Secondary preventive medication persistence and adherence 1 year after stroke

Interruption to antiplatelet therapy early after acute ischaemic stroke: a nested case-control study

AIMS

Antiplatelet drugs are often discontinued early after ischaemic stroke, either because of poor compliance, complications or withdrawal of care. It is unclear whether this places patients at increased risk of recurrence. We explored the association between cardiovascular event rate and persistence with prescribed antiplatelet drugs.

METHODS

We used a matched case-control design using the Virtual International Stroke Trials Archive (VISTA). Cases were patients who had an acute coronary syndrome, recurrent stroke or transient ischaemic attack within 90 days post-stroke and were matched for age ± 10 years and sex with up to four controls. Antiplatelet use was categorized as persistent (used for >3 days and continued up to day 90), early cessation (used antiplatelet <3 days) or stopped/interrupted users (used for >3 days but stopped prior to day 90). These categories were compared in cases and controls using a conditional logistic regression model that adjusted for potential confounders.

RESULTS

A total of 970 patients were included, of whom 194 were cases and 776 were matched controls. At 90 days, 10 cases (5.2%) and 58 controls (7.5%) stopped/interrupted their antiplatelet. The risk of cardiovascular event was not different in stopped/interrupted users (adjusted odds ratio 0.70, 95% confidence interval 0.33, 1.48; P = 0.352) and early cessations (adjusted odds ratio 1.04, 95% confidence interval 0.62, 1.74; P = 0.876) when compared to persistent users.

CONCLUSION

We found no increased risk in patients who stopped and interrupted antiplatelets early after stroke but the study was limited by a small sample size and further research is needed.

[Organized Post-Stroke Care through Case Management on the Basis of a Standardized Treatment Pathway : Results of a Single-Centre Pilot Study]

BACKGROUND

Post-stroke care programs based on a standardized treatment pathway supported by case management may prevent secondary stroke and minimize risk factors.

OBJECTIVES

We aimed to determine the feasibility of a standardized treatment pathway and its impact on risk factor control, life-style changes and adherence to secondary prevention medication.

METHODS

We conducted a prospective pilot study in consecutive stroke patients. The 12-month post-stroke care program included regular perosnal and phone contact with a certified case manager. Target values for vascular risk factors following current recommendations of stroke guidelines were monitored and treated if necessary. In the case of deviations from the treatment pathway the case manager intervened. Patients were screened for recurrent stroke at the end of the program after 12 months.

RESULTS

We enrolled 101 patients: 57.4 % were male, the median age was 72 (IQR, 62-80) years, median baseline NIHSS score was 2(IQR, 1-5), 79.2 % had an ischemic stroke, 3 % a hemorrhagic stroke, and 17.8 % a transient ischemic attack (TIA). Eighty-six (85.1 %) patients completed the program, 12 (11.9 %) withdrew from the program and 3 died of malignant diseases. In total, 628 personal (6.2/patient) and 2,683 phone contacts (26.6/patient) were conducted by the case manager. Three hundred-seventy-nine specific interventions were necessary mostly because of missing medication, non-compliance, and social needs. After 12 months, target goals for blood pressure, body mass index, nicotine use, and cholesterol were more frequently (p < 0.05) achieved than at baseline. No recurrent stroke occurred during the program.

CONCLUSIONS

Our pilot data demonstrate that case management-based post-stroke care is feasible and may contribute to effective secondary prevention of stroke.

Preliminary development of the Medication Nonpersistence Scale

OBJECTIVES

To develop the Medication Nonpersistence Scale (MNPS)-a multi-item self-reported scale to measure medication persistence.

SETTING

Six hundred seventy-five patients patronizing 3 separate independent community pharmacies in the southeastern United States participated in this research.

PRACTICE INNOVATION

The MNPS, a self-reported measure, developed to provide an estimate of, and reasons for, medication nonpersistence.

EVALUATION

Cross-sectional survey data were linked with retrospective prescription fill data obtained from 3 independent community pharmacies in the southeastern United States. The MNPS factor structure was studied by means of confirmatory factor analysis (CFA), and its scale reliability and convergent validity were evaluated with the use of the results of this analysis. Its concurrent validity was tested against a standardized days-to-discontinuation measure calculated over the past 12 months, and an attempt was made to arrive at an optimum cutoff point to identify patients who have been nonpersistent with their medications.

RESULTS

The survey yielded 675 usable patients. The CFA confirmed a single-factor solution with good model fit (root mean square error of approximation = 0.06 [90% CI 0.05-0.07]; comparative fit index = 0.96). Moderate to strong evidence of scale reliability (Cronbach alpha = 0.75; construct reliability = 0.94; index of composite reliability developed for binary items = 0.91), convergent validity (standardized factor loadings >0.5 and statistically significant), and concurrent validity (unstandardized regression coefficient = -3.97; P = 0.03) was observed. Individuals who score 1 or higher on the MNPS were considered to be nonpersistent.

CONCLUSION

The MNPS demonstrated good psychometric properties and offers a useful first step toward the self-reported measurement of medication persistence in clinical practice and research.

2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.

Baseline Prescription and One-Year Persistence of Secondary Prevention Drugs after an index Stroke in Central Ghana

BACKGROUND AND PURPOSE

There is a paucity of data on persistence of secondary prevention medications among stroke survivors in resource-limited settings where stroke is on a rapid upward trajectory and its management severely challenged. To avert new cardiovascular events after stroke, preventive medications should be promptly instituted and used continuously. We report 1-year rates and determinants of persistent utilization of secondary prevention therapies after stroke in Ghana.

METHODS

A retrospective observational study involving 418 stroke survivors enrolled into a Neurology clinic in a tertiary institution in central Ghana between January 2011 and December 2013. Data on demography, stroke type, risk factor profile and five secondary risk prevention medication classes namely antihypertensive, antiplatelet, statins, antidiabetic and anticoagulants were collected from patient charts. Persistence within first year after stroke was defined as continuation of all secondary preventive medications prescribed at enrollment to the Neurology clinic and it excluded 126 (≈30%) patients who could not complete 12 month follow up. Data was closed for analysis in June 2015 to allow for at least 12 months of follow-up.

RESULTS

Rates of utilization of secondary preventive medications and its intensity were influenced by stroke type and prevailing vascular risk factors. In decreasing order, antihypertensive, lipid-modifying, anti-platelet, anti-diabetic medications and anti-coagulants were prescribed at frequencies (%) of 394 (94.3%), 303 (72.5%), 274 (65.6%), 61 (14.6%) and 2 (0.5%) respectively at enrollment into the Neurology clinic (n=418). Overall, 92.1% of subjects (n=292) under follow-up for 1 year were persistent on secondary prevention medications initiated at enrollment into the neurology clinic with medication class specific rates of 97.5% for antihypertensive, 94.8% for anti-platelets, 94.1% for statins, 85.7% for anti-diabetic and 50% for anticoagulants. Abuse of alcohol was significantly associated with non-persistence, adjusted OR (95% CI) of 3.08 (1.13-8.38).

CONCLUSION

Persistence of secondary preventive medications among stroke survivors in this resource-limited setting is excellent and comparable to those in resource-replete countries. There is however the need to investigate the causes of high attrition rates from care.

Sociodemographic factors are associated with utilisation of statins after ischaemic stroke/TIA

OBJECTIVES

To analyse if there are sociodemographic differences in the utilisation of statins 9-12 months after ischaemic stroke or transitory ischaemic attack.

