Secondary preventive medication persistence and adherence 1 year after stroke

A bibliometric analysis of income and cardiovascular disease: Status, Hotspots, Trends and Outlook

BACKGROUND

Income is 1 of the socio-economic indicators and could directly influence the health outcomes of cardiovascular disease (CVD). The relationship between income and CVD has attracted more and more scholars' attention in the past 20 years.

METHODS

To study the current research dynamics of this field, a bibliometric analysis was conducted to evaluate the publications from 1990 to 2018 based on the Science Citation Index Expanded database. By using the Derwent Date Analyzer software, the following aspects were explored: RESULTS:: The USA ranked first in this field, followed by UK and Canada in terms of number of publications. As for institutions, Harvard University took the leading place in the number of publications, as well as the h-index. Plos One had the most publications and "health" was the most frequent used keyword. The leading research area was "public environmental occupational health".

CONCLUSIONS

In conclusion, the elderly, the children and the puerpera were the main study population in this field and "disease prevention" was the main study direction. The most concerned health issues in this field were "obesity" and "diet". There might be a lack of articles that explore the associations between income and CVD with a global perspective. Articles on this content are urgently warranted.

Factors associated with medication persistence among ischemic stroke patients: a systematic review

OBJECTIVE

An investigation of the prevalence of medication persistence and associated factors in order to inform effective strategies for improving medication persistence.

METHODS

A systematic review of the literature from 2010 to the present was performed, using the PRISMA protocol. Primary and empirical observational studies of adult ischemic stroke or transient ischemic attack patients were included. PubMed, CINAHL, Web of Science, Cochrane Library, and PsycInfo databases were searched using the key terms stroke, ischemic stroke, medication persistence, medication adherence, and patient compliance.

RESULTS

Of four hundred twenty-eight journal articles retrieved, a final 18 articles were included. Short-term medication persistence was 46.2-96.7%, and long-term medication persistence was 41.7-93.0%. Identified hospital-related factors for medication persistence were stroke unit care, in-hospital medical complications, and early follow-up visit. Demographic factors for medication persistence were older age, and high/adequate financial status; disease-related factors were disease history, stroke subtype, and symptom severity. Age less than 75, female sex, comorbidity, antiplatelet medication switch, and polypharmacy were identified as factors of medication nonpersistence.

CONCLUSIONS

Stroke patients' medication persistence decreases over time, and persistence on antiplatelets, anticoagulants, and statin was poor. Several factors were associated with medication persistence, and these factors should be considered in future secondary preventative strategies.

Treatment Adherence and Secondary Prevention of Ischemic Stroke Among Discharged Patients Using Mobile Phone- and WeChat-Based Improvement Services: Cohort Study

BACKGROUND

Real-world studies have indicated that adherence is important for guaranteeing medication effectiveness. Few studies have tested the feasibility and efficacy of WeChat-based improvement services, via mobile phone, in secondary prevention-specific follow-up among discharged stroke patients.

OBJECTIVE

We evaluated a quadruple-domain, WeChat-based service for ischemic stroke secondary prevention designed to improve treatment adherence of discharged patients. This service focuses on sending reminders for drug use, blood pressure recording, and glucose recording; it also records medication use. We compared the endpoint event rate between WeChat self-monitoring and traditional monitoring.

METHODS

A cohort study was used to determine the feasibility of a physician-assisted, WeChat-based improvement service and follow-up self-monitoring platform for the secondary prevention of ischemic stroke. The platform was developed by the Peking University Third Hospital based on the information-motivation-behavioral skills model. The overall adherence rate was calculated as the proportion of medication doses verified via uploading. The ischemic endpoint event rate and medication noncompliance rate were compared between traditional prevention monitoring and WeChat self-monitoring. Factors influencing adherence were summarized.

RESULTS

The 1-year follow-up event rate of the WeChat self-monitoring group was 11.9% (12/101), which was less than that of the traditional group (21/157, 13.4%). Compared with the traditional group, the risk ratio of the WeChat group was 0.983 (95% CI 0.895-1.080); this difference was not noted to be significant. The 1-year medication noncompliance ratio tended to be lower in the WeChat monitoring group (3/101, 3.0%) than in the traditional group (11/157, 7.0%; χ²=1.9, df=1, P=.16). Of the platform registry participants, 89.7% (210/234: 167 hospital-based and 43 community-based participants) adhered to inputting information into WeChat for 8-96 weeks. The average adherence time was 16.54 (SD 0.80, range 2-24) months. The average decrease in adherence was 4 participants (1.1%) per month. Being a member of a community-based population was an influencing factor for good adherence at the 2-year follow-up (OR 2.373, 95% CI 1.019-5.527, P=.045), whereas transient ischemic attack was an influencing factor for poor adherence at the 2-year follow-up (OR 0.122, 95% CI 0.016-0.940, P=.04).

CONCLUSIONS

Use of WeChat self-monitoring showed a trend of increasing medication compliance and decreasing ischemic endpoint event rate compared with traditional monitoring. However, there were ceiling effects in the outcomes, and a relatively small sample size was used. Male participants displayed better adherence to WeChat self-monitoring. The community-based population displayed good adherence when using WeChat self-monitoring.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02618265; https://clinicaltrials.gov/ct2/show/NCT02618265.

Using a structured, patient-centred, educational exchange to facilitate a shared conversation about stroke prevention medications

OBJECTIVE

The aim of this study was to investigate the feasibility of a structured patient-centred educational exchange to facilitate a shared conversation about stroke prevention medications.

METHODS

Participants (18 years or older) with a principal diagnosis of stroke or transient ischaemic attack were purposively sampled from the stroke unit of a 780-bed teaching hospital in Australia and consented to participate in the study. A patient-centred educational exchange was conducted face to face at the bedside before discharge and by telephone post discharge. The structure of these sessions was adapted from academic detailing, an educational strategy, which includes identifying experience, listening to the needs of the audience, and tailoring messages to influence behaviour. To facilitate sharing of needs, three questionnaires, validated as research tools, were used to identify participants' experience, perceptions, and beliefs. The identified perceptions were used to personalize educational messages. The outcomes of the study were to provide descriptions of patients' perceptions necessities and concerns about their condition and medications, provide examples of personalized responses to these, evaluate acceptability by patients, and determine the time taken to share the information.

RESULTS

Sixteen participants completed both the bedside session (average duration 27 minutes) and the telephone follow-up (average duration 23 minutes). The strongest patient concern identified was having another stroke. Personalized responses included emphasizing long-term treatment in response to the perception that stroke will last for a short time, reinforcement of necessity for medications, and further exploration of concerns.

CONCLUSION

The questionnaires engaged the participants, allowing them to share perceptions and beliefs, facilitating a patient-centred educational exchange in a timely manner.

Factors Influencing 1-Year Medication Adherence of Korean Ischemic Stroke Survivors

BACKGROUND

Medication adherence is important for secondary stroke prevention. However, suboptimal adherence to medication among patients after stroke or transient ischemic attack is reportedly 30.9%. We assessed medication adherence of Korean stroke survivors within 1 year of acute ischemic stroke and identified factors that influence adherence.

METHODS

We consecutively enrolled ischemic stroke survivors who visited the Department of Neurology of a university hospital from March 9 to June 15, 2016. Data were collected by face-to-face interviews using a structured questionnaire which assessed general characteristics, clinical characteristics, medication beliefs, social support, and depression. Medication adherence was measured using the 8-item Morisky Medication Adherence Scale. Multiple logistic regression was used to identify factors independently associated with medication adherence.

