Stroke prevention

Strokes are sudden and have an immediate effect. They are a leading cause of long term disability in adults. In 2010, strokes accounted for 8.7% of total deaths in Malta. In addition there were six hundred and fifteen discharged cases of stroke in Malta and Gozo in the year 2011. Stroke is also the second leading cause of death in the Western world after ischaemic heart disease, with an exponential increase in its occurrence with increasing age.peer-reviewe

Blood pressure control versus atrial fibrillation management in stroke prevention

Hypertension is one of the major risk factors for atrial fibrillation which in turn is the most prevalent concomitant condition in hypertensive patients. While both these pathological conditions are independent risk factors for stroke, the association of hypertension and atrial fibrillation increases the incidence of disabling strokes. Moreover, documented or silent atrial fibrillation doubles the rate of cardiovascular death. Lowering blood pressure is strongly recommended, particularly for primary stroke prevention. However, a relatively small percentage of hypertensive patients still achieve the recommended blood pressure goals. The management of atrial fibrillation with respect to stroke prevention is changing. New oral anticoagulants represent a major advancement in long-term anticoagulation therapy in non valvular atrial fibrillation. They have several benefits over warfarin, including improved adherence to the anticoagulation therapy. This is an important issue since non-adherence to stroke prevention medications is a risk factor for first and recurrent strokes

Cerebral Microbleeds in a Stroke Prevention Clinic.

The objective of this study is to assess the effectiveness of a stroke clinic in stroke prevention and progression of cerebral microbleeds (CMB). We conducted a retrospective observational study of patients who visited a stroke clinic between January 2011 and March 2017. Susceptibility-weighted imaging (SWI) MRI studies were obtained at baseline and follow-up visits to identify new infarctions and CMB progression. Patients with CMB who also underwent brain computed tomography (CT) imaging were identified and their cerebral arterial calcification was quantified to evaluate the relationship between the extent of intracranial calcification and CMB burden. A total of 64 stroke patients (mean age 73.1 ± 11.0, 47% males) had CMB on baseline and follow-up MRI studies. During a mean follow-up period of 22.6 months, four strokes occurred (4/64, 6%; 3 ischemic, 1 hemorrhagic), producing mild neurological deficit. Progression of CMB was observed in 54% of patients with two MRIs and was significantly associated with length of follow-up. Subjects with intracranial calcification score > 300 cm3 had higher CMB count than those with scores <300 cm3 at both baseline (12.6 ± 11.7 vs. 4.9 ± 2.2, p = 0.02) and follow-up (14.1 ± 11.8 vs. 5.6 ± 2.4, p = 0.03) MRI evaluations. Patients with CMB had a relatively benign overall clinical course. The association between CMB burden and intracranial calcification warrants further study

Adherence to secondary stroke prevention strategies - Results from the German stroke data bank

Only very limited data are available concerning patient adherence to antithrombotic medication intended to prevent a recurrent stroke. Reduced adherence and compliance could significantly influence the effects of any stroke prevention strategies. This study from a large stroke data bank provides representative data concerning the rate of stroke victims adhering to their recommended preventive medication. During a 2-year period beginning January 1, 1998, all patients with acute stroke or TIA in 23 neurological departments with an acute stroke unit were included in the German Stroke Data Bank. Data were collected prospectively, reviewed, validated and processed in a central data management unit. Only 12 centers with a follow-up rate of 80% or higher were included in this evaluation. 3,420 patients were followed up after 3 months, and 2,640 patients were followed up one year after their stroke. After one year, 96% of all patients reported still adhere to at least one medical stroke prevention strategy. Of the patients receiving aspirin at discharge, 92.6% reported to use that medication after 3 months and 84% after one year, while 81.6 and 61.6% were the respective figures for clopidogrel, and 85.2 and 77.4% for oral anticoagulation. Most patients who changed medication switched from aspirin to clopidogrel. Under the conditions of this observational study, adherence to stroke prevention strategies is excellent. The highest adherence rate is noticed for aspirin and oral anticoagulation. After one year, very few patients stopped taking stroke preventive medication. Copyright (C) 2003 S. Karger AG, Basel

Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke:Pooled analysis of randomized trials

Background and Purpose: Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke. Methods: We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I2. Results: We included 17 trials with 42 234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62–0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30–0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75–1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75–1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68–1.00, 3 studies; ischemic stroke RR 0.80, 0.62–1.02, 3 studies; composite outcome RR 0.90, 0.80–1.02, 3 studies). Conclusions: Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype

Anticoagulation in Atrial Fibrillation:Consideration for treatment and health economic aspects

Atrial fibrillation (AF) is the most common cardiac arrhythmia with an increased risk of stroke and mortality. Effective stroke prevention leads to an improved quality of life and a lower economic disease burden. Anticoagulants such as the oral vitamin K antagonist and non-vitamin K antagonist oral anticoagulants can be used to reduce the stroke risk. In this thesis, Maartje Jacobs describes different aspects of AF treatment with a focus on stroke prevention. The research emphasizes on disease detection, drug treatment and how to handle specific subgroups. This thesis captures the aspects that are relevant from a clinical perspective as well as a payer’s and societal perspective. Important factors in stroke prevention are early detection of AF using screening, optimized prescription of the oral anticoagulants and appropriate use by the patient. Jacobs showed in this thesis that screening for AF can be a cost-effective, and even cost-saving, approach to detect new patients and to initiate stroke prevention. Specific subgroups would require a tailored approach for stroke prevention. Subpopulations with more challenges in AF treatment are for example critically ill patients, patients undergoing surgery and patients with co-existing coronary artery disease. Jacobs concludes that healthcare should be delivered in a way that best fits the patient, meaning: individualized treatment choices to optimize the AF risk management leading to improved patient outcomes. Since stroke induces a high economic burden to society, AF detection and stroke prevention are a good starting point for healthcare optimization

Primary stroke prevention worldwide: translating evidence into action

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course

Secondary Stroke Prevention Among Filipinos Compared with Other Racial Groups in Hawaii

Purpose/Background: As the fifth leading cause of death in the United States and a main cause of disability, stroke results in immense health and economic burden. Filipinos (FI) were found to have the highest mortality due to major CVD and stroke in Hawaii, and it is unclear whether the increased stroke risk among FI might be reduced by increasing the use of guideline recommended medications for secondary stroke prevention. Additionally, the attitudes and concerns of FI patients in Hawaii regarding stroke prevention have not been studied. The purpose of this study is to utilize a mixed-method approach to elucidate health disparities in FI after stroke compared with other racial groups in Hawaii, Whites, other Asians, Native Hawaiian and other Pacific Islanders (NHOPI) and other race. Materials & Methods: The Get With the Guidelines – Stroke (GWTG-Stroke) data from The Queenʼs Medical Center (QMC) will be used to identify patients hospitalized for stroke from years 2006-2016. Subjects will be excluded if diagnosed with non-ischemic stroke and with disposition other than home. Multivariable logistic regression models will examine differences in appropriate medication use at discharge related to race/ethnicity, controlling for age, sex, insurance, prior use of medications, and stroke risk factors. Additionally, semi-structured key informant interviews will be conducted among FI and other stroke patients from QMC. Transcripts from the interviews will be reviewed, coded, and interpreted for congruent themes. Results: Preliminary results from the GWTG-Stroke 2013 to 2016 data identified a total of 3574 stroke patients. After meeting inclusion criteria, a total of 1489 subjects were identified. The subjects included 398 Whites, 191 FI, 528 other Asian, 346 NHOPI, and 26 other race. At baseline, there was no difference in the average age of FI compared with Whites (66 vs 67 years old, respectively, P=0.15); however, other Asians (70 years old, P=0.002) were older, and NHOPI (60 years old, P\u3c0.001) were younger than Whites. Furthermore, FI, other Asians, and NHOPI had significantly higher rates of hypertension, diabetes mellitus, and dyslipidemia than Whites. Multivariable logistic regression results showed no statistically significant racial difference in prescribing of antithrombotics or statins at discharge. Age [OR=0.97; 95% CI (0.95, 0.995)], however, was a negative predictor of antithrombotic prescription, and being female [OR=0.68; 95% CI (0.51, 0.90)] was associated with lower rates of statin prescription on discharge (Table 1). Discussion/Conclusion: Analyses of data from a large hospital in Hawaii from 2013 to 2016 found race was not associated with prescribing differences for the guideline recommended medications for secondary stroke prevention. Further study is needed to better understand why female gender was associated with fewer statin prescriptions. The pending results of the key informant interviews may shed light on the attitudes and concerns regarding stroke prevention among FI and other racial groups in Hawaii