METHODS

Anonymised linkage of registry data on all patients >18 years discharged from the hospitals in Stockholm, Sweden 2006-2010 with diagnosis of ischaemic stroke (ICD-10: I63.0-9) or TIA (ICD-10: G45.9) was performed. Data on hospitalisations and diagnoses were collected from the Stockholm County Council administrative databases on healthcare consumption. Dispensed prescriptions with statins and, for comparative purposes, antihypertensive agents 9-12 months after discharge were acquired from the National Swedish Prescribed Drug Register. Data about socioeconomic factors were obtained from Statistics Sweden. The dispensing of statins and antihypertensive agents, relative to sociodemographic variables were analysed. Using logistic regression odds ratios, crude, and adjusted with education, income, origin of birth, age, and sex as predictors where calculated.

RESULTS

Of 24 312 patients with ischaemic stroke/TIA, 19 335 were alive 12 months after discharge. Statins were dispensed to 44% of all patients in the cohort, more frequently to men of all age groups, to patients with higher education, and to those with higher income. Antihypertensive agents were dispensed to 68% of all patients and there were no differences related to sex and income whilst patients with lower education were dispensed with antihypertensives more frequently.

CONCLUSION

We find a low utilisation of statins one year after ischaemic stroke/TIA. Patients with low education, low income, and female sex were dispensed fewer prescriptions of statins indicating a need for improvement.

A pilot study to assess the practicality, acceptability and feasibility of a randomised controlled trial to evaluate the impact of a pharmacist complex intervention on patients with stroke in their own homes

OBJECTIVE

To test the practicality, acceptability and feasibility of recruitment, data collection, blood pressure (BP) monitoring and pharmaceutical care processes, in order to inform the design of a definitive randomised controlled trial of a pharmacist complex intervention on patients with stroke in their own homes.

METHODS

Patients with new stroke from acute, rehabilitation wards and a neurovascular clinic (NVC) were randomised to usual care or to an intervention group who received a home visit at 1, 3 and 6 months from a clinical pharmacist. Pharmaceutical care comprised medication review, medicines and lifestyle advice, pharmaceutical care issue (PCI) resolution and supply of individualised patient information. A pharmaceutical care plan was sent to the General Practitioner and Community Pharmacy. BP and lipids were measured for both groups at baseline and at 6 months. Questionnaires covering satisfaction, quality of life and medicine adherence were administered at 6 months.

RESULTS

Of the 430 potentially eligible patients, 30 inpatients and 10 NVC outpatients were recruited. Only 33/364 NVC outpatients (9.1%) had new stroke. 35 patients completed the study (intervention=18, usual care=17). Questionnaire completion rates were 91.4% and 84.4%, respectively. BP and lipid measurement processes were unreliable. From 104 identified PCIs, 19/23 recommendations (83%) made to general practitioners were accepted.

CONCLUSION

Modifications to recruitment is required to include patients with transient ischaemic attack. Questionnaire response rates met criteria but completion rates did not, which merits further analysis. Lipid measurements are not necessary as an outcome measure. A reliable BP-monitoring process is required.

Associations between Ischemic Stroke Follow-Up, Socioeconomic Status, and Adherence to Secondary Preventive Drugs in Southern Sweden: Observations from the Swedish Stroke Register (Riksstroke)

Background: Currently, the knowledge that one has on adequate stroke follow-up practices is limited. We report associations between 90-day stroke follow-up, socio-economy and adherence to secondary prevention in southern Sweden. Methods: Data on 5,602 patients with ischemic stroke January 1, 2008-December 31, 2010, were obtained from Riksstroke and linked to official registers for information on education, birth country, doctor's follow-ups, and secondary prevention. Primary adherence at 4 months and persistence at 14 months post-stroke were calculated for warfarin, statins, antihypertensive, and antiplatelet drugs. Results: The 90-day follow-up rate was 75%. Patients not receiving a 90-day follow-up had lower age-adjusted OR of persistent drug use at 14 months for antihypertensive agents (OR = 0.74, 95% CI 0.60-0.91) and for antiplatelet drugs (OR = 0.72, 95% CI 0.60-0.87). Drug adherence rates 14 months post-stroke were 85% for antiplatelet drugs, 69% for warfarin, 88% for antihypertensive agents, and 76% for statins. One in three patients discontinued using one or more drug class within 14 months, and nonadherence was associated with activities of daily living dependency at 3 months (age-adjusted OR 0.63, 95% CI 0.57-0.69), but not with age, gender, or educational status. Conclusions: The use of secondary preventive drugs decreases over the first year after stroke and remains suboptimal. Specific reasons for nonadherence warrant further study.

A Systematic Review of Randomized Controlled Trials of Medication Adherence Interventions in Adult Stroke Survivors

BACKGROUND

Stroke survivors are at an increased risk for recurrent stroke. Despite recommendations to avoid recurrence from the American Heart Association/American Stroke Association, medication adherence (MA) in persons with chronic conditions such as stroke is only 50%.

PURPOSE

The aim of this study was to synthesize randomized controlled trial intervention studies designed to increase MA in adult stroke survivors.

SEARCH METHODS

The Cumulative Index of Nursing and Allied Health Literature, PsycINFO, PubMed, and Excerpta Medica database from January 1, 2009, to December 31, 2015, were searched.

STUDY SELECTION

This study reviewed randomized controlled trials evaluating MA interventions in stroke survivors.

DATA EXTRACTION

Two reviewers independently assessed all full-text articles, and those not meeting the inclusion criteria by both researchers were excluded.

RESULTS

This review included 18 studies involving 10 292 participants. Overall, the strength of the included studies was strong. Statistically significant results were reported in 5 of the 18 (28%) studies. Of these, 3 used cognitive/behavioral interventions to increase MA, whereas 2 studies used an educational-based intervention.

CONCLUSIONS

Despite some isolated success, most MA interventions in stroke survivors do not show statistically significant improvement. Future MA research must address the lack of consistent use of objective measurement tools and focus on the long-term benefits of MA interventions.

One-Year Rates and Determinants of Poststroke Systolic Blood Pressure Control among Ghanaians

BACKGROUND AND OBJECTIVE

Elevated systolic blood pressure (SBP) is potently associated with risk of recurrent strokes. In resource-limited settings, there is a dearth of data on the rates and determinants of uncontrolled SBP among stroke survivors at high risk of recurrent events. The objective of this study is to assess the rates and determinants of uncontrolled SBP over the first year post stroke.

METHODS

This is a retrospective observational study involving stroke survivors who enrolled into an outpatient neurology clinic in Kumasi, Ghana, between January 2012 and June 2014. Baseline demographic features, clinical characteristics, antihypertensive medications prescribed at each clinic visit, treatment modifications, and clinic blood pressure measurements were recorded. Predictors of uncontrolled SBP during follow-up were assessed using a multivariable logistic regression model.

RESULTS

A total of 602 stroke survivors enrolled for follow-up within the study period of which 89.8% had hypertension. Up to 35% of subjects had an SBP above 140 mmHg during follow-up clinic visits. Among those with uncontrolled SBP, 17% had antihypertensive treatment modifications during follow-up. Predictors of uncontrolled SBP were SBP at enrollment into clinic, with an adjusted odds ratio (OR [95% confidence interval {CI}]) of 1.31 (1.17-1.47)/10 mmHg increase, and average number of antihypertensive medications prescribed, with an adjusted OR (95% CI) of 1.30 (1.06-1.60) for an increase in the number of antihypertensives prescribed.