RESULTS

Of the total 250 participants, 183 (73%) were in the optimal adherence group. Age (p = 0.035), smoking (p = 0.020), number of prescribed medicines (p = 0.037), frequency of daily doses (p = 0.040), and beliefs about medication (p < 0.001) were associated with medication adherence. Optimal medication adherence was associated with being a non-smoker (OR, 3.19; 95% CI, 1.29-7.87; p = 0.012), more prescribed medicines (OR, 1.27; 95% CI, 1.05-1.54; p = 0.014), less frequency of daily doses (OR, 0.37; 95% CI, 0.18-0.79; p = 0.010), and stronger beliefs about medication (OR, 1.09; 95% CI, 1.03-1.15; p = 0.004).

CONCLUSION

To improve medication adherence of stroke survivors, post-stroke care should focus on bolstering patients' belief in the necessity of medication and encouraging lifestyle modifications, such as quitting smoking, as well as prescribing medicine with simple regimens.

Stroke coach: a pilot study of a personal digital coaching program for patients after ischemic stroke

Despite recent advances in acute stroke care, the risk of recurrent stroke remains high. On behalf of the Belgian Stroke Council (BSC), a nurse-led self-management program was developed, using a personal coach and digital platform with the aim of improving cardiovascular risk factor control in patients after ischemic stroke. The program was implemented in four Belgian hospitals. The stroke coach provided one educational session during hospitalization. After discharge, the patient received tips and tricks concerning a healthy lifestyle through the customized platform. The stroke coach set up video appointments through the platform at regular intervals. Primary endpoint of our study was the change in SCORE (Systematic COronary Risk Evaluation: High and Low cardiovascular Risk Charts) risk at baseline and 6 months compared with a historical control group who received standard care. A total of 147 patients were included for a follow-up period of 6 months. The mean SCORE in the intervention group showed a statistically significant reduction of 3.2 (p < 0.001) at 6 months. However, comparison between control and intervention groups was non-significant (p = 0.55). Secondary endpoints are promising with a medication adherence of 96%. Reported quality of life also improved (p < 0.001). No significant improvement in the modified Rankin scale (mRS) was observed (p = 0.720). Five percent of patients suffered a recurrent stroke. Our project consisting of a coached lifestyle intervention and digital platform shows promise in improving stroke recurrence rates, therapeutic adherence and quality of life in a Belgian healthcare setting.

Risk Factors for Recurrent Arterial Ischemic Stroke in Children and Young Adults

Arterial ischemic stroke (AIS) experienced at a young age is undoubtedly a serious medical problem. AIS very rarely occurs at a developmental age, whereas in young adults, it occurs with a higher frequency. The etiologic mechanisms of AIS occurring in childhood and adulthood differ. However, for both age populations, neurological consequences of AIS, including post-stroke seizures, motor disability, and recurrence of the disease, are connected to many years of care, rehabilitation, and treatment. Recurrent stroke was observed to increase the risk of patients' mortality. One of the confirmed risk factors for recurrent stroke in children is the presence of vasculopathies, especially Moyamoya disease and syndrome, and focal cerebral arteriopathy of childhood (FCA). FCA causes a 5-fold increase in the risk of recurrent stroke in comparison with idiopathic AIS. In turn, young adults with recurrent stroke were found to more often suffer from hypertension, diabetes mellitus, or peripheral artery disease than young patients with first-ever stroke. Some reports also indicate relationships between specific genetic polymorphisms and AIS recurrence in both age groups. The aim of the present literature review was to discuss available data regarding the risk factors for recurrent AIS in children and young adults.

Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) study protocol

RATIONALE

Recurrent stroke, cardiovascular morbidity, and mortality are important causes of poor outcome in patients with index stroke. Despite the availability of best medical management recurrent stroke occur in up to 15-20% of patients with stroke in India. Education for stroke prevention could be a strategy to prevent recurrent strokes.

HYPOTHESIS

We hypothesize that a structured semi-interactive stroke prevention package can reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke at the end of one year.

DESIGN

Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) is a multi-center stroke trial involving 25 centers under the Indian Stroke Clinical Trial Network. Patients with first ever sub-acute stroke within two days to three months of onset, age 18-85 years, mRS <5, showing recent stroke in imaging are included. Participants or caregivers able to read and complete tasks suggested in a stroke prevention workbook and have a cellular device for receiving short message service and watching videos. A total of 5830 stroke patients speaking 11 different languages are being randomized to intervention or control arm. Patients in the intervention arm are receiving a stroke prevention workbook, regular educational short messages, and videos. All patients in the control arm are receiving standard of care management.

SUMMARY

Structured semi-interactive stroke prevention package may reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke.

TRIAL REGISTRATION

This trial is registered with clinicaltrials.gov (NCT03228979) and CTRI (Clinical Trial Registry India; CTRI/2017/09/009600).

The Association Among Medication Beliefs, Perception of Illness and Medication Adherence in Ischemic Stroke Patients: A Cross-Sectional Study in China

PURPOSE

To examine the association and the mediating effect among medication beliefs, perception of illness, and medication adherence in ischemic stroke patients.

PATIENTS AND METHODS

This is a cross-sectional study, 306 ischemic stroke patients recruited from The Second Affiliated Hospital of Harbin Medical University, China between June 2018 and October 2018. The Beliefs about Medications Questionnaire (BMQ) was used to assess a patient's beliefs about medication. The Brief Illness Perceptions Questionnaire (BIPQ) was used to rapidly determine the cognitive and emotional representation of ischemic stroke. Self-reported adherence was assessed using the Medication Adherence Report Scale (MARS). Logistic regression analysis, Pearson correlations, and mediation analysis were used to evaluate the association and mediating effects among medication beliefs, perception of illness, and medication adherence.

RESULTS

Overall, 220 (65.48%) participants were non-adherent to their ischemic stroke medications. Non-adherent patients had greater stroke severity (p = 0.031) compared to adherent patients. After adjusting for demographic characteristics, specific concern (odds ratio [OR]: 0.652, 95% confidence interval [CI]: 0.431 to 0.987, p-value [P] = 0.043), and the perception of illness (overall score) (OR: 0.964, 95% CI: 0.944 to 0.985, P = 0.001) were significantly associated with medication adherence in ischemic stroke patients. The mediation analysis showed the significant indirect effects of specific concern, general overuse, and general harm. It suggested that some impacts of medication beliefs have been mediated on medication adherence.

CONCLUSION

Perceived concern about adverse effects of medicines and perception of illness have an influential impact on self-reported medication adherence in ischemic stroke patients. To enhance adherence, patients' beliefs about medication and perceptions of their disease should be reconsidered. Future work should investigate interventions to influence patient adherence by addressing concerns about their ischemic stroke medications and the perception of the disease.

Post-stroke medication adherence and persistence rates: a meta-analysis of observational studies

BACKGROUND

Following a doctor's prescribed medication regimen is the key to prevent recurrent stroke and adverse outcomes. Many studies have investigated post-stroke drug adherence and persistence in patients. However, a comprehensive analysis of the data is lacking.

OBJECTIVES

A meta-analysis of published literature was conducted to summarize the ratio of medication adherence and persistence in patients after stroke.

METHODS

Relevant studies were identified by conducting a literature search using PubMed, EMBASE and Web of Science up to April 2019. We also reviewed the reference list of the retrieved articles to identify additional studies. We included observational studies that reported data on patients' medication adherence or persistence status, or the rate of medication adherence or persistence among patients with stroke could be calculated based on the information provided.

