Abstract 4371406: Missed Opportunities for Stroke Prevention in Hypertensive Patients: A Retrospective Case-Control Study

Abstract

Background: Hypertension, observed in 64% of patients presenting with stroke, is a well-established risk factor for stroke-related mortality, with elevated systolic blood pressure (BP) playing a particularly significant role. Research Questions: To what extent are missed opportunities in outpatient hypertension management associated with increased risk of ischemic stroke? Methods: We conducted a retrospective case-control study within a longitudinal cohort of hypertensive patients using electronic health records from Sentara Health. First-ever ischemic stroke cases were matched 1:4 to hypertensive controls without stroke by age, sex, race, ethnicity, and onset date of hypertension (T0). Follow-up spanned from T0 to first stroke admission (T1) or a matched outpatient visit (pseudo-T1) for controls. We evaluated the following metrics in follow-up periods: (1) total number of outpatient visits with BP recorded; (2) the total number of antihypertensive prescriptions received; and (3) the percentage of outpatient visits with antihypertensive drug adjustment (change in antihypertensive drug class). Group differences were tested using t-tests and chi-square tests. Adjusted odds ratios (aORs) for stroke were estimated using conditional multivariable logistic regression controlling for demographics and comorbidities. Results: The study included 10,825 stroke cases and 37,195 matched controls. Among the total 48,020 individuals, 26,201 (54.6%) were women. The mean (SD) age was 64.3 (12.8) years, and the mean (SD) follow-up duration (T1–T0) was 5.4 (3.6) years. Compared with controls, stroke cases had fewer total outpatient visits (mean: 16.2 vs. 18.1; p < 0.001), fewer total antihypertensive prescriptions received (3.6 vs. 4.4; p < 0.001), and lower rate of medication adjustments (16.8% vs. 19.4%; p < 0.001). The adjusted conditional logistic regression showed that more outpatient visits (aOR = 0.991; 95% CI: 0.990–0.992), antihypertensive prescriptions (aOR = 0.995; 95% CI: 0.985–0.999), and higher medication adjustment percentage (aOR = 0.993; 95% CI: 0.991–0.994) were all significantly associated with reduced odds of stroke. Conclusion: Missed opportunities in hypertension management including lack of follow-up, underuse and infrequent adjustment of antihypertensive therapy, which are associated with higher stroke risk. Interventions targeting more aggressive medication prescribing and adjustment practices may reduce the burden of stroke among hypertensive patients.