CONCLUSION

A third of stroke survivors had SBP not on target during follow-up possibly due to a combination of therapeutic inertia, apparent treatment resistance, and poor adherence to therapy. Longer-term prospective interventional studies on hypertension control among stroke survivors are warranted in sub-Saharan Africa.

Relationship Between Language Preference and Intravenous Thrombolysis Among Acute Ischemic Stroke Patients

BACKGROUND

Approximately 20% of the US population primarily speaks a language other than English at home. Yet the effect of language preference on treatment of acute ischemic stroke (AIS) patients remains unknown. We aimed to evaluate the influence of language preference on AIS patients' receipt of intravenous (IV) thrombolysis.

METHODS AND RESULTS

We analyzed data from 3894 AIS patients who participated in the American Heart Association "Get With The Guidelines®-Stroke" program at our hospital from January 1, 2003 to April 30, 2014. Information included patients' language in which they preferred to receive medical care. We used descriptive statistics and stepwise logistic regression models to examine associations between patients' language preference and receipt of IV thrombolysis, adjusting for relevant covariates. A total of 306/3295 (9.3%) AIS patients preferred to speak a non-English language and represented 25 different languages. Multivariable analyses adjusting for other socioeconomic factors showed that non-English-preferring patients were more likely than English-preferring patients to receive IV thrombolysis (OR=1.64; CI=1.09-2.48; P=0.02). However, in models that also included age, sex, and initial NIH Stroke Scale, patients' language preference was no longer significant (OR 1.38; CI=0.88-2.15; P=0.16), but NIH Stroke Scale was strongly associated with receiving IV thrombolysis (OR=1.15 per point; CI=1.13-1.16; P<0.0001).

CONCLUSIONS

Contrary to our hypothesis, non-English-preferring was not associated with lower rates of IV thrombolysis among AIS patients once initial stroke severity was accounted for.

Predicting prolonged dose titration in patients starting warfarin

PURPOSE

Patients initiating warfarin therapy generally experience a dose-titration period of weeks to months, during which time they are at higher risk of both thromboembolic and bleeding events. Accurate prediction of prolonged dose titration could help clinicians determine which patients might be better treated by alternative anticoagulants that, while more costly, do not require dose titration.

METHODS

A prediction model was derived in a prospective cohort of patients starting warfarin (n = 390), using Cox regression, and validated in an external cohort (n = 663) from a later time period. Prolonged dose titration was defined as a dose-titration period >12 weeks. Predictor variables were selected using a modified best subsets algorithm, using leave-one-out cross-validation to reduce overfitting.

RESULTS

The final model had five variables: warfarin indication, insurance status, number of doctor's visits in the previous year, smoking status, and heart failure. The area under the ROC curve (AUC) in the derivation cohort was 0.66 (95%CI 0.60, 0.74) using leave-one-out cross-validation, but only 0.59 (95%CI 0.54, 0.64) in the external validation cohort, and varied across clinics. Including genetic factors in the model did not improve the area under the ROC curve (0.59; 95%CI 0.54, 0.65). Relative utility curves indicated that the model was unlikely to provide a clinically meaningful benefit compared with no prediction.

CONCLUSIONS

Our results suggest that prolonged dose titration cannot be accurately predicted in warfarin patients using traditional clinical, social, and genetic predictors, and that accurate prediction will need to accommodate heterogeneities across clinical sites and over time. Copyright © 2016 John Wiley & Sons, Ltd.

Improved persistence with non-vitamin-K oral anticoagulants compared with warfarin in patients with atrial fibrillation: recent Australian experience

OBJECTIVE

Long-term anticoagulant therapy in patients with non-valvular atrial fibrillation (AF) is essential to prevent thromboembolic complications, especially ischemic stroke, but treatment persistence with warfarin is poor. This study examines Australian nationwide persistence in AF patients using a non-vitamin-K oral anticoagulant (NOAC) drug.

RESEARCH DESIGN AND METHODS

We assessed national Pharmaceutical Benefit Scheme records November-December 2013 through March 2015 for prescription of NOAC drugs in a 10% random sample of long-term concession card holders. An historical comparison was made with patients prescribed warfarin in 2008. Key outcome measures were (i) the proportion not filling first repeat prescription and (ii) discontinuation within 12 months.

RESULTS

A total of 1471 patients with AF were new users of a NOAC drug (228 apixaban, 645 dabigatran, 598 rivaroxaban) and 1348 were new users of warfarin. Mean age on a NOAC was 76 years (58% male), on warfarin 74 years (54% male). Only 9% (95% CI 7-10) failed to collect the first repeat prescription on a NOAC, 30% (27-32) discontinued within 12 months; corresponding proportions on warfarin were 14% (12-16) and 62% (60-65). In a regression model adjusted for age, gender, heart failure, hypertension and diabetes, warfarin-treated patients were 2.5 times more likely to discontinue over 12 months than those who were NOAC treated (hazard ratio =2.47 [95% CI 2.19-2.79]).

CONCLUSIONS

Persistence with NOAC drugs in patients with AF appears to be superior to warfarin. If continued long-term, this alone will be of clinical importance in the prevention of stroke and death.

Health system barriers and facilitators to medication adherence for the secondary prevention of cardiovascular disease: a systematic review

Background

Secondary prevention is cost-effective for cardiovascular disease (CVD), but uptake is suboptimal. Understanding barriers and facilitators to adherence to secondary prevention for CVD at multiple health system levels may inform policy.

Objectives

To conduct a systematic review of barriers and facilitators to adherence/persistence to secondary CVD prevention medications at health system level.

Methods

Included studies reported effects of health system level factors on adherence/persistence to secondary prevention medications for CVD (coronary artery or cerebrovascular disease). Studies considered at least one of β blockers, statins, angiotensin–renin system blockers and aspirin. Relevant databases were searched from 1 January 1966 until 1 October 2015. Full texts were screened for inclusion by 2 independent reviewers.

Results

Of 2246 screened articles, 25 studies were included (12 trials, 11 cohort studies, 1 cross-sectional study and 1 case–control study) with 132 140 individuals overall (smallest n=30, largest n=63 301). 3 studies included upper middle-income countries, 1 included a low middle-income country and 21 (84%) included high-income countries (9 in the USA). Studies concerned established CVD (n=4), cerebrovascular disease (n=7) and coronary heart disease (n=14). Three studies considered persistence and adherence. Quantity and quality of evidence was limited for adherence, persistence and across drug classes. Studies were concerned with governance and delivery (n=19, including 4 trials of fixed-dose combination therapy, FDC), intellectual resources (n=1), human resources (n=1) and health system financing (n=4). Full prescription coverage, reduced copayments, FDC and counselling were facilitators associated with higher adherence.

Conclusions

High-quality evidence on health system barriers and facilitators to adherence to secondary prevention medications for CVD is lacking, especially for low-income settings. Full prescription coverage, reduced copayments, FDC and counselling may be effective in improving adherence and are priorities for further research.