RESULTS

The overall high medication adherence rate of patients with stroke was 64.1% (95% CI: 57.4%-70.8%), and the persistence rate of patients with stroke was 72.2% (95% CI: 69.1%-75.3%). The highest persistence rate was observed in cohort studies which was 80.1% (95% CI: 76.7%-83.4%). The medication adherence rate was the highest in cases where the rates were assessed through interviews or self-reports (77.7% (95% CI: 71.3%-84.1%)).

CONCLUSIONS

Medication adherence and persistence rates are low in patients after suffering a stroke. Patient medication adherence or persistence and their influencing factors should be considered for the treatment of stroke patients. More detailed disease prevention and management strategies need to be developed for stroke patients with different comorbidities.

The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study

BACKGROUND

Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care.

OBJECTIVE

To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke.

DESIGN

Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605).

MAIN MEASURES

Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated.

KEY RESULTS

For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed.

CONCLUSIONS

Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted.

REGISTRATION

None.

A Pilot Randomized Controlled Trial Testing the Feasibility and Acceptability of a SystemCHANGE Intervention to Improve Medication Adherence in Older Adult Stroke Survivors

BACKGROUND

Adhering to an antithrombotic medication regimen is essential to reducing recurrent stroke in adult stroke survivors. The purpose of this study was to evaluate the feasibility and acceptability of the SystemCHANGE (SC) and attention control (AC) intervention in older adult, nonadherent ischemic stroke patients.

METHODS

A pilot randomized controlled trial was conducted to determine the feasibility and acceptability of an SC versus AC intervention in older adult, nonadherent stroke survivors in the management of antithrombotic medication. Participants were masked to group assignment. Stroke survivors 50 years or older, taking at least 1 once-a-day antithrombotic medication, were recruited from a Midwest Comprehensive Stroke Center-affiliated neurology office. They were screened electronically using the Medication Event Monitoring System for 2 months to determine baseline medication adherence. Nonadherent stroke survivors (medication adherence < 0.97) were randomized to SC or AC intervention and monitored for 3 months. SC focused on redesigning the interpersonal environmental system and daily routines. The AC group was provided education materials on stroke that consisted of stroke risk factor reduction, stroke facts, rehabilitation, and nutrition with the primary investigator. Participation and intervention experience interviews were evaluated for themes.

RESULTS

Thirty participants were recruited: median age was 64 years, 46.7% of them were male, and they took an average of 7.77 (SD, 3.191; range, 3-15) prescribed medications. The number of over-the-counter medications taken (excluding aspirin) on a regular basis averaged 1.9 (SD, 0.8; range, 1-4). Two participants were nonadherent and were randomized to the 2 arms. Both participants had positive feedback and were not inconvenienced by their participation in the study. Neither participant voiced concerns about the intervention, survey demands, time requirement, or completing the surveys on the primary investigator's laptop.

CONCLUSION

The SC and AC intervention protocols were feasible and acceptable to the participants in this study. Additional pilot testing is needed to further evaluate the intervention and its effect on medication adherence in this population.

Development of a tool to support person-centred medicine-focused consultations with stroke survivors

OBJECTIVE

To develop a tool to support medicine-focused person-centred consultations between community pharmacists and stroke survivors.

METHOD

Semi-structured interviews with 15 stroke survivors and 16 community pharmacists were conducted. Thematic analysis of the data was performed and emerging themes examined to determine their relevance to the principles of delivering person-centred care. Findings were used to generate a framework from which a consultation tool was created. Face validity and the feasibility of using the tool in practice were explored with participating pharmacists.

RESULTS

Three major themes were identified; personal, process and environmental factors. A tool, in two parts, was developed, A 'Getting to know me' form which would help the pharmacist to appreciate the individual needs of the stroke survivor and a consultation guide to facilitate the consultation process. Pharmacists considered that both were useful and would support a person-centred medicine-focussed consultation.

CONCLUSION

A consultation tool, reflecting the needs of stroke survivors, has been developed and is feasible for use within community pharmacy practice.

PRACTICE IMPLICATIONS

Pharmacists must recognise the individual needs of stroke survivors to ensure that they provide consultations which are truly person-centred. The tool developed could support medicine-related consultations with patients with other long term conditions.

Statin use and high-dose statin use after ischemic stroke in the UK: a retrospective cohort study

Background: Trial evidence supports statin use after ischemic stroke and recent American, European and British guidelines recommend high-intensity statins for this indication. Limited data are available describing current statin use among these patients in unselected settings. We conducted a cohort study to examine secular trends and factors associated with statin use and dose following ischemic stroke. Methods: A retrospective cohort study of patients with first ischemic stroke between 2000 and 2014 was conducted using the Clinical Practice Research Datalink (CPRD). Proportions of statin users and high-intensity statin users within 2 years after stroke were estimated for each calendar year. We used Cox regression models to explore potential factors associated with statin use and Poisson regression models to calculate risk ratios for the use of a high-intensity statin. Results: A total of 80,442 patients with first stroke were analyzed. The proportion using statins within 2 years after stroke increased from 25% in 2000 to 70% in 2006 and remained at about 75% through 2014. Among post-stroke statin users, high-intensity use accounted for approximately 15% between 2004 and 2011 and then increased to almost 35% in 2014. Older patients (aged ≥75 years), younger patients (<45 years), patients with no prior statin treatment, dementia, underweight, or absence of cardiovascular factors (coronary heart disease, smoking, obesity, diabetes, hypertension, or transient ischemic attack) were less likely to use statins and less likely to receive a high-intensity statin. Conclusion: There has been an increase over time in both statin use and dose, but many patients with ischemic stroke continue to be under-treated. Clinical trials and policy interventions to improve appropriate post-stroke statin use should focus on younger and older patients, patients with no pre-stroke statin treatment, and patients without additional cardiovascular risk factors.

Impact of age on cardiovascular drug use in patients with chronic kidney disease

Background

Elderly patients with chronic kidney disease (CKD) are often excluded from clinical trials; this may affect their use of essential drugs for cardiovascular complications. We sought to assess the impact of age on cardiovascular drug use in elderly patients with CKD.

Methods

We used baseline data from the Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort including 3033 adult patients with CKD Stages 3 and 4. We studied the use of recommended drugs for coronary artery disease (CAD), stroke and atrial fibrillation by age, after adjusting for socio-demographic and clinical conditions.

Results

The patients’ mean age was 66.8 years (mean estimated glomerular filtration rate 32.9 mL/min/1.73 m²). The prevalence of CAD was 24.5% [81.3% receiving antiplatelet agents, 75.6% renin–angiotensin system (RAS) blockers, 65.4% β-blockers and 81.3% lipid-lowering therapy], that of stroke 10.0% (88.8% receiving antithrombotic drugs) and that of atrial fibrillation 11.1% (69.5% receiving oral anticoagulants). Compared with patients aged <65 years, older age (≥65 years) was associated with greater use of antithrombotic drugs in stroke [adjusted odds ratio (aOR) (95% confidence interval) = 2.83 (1.04–7.73) for patients aged (75–84 years)] and less use of RAS blockers [aOR = 0.39 (0.16–0.89) for patients aged ≥85 years], β-blockers [aOR = 0.31 (0.19–0.53) for patients aged 75–84 years] and lipid-lowering therapy [aOR = 0.39 (0.15–1.02) for patients aged ≥85 years, P for trend = 0.01] in CAD. Older age was not associated with less use of antiplatelet agents in CAD or oral anticoagulants in atrial fibrillation.

Conclusions

In patients with CKD, older age per se was not associated with the underuse of antithrombotic drugs but was for other major drugs, with a potential impact on cardiovascular outcomes.

