Implementation gaps in secondary prevention between coronary and cerebrovascular disease: a multicenter real-world study

Background

High-intensity statins and antithrombotic therapy are Class I, Level A recommendations for secondary prevention in patients with established atherosclerotic cardiovascular disease according to ESC guidelines. Whether ther real- world implementation differs across vascular territories remains insufficiently characterized.

Methods

We conducted a prospective, multicenter registry across 30 cardiology centers in Argentina between April 2023 and October 2024. Among 2,937 patients hospitalized for cardiovascular conditions (emergency or elective), those classified as secondary prevention were included in this analysis. Secondary prevention was defined as prior coronary artery disease (CAD), including acute coronary syndrome, percutaneous coronary intervention, or coronary artery bypass grafting, or prior cerebrovascular disease, including ischemic stroke, transient ischemic attack, or carotid revascularization.

Patients were categorized into mutually exclusive vascular territories. In cases of overlapping disease, patients were classified within the CAD group. We assessed the use of statins, high-intensity statins (rosuvastatin ≥20 mg or atorvastatin ≥40 mg daily), ezetimibe, aspirin, and any antithrombotic therapy (antiplatelet or oral anticoagulant). Multivariable logistic regression models were adjusted for age, sex, hypertension, diabetes, smoking status, and dyslipidemia.

Results

Among 1,151 patients classified as secondary prevention, 83.3% had CAD and 16.7% had cerebrovascular disease. Mean age was 70.5 ± 10.3 years, and 26.2% were women. Baseline characteristics are detailed in Table 1.

Compared with patients with CAD, those with cerebrovascular disease were significantly less likely to receive statins (66.1% vs 81.3%, p<0.001) and high-intensity statins (31.2% vs 53.2%, p<0.001). Similarly, any antithrombotic therapy was less frequently prescribed in the cerebrovascular group (70.3% vs 86.4%, p<0.001).

Patterns of secondary prevention strategies are summarized in Table 2.

After multivariable adjustment, CAD remained independently associated with a higher likelihood of receiving statins (OR 1.91, 95% CI 1.33–2.75; p=0.001), high-intensity statins (OR 2.34, 95% CI 1.67–3.28; p<0.001), and any antithrombotic therapy (OR 2.60, 95% CI 1.70–3.99; p<0.001).

Notably, most patients (86.0%) had at least one outpatient visit in the previous year, 47.4% were followed by a cardiologist, 27.9%, 15.1% exclusively by an internist, and 27.9% by both a cardiologist and an internist.

Conclusion

Despite robust evidence supporting intensive lipid-lowering and antithrombotic therapy in secondary prevention, patients with cerebrovascular disease were consistently less likely to receive these treatments compared with patients with CAD. These findings identify a consistent implementation gap in secondary prevention across vascular territories, which likely contributes to residual cardiovascular risk in cerebrovascular patients.