In-hospital medical complications associated with stroke recurrence after initial ischemic stroke: A prospective cohort study from the China National Stroke Registry

In-hospital medical complications are common and strongly associated with the risk of death and dependency in stroke patients. Whether similar associations extend to stroke recurrence is unclear. We prospectively and systematically investigated whether in-hospital medical complications are associated with recurrent stroke of patients in the China National Stroke Registry (CNSR). We examined patients with initial ischemic stroke enrolled in CNSR between 2007 and 2008. Recurrent stroke at 3, 6, and 12 months post-stroke was used as stroke outcome. Medical complications were associated with stroke outcomes using multivariable logistic regression.Of the 7593 study patients, recurrent stroke occurred in 1115 (14.7%) within 12 months after stroke onset. In-hospital medical complications were independent risk factors for stroke recurrence in patients with initial ischemic stroke at 3 months (adjusted odds ratio (OR) = 2.19, 95% confidence interval (CI) 1.85 to 2.60), 6 months (adjusted OR = 2.04, 95% CI 1.74 to 2.38), and 12 months (adjusted OR = 1.88; 95% CI 1.62 to 2.19) after onset. The persistence of secondary prevention medications in patients with complications was lower than that in patients without complications.Stroke recurrence post-acute ischemic stroke is significantly associated with in-hospital medical complications.

Changes in pre-hospital management of vascular risk factors among patients admitted due to recurrent stroke in Poland from 1995 to 2013

INTRODUCTION

The aim of this study was to investigate long-term trends in secondary stroke prevention through management of vascular risk factors directly before hospital admission for recurrent stroke.

MATERIAL AND METHODS

This is a retrospective registry-based analysis of consecutive recurrent acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013 with previous ischemic stroke. We compared between four consecutive time periods: 1995-1999, 2000-2004, 2005-2009 and 2010-2013.

RESULTS

During the study period, 894 patients with recurrent strokes were admitted (18% of all strokes), including 867 with previous ischemic stroke (our study group). Among those patients, the proportion of recurrent ischemic strokes (88.1% to 93.9%) (p = 0.319) and males (44% to 49.7%) (p = 0.5) remained stable. However, there was a rising trend in patients' age (median age of 73, 74, 76 and 77 years, respectively). There was also an increase in the use of antihypertensives (from 70.2% to 83.8%) (p = 0.013), vitamin K antagonists (from 4.8% to 15.6%) (p = 0.012) and statins (from 32.5% to 59.4%) (p < 0.001). Nonetheless, 21% of patients did not receive any antithrombotic prophylaxis. Tobacco smoking pattern remained unchanged.

CONCLUSIONS

Our data indicate a clear overall improvement of secondary stroke prevention. However, persistent use of antithrombotic drugs and tobacco smoking after the first ischemic stroke is constantly suboptimal.

Effectiveness of Goal-Setting Telephone Follow-Up on Health Behaviors of Patients with Ischemic Stroke: A Randomized Controlled Trial

BACKGROUND

Adopting healthy behaviors is critical for secondary stroke prevention, but many patients fail to follow national guidelines regarding diet, exercise, and abstinence from risk factors. Compliance often decreases with time after hospital discharge, yet few studies have examined programs promoting long-term adherence to health behaviors. Goal setting and telephone follow-up have been proven to be effective in other areas of medicine, so this study evaluated the effectiveness of a guideline-based, goal-setting telephone follow-up program for patients with ischemic stroke.

METHODS

This was a multicenter, assessor-blinded, parallel-group, randomized controlled trial. Ninety-one stroke patients were randomized to either a control group or an intervention group. Intervention consisted of predischarge education and 3 goal-setting follow-up sessions conducted by phone. Data were collected at baseline and during the third and sixth months after hospital discharge.

RESULTS

Six months after discharge, patients in the intervention group exhibited significantly higher medication adherence than patients in the control group. There were no statistically significant differences in physical activity, nutrition, low-salt diet adherence, blood pressure monitoring, smoking abstinence, unhealthy use of alcohol, and modified Rankin Scale (mRS) scores between the 2 groups.

CONCLUSIONS

Goal-setting telephone follow-up intervention for ischemic stroke patients is feasible and leads to improved medication adherence. However, the lack of group differences in other health behavior subcategories and in themRS score indicates a need for more effective intervention strategies to help patients reach guideline-recommended targets.

Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses

Purpose

Non-adherence to secondary preventative medications after stroke is relatively common and associated with poorer outcomes. Non-adherence can be due to a number of patient, disease, medication or institutional factors. The aim of this review was to identify factors associated with non-adherence after stroke.

Method

We performed a systematic review and meta-analysis of studies reporting factors associated with medication adherence after stroke. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Knowledge. We followed PRISMA guidance. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance and the Newcastle–Ottawa scales. Where data allowed, we evaluated summary prevalence of non-adherence and association of factors commonly reported with medication adherence in included studies using random-effects model meta-analysis.

Findings

From 12,237 titles, we included 29 studies in our review. These included 69,137 patients. The majority of included studies (27/29) were considered to be at high risk of bias mainly due to performance bias. Non-adherence rate to secondary preventative medication reported by included studies was 30.9% (95% CI 26.8%–35.3%). Although many factors were reported as related to adherence in individual studies, on meta-analysis, absent history of atrial fibrillation (OR 1.02, 95% CI 0.72–1.5), disability (OR 1.27, 95% CI 0.93–1.72), polypharmacy (OR 1.29, 95% CI 0.9–1.9) and age (OR 1.04, 95% CI 0.96–1.14) were not associated with adherence.

Discussion

This review identified many factors related to adherence to preventative medications after stroke of which many are modifiable. Commonly reported factors included concerns about treatment, lack of support with medication intake, polypharmacy, increased disability and having more severe stroke.

Conclusion

Understanding factors associated with medication taking could inform strategies to improve adherence. Further research should assess whether interventions to promote adherence also improve outcomes.

The stroke east Saxony pilot project for organized post-stroke care: a case-control study

BACKGROUND

Low adherence to secondary prevention guidelines in stroke survivors may increase the risk for recurrent stroke and adversely impact quality of life. We aimed to determine the feasibility of a self-developed standardized post-stroke pathway and its impact on secondary stroke prevention and long-term outcome in patients with acute stroke.

METHODS

Consecutive patients with acute stroke were prospectively included in a standardized post-stroke pathway accomplished through a single certified CM (case manager), which comprised educational discussions and quarterly checkups for vascular risk factors and adherence to antithrombotic/anticoagulant medication in addition to usual care. At 12 months, we compared achieved target goals for secondary prevention, functional outcome, stroke recurrence, and vascular death with age- and gender-matched controls that received only usual care after stroke.

RESULTS

We included 45 cases and 45 controls. The following target goals were more frequently achieved in CM-patients than in controls: blood pressure (100% vs. 46.2%, P < 0.001), cholesterol (100% vs. 74.4%, P < 0.001), and body mass index (67.4% vs. 46.2%, P = 0.052). The CM-intervention emerged as an independent predictor of favorable functional outcome (mRS ≤ 2) at 12 months after adjusting for stroke severity and systemic thrombolysis (OR: 4.27; 95%CI:1.2-15.21; P = 0.025). Quality of life was rated significantly higher in CM-patients than in controls (P = 0.049). As opposed to controls, none of the cases experienced a recurrent stroke (0% vs. 13.3%; P = 0.026) or suffered from vascular death (0% vs. 6.7%; P = 0.242).

CONCLUSIONS

Our pilot data suggest that organized post-stroke care enhances achievement of secondary prevention goals. Its possible effect on stroke recurrence, long-term disability, and quality of life is currently investigated in a prospective cohort study.