Farmalarm

Background and Purpose- Risk factor control and treatment compliance in the following months after stroke are poor. We aim to validate a digital platform for smartphones to raise awareness among patients about the need to adopt healthy lifestyle, improve communication with medical staff, and treatment compliance. Methods- Farmalarm is an application (app) for smartphones designed to increase stroke awareness by medication alerts and compliance control, chat communication with medical staff, didactic video files, exercise monitoring. Patients with stroke discharged home were screened for participation and divided into groups: to follow the FARMALARM program for 3 to 4 weeks or standard of care follow-up. We determined achievement of risk factor control goals at 90 days. Results- From August 2015 to December 2016, from the 457 patients discharged home, 159 (34.8%) were included: Farmalarm (n=107); age 57±12, Control (n=52), age 59±10; without significant differences in baseline characteristics between groups. At 90 days, knowledge of vascular risk factors was higher in FARMALARM group (86.0% versus 69.2%, P<0.01). The rate of patients with diabetes mellitus (83.2% versus 63.5%, P<0.01) and hypercholesterolemia (80.3% versus 63.5%, P=0.03) under control and the rate of patients with 4 out of 4 risk factors under control was higher in FARMALARM group (50.4% versus 30.7%, P=0.02). A regression model showed that the use of Farmalarm was independently associated with all risk factors under control at 90 days (odds ratio, 2.3; 95% CI, 1.14-4.6; P=0.02). Conclusions- In patients with stroke discharged home, the use of mobile apps to monitor medication compliance and increase stroke awareness is feasible and seems to improve the control of vascular risk factors.

Ethnic Differences in 90-Day Poststroke Medication Adherence

Background and Purpose- We assessed ethnic differences in medication adherence 3 months poststroke in a population-based study as an initial step in investigating the increased stroke recurrence risk in Mexican Americans compared with non-Hispanic whites. Methods- Ischemic stroke cases from 2008 to 2015 from the Brain Attack Surveillance in Corpus Christi project in Texas were followed prospectively for 3 months poststroke to assess medication adherence. Medications in 5 drug classes were analyzed: statins, antiplatelets, anticoagulants, antihypertensives, and antidepressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. The χ² tests or Kruskal-Wallis nonparametric tests were used for ethnic comparisons of demographics, risk factors, and medication adherence. A multivariable logistic regression model was constructed for the association of ethnicity and medication nonadherence. Results- Mexican Americans (n=692) were younger (median 65 years versus 68 years, P<0.001), had more diabetes mellitus ( P<0.001) and hypertension ( P<0.001) and less atrial fibrillation ( P=0.003), smoking ( P=0.003), and education ( P<0.001) than non-Hispanic whites (n=422). Sex, insurance status, high cholesterol, previous stroke/transient ischemic attack history, excessive alcohol use, tPA (tissue-type plasminogen activator) treatment, National Institutes of Health Stroke Scale score, and comorbidity index did not significantly differ by ethnicity. There was no significant difference in medication adherence for any of the 5 drug classes between Mexican Americans and non-Hispanic whites. Conclusions- This study did not find ethnic differences in medication adherence, thus challenging this patient-level factor as an explanation for stroke recurrence disparities. Other reasons for the excessive stroke recurrence burden in Mexican Americans, including provider and health system factors, should be explored.

Therapeutic Vaccine Against S100A9 (S100 Calcium-Binding Protein A9) Inhibits Thrombosis Without Increasing the Risk of Bleeding in Ischemic Stroke in Mice

Decreased adherence to daily ingestion of antiplatelet drugs is a critical issue, increasing mortality and morbidity in poststroke patients. As vaccination could be a promising approach to solving this, we designed an antiplatelet vaccine that inhibited S100A9 (S100 calcium-binding protein A9)/CD36 (cluster of differentiation 36) signaling in platelets, which was reported to be a key signal in arterial thrombosis, but not hemostasis. Immunization with this vaccine induced a sustainable increase in the anti-S100A9 antibody titer for >2 months and an additional booster immunization enhanced the antibody production further. The middle cerebral artery occlusion time was successfully prolonged in the vaccinated mice, which was comparable to that in mice treated with clopidogrel. The antithrombotic effect lasted for 84 days after the last vaccination, as well as after the booster immunization. Importantly, the bleeding time was not affected in the immunized mice. The antithrombotic effect was also observed in the common carotid artery, which was similar to that found in CD36^-/- mice. Vascular injury increased the expression of S100A9 in the serum and phosphorylation of JNK (c-Jun N-terminal kinase) and VAV1 in the platelets, but these increases were inhibited in the immunized mice. Moreover, the S100A9 vaccine did not induce cell-mediated autoimmunity, as demonstrated by the enzyme-linked immunosorbent spot assay. Thus, immunization with the S100A9 vaccine resulted in long-term inhibition of thrombus formation through inhibition of increased S100A9/CD36 signaling without risk of bleeding or adverse autoimmune responses. Vaccination against S100A9 might be a novel therapy to prevent recurrent ischemic stroke.

Clusters of non-adherence to medication in neurological patients

BACKGROUND

Non-adherence to medication is a common and serious problem in health care. To develop more effective interventions to improve adherence, there is a need for a better understanding of the individual types of non-adherence.

OBJECTIVE

To determine clusters of non-adherence in neurological patients using a complex adherence questionnaire.

METHODS

In this observational, monocentric study 500 neurological patients (consecutive sampling) were recruited in the Department of Neurology at the Jena University Hospital, Germany (outpatient clinic, wards) over a period of 5 months. Patients with severe dementia or delirium who were unable to complete the questionnaire were excluded. Due to missing adherence data, in total, 429 patients with common neurological disorders were analyzed. Different types and clusters of non-adherence using the German Stendal Adherence to Medication Score (SAMS) were determined.

RESULTS

For the 429 patients, the mean age was 63 years (SD = 16), 189 were female. According to the SAMS total score 74 (17.2%) were fully adherent, 252 (58.7%) showed moderate non-adherence and 103 (24%) showed clinically significant non-adherence. Principal component analysis with Varimax rotation revealed three independent factors explaining 60.5% of the SAMS variance. The bulk of non-adherence was attributed to modifications of medication (41.7%) and forgetting to take the medication (33.2%) followed by lack of knowledge 25.1% about reasons, dosages and time of administration for the medication.

CONCLUSIONS

Intentional non-adherence was the primary self-reported behavior identified among non-adherent neurological participants. Many patients modified their prescribed medication due to various reasons, such as side effects or lacking effect. Different clusters require different interventions. While for the cluster ´forgetfulness' the reduction of poly-medication and a behavioral approach with reminders seems reasonable, patients in cluster ´missing knowledge' and cluster ´modifications' may need an educational approach.

Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a randomized controlled trial sub-study

BACKGROUND

The objective of this study was to analyze the impact of two forms of secondary preventive follow-up on the association between education level and levels of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) after stroke/transient ischemic attack (TIA).

METHODS

We included a population-based cohort of 771 stroke and TIA patients randomly assigned (1:1) to secondary preventive follow-up within primary health care (control) or nurse-led, telephone-based follow-up (intervention) between January 1, 2010, and December 31, 2013, as part of the NAILED (nurse-based age-independent intervention to limit evolution of disease) stroke risk factor trial. We compared BP and LDL-C levels 12 months after hospital discharge in relation to education level (low, ≤10 years; high, >10 years) separately for the intervention and control groups.

