Secondary preventive medication persistence and adherence 1 year after stroke

Barriers and facilitators for medication adherence in stroke patients: a qualitative study conducted in French neurological rehabilitation units

OBJECTIVE

To describe the perceptions of French patients, caregivers and healthcare professionals on stroke and secondary preventive medications.

METHOD

A qualitative study was conducted, based on four predetermined topics: stroke, secondary prevention medications, patient's experience, relationship between patient/caregiver and healthcare team.

RESULTS

Twenty-six interviews were conducted. Difficulties in taking medications, lack of knowledge on stroke and medication benefits, fear of over medication were identified as barriers for adherence in patients. Doubts about generic drugs were expressed by caregivers. Healthcare professionals reported lack of knowledge and absence of clinical symptoms as barriers. On the other hand, support from caregivers and healthcare professional support is essential for compliance in all participants. Patients and caregivers expressed that fear of recurrence was a facilitator for treatment compliance.

CONCLUSION

This study highlights the barriers and facilitators for stroke treatment adherence and underlines the similarities and differences between the perceptions of patients, caregivers and healthcare professionals. These results must be integrated into the future French educational programs to improve medication adherence.

Nontraditional serum lipid variables and recurrent stroke risk

BACKGROUND AND PURPOSE

Expert consensus guidelines recommend low-density lipoprotein cholesterol as the primary serum lipid target for recurrent stroke risk reduction. However, mounting evidence suggests that other lipid parameters might be additional therapeutic targets or at least also predict cardiovascular risk. Little is known about the effects of nontraditional lipid variables on recurrent stroke risk.

METHODS

We analyzed the Vitamin Intervention for Stroke Prevention study database comprising 3680 recent (<120 days) noncardioembolic stroke patients followed up for 2 years. Independent associations of baseline serum lipid variables with recurrent ischemic stroke (primary outcome) and the composite end point of ischemic stroke/coronary heart disease/vascular death (secondary outcomes) were assessed.

RESULTS

Of all variables evaluated, only triglycerides/high-density lipoprotein cholesterol (HDL-C) ratio was consistently and independently related to both outcomes: compared with the lowest quintile, the highest triglycerides/HDL-C ratio quintile was associated with stroke (adjusted hazard ratio, 1.56; 95% confidence interval, 1.05-2.32) and stroke/coronary heart disease/vascular death (1.39; 1.05-1.83), including adjustment for lipid modifier use. Compared with the lowest quintile, the highest total cholesterol/HDL-C ratio quintile was associated with stroke/coronary heart disease/vascular death (1.45; 1.03-2.03). Low-density lipoprotein cholesterol/HDL-C ratio, non-HDL-C, elevated triglycerides alone, and low HDL-C alone were not independently linked to either outcome.

CONCLUSIONS

Of various nontraditional lipid variables, elevated baseline triglycerides/HDL-C and total cholesterol/HDL-C ratios predict future vascular risk after a stroke, but only elevated triglycerides/HDL-C ratio is related to risk of recurrent stroke. Future studies should assess the role of triglycerides/HDL-C as a potential therapeutic target for global vascular risk reduction after stroke.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack

BACKGROUND

This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA).

METHODS

A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated.

RESULTS

There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively.

CONCLUSION

Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.

Evidence-to-practice gaps in post-stroke management: a focus on care in a stroke unit and anticoagulation to prevent death, disability and recurrent stroke

ABSTRACT: 

The global burden of stroke is large. Over the last 15 years significant advances have been made to improve acute stroke care and prevention management providing the ability to mitigate much of this burden. In this article, we describe the importance of two main elements of stroke care: stroke units to reduce death and disability and anticoagulation therapy to prevent recurrent, often fatal or disabling, cardioembolic stroke. We also describe the issues related to translating these interventions into practice and the related economic implications. Despite the proven effectiveness and cost–effectiveness of these and other interventions, many people experiencing stroke are not receiving these interventions. Effective evidence translation initiatives and routine monitoring of healthcare is needed to address important gaps in stroke management in promoting societal well-being.

Risk factor management for stroke prevention

PURPOSE OF REVIEW

This review focuses on the recommendations for management of hypertension, dyslipidemia, diabetes mellitus, diet, physical activity, and lifestyle choices commonly encountered in neurologic practice. Specific studies, including those relevant to lipid targets, blood pressure targets, and adherence to medications after stroke, are reviewed.

RECENT FINDINGS

In addition to traditional risk factors such as hypertension, dyslipidemia, and diabetes mellitus, this review discusses sleep apnea, diet, physical activity, and other novel risk factors that are potentially modifiable. Recent studies confirm that pharmacologic strategies to achieve aggressive targets for lipid and blood pressure lowering have significant impact on recurrent stroke risk.

