Do Not Cite. Draft for Work Group Review.

High and Moderate Intensity Statin Therapy Following Stroke

Measure Description
Percentage of patients aged 18 years to 74 years with a diagnosis of acute ischemic stroke or TIA who
were prescribed± high intensity statin therapy* and patients aged 75 and older who were prescribed
moderate^ or high intensity statin therapy at discharge.

Measure Components
Numerator Patients aged 18 years to 74 years with a diagnosis of acute ischemic stroke
Statement or TIA who were prescribed± high intensity statin therapy* and patients aged
75 and older who were prescribed moderate^ or high intensity statin therapy
at discharge.
Definitions:
*High Intensity Statin Therapy–defined as dose expected to reduce LDL-
C by greater than or equal to 50% and includes the following: (1,2)
Atorvastatin 40-80mg everyday
Rosuvastatin 20-40mg everyday

^Moderate Intensity Statin Therapy - defined as dose expected to reduce

LDL-C by 30-50% and includes the following: (1,2)
Atorvastatin 10-20mg everyday
Fluvastatin 40mg twice daily
Fluvastatin XL 80mg everyday
Lovastatin 40mg everyday
Pitavastatin 2-4mg everyday
Pravastatin 40-80mg everyday
Rosuvastatin 5-10mg everyday
Simvastatin 20-40mg everyday

±Prescribed – May include prescription given to the patient for statin

therapy at discharge OR statin therapy to be continued after discharge as
documented in the discharge medication list
Denominator All patients aged 18 years and older with a diagnosis of acute ischemic
Statement stroke or TIA
Denominator x Documentation of medical reason(s) for not prescribing high intensity
Exceptions statin therapy at discharge:
o Contraindication to statin therapy including but not limited to:
liver disease, patient taking medication with significant
interaction to statin, statin allergy/intolerance
o etiology of stroke presumed to be NON-atherosclerotic (e.g.
cardioembolic, secondary to dissection/trauma, vasculitis, etc.)
AND absence of clinical ASCVD**
x Documentation of patient reason(s) for not prescribing high intensity
statin therapy at discharge:
o Patient expired during hospitalization
o patient discharged to hospice or made comfort care
41
©2017. American Academy of Neurology Institute. All Rights Reserved.
CPT® Copyright 2004-2016 American Medical Association.
Do Not Cite. Draft for Work Group Review.

o patient left against medical advice

o patient refused treatment

Exception A medical reason exception has been included so that clinicians can
Justification exclude patients for whom prescribing a statin may not be appropriate.

A patient reason exception has been included for patients who may
decline receiving a statin. This exception should remove all patients
who do not have a stroke due to atherosclerotic etiology.
**Clinical Atherosclerotic Cardiovascular Disease (ASCVD) - includes
acute coronary syndromes, history of myocardial infarction, stable or
unstable angina, coronary or other arterial revascularization, stroke or TIA,
or peripheral atherosclerotic arterial disease.(2)

Supporting The following clinical recommendation statements are quoted verbatim

Guideline & Other from the referenced clinical guidelines and represent the evidence base
References for the measure:
x “For patients with ASCVD or diabetes mellitus, consideration
should be given to use of moderate- or high-intensity statin therapy,
irrespective of baseline atherogenic cholesterol levels (Strength-A,
Quality-High).”(1)
x “First-line cholesterol-lowering drug therapy, unless contraindicated,
is moderate- to high-intensity statin. The statin dosage may be
increased or the patient switched to a more efficacious agent, if goal
levels of atherogenic cholesterol are not achieved (Strength-A,
Quality-High).”(1)
x “The appropriate intensity of statin therapy should be initiated or
continued:
o A. Clinical ASCVD
ƒ 1. Age ≤ 75 and no safety concerns: High-intensity
statin (Class I ; Level of Evidence A)
ƒ 2. Age > 75 or safety concerns: Moderate-intensity
statin (Class I; Level of Evidence A)”(2)
x “Statin therapy with intensive lipid-lowering effects is recommended
to reduce risk of stroke and cardiovascular events among patients
with ischemic stroke or TIA presumed to be of atherosclerotic origin
and an LDL-C level ≥100 mg/dL with or without evidence for other
ASCVD (Class I; Level of Evidence B).”(3)
x “Statin therapy with intensive lipid-lowering effects is recommended
to reduce risk of stroke and cardiovascular events among patients
with ischemic stroke or TIA presumed to be of atherosclerotic
origin, an LDL-C level <100 mg/dL, and no evidence for other
clinical ASCVD (Class I; Level of Evidence C).”(3)
Relationship to A large body of evidence exists supporting the use of appropriate intensity
Desired Outcome statin therapy for secondary prevention in patients with clinical
atherosclerotic cardiovascular disease including patients with ischemic
stroke due to large artery atherosclerosis, intrinsic small vessel disease as
well as in patients with ischemic stroke not directly due to atherosclerosis
but with evidence of atherosclerosis in an uninvolved cerebral or noncerebral
42
©2017. American Academy of Neurology Institute. All Rights Reserved.
CPT® Copyright 2004-2016 American Medical Association.
Do Not Cite. Draft for Work Group Review.