RESULTS

Among controls, systolic BP (SBP) decreased only among the highly educated (-2.5 mm Hg, 95% confidence interval (CI) -0.2 to -4.8), whereas LDL-C increased in the low-education group (0.2 mmol/L, 95% CI 0.1 to 0.3). At 12 months, controls with low education not more than 70 years of age had higher SBP than controls of the same age with high education (5.8 mm Hg, 95% CI 1.0 to 10.6). In contrast, SBP in the intervention group decreased similarly regardless of education level, LDL-C decreased among those with low education (-0.3 mmol/L, 95% CI -0.2 to -0.4) and, in the subgroup not more than 70 years old, low-educated participants had lower LDL-C at 12 months than those with high education (0.3 mmol/L, 95% CI 0.1 to 0.5).

CONCLUSIONS

Nurse-led, telephone-based secondary preventive follow-up led to comparable improvements in BP across education groups, while routine follow-up disfavored those with low education.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN23868518 , June 19, 2012 - Retrospectively registered.

Executive Summary of Stroke Statistics in Korea 2018: A Report from the Epidemiology Research Council of the Korean Stroke Society

Despite the great socioeconomic burden of stroke, there have been few reports of stroke statistics in Korea. In this scenario, the Epidemiologic Research Council of the Korean Stroke Society launched the “Stroke Statistics in Korea” project, aimed at writing a contemporary, comprehensive, and representative report on stroke epidemiology in Korea. This report contains general statistics of stroke, prevalence of behavioral and vascular risk factors, stroke characteristics, pre-hospital system of care, hospital management, quality of stroke care, and outcomes. In this report, we analyzed the most up-to-date and nationally representative databases, rather than performing a systematic review of existing evidence. In summary, one in 40 adults are patients with stroke and 232 subjects per 100,000 experience a stroke event every year. Among the 100 patients with stroke in 2014, 76 had ischemic stroke, 15 had intracerebral hemorrhage, and nine had subarachnoid hemorrhage. Stroke mortality is gradually declining, but it remains as high as 30 deaths per 100,000 individuals, with regional disparities. As for stroke risk factors, the prevalence of smoking is decreasing in men but not in women, and the prevalence of alcohol drinking is increasing in women but not in men. Population-attributable risk factors vary with age. Smoking plays a role in young-aged individuals, hypertension and diabetes in middle-aged individuals, and atrial fibrillation in the elderly. About four out of 10 hospitalized patients with stroke are visiting an emergency room within 3 hours of symptom onset, and only half use an ambulance. Regarding acute management, the proportion of patients with ischemic stroke receiving intravenous thrombolysis and endovascular treatment was 10.7% and 3.6%, respectively. Decompressive surgery was performed in 1.4% of patients with ischemic stroke and in 28.1% of those with intracerebral hemorrhage. The cumulative incidence of bleeding and fracture at 1 year after stroke was 8.9% and 4.7%, respectively. The direct costs of stroke were about ₩1.68 trillion (KRW), of which ₩1.11 trillion were for ischemic stroke and ₩540 billion for hemorrhagic stroke. The great burden of stroke in Korea can be reduced through more concentrated efforts to control major attributable risk factors for age and sex, reorganize emergency medical service systems to give patients with stroke more opportunities for reperfusion therapy, disseminate stroke unit care, and reduce regional disparities. We hope that this report can contribute to achieving these tasks.

Intensive Versus Moderate Statin Therapy Discontinuation in Patients With Acute Ischemic Stroke or Transient Ischemic Attack

PURPOSE

The differences of discontinuation risk between intensive and mild-to-moderate statin therapy in patients with acute ischemic stroke is not clear. This study aimed to clarify whether intensive statin therapy resulted in a significant increase in discontinuation early after discharge.

METHODS

This multicenter registry study enrolled consecutive hospitalized patients with ischemic stroke or transient ischemic attack. All the patients were prescribed statin therapy at discharge. Intensity of statin therapy was defined according to the 2013 American College of Cardiology/American Heart Association guideline on the treatment of blood cholesterol. A logistic regression model was used to analyze the association between statin therapy intensity and discontinuation.

FINDINGS

This study included 505 patients, of whom 64 and 441 received intensive and moderate statin therapy, respectively (mean follow-up, approximately 6 months). The rates of discontinuation of intensive and moderate statin therapy were 31.3% and 10.7% (P < 0.001), respectively. Variables with significant differences between the intensive and moderate statin therapy groups were included in the adjusted logistic regression model. Intensive statin therapy significantly increased discontinuation risk by 273.0% (odds ratio = 3.730; 95% CI, 2.013-6.911; P < .001) compared with moderate statin therapy. The result was consistent in most subgroups, except for patients with National Institutes of Health Stroke Scale scores ≥4.

IMPLICATIONS

In stroke secondary prevention, intensive statin therapy may significantly increase the risk of early discontinuation compared with moderate statin therapy. Future clinical trials that involve a comparison between intensive and moderate statin therapy for stroke secondary prevention should address the differences in discontinuation between these 2 groups.

Pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack -study protocol

BACKGROUND

Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of future cardiovascular events. Despite compelling evidence about the efficacy of secondary prevention, a substantial gap exists between risk factor management in real life and that recommended by international guidelines. Moreover, stroke is a leading cause of disability and morbidity which partly emerges from post-stroke complications.

METHODS/DESIGN

We designed a block-randomised (2:1 ratio) open pragmatic trial [NCT02156778] with blinded outcome assessment comparing STROKE-CARD to usual post-stroke-patient care. STROKE-CARD is a multifaceted post-stroke disease management program with the objective of reducing recurrent cardiovascular events and improving quality of life in ischaemic stroke and TIA-patients. It combines intensified multi-domain secondary prevention, systematic detection and treatment of post-stroke complications, and patient self-empowerment. Enrolment of 2160 patients with acute ischaemic stroke or TIA (ABCD2-Score ≥ 3) is planned at two study centres in Austria. The co-primary efficacy endpoints are (i) the composite of major recurrent cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, and vascular death) occurring within 12 months after the index event and (ii) one-year health-related quality-of-life measured with the European Quality of Life-5 Dimensions (EQ-5D-3 L) questionaire. Secondary endpoints include all-cause mortality, functional outcome, and target-level achievement in risk factor management.

DISCUSSION

This trial will provide evidence on whether the pragmatic post-stroke intervention program STROKE-CARD can help prevent cardiovascular events and improve quality-of-life within the setting of a high-quality acute stroke care system. In case of success, STROKE-CARD may be implemented in daily clinical routine and serve as a model for other disease management initiatives.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02156778 . (June 5, 2014, retrospectively registered).

Use of a patient-centred educational exchange (PCEE) to improve patient's self-management of medicines after a stroke: a randomised controlled trial study protocol

INTRODUCTION

National and international guidelines make recommendations for secondary prevention of stroke including the use of medications. A strategy which engages patients in a conversation to personalise evidence-based educational material (patient-centred educational exchange; PCEE) may empower patients to better manage their medications.

METHODS AND ANALYSIS

This protocol outlines a non-blinded randomised controlled trial. Consenting patients admitted with a diagnosis of stroke or transient ischaemic attack will be randomised 1:1 to receive either a PCEE composed of two sessions, one at the bedside before discharge and one by telephone at least 10 days after discharge from hospital in addition to usual care (intervention) or usual care alone (control). The primary aim of this study is to determine whether a PCEE improves adherence to antithrombotic, antihypertensive and lipid-lowering medications prescribed for secondary prevention of stroke over the 3 months after discharge, measured using prescription-refill data. Secondary aims include investigation of the impact of the PCEE on adherence over 12 months using prescription-refill data, self-reported medication taking behaviour, self-reported clinical outcomes (blood pressure, cholesterol, adverse medication events and readmission), quality of life, the cost utility of the intervention and changes in beliefs towards medicines and illness.