SUMMARY

Optimal secondary prevention strategies can prevent as much as 80% of all recurrent strokes.

The relevance of living supports on antiplatelet adherence and trial participation: the SPS3 trial

BACKGROUND

While living with others has been associated with improved functional outcome after acute stroke, it is unclear if this affects adherence to stroke prevention measures.

AIMS

We examined the relationship between living arrangements and adherence to antiplatelet therapy assignment and participation status in an international randomized trial for secondary stroke prevention.

METHOD

Antiplatelet therapy adherence, trial retention outcomes, and baseline characteristics for participants enrolled in the Secondary Prevention of Small Subcortical Strokes study were compared between those who lived alone vs. with others (n = 2374). Participant status at end-of-trial was categorized into (1) on assigned antiplatelet, (2) off assigned antiplatelet by participant request, or (3) participant withdrew consent/lost to follow-up. Multivariable multivariate logistic regression was used to identify patient features at entry predictive of participant status at trial end.

RESULTS

Living arrangement, alone vs. with other(s), was not significantly associated with participant status. Participants enrolled in the United States/Canada (odds ratio 3.1, confidence intervals 2.0-5.0, vs. Latin America), taking more (7+) prescription medications (odds ratio 1.7, confidence intervals 1.1-2.7, vs. 0-2 medications), and scoring lower on the Stroke Specific Quality of Life scale (odds ratio 1.3, confidence intervals 1.1-1.5, per 10 points) were more likely to withdraw or become lost to follow-up in the study vs. completing the study on assigned antiplatelet therapy. Participants enrolled in the United States/Canada (odds ratio 5.0, confidence intervals 2.4-10.0, vs. Latin America) and taking fewer (0-2) medications (odds ratio 1.9, confidence intervals 1.2-3.1 vs. 3-6 medications) were more likely to request discontinuation of assigned antiplatelet medication vs. completing the study.

CONCLUSION

Living with others was not independently predictive of protocol adherence in this cohort. Number of medications and Stroke Specific Quality of Life scale score may be more indicative of likelihood of trial participation and acceptance of long-term antiplatelet regimen.

Effectiveness and Safety of Antiplatelet in Stroke Patients with End-Stage Renal Disease Undergoing Dialysis

Background

Antiplatelet therapy is known to decrease the risk of secondary ischemic stroke. However, the effectiveness and safety of antiplatelet therapy in patients with end-stage renal disease are uncertain, especially in dialysis.

Aims and/or hypothesis

We estimated the effectiveness and safety of antiplatelet drugs (aspirin and clopidogrel) for the prevention of recurrent ischemic stroke in end-stage renal disease patients undergoing dialysis during long-term follow-up after first-time ischemic stroke.

Methods

The cases were identified from the National Health Insurance Research Database. Antiplatelet therapy was administered for 11 years to patients experiencing a first ischemic stroke between 1998 and 2006. Primary outcomes, including death and readmission to hospital for stroke, and secondary outcomes, including death, stroke, and acute myocardial infarction or bleeding, were examined.

Results

In total, 1936 patients experienced a first ischemic stroke during the follow-up. In a time-dependent analysis, the hazard ratio for primary outcomes in patients treated with aspirin was 0·671 ( P < 0·001) and that for clopidogrel was 0·933 ( P = 0·497). At secondary outcomes, patients treated with aspirin, hazard ratio for readmission for stroke was 0·715 ( P = 0·002) and that for bleeding was 0·885 ( P = 0·291). Independent risk factors for mortality and readmission due to ischemic stroke included age, diabetes mellitus, and administration of proton pump inhibitors.

Conclusions

Antiplatelet therapy, especially aspirin, still offers safe and effective treatment for ischemic stroke prevention in patients with end-stage renal disease undergoing dialysis.

Discharge Is a Critical Time to Influence 10-Year Use of Secondary Prevention Therapies for Stroke

Background and Purpose—

When optimally managed, patients with stroke are less likely to have further vascular events. We aimed to identify factors associated with optimal use of secondary prevention therapies in long-term survivors of stroke.

Methods—

We carefully documented discharge medications at baseline and self-reported use of medications at annual follow-up in the Northeast Melbourne Stroke Incidence Study (NEMESIS). We defined optimal medication use when patients reported taking (1) antihypertensive agents and (2) statin and antithrombotic agents (ischemic stroke only). Logistic regression was used to assess factors associated with optimal medication use between 2 and 10 years after stroke.