Association of black race with recurrent stroke risk

BACKGROUND

The significantly higher risk of primary stroke in Black vs. Whites is very well established. However, very few studies have specifically examined the presence of this racial disparity in recurrent stroke risk.

METHODS

We conducted an analysis of a clinical trial dataset comprising 3470 recent non-cardioembolic stroke patients aged ≥35years and followed for 2years. Subjects were categorized by race into Whites and Blacks. Cox regression analysis was used to evaluate the associations between Black (vs. White) and ischemic stroke (primary outcome); and stroke/coronary heart disease (CHD)/vascular death as major vascular events (secondary outcome) with and without adjustment for comorbid conditions associated with stroke.

RESULTS

Among participants (2925 Whites and 545 Blacks), a total of 287 (8.3%) incident stroke and 582 (16.8%) major vascular events occurred. Compared with Whites, Blacks had higher frequencies of prior stroke, hypertension, diabetes mellitus, and smoking; but were younger with lower prevalence of CHD. Frequency of stroke was higher in Blacks vs. Whites (11.4% vs. 7.7%; P=0.004), but there was no difference in major vascular events (16.9% vs. 16.8%). Compared with Whites, Blacks experienced a significantly higher risk of recurrent stroke (HR 1.58; 95% CI, 1.19-2.09), but the stroke risk was not significant after multivariable adjustment (1.13; 0.81-1.59).

CONCLUSION

Blacks are ~60% more likely to experience a recurrent stroke within 2years than their Whites, but this risk is likely mediated via stroke risk factors. These results underscore a need to optimize and sustain risk factor control in Black stroke populations.

A comparison of secondary prevention practice in poststroke and coronary heart disease patients

OBJECTIVES

It is evident that patients with atherosclerotic vascular disease (AVD) benefit from appropriate secondary prevention. In clinical reality, the secondary prevention in AVD patients other than those with coronary heart disease (CHD) is often overlooked. Therefore, we compared the adherence to secondary prevention principles between poststroke and CHD patients.

STUDY DESIGN

Descriptive (cross-sectional) study with prospective mortality follow-up.

METHODS

We examined 1729 chronic patients with AVD (mean age 65.9 (±SD 9.6) years), 964 with CHD, and 765 poststroke (pooled data of Czech samples of EUROASPIRE III, IV, and the ESH stroke survey). The interview was performed 6-36 months after the coronary event/revascularization or the first ischemic stroke, while the mortality follow-up 5 years after this interview.

RESULTS

Poststroke patients had a significantly higher risk of persistent smoking, blood pressure ≥140/90 mmHg and LDL ≥2.5 mmol/L than CHD patients [odds ratios adjusted for age, gender and survey were 1.63 (95% CI: 1.13-2.33), 1.38 (95% CI: 1.13-1.69) and 2.26 (95% CI: 1.84-2.78), respectively]. In contrast, poststroke patients showed a lower risk of inappropriate glucose control and hypertriglyceridemia [0.66 (95%CI: 0.54-0.82) and 0.74 (95%CI: 0.61-0.91), respectively]. The prescription rates of antiplatelets/anticoagulants, antihypertensives and statins were also significantly lower in poststroke than in CHD patients (89.4 vs 93.7, 85.9 vs 97.5, and 57.7 vs 89.8, respectively). Mortality analysis was performed in a subsample of 815 subjects interviewed in 2006/07. The 5-year all-cause mortality rates were 25.8% and 13.3% in poststroke and coronary patients, respectively (P = 0.0023); the hazard ratio for stroke adjusted for major risk factors was 1.85 (95% CI: 1.31-2.63).

CONCLUSIONS

Compared to CHD patients, poststroke patients are strongly handicapped in terms of poor adherence to secondary prevention target, prescription of basic pharmacotherapies and mortality risk.

Personalized medicine and stroke prevention: where are we?

There are many recommended pharmacological and non-pharmacological therapies for the prevention of stroke, and an ongoing challenge is to improve their uptake. Personalized medicine is seen as a possible solution to this challenge. Although the use of genetic information to guide health care could be considered as the apex of personalized medicine, genetics is not yet routinely used to guide prevention of stroke. Currently personalized aspects of prevention of stroke include tailoring interventions based on global risk, the utilization of individualized management plans within a model of organized care, and patient education. In this review we discuss the progress made in these aspects of prevention of stroke and present a case study to illustrate the issues faced by health care providers and patients with stroke that could be overcome with a personalized approach to the prevention of stroke.

Community physicians' knowledge of secondary prevention after ischemic stroke: a questionnaire survey in Shanxi Province, China

BACKGROUND

This cross-sectional, questionnaire-based survey, conducted in Shanxi Province, China, evaluated the knowledge of community physicians of secondary prevention of ischemic stroke and transient ischemic attacks (TIAs).

METHODS

A total of 1910 physicians practicing at 832 community-based clinics, hospitals and other care centers in 11 prefectures of Shanxi Province completed the questionnaires between 1 July and 30 September 2013.

RESULTS

Over 90 % of participants were aware of the most common risk factors for stroke, but lifestyle-related factors were seen as of low or medium importance for secondary prevention. Only about 50 % of physicians were aware of the existence of commonly used stroke scales, and fewer said that they would use those scales in their clinical practice. There were slight differences in the responses to some of the questions on risk factors and stroke scales were associated with the physicians' gender, academic qualifications, practice duration and location. Less than half of the participants were aware of the secondary prevention recommendations included in the most recent guidelines.

CONCLUSION

The survey revealed a huge gap in knowledge of current guidelines for secondary prevention of ischemic stroke and TIA among the physicians surveyed. Continuing education and training of community physicians, administered as a public health program, is needed to improve the healthcare of ischemic stroke and TIA patients.

Relationship of functional disability after a recent stroke with recurrent stroke risk

BACKGROUND AND PURPOSE

Post-stroke disability status is primarily focused on recovery prognostication but the influence of post-stroke disability on future vascular risk is unknown. The relationship between functional disability after an index stroke and risk of recurrent vascular events was examined.

METHODS

A cohort analysis of 3680 recent non-cardioembolic, non-to-moderate disabled [modified Rankin Scale (mRS) ≤3] stroke patients aged ≥35 years and followed for 2 years was reviewed. The mRS measured at a median of 35 days after the index stroke was analyzed as a dichotomous variable (mRS 3 vs. ≤2) and in a stepwise manner. Independent associations of post-stroke disability by mRS score with ischaemic stroke (primary outcome), stroke/coronary heart disease/vascular death as major vascular events (secondary outcome) and all-cause death (tertiary outcome) were analyzed.

RESULTS

Amongst study participants, 435 (11.8%) had an mRS of 3. Compared with mRS ≤2 as no/slight disability, mRS 3 as moderate disability was associated with a higher risk of stroke (adjusted hazard ratio 1.45, 95% confidence interval 1.06-1.99). Compared with mRS 0, there was a progressively higher independent risk for each of the study outcomes: stroke, mRS 1 (1.42, 0.97-2.08), mRS 2 (1.46, 0.97-2.20), mRS 3 (1.89, 1.20-2.97); major vascular events, mRS 1 (1.31, 1.01-1.70), mRS 2 (1.31, 0.99-1.74), mRS 3 (1.46, 1.06-2.01); and all-cause death, mRS 1 (1.75, 1.03-2.98), mRS 2 (2.49, 1.44-4.31), mRS 3 (2.72, 1.43-5.19).