ETHICS AND DISSEMINATION

Communication of the trial results will provide evidence to aid clinicians in conversations with patients about medication taking behaviour related to stroke prevention. The targeted audiences will be health practitioners and consumers interested in medication taking behaviour in chronic diseases and in particular those interested in secondary prevention of stroke.The trial has ethics approval from Metro South Human Research Ethics Committee (HREC/15/QPAH/531) and The University of Queensland Institutional Human Research Ethics (2015001612).

TRIAL REGISTRATION NUMBER

ACTRN12615000888561; Pre-results.

Implementing a STEMI system of care in urban Bangalore: Rationale and Study Design for heart rescue India

Background

A system of care designed to measure and improve process measures such as symptom recognition, emergency response, and hospital care has the potential to reduce mortality and improve quality of life for patients with ST-elevation myocardial infarction (STEMI).

Objective

To document the methodology and rationale for the implementation and impact measurement of the Heart Rescue India project on STEMI morbidity and mortality in Bangalore, India.

Study Design

A hub and spoke STEMI system of care comprised of two interventional, hub hospitals and five spoke hospitals will build and deploy a dedicated emergency response and transport system covering a 10 Km. radius area of Bangalore, India. High risk patients will receive a dedicated emergency response number to call for symptoms of heart attack. A dedicated operations center will use geo-tracking strategies to optimize response times including first responder motor scooter transport, equipped with ECG machines to transmit ECG's for immediate interpretation and optimal triage. At the same time, a dedicated ambulance will be deployed for transport of appropriate STEMI patients to a hub hospital while non-STEMI patients will be transported to spoke hospitals. To enhance patient recognition and initiation of therapy, school children will be trained in basic CPR and signs and symptom of chest pain. Hub hospitals will refine their emergency department and cardiac catheterization laboratory protocols using continuous quality improvement techniques to minimize treatment delays. Prior to hospital discharge, secondary prevention measures will be initiated to enhance long-term patient outcomes.

Do individual versus illness belief schema differ in the prediction of post-stroke recovery?

This longitudinal observational study examined how individual versus illness belief schema compare as predictors of post-stroke recovery. A total of 42 stroke survivors (mean age = 66.9 years/range = 29–96 years; 68% male) were involved. The primary outcome, Health-Related Quality of Life was measured using EQ-5D-5L, mood using Patient Health Questionnaire-9 and disability using Nottingham Extended Activities of Daily Living Scale. Stroke Illness Perception Questionnaire-Revised measured illness beliefs. Linear regressions showed that individual illness beliefs significantly explained more of the variance in 3-month post-stroke recovery than schema (7.4%–22.5% versus 1.9%–9.9%). Individual versus illness belief schema predict outcomes differently, but which approach predicts outcomes better remains unclear.

Secondary Prevention Three and Six Years after Stroke Using the French National Insurance Healthcare System Database

BACKGROUND

Secondary prevention is inadequate in the first 2 years after stroke but what happens after that is less documented. The aim of this study was to assess the use and the adherence to preventive drugs 3 and 6 years after experiencing a transient ischemic attack (TIA) or an ischemic stroke (IS).

METHODS

The population study was from the AVC69 cohort (IS or TIA admitted in an emergency or stroke unit in the Rhône area, France, for an IS or a TIA during a 7-month period). Medication use was defined as ≥1 purchase during the studied year and adherence as Continuous Measure of Medication Acquisition ≥0.8 using the French medical insurance health care funding database.

RESULTS

The study population consisted of 210 patients at 3 years and 163 patients at 6 years. Medication use at 3 and 6 years was, respectively, 80.9 and 79.8% for antithrombotics, 69.1 and 66.3% for antihypertensives, 60.5 and 55.2% for statins and 48.6 and 46.6% for optimal treatment defined as the treatment achieved by the use of the 3 drugs. Adherence to each class was good at 3 years and tends to decrease at 6 years.

CONCLUSIONS

More than one patient out of 2 do not use the optimal preventive treatment.

Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment (SMAART): study protocol for a randomized controlled trial

Background

There is an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA). Secondary prevention guidelines recommend that antihypertensive, statin and antiplatelet therapy be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular-risk reduction. However, these goals are seldom realized in routine clinical care settings in SSA due to logistical challenges.

We seek to assess whether a polypill containing fixed doses of three antihypertensive agents, a statin and antiplatelet therapy taken once daily per os for 12 months among recent stroke survivors would result in carotid intimal thickness regression compared with usual care (UC).

Methods

The Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment (SMAART) trial is a phase 2, open-label, evaluator-blinded trial involving 120 Ghanaian recent-ischemic-stroke survivors. Using a computer-generated sequence, patients will be randomly allocated 1:1 into either the intervention arm or UC. Patients in the intervention arm will receive Polycap DS® (containing aspirin, 100 mg; atenolol, 50 mg; ramipril, 5 mg; thiazide, 12.5 mg; simvastatin, 20 mg) taken as two capsules once daily. Patients in the UC will receive separate, individual secondary preventive medications prescribed at the physician’s discretion. Both groups will be followed for 12 months to assess changes in carotid intimal thickness regression – a surrogate marker of atherosclerosis – as primary outcome measure. Secondary outcome measures include adherence to therapy, safety and tolerability, health-related quality of life, patient satisfaction, functional status, depression and cognitive dysfunction.

Discussion

An efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, parallel-group, randomized controlled trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in SSA.

Trial registration

ClinicalTrials.gov, ID: NCT03329599. Registered on 11 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2564-0) contains supplementary material, which is available to authorized users.

Evaluating practical support stroke survivors get with medicines and unmet needs in primary care: a survey

OBJECTIVES

To design a questionnaire and use it to explore unmet needs with practical aspects of medicine taking after stroke, predictors of medicine taking and to estimate the proportion of survivors who get support with daily medication taking.

DESIGN

Four workshops with stroke survivors and caregivers to design the questionnaire.A cross-sectional postal questionnaire in primary care.

SETTING

18 general practitioner practices in the East of England and London. Questionnaires posted between September 2016 and February 2017.

PARTICIPANTS

1687 stroke survivors living in the community outside institutional long-term care.

PRIMARY OUTCOME MEASURES

The proportion of community stroke survivors receiving support from caregivers for practical aspects of medicine taking; the proportion with unmet needs in this respect; the predictors of experiencing unmet needs and missing taking medications.

RESULTS

A five-item questionnaire was developed to cover the different aspects of medicine taking. 596/1687 (35%) questionnaires were returned. 56% reported getting help in at least one aspect of taking medication and 11% needing more help. 35% reported missing taking their medicines. Unmet needs were associated with receiving help with medications (OR 5.9, P<0.001), being on a higher number of medications (OR 1.2, P<0.001) and being dependent for activities of daily living (OR 4.9, P=0.001). Missing medication was associated with having unmet needs (OR 5.3, P<0.001), receiving help with medications (OR 2.1, P<0.001), being on a higher number of medicines (OR 1.1, P=0.008) and being older than 70 years (OR 0.6, P=0.006).

CONCLUSIONS

More than half of patients who replied needed help with taking medication, and 1 in 10 had unmet needs in this regard. Stroke survivors dependent on others have more unmet needs, are more likely to miss medicines and might benefit from focused clinical and research attention. Novel primary care interventions focusing on the practicalities of taking medicines are warranted.

