those head‐to‐head randomized trials comparing remission (HAMD‐17 ≤7–8, MADRS ≤10–12) after 8–12 weeks of therapeutic doses of SSRIs or SNRIs in patients diagnosed with MDD were targeted for analysis. Reviews, letters, commentaries, economic studies, etc. were excluded. Studies were reviewed by two independent researchers. Where disagreements occurred in study selection, a consensus approach was used. Data extraction and analysis: Targeted outcome data included number of patients achieving remission, withdrawing from therapy due to lack of efficacy (LoE) and/or adverse drug reactions (ADRs), and total patients in trial. A random effects model combined intent‐to‐treat (ITT) and per‐protocol (PP) odds ratio (OR), and remission and dropout rates. Chi‐square assessed heterogeneity. Quality assessment was done using Downs‐Black checklist. Results: Thirty‐three studies were identified; 18 were rejected (patients had co‐morbidities in 7, outcomes differed in 5, different follow‐up in 3, and three reviews). Fifteen head‐to‐head trials of 3094 patients, average age was 41·9 ± 11·9 years (for SNRIs) and 41·6 ± 12·1 years (for SSRIs), P = 0·941. All analyses displayed non‐heterogeneity (P > 0·05). The OR (under ITT) was 1·27 (1·06–1·52 95% CI) favoring SNRIs. Meta‐analytic remission rates were 48·5 ± 3·2% and 41·9 ± 4·2% for SNRIs and SSRIs, respectively. The meta‐analytic difference in remission rates between drugs was 5·7% (P = 0·007). Dropout rates due to ADRs were higher with SNRIs than SSRIs (3·2% difference, P < 0·001). Dropout rates due to LoE were non‐significant between studied groups (P > 0·05). Conclusions: Serotonin and norepinephrine reuptake inhibitors showed statistical but not clinical significance when compared with SSRIs in treating MDD.     

Statins after recent stroke reduces recurrence and improves survival in an aging Mediterranean population without known coronary heart disease

What is known and Objective: The effect of a statin‐based medical intervention on prevention of fatal and non‐fatal stroke recurrence and the incidence of all‐causes mortality have been explored previously in aging populations within the scope of clinical trials research. However, such evidence needs to be explored under conditions of routine clinical practice. The objective of this study was to determine whether statin therapy in patients with a first stroke episode reduces the incidence of 6‐year recurrent fatal or non‐fatal stroke and all‐cause mortality in an aging Mediterranean population without known coronary heart disease followed in routine medical practice. Methods: A retrospective study was carried out using records on death, hospitalizations owing to stroke and history of statin therapy included in the Badalona Serveis Assistencials (BSA) database. The cohort studied consisted of consecutive patients covered by the BSA health provider plan with a first‐ever acute stroke episode during January 2003 until December 2008, for whom there was available information covering the 6‐year follow‐up period. Recurrence rate (RR) and incidence rate (IR) of fatal/non‐fatal stroke and all‐causes mortality were computed. Association with statin therapy was assessed by means of calculation of relative risk (RR) and hazard ratio (HR) using multivariate logistic regression and Cox proportional hazards models controlling for confounding covariates. Results and Discussion: The cohort comprised a series of 601 consecutive patients [57% men, 75·9 (12·4) years old (88% >60 years)]. Of these, 32% received statins, which were associated with lower fatal/non‐fatal recurrent stroke RR; 7% vs. 18% [adjusted RR = 0·32 (CI: 0·16–0·61), P = 0·001] and lower IR; 16·78 vs. 45·22 events/year‐1000 subjects [adjusted HR = 0·35 (0·19–0·64), P = 0·001]. Similarly, observed all‐causes mortality was lower in the cohort receiving statins; 11% vs. 16% [adjusted RR = 0·29 (CI: 0·08–1·12), P = 0·072], and also mortality rate; 26·09 vs. 36·25 deaths/year‐1000 subjects [adjusted HR = 0·23 (0·08–0·67), P = 0·007]. What is new and Conclusions:  Statin therapy in patients with first‐ever acute stroke lowers the risk of 6‐year stroke recurrence and improves survival in an aging Mediterranean cohort. These results add additional evidence in routine clinical practice to the observed effects of statins in clinical trials.