CONCLUSION

Compared with no/slight disability, moderate disability after a recent stroke is linked to a higher risk of recurrent stroke.

Adherence to oral anticoagulants in patients with atrial fibrillation-a population-based retrospective cohort study linking health information systems in the Valencia region, Spain: a study protocol

INTRODUCTION

Adherence to oral anticoagulation (OAC) treatment, vitamin K antagonists or new oral anticoagulants, is an essential element for effectiveness. Information on adherence to OAC in atrial fibrillation (AF) and the impact of adherence on clinical outcomes using real-world data barely exists. We aim to describe the patterns of adherence to OAC over time in patients with AF, estimate the associated factors and their impact on clinical events, and assess the same issues with conventional measures of primary and secondary adherence-proportion of days covered (PDC) and persistence-in routine clinical practice.

METHODS AND ANALYSIS

This is a population-based retrospective cohort study including all patients with AF treated with OAC from 2010 to date in Valencia, Spain; data will be obtained from diverse electronic records of the Valencia Health Agency.

PRIMARY OUTCOME MEASURE

adherence trajectories.

SECONDARY OUTCOMES

(1) primary non-adherence; (2) secondary adherence: (a) PDC, (b) persistence. Clinical outcomes: hospitalisation for haemorrhagic or thromboembolic events and death during follow-up.

ANALYSIS

(1) description of baseline characteristics, adherence patterns (trajectory models or latent class growth analysis models) and conventional adherence measures; (2) logistic or Cox multivariate regression models, to assess the associations between adherence measures and the covariates, and logistic multinomial regression models, to identify characteristics associated with each trajectory; (3) Cox proportional hazard models, to assess the relationship between adherence and clinical outcomes, with propensity score adjustment applied to further control for potential confounders; (4) to estimate the importance of different healthcare levels in the variations of adherence, logistic or Cox multilevel regression models.

ETHICS AND DISSEMINATION

This study has been approved by the corresponding Clinical Research Ethics Committee. We plan to disseminate the project's findings through peer-reviewed publications and presentations at relevant health conferences. Policy reports will also be prepared in order to promote the translation of our findings into policy and clinical practice.

Healthcare provider targeted interventions to improve medication adherence: systematic review and meta-analysis

OBJECTIVE

This systematic review applied meta-analytic procedures to synthesise medication adherence (also termed compliance) interventions that focus on healthcare providers.

DESIGN

Comprehensive searching located studies testing interventions that targeted healthcare providers and reported patient medication adherence behaviour outcomes. Search strategies included 13 computerised databases, hand searches of 57 journals, and both author and ancestry searches. Study sample, intervention characteristics, design and outcomes were reliably coded. Standardised mean difference effect sizes were calculated using random-effects models. Heterogeneity was examined with Q and I(2) statistics. Exploratory moderator analyses used meta-analytic analogue of ANOVA and regression.

RESULTS

Codable data were extracted from 218 reports of 151,182 subjects. The mean difference effect size was 0.233. Effect sizes for individual interventions varied from 0.088 to 0.301. Interventions were more effective when they included multiple strategies. Risk of bias assessment documented larger effect sizes in studies with larger samples, studies that used true control groups (as compared with attention control), and studies without intention-to-treat analyses.

CONCLUSION

Overall, this meta-analysis documented that interventions targeted to healthcare providers significantly improved patient medication adherence. The modest overall effect size suggests that interventions addressing multiple levels of influence on medication adherence may be necessary to achieve therapeutic outcomes.

Warfarin persistence among stroke patients with atrial fibrillation

INTRODUCTION

Warfarin treatment discontinuation is significant among patients with atrial fibrillation (AF). For AF patients with stroke a warfarin persistence rate of 0.45 after 2years has previously been reported. No consistent predictors for discontinuation have been established.

AIMS

Evaluation of warfarin persistence and variables associated with discontinuation, in a large Swedish cohort with unselected stroke/TIA patients with AF treated with warfarin.

MATERIALS AND METHODS

4 583 patients with stroke/TIA and AF in the Swedish National Patient Register (NPR), from 1. Jan 2006 to 31. Dec 2011, were matched with the Swedish national quality register AuriculA. They were followed until treatment cessation, death or end of study. Baseline characteristics and CHA2DS2VASc score were retrieved from NPR. Treatment-time was retrieved from AuriculA.

RESULTS

Overall proportion of warfarin persistence was 0.78 (95% confidence interval (CI) 0.76 to 0.80) after one year, 0.69 (95% CI 0.67 to 0.71) after 2years and 0.47 (95% CI 0.43 to 0.51) after 5years. Variables clearly associated with higher discontinuation were dementia (hazard ratio (HR) 2.22, CI 1.51-3.27) and alcohol abuse (HR 1.66, CI 1.19-2.33). Chronic obstructive pulmonary disease (COPD), cancer and chronic heart failure (CHF) were each associated with over 20% increased risk of treatment discontinuation. Higher CHA2DS2VASc score and start-age lead to lower persistence (p<0.001).

CONCLUSIONS

Persistence to warfarin in unselected stroke/TIA patients with AF is in Sweden greater than previously reported. Lower persistence is found among patients with high treatment start-age, incidence of dementia, alcohol abuse, cancer, CHF, COPD and/or high CHA2DS2VASc score.

Early Medication Nonadherence After Acute Myocardial Infarction: Insights into Actionable Opportunities From the TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) Study

BACKGROUND

Nonadherence to prescribed evidence-based medications after acute myocardial infarction (MI) can contribute to worse outcomes and higher costs. We sought to better understand the modifiable factors contributing to early nonadherence of evidence-based medications after acute MI.

METHODS AND RESULTS

We assessed 7425 acute MI patients treated with percutaneous coronary intervention at 216 US hospitals participating in TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) between April 2010 and May 2012. Using the validated Morisky instrument to assess cardiovascular medication adherence at 6 weeks post MI, we stratified patients into self-reported high (score, 8), moderate (score, 6-7), and low (score, <6) adherence groups. Moderate and low adherence was reported in 25% and 4% of patients, respectively. One third of low adherence patients described missing doses of antiplatelet therapy at least twice a week after percutaneous coronary intervention. Signs of depression and patient-reported financial hardship because of medication expenses were independently associated with a higher likelihood of medication nonadherence. Patients were more likely to be adherent at 6 weeks if they had follow-up appointments made before discharge and had a provider explain potential side effects of their medications. Lower medication adherence may be associated with a higher risk of 3-month death/readmission (adjusted hazard ratio, 1.35; 95% confidence interval, 0.98-1.87) although this did not reach statistical significance.

CONCLUSIONS

Even early after MI, a substantial proportion of patients report suboptimal adherence to prescribed medications. Tailored patient education and pre discharge planning may represent actionable opportunities to optimize patient adherence and clinical outcomes.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.

Apparent Treatment-resistant Hypertension Among Individuals with History of Stroke or Transient Ischemic Attack

BACKGROUND

Blood pressure control is a paramount goal in secondary stroke prevention; however, high prevalence of uncontrolled blood pressure and use of multiple antihypertensive medication classes in stroke patients suggest this goal is not being met. We determined the prevalence and factors associated with apparent treatment-resistant hypertension in persons with/without stroke or transient ischemic attack.