Non-persistence in ischaemic stroke: Risk of recurrent vascular events

OBJECTIVES

Ischaemic stroke is one of the leading causes of death and disability worldwide. Although the secondary preventive medication should be continued for life, its use commonly declines in time. This may lead to recurrent vascular events. In this study, we investigated if during a long follow-up period discontinuation of medication (non-persistence) in real life ischaemic stroke patients increased the risk of recurrent vascular events.

MATERIALS AND METHODS

This was a retrospective cohort study with the data retrieved from a database and the original patient records. The occurrence of new vascular events was determined from the electronic medical record. Medication use at time of follow-up was ascertained using the pharmacy-link in the electronic medical file and through a telephone interview. Primary endpoint was recurrent vascular events. Patients with two or more vascular risk factors were considered as having a high-risk profile.

RESULTS

A total of 286 patients (persistent n = 182 and non-persistent n = 104) were included. After median follow-up period of 5½ years in the persistent group 14.8% had a recurrent vascular event, vs 23.1% in the non-persistent group (P = .801). In the patients with a high-risk profile, the persistent group had significantly less recurrent vascular events than the non-persistent group (23.5% against 46.4% P = .021).

CONCLUSION

After a long follow-up period, ischaemic stroke patients with a high vascular risk profile who stopped taking their secondary preventive medication had an increased risk of a recurrent vascular events.

Non-persistence with antiplatelet therapy in elderly patients after a transient ischemic attack

BACKGROUND

Antiplatelet therapy following a transient ischemic attack (TIA) constitutes an important secondary prevention measure.

AIMS

The study was aimed at evaluating the development of non-persistence with antiplatelet therapy in elderly patients after a TIA and identifying patient-related characteristics associated with the probability of non-persistence during the follow-up period.

METHODS

The study cohort (n = 854) was selected from the database of the largest health insurance provider of the Slovak Republic. It included patients aged ≥65 years, in whom antiplatelet medication was initiated following a TIA diagnosis during the period between 1 January 2010 and 31 December 2010. Each patient was followed for a period of 3 years from the date of the first antiplatelet medication prescription associated with TIA diagnosis. Patients in whom there was a treatment gap of at least 6 months without antiplatelet medication prescription were defined as "non-persistent". The factors predicting non-persistence were identified in the Cox proportional hazards model.

RESULTS

At the end of the follow-up period, 345 (40.4%) patients were non-persistent with antiplatelet medication. Protective factors decreasing a patient´s likelihood of becoming non-persistent were age ≥75 years [hazard ratio (HR) = 0.75], polypharmacy (concurrent use of ≥6 drugs) (HR = 0.79), arterial hypertension (HR = 0.68), diabetes mellitus (HR = 0.74), hypercholesterolemia (HR = 0.75), and antiplatelet medication switching during the follow-up period (HR = 0.73).

CONCLUSIONS

It is concluded that following a TIA, elderly patients aged <75 years or those with normal serum cholesterol levels, without certain comorbid conditions and polypharmacy may benefit from special counselling to encourage persistence with secondary preventive medication.

Psychological Determinants of Medication Adherence in Stroke Survivors: a Systematic Review of Observational Studies

BACKGROUND

Medications targeting stroke risk factors have shown good efficacy, yet adherence is suboptimal. To improve adherence, its determinants must be understood. To date, no systematic review has mapped identified determinants into the Theoretical Domains Framework (TDF) in order to establish a more complete understanding of medication adherence.

PURPOSE

The aim of this study was to identify psychological determinants that most influence stroke survivors' medication adherence.

METHODS

In line with the prospectively registered protocol (PROSPERO CRD42015016222), five electronic databases were searched (1953-2015). Hand searches of included full text references were undertaken. Two reviewers conducted screening, data extraction and quality assessment. Determinants were mapped into the TDF.

RESULTS

Of 32,825 articles, 12 fulfilled selection criteria (N = 43,984 stroke survivors). Tested determinants mapped into 8/14 TDF domains. Studies were too heterogeneous for meta-analysis. Three TDF domains appeared most influential. Negative emotions ('Emotions' domain) such as anxiety and concerns about medications ('Beliefs about Consequences' domain) were associated with reduced adherence. Increased adherence was associated with better knowledge of medications ('Knowledge' domain) and stronger beliefs about medication necessity ('Beliefs about Consequences' domain). Study quality varied, often lacking information on sample size calculations.

CONCLUSIONS

This review provides foundations for evidence-based intervention design by establishing psychological determinants most influential in stroke survivors' medication adherence. Six TDF domains do not appear to have been tested, possibly representing gaps in research design. Future research should standardise and clearly report determinant and medication adherence measurement to facilitate meta-analysis. The range of determinants explored should be broadened to enable more complete understanding of stroke survivors' medication adherence.

Self-Care Performance of Middle-Aged Stroke Patients in Korea

The incidence rate of middle-aged ischemic stroke patients has been increasing. Because of their high risk of recurrence, it is important for them to adhere to their self-care performance. The purpose of this study was to investigate predictors of self-care performance among middle-aged ischemic stroke patients. A descriptive correlational and cross-sectional survey design was used. About 140 participants who had been diagnosed with ischemic stroke within a year and visited neurological outpatients were investigated. Participants answered self-report questionnaires, the Secondary Stroke Prevention Knowledge Scale, the Health-Related Hardiness Scale, and the Subjective Self-Care Performance Scale. Hardiness, secondary-stroke-prevention knowledge, age, and stroke-diagnosis duration had statistically significant influences on self-care performance; hardiness had the largest effect. This study highlighted hardiness as the major predictor of self-care performance. To improve middle-aged ischemic stroke patients' self-care performance, nurses need an integrated approach that considers a patient's age, diagnosis duration, secondary-stroke-prevention knowledge, and, especially, hardiness.

Independent predictors of medication adherence among Singaporean patients following an ischaemic stroke or transient ischaemic attack

OBJECTIVES

To investigate the independent predictors of medication adherence among Singaporean patients following an ischaemic stroke or transient ischaemic attack.

BACKGROUND

Secondary prevention of stroke includes optimal control over modifiable risk factors, and medication adherence is important in controlling the effect of comorbidities. However, there is a paucity of published literature on the topics of medication adherence among stroke patients, especially in the Asian population.

DESIGN

A cross-sectional, descriptive, correlational study.

METHODS

One hundred and twenty-one patients with ischaemic stroke or transient ischaemic attack were recruited from a tertiary hospital in Singapore. Data collection included the Morisky Medication Adherence Scale-8 (MMAS-8), General Self-Efficacy Survey (GSES) and Medical Outcome Study Social Support Survey. Multiple linear regression analyses were used to evaluate predictors of medication adherence, measured by MMAS-8.

RESULTS

The mean score of the MMAS-8 was 5.07 (SD = 2.20, range 0-8), and more than 80% of the participants had low (n = 65, 53.7%) or medium (n = 34, 28.1%) levels of medication adherence. Multivariate linear regression analysis showed that two factors, namely "understanding the benefits of medications" (β = 0.238, p = .010) and "having suffered from stroke twice or more" (β = 0.235, p = .014), were identified as independent predictors of medication adherence in stroke patients while the other variables were adjusted. These two factors accounted for 12.4% of the variance.

CONCLUSION

Medication adherence was poor in Singaporean patients following an ischaemic stroke or transient ischaemic attack. The independent predictors identified in this study will support healthcare professionals to develop tailored intervention to improve medication adherence among this group of patients.

RELEVANCE TO CLINICAL PRACTICE

Nurses play an important role in promoting patients' medication adherence. Helping stroke patients understand the long-term benefits of their medications is essential to enhance patients' medication adherence and results in better health outcomes.

