The Research Question Aims Stroke is a leading cause of death and disability Primary stroke prevention is suboptimal Aims Calculate the proportion of strokes/TIAs with prior missed opportunities for prevention Determine if the proportion of missed opportunities has changed over time Investigate the association with patient or demographic characteristics Incidence of stroke worldwide is 17 million and it is a leading cause of death and disability worldwide. Modifiable risk factors can be targeted through stroke prevention drugs; however, prescribing is likely to be suboptimal.

What the Researchers Did Retrospective analysis of anonymised, electronic UK primary care records Population First-stroke/TIA ≥18 years 2009-2013 Outcomes Anticoagulant, Antihypertensive or Lipid Lowering drugs NOT prescribed when clinically indicated Analysis % of patients with missed prevention opportunities Logistic regression Used anonymised electronic primary care records from over 500 general practices in the UK. The study population comprised people who had a first stroke or TIA between 2009 and 2013. The outcomes were missed opportunities: People eligible for a stroke prevention drug but not prescribed them. Analysis calculated the proportion of strokes and TIAs with prior missed opportunities over; looked if this had changed between 2009 and 2010 and used logistic regression to determine patient and demographic characteristics which were predictive of having a missed opportunity for prevention.

What the Researchers Found % Missed opportunities: Any prevention drug: 54% (9,579/17,680) Anticoagulants: 52% (1,647/3,194) Lipid lowering drugs: 49% (7,836/16,028) Antihypertensives: 25% (1,740/7,008) Change over time (2009-2013) Only anticoagulant drug prescribing improved Predictive patient/ demographic characteristics Different profile for each drug Over half of people who had a stroke/TIA and had been eligible for one or more stroke prevention drug were not prescribed them. Half of people who were eligible for anticoagulant and lipid lowering drugs were not prescribed them. A quarter of people eligible for antihypertensive drugs were not prescribed them. Only anticoagulant prescribing improved over time. Different patient and demographic characteristics were predictive of non prescribing for each drug. For example, females were less likely to be prescribed anticoagulant drugs compared to males but more likely to be prescribed antihypertensive drugs; however, there was no sex effect for lipid lowering drugs.

What This Means for Clinical Practice Primary stroke prevention is inadequate • Ageing population • Guideline changes • Legal considerations Barriers to prescribing Patient GP Organisational Primary stroke prevention is inadequate. This is important because the population is ageing- older age is the most important non-modifiable risk factor for stroke; updated guidelines make more people eligible for prevention drugs so missed opportunities will be larger; patients with missed opportunities could take medicolegal action. Prescribing is complex and there are multiple barriers which need to be addressed to improve primary stroke prevention.