METHODS

Data came from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based cohort of 30,239 black and white adults aged ≥45 years, enrolled 2003-2007, restricted to 11,719 participants with treated hypertension. Apparent treatment-resistant hypertension was defined as (1) uncontrolled blood pressure (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) with ≥3 antihypertensive medication classes, or (2) use of ≥4 antihypertensive medication classes, regardless of blood pressure level. Poisson regression was used to calculate characteristics associated with apparent treatment-resistant hypertension.

RESULTS

Among hypertensive participants, prevalence of apparent treatment-resistant hypertension was 24.9% (422 of 1694) and 17.0% (1708 of 10,025) in individuals with and without history of stroke or transient ischemic attack, respectively. After adjustment for cardiovascular risk factors, the prevalence ratio for apparent treatment-resistant hypertension for those with versus without stroke or transient ischemic attack was 1.14 (95% confidence interval, 1.03-1.27). Among hypertensive participants with stroke or transient attack, male sex, black race, larger waist circumference, longer duration of hypertension, and reduced kidney function were associated with apparent treatment-resistant hypertension.

CONCLUSIONS

The high prevalence of apparent treatment-resistant hypertension among hypertensive persons with history of stroke or transient ischemic attack suggests the need for more individualized blood pressure monitoring and management.

Persistence with secondary prevention medications after acute myocardial infarction: Insights from the TRANSLATE-ACS study

BACKGROUND

Persistent use of secondary prevention therapies after acute myocardial infarction (MI) is critical to optimizing long-term outcomes.

METHODS

Medication persistence was assessed among 7,955 MI patients in 216 hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome study from 2010 to 2012. Persistence was defined as continuation of aspirin, adenosine diphosphate receptor inhibitors, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins from discharge to 6 months post-MI. Multivariable logistic regression modeling was used to determine factors associated with nonpersistence, defined as <80% persistence with all medication classes.

RESULTS

Overall, 31% of MI patients stopped taking a least 1 medication by 6 months. The most common reasons cited for medications discontinuation were side effects and physician instruction (57%), whereas financial concerns were cited in 8% overall. After multivariable modeling, black race (odds ratio 1.36, 95% CI 1.15-1.62), older age (odds ratio 1.07, 95% CI 1.02-1.12), atrial fibrillation (odds ratio 1.67, 95% CI 1.33-2.09), dialysis (odds ratio 1.79, 95% CI 1.15-2.78), and depression (odds ratio 1.22, 95% CI 1.02-1.45) were associated with lower likelihood of persistence. Private insurance (odds ratio 0.85, 95% 0.76-0.95), prescription cost assistance (odds ratio 0.63, 95% CI 0.54-0.75), and outpatient follow-up arranged before discharge (odds ratio 0.89, 95% CI 0.80-0.99) were associated with higher persistence.

CONCLUSIONS

Nearly one-third of MI patients are no longer persistent with their prescribed medications by 6 months. Patients at high risk for nonpersistence may be identified by clinical and sociodemographic features. These observations underscore key opportunities to optimize longitudinal use of secondary prevention therapies.

Reducing stroke in women with risk factor management: blood pressure and cholesterol

Stroke is a major cause of death and disability in adults worldwide. Prevention focused on modifiable risk factors, such as hypertension and hyperlipidemia, has shown them to be of significant importance in decreasing the risk of stroke. Multiple studies have brought to light the differences between men and women with regards to stroke and these risk factors. Women have a higher prevalence of stroke, mortality and disability and it has been shown that preventive and treatment options are not as comprehensive for women. Hence, it is of great necessity to evaluate and summarize the differences in gender and stroke risk factors in order to target disparities and optimize prevention, especially because women have a higher lifetime risk of stroke. The purpose of this review is to summarize sex differences in the prevalence of hypertension and hyperlipidemia. In addition, we will review the sex differences in stroke prevention effectiveness and adherence to blood pressure and cholesterol medications, and suggest future directions for research to reduce the burden of stroke in women.

Strokes in young adults: epidemiology and prevention

Strokes in young adults are reported as being uncommon, comprising 10%-15% of all stroke patients. However, compared with stroke in older adults, stroke in the young has a disproportionately large economic impact by leaving victims disabled before their most productive years. Recent publications report an increased incidence of stroke in young adults. This is important given the fact that younger stroke patients have a clearly increased risk of death compared with the general population. The prevalence of standard modifiable vascular risk factors in young stroke patients is different from that in older patients. Modifiable risk factors for stroke, such as dyslipidemia, smoking, and hypertension, are highly prevalent in the young stroke population, with no significant difference in geographic, climatic, nutritional, lifestyle, or genetic diversity. The list of potential stroke etiologies among young adults is extensive. Strokes of undetermined and of other determined etiology are the most common types among young patients according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Prevention is the primary treatment strategy aimed at reducing morbidity and mortality related to stroke. Therefore, primary prevention is very important with regard to stroke in young adults, and aggressive treatment of risk factors for stroke, such as hypertension, smoking, and dyslipidemia, is essential. The best form of secondary stroke prevention is directed toward stroke etiology as well as treatment of additional risk factors. However, there is a lack of specific recommendations and guidelines for stroke management in young adults. In conclusion, strokes in young adults are a major public health problem and further research, with standardized methodology, is needed in order to give us more precise epidemiologic data. Given the increasing incidence of stroke in the young, there is an objective need for more research in order to reduce this burden.

Multifaceted intervention including motivational interviewing to support medication adherence after stroke/transient ischemic attack: a randomized trial

Background and Purpose

Adherence to medication is often suboptimal after stroke and transient ischemic attack (TIA), which increases the risk of recurrent stroke and death. Complex interventions and motivational interviewing (MI) have been proven effective in other areas of medicine. The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention.

Methods

In this randomized controlled trial, TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care. The intervention consisted of a focused medication review, an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months. The primary outcome was a composite medication possession ratio (MPR) for antiplatelets, anticoagulants and statins in the year after hospitalization, assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome. Secondary outcomes included composite MPRs at 3, 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months. Clinical outcomes included a combined end point of cardiovascular death, stroke or acute myocardial infarction. Patient satisfaction with the service was assessed for the intervention patients.

Results

The analyses included 102 intervention patients and 101 controls. At 12 months, the median MPRs (IQR) were 0.95 (0.77-1) in the intervention group and 0.91 (0.83-0.99) in the control group, and 28 and 21% of the patients, respectively, were nonadherent (MPR <0.80; risk difference: 7%; 95% CI: −5 to 19%). In both groups, the median MPR decreased over time. From 3 to 12 months, the MPR fell by 5% (p < 0.05) in the intervention group and by 9% (p < 0.05) in the control group, but between the groups, comparisons showed no statistically significant difference. No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome. The intervention patients were satisfied with the service; about half of them reported increased knowledge about medication, and one third reported increased confidence with medication use. Pharmacists identified drug-related problems in one third of the patients.

Conclusions

A multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes. However, due to the high adherence rates, only little room for improvement existed. Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions.