Age and composite end-point events in medium follow-up of patients with carotid artery total occlusion using drug therapy

BACKGROUND AND AIMS

The outcome of carotid artery total occlusion (CATO) is unclear. The aim of this study is to report the medium incidence of composite end-point events and risk factors (especially age), in patients with CATO, treated medically.

METHODS

This was a single center retrospective study. Composite end-point events included death, ischemic stroke, transient ischemic attack, hemorrhagic stroke, myocardial infarction, or angina. Logistic regression analysis was used to analyze risk factors of composite end-point events.

RESULTS

A total of 94 patients with CATO were included in the study. The mean follow-up duration was 30 ± 16 months. There were 16 cases who experienced composite end-point events (17.0%); among them, there were 15 cases of death (16.0%), 8 cases of ischemic stroke (7 cases of fatal stroke and 1 case of non-fatal stroke) (8.5%), and 1 case of angina pectoris (1%) (the patient later developed ischemic stroke). With increased age, the incidence of composite end-point events was significantly increased (p = 0.002). Multivariate logistic regression analysis showed that only age was a risk factor (OR = 3.051 (1.351-6.890), p = 0.007).

CONCLUSIONS

The incidence of composite end-point events in patients with CATO was as high as 17.0% at approximately 3 years after drug therapy alone. For every 10 years of age increase, the risk increase of composite end-point events doubles.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

Angiotensin II Peptide Vaccine Protects Ischemic Brain Through Reducing Oxidative Stress

Background and Purpose—

Medication nonadherence is one of major risk factors for the poor outcome in ischemic stroke. Vaccination is expected to solve such a problem because of its long-lasting effects, but its effect on ischemic brain damage is still unknown. Here, we focused on vaccination for renin–angiotensin system and examined the effects of angiotensin II (Ang II) peptide vaccine in permanent middle cerebral artery occlusion model in rats.

Methods—

Male Wistar rats were exposed to permanent middle cerebral artery occlusion after 3× injections of Ang II peptide vaccine, and the serum or brain level of anti–Ang II antibody was examined. The effects of the vaccine were evaluated by differences in infarction volume, brain renin–angiotensin system components, and markers for neurodegeneration and oxidative stress.

Results—

Ang II vaccination successfully produced anti–Ang II antibodies in serum without concomitant change in blood pressure. Sufficient production of serum anti–Ang II antibody led to reduction of infarct volume and induced the penetration of anti–Ang II antibody in ischemic hemisphere, with suppressed expression of Ang II type 1 receptor mRNA. Vaccinated rats with sufficient antibody production showed the reduction of Fluoro-Jade B–positive cells, spectrin fragmentation, 4-hydroxynonenal-positive cells, and Nox 2 mRNA expression.

Conclusions—

Our findings indicate that Ang II vaccination exerts neuroprotective and antioxidative effects in cerebral ischemia, with renin–angiotensin system blockade by penetration of anti–Ang II antibodies into ischemic brain lesion. Ang II peptide vaccination could be a promising approach to treat ischemic stroke.

Stroke minimization through additive anti-atherosclerotic agents in routine treatment (SMAART): A pilot trial concept for improving stroke outcomes in sub-Saharan Africa

There has been an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA), which when compared to stroke profiles in high-income countries (HIC) is characterized by a younger age of onset, higher case fatality rates, and more severe disability among survivors. Stroke survivors in SSA (vs. HIC) are especially at high risk for recurrent vascular events or death due to undiagnosed or under-controlled vascular risk factors, logistical challenges, low health literacy, and lack of care affordability. While international expert consensus secondary prevention guidelines recommend that antihypertensive, statin and anti-platelet therapy, be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular risk reduction, these goals are seldom realized in routine clinical care settings in SSA. A relatively simple, low-cost, evidence-based strategy that could be largely applied in a uniform manner to stroke survivors in low-to-middle income countries (LMICs), including the nations of SSA, is sorely needed. Fixed-dose combination pills, also known "polypills", containing generic drugs, i.e. Aspirin, a statin, and blood pressure (BP) lowering medication(s) may be a viable avenue to improve medication adherence and consequently reduce risk of further disability or death on a large scale among stroke survivors encountered in resource-constrained regions. In this conceptual article, we review the data supporting the rationale for a polypill to improve stroke outcomes in SSA and propose the conduct of a Stroke Minimization through Additive Anti-atherosclerotic Agent in Routine Treatment (SMAART) pilot study to determine the impact of a polypill such as the Polycap DS® in reducing future vascular risk compared to usual care in recent stroke in SSA. A preliminarily feasible and efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, randomized trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in LMICs.

Racial differences in statin adherence following hospital discharge for ischemic stroke

OBJECTIVE

To compare nonadherence to statins in older black and white adults following an ischemic stroke.

METHODS

We studied black and white adults ≥66 years of age with Medicare fee-for-service insurance coverage hospitalized for ischemic stroke from 2007 to 2012 who filled a statin prescription within 30 days following discharge. Nonadherence was defined as a proportion of days covered <80% in the 365 days following hospital discharge. In addition, we evaluated factors associated with nonadherence for white and black participants separately.

RESULTS

Overall 2,763 beneficiaries met the inclusion criteria (13.5% black). Black adults were more likely than white adults to be nonadherent (49.7% vs 41.5%) even after adjustment for demographics, receipt of a low-income subsidy, and baseline comorbidities (adjusted relative risk [RR] 1.14, 95% confidence interval [CI] 1.01-1.29). Among white adults, receipt of a low-income subsidy (adjusted RR 1.13, 95% CI 1.02-1.26), history of coronary heart disease (adjusted RR 1.15, 95% CI 1.01-1.30), and discharge directly home following stroke hospitalization (adjusted RR 1.26, 95% CI 1.10-1.44) were associated with a higher risk of nonadherence. Among black adults, a 1-unit increase in the Charlson comorbidity index (adjusted RR 1.04, 95% CI 1.01-1.09), history of carotid artery disease (adjusted RR 2.38, 95% CI 1.08-5.25), and hospitalization during the 365 days prior to the index stroke (adjusted RR 1.34, 95% CI 1.01-1.78) were associated with nonadherence.

CONCLUSIONS

Compared with white adults, black adults were more likely to be nonadherent to statins following hospitalization for ischemic stroke.

Secondary prevention and cognitive function after stroke: a study protocol for a 5-year follow-up of the ASPIRE-S cohort

INTRODUCTION

Cognitive impairment is common following stroke and can increase disability and levels of dependency of patients, potentially leading to greater burden on carers and the healthcare system. Effective cardiovascular risk factor control through secondary preventive medications may reduce the risk of cognitive decline. However, adherence to medications is often poor and can be adversely affected by cognitive deficits. Suboptimal medication adherence negatively impacts secondary prevention targets, increasing the risk of recurrent stroke and further cognitive decline. The aim of this study is to profile cognitive function and secondary prevention, including adherence to secondary preventive medications and healthcare usage, 5 years post-stroke. The prospective associations between cognition, cardiovascular risk factors, adherence to secondary preventive medications, and rates of recurrent stroke or other cardiovascular events will also be explored.

METHODS AND ANALYSIS

This is a 5-year follow-up of a prospective study of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort of patients with stroke. This cohort will have a detailed assessment of cognitive function, adherence to secondary preventive medications and cardiovascular risk factor control.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted by the Research Ethics Committees at Beaumont Hospital, Dublin and Connolly Hospital, Dublin, Mater Misericordiae University Hospital, Dublin, and the Royal College of Surgeons in Ireland. Findings will be disseminated through presentations and peer-reviewed publications.