vascular bed.(2) The Stroke Prevention by Aggressive Reduction in

Cholesterol Levels ( SPARCL) study convincingly demonstrated that
intensive lipid lowering therapy using statin medication was associated with
significant reduction in the rate of recurrent ischemic stroke and other major
coronary events.(4)
Opportunity for Patients suffering from ischemic stroke frequently have atherosclerosis of
Improvement cerebral or noncerebral vascular bed, or have clinical atherosclerotic
cardiovascular disease and would benefit from high intensity statin therapy.
However, rate of use of high intensity statin therapy is low, ranging from
15.9-20.8% among eligible patients.(5) In a review of Get with the Guideline
data, only 1 in 5 patients with a prior TIA/stroke had LDL levels <70 mg/dL
indicating further opportunity to improve.(6)

This measure represents current best evidence, and will be updated on a

regular basis to ensure medication list is consistent with current evidence.
National Quality ☐ Patient and Family Engagement
Strategy Domains ☐ Patient Safety
☐Care Coordination
☐ Population/Public Health
☐ Efficient Use of Healthcare Resources
☒ Clinical Process/Effectiveness
Harmonization with Similar measures exist, including, Lipid Management in Adult and
Existing Measures NQF#0439 Discharged on Statin Medication (Joint Commission STK 06),
but a separate measure was required to address this denominator
population.(7-9) Treatment requirements and guidelines are sufficiently
unique that harmonization of denominators was not possible.
Measure Purpose ☒ Quality improvement
(Check all that apply) ☒ Accountability
Type of Measure ☒ Process
(Check all that apply) ☐ Outcome
☐ Structure
Level of ☒ Individual Provider
Measurement ☐ Practice
(Check all that apply) ☐ System
Care Setting (Check ☐ Emergency Departments
all that apply) ☒ Inpatient
☐Outpatient
☐Post-Acute Care
Data Source (Check ☒ Electronic health record (EHR) data
all that apply) ☐Administrative Data/Claims
☒Chart Review
☒ Registry
References
1. Jacobson TA, Ito MK, Maki KC, et al. National lipid association recommendations for patient-centered
management of dyslipidemia: part 1--full report. J Clin Lipidol. 2015;9(2):129-169.
2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood
cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of

43
©2017. American Academy of Neurology Institute. All Rights Reserved.
CPT® Copyright 2004-2016 American Medical Association.
Do Not Cite. Draft for Work Group Review.

Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation.

2014;129(suppl 2):S1–S45.
3. Kernan WN, Ovbiagele B, Black HR, et al; on behalf of the American Heart Association Stroke
Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council
on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and
transient ischemic attack: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2014;45:2160-2236.
4. Amarenco P, Goldstein LB, Szarek M, et al. Effects of intense low-density lipoprotein cholesterol
reduction in patients with stroke or transient ischemic attack: the Stroke Prevention by Aggressive
Reduction in Cholesterol Levels (SPARCL) trial. Stroke. 2007;38(12):3198-3204.
5. Cumbler E, Wald H, Bhatt DL, et al., Quality of care and outcomes for in-hospital ischemic stroke:
findings from the National Get With The Guidelines-Stroke. Stroke. 2014;45(1):231-238.
6. Saposnik G, Fonarow GC, Pan W, et al. Guideline-directed low-density lipoprotein management in
high-risk patients with ischemic stroke: findings from Get with the Guidelines – Stroke 2003 to 2012.
Stroke 2014;45(11):3343-3351.
7. Woolley T, Canoniero M, Conroy W, et al. Institute for Clinical Systems Improvement. Lipid
Management in Adults. Updated November 2013. Available at:
https://www.icsi.org/_asset/qz5ydq/LipidMgmt.pdf. Accessed on May 31, 2016.
8. Smith EE, Saver JL, Alexander DN, et al. Clinical performance measures for adults hospitalized with
acute ischemic stroke: performance measures for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2014;45(11):3472-3498.
9. The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures
Available at:
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measur
es.aspx. Accessed on May 31, 2016.

44
©2017. American Academy of Neurology Institute. All Rights Reserved.
CPT® Copyright 2004-2016 American Medical Association.