Antihypertensive medication persistence 1-year post-stroke hospitalization

To optimize the translation of clinical trial evidence that antihypertensive treatment reduces recurrent stroke risk into clinical practice, it is important to assess the frequency of long-term antihypertensive drug persistence after stroke and identify the factors associated with low persistence. Structured telephone interviews to determine antihypertensive regimen persistence 1-year post-stroke hospitalization were conducted in 270 stroke survivors, of which 212 (78.5%) were discharged on antihypertensive therapy (two thirds on >1 drug class). Continued use of any antihypertensive agent at 1 year of follow-up was relatively high (87.3%); however, persistence on all or two or more drug classes prescribed at discharge was relatively low (38.7%). Continued use varied by drug class, with the highest rates among angiotensin-converting enzyme inhibitor (69.1%) and the lowest rates among diuretic (24.4%) users. Black patients (adjusted odds ratio, 0.35; 95% confidence interval, 0.16-0.78) and those with a high comorbidity burden (adjusted odds ratio , 0.39; 95% confidence interval, 0.18-0.86) were less likely to exhibit persistence on prescribed treatments 1-year post-stroke hospitalization. These results indicate the need for further study to identify appropriate persistence of antihypertensive therapies for secondary stroke prevention and to investigate reasons for racial disparities in persistence on prescribed treatments in a real-world clinical setting.

Web-based tool for dynamic functional outcome after acute ischemic stroke and comparison with existing models

BACKGROUND

Acute ischemic stroke (AIS) is one of the leading causes of death and adult disability worldwide. In the present study, we aimed to develop a web-based risk model for predicting dynamic functional status at discharge, 3-month, 6-month, and 1-year after acute ischemic stroke (Dynamic Functional Status after Acute Ischemic Stroke, DFS-AIS).

METHODS

The DFS-AIS was developed based on the China National Stroke Registry (CNSR), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. Good functional outcome was defined as modified Rankin Scale (mRS) score ≤ 2 at discharge, 3-month, 6-month, and 1-year after AIS, respectively. Independent predictors of each outcome measure were obtained using multivariable logistic regression. The area under the receiver operating characteristic curve (AUROC) and plot of observed and predicted risk were used to assess model discrimination and calibration.

RESULTS

A total of 12,026 patients were included and the median age was 67 (interquartile range: 57-75). The proportion of patients with good functional outcome at discharge, 3-month, 6-month, and 1-year after AIS was 67.9%, 66.5%, 66.9% and 66.9%, respectively. Age, gender, medical history of diabetes mellitus, stroke or transient ischemic attack, current smoking and atrial fibrillation, pre-stroke dependence, pre-stroke statins using, admission National Institutes of Health Stroke Scale score, admission blood glucose were identified as independent predictors of functional outcome at different time points after AIS. The DFS-AIS was developed from sets of predictors of mRS ≤ 2 at different time points following AIS. The DFS-AIS demonstrated good discrimination in the derivation and validation cohorts (AUROC range: 0.837-0.845). Plots of observed versus predicted likelihood showed excellent calibration in the derivation and validation cohorts (all r = 0.99, P < 0.001). When compared to 8 existing models, the DFS-AIS showed significantly better discrimination for good functional outcome and mortality at discharge, 3-month, 6-month, and 1-year after AIS (all P < 0.0001).

CONCLUSION

The DFS-AIS is a valid risk model to predict functional outcome at discharge, 3-month, 6-month, and 1-year after AIS.

Optimal combination secondary prevention drug treatment and stroke outcomes

OBJECTIVE

To investigate the effect of optimal combination of evidence-based drug therapies including antihypertensive agents, lipid modifiers, and antithrombotic agents on risk of recurrent vascular events after stroke.

METHODS

We analyzed the database of a multicenter trial involving 3,680 recent noncardioembolic stroke patients aged 35 years or older and followed for 2 years. Patients were categorized by appropriateness level 0 to III depending on the number of drugs prescribed divided by the number of drugs potentially indicated for each patient (0 = none of the indicated medications prescribed and III = all indicated medications prescribed). Independent associations of medication appropriateness level with recurrent stroke (primary outcome), stroke/coronary heart disease/vascular death as major vascular events (secondary outcome), and death (tertiary outcome) were assessed.

RESULTS

The unadjusted rate of stroke declined with increasing medication appropriateness level (15.9% for level 0, 10.3% for level I, 8.6% for level II, and 7.3% for level III). Compared with level 0: the adjusted hazard ratio of stroke for level I was 0.51 (95% confidence interval, 0.21-1.25), level II 0.50 (0.23-1.09), and level III 0.39 (0.18-0.84); of stroke/coronary heart disease/vascular death for level I 0.60 (0.32-1.14), level II 0.45 (0.25-0.80), and level III 0.39 (0.22-0.69); and of death for level I 0.89 (0.30-2.64), level II 0.71 (0.26-1.93), and level III 0.35 (0.13-0.96).

CONCLUSIONS

Optimal combination of secondary prevention medication classes after a recent noncardioembolic stroke is associated with a significantly lower risk of stroke, major vascular events, and death.

A new model for secondary prevention of stroke: transition coaching for stroke

Non-adherence to stroke prevention medications is a risk factor for first-ever and recurrent stroke. As of yet, there are no guidelines for processes to recognize and address medication non-adherence in stroke patients. We developed a new model of post-discharge prevention care that measures and addresses medication-taking (transition coaching for stroke or TRACS). TRACS includes personalized education about risk factors and medications prior to discharge, follow-up telephone calls, and appointments with a stroke nurse practitioner (NP). The stroke NP asks about medication use (persistence) and whether doses are missed (adherence), and helps to solve problems with access to medications or side effects. In an analysis of 142 patients enrolled in TRACS from October 2012 to February 2014, medication persistence (use of medications from discharge to the time of measurement) was about 80%. Medication persistence at NP visit was higher in those patients with a first-ever stroke (78.9%) vs. those with recurrent stroke (60.7%; p = 0.045). Concerted efforts with 2-day RN follow-up calls and earlier NP appointments to improve medication-taking behaviors are underway.

Discontinuation of antiplatelet treatment and risk of recurrent stroke and all-cause death: a cohort study

BACKGROUND

We wished to examine the impact of antiplatelet drug discontinuation on recurrent stroke and all-cause mortality.

METHODS

We identified a cohort of incident ischaemic stroke patients in a Danish stroke registry, 2007-2011. Using population-based registries we assessed subjects' drug use and followed them up for stroke recurrence, or all-cause death. Person-time was classified by antiplatelet drug use into current use, recent use (≤150 days after last use), and non-use (>150 days after last use). Lipid-lowering drug (LLD) use was classified by the same rules. We used Cox proportional hazard models to calculate the adjusted hazard ratio (HR) and corresponding 95% confidence intervals (CIs) for the risk of recurrent stroke or death associated with discontinuation of antiplatelet or LLD drugs.

RESULTS

Among 4,670 stroke patients followed up for up a median of 1.5 years, 237 experienced a second stroke and 600 died. Compared with current antiplatelet drug use, both recent use (1.3 (0.8-2.0)), and non-use (1.3 (0.8-1.9)) were associated with increased recurrent stroke risk. The corresponding HRs of death were 1.9 (1.4-2.5) for recent and 1.8 (1.4-2.3) for non-use of antiplatelet drugs. Recent statin use was associated with markedly increased risk of death (2.1 (1.7-2.6)), and only marginally with recurrent stroke (1.2 (0.9-1.6)).

CONCLUSIONS

Antiplatelet drug discontinuation may be associated with an increased recurrent stroke risk. Our results on death risk indicate that non-pharmacological biases, such as 'sick stopper', may threaten the validity of this risk estimate.