Results—

We recruited 1241 patients with stroke. Optimal prescription at discharge from hospital was the most important factor associated with optimal medication use at each time point: odds ratio (OR), 32.2 (95% confidence interval [CI], 13.6–76.1) at 2 years; OR, 7.86 (95% CI, 4.48–13.8) at 5 years (425 of 505 survivors); OR, 6.04 (95% CI, 3.18–11.5) at 7 years (326 of 390 survivors); and OR, 2.62 (95% CI, 1.19–5.77) at 10 years (256 of 293 survivors). Associations were similar in men and women. The association between optimal prescription at discharge and optimal medication use at each time point was greater in those who were not disadvantaged, particularly women.

Conclusions—

Prescription of medications at hospital discharge was the strongest predictor of ongoing medication use in survivors of stroke, even at 10 years after stroke. Ensuring that patients with stroke are discharged on optimal medications is likely to improve their long-term management, but further strategies might be required among those who are disadvantaged.

Twelve-month medication persistence in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

AIMS

This study aimed to assess patients' baseline characteristics and provider factors influencing the continuation of medication for 12 months in patients who were newly diagnosed with benign prostatic hyperplasia (BPH).

METHODS

This study was conducted in patients with newly diagnosed lower urinary tract symptoms (LUTS)/BPH (age ≥ 40) who received either one or a combination of the two pharmacological classes of drugs (alpha-blockers or 5-alpha-reductase inhibitors) from January 2008 to January 2010. Patient demographics and clinical data were assessed from the electronic patient records and telephone surveys. Persistence was defined as continuation of all BPH medications prescribed at the start of the first treatment. Logistic regression analysis was used to evaluate the association between 12-month persistence and patient or provider factors.

RESULTS

Of the 789 newly diagnosed LUTS/BPH patients, 670 (84.9%) were included in the study. Twelve-month persistence for LUTS/BPH medication was 36.6%. Independent predictors of 12-month medication persistence included larger prostate volume, higher prostate specific antigen, having an adequate income and a good patient-doctor relationship. Important reasons for discontinuation were resolved symptoms (31.1%), no improvement in symptoms (23.7%) and adverse events (20.0%).

CONCLUSIONS

About two-thirds of newly diagnosed LUTS/BPH patients discontinued medications within 1 year of starting treatment. We found several potential patient and provider factors associated with persistence, which could be exploited to increase continuation of treatment in future clinical settings.

Differences in the knowledge and compliance with secondary prevention of stroke between transient ischaemic attack patients with and without subsequent stroke

AIMS AND OBJECTIVES

To evaluate the differences in the knowledge and compliance with secondary prevention of stroke between transient ischaemic attack patients with and without subsequent stroke.

BACKGROUND

No previous study has demonstrated whether there are differences in the knowledge and compliance with secondary prevention of stroke between transient ischaemic attack patients with and without subsequent stroke. If there are differences, the health education regarding the stroke knowledge should be conducted separately and differently for the two groups.

METHODS AND DESIGN

We consecutively recruited 355 transient ischaemic attack patients with/without subsequent stroke from our hospital from 1 December 2008-31 December 2011. There were 304 patients receiving health education both upon hospital discharge and 90 days after discharge. Through telephone interviews, six months after discharge, only 180 patients completed the survey to determine in detail their general knowledge and compliance with secondary prevention of stroke.

RESULTS

The transient ischaemic attack patients with subsequent stroke exhibited a higher identification rate of speech disorder, weakness and decreased sensation or inability to feel things, compared with those without subsequent stroke (76·1 vs. 66·3%, p < 0·05; 91·5 vs. 73·5%, p < 0·05; 62·2 vs. 46·9%, p < 0·05). The compliance rates to antiplatelet agents and statins therapy were higher in transient ischaemic attack patients with subsequent stroke compared with those without subsequent stroke (80·5 vs. 65·3%, p < 0·05; 53·7 vs. 35·7%, p < 0·05).

CONCLUSIONS

The transient ischaemic attack patients with subsequent stroke exhibit a higher identification rate of most of the warning signs of stroke and a better compliance with antiplatelet agents and statins therapy of stroke compared with those without subsequent stroke. Thus, we suggest that transient ischaemic attack patients should receive additional health education to increase their awareness of the harms of stroke.

RELEVANCE TO CLINICAL PRACTICE

Clinicians should be aware of conducting different health education to patients with transient ischaemic attack and stroke. Also, it is important to give health education to individualised patients based on their actual risk of stroke.

Long-term use of antiplatelet drugs by patients with transient ischaemic attack

PURPOSE

To determine the degree of long-term non-persistence to antiplatelet drugs in patients with transient ischaemic attack (TIA) and identify determinants of this drug-use pattern.

METHODS

We used community-based prescription registry data to determine antiplatelet drug use in TIA patients presenting to a Danish neurology department in the period 2006-2010. Non-persistence was defined as failure to present a prescription for antiplatelet drugs within 180 days after the dosage of a previous prescription had run out. We used Cox regression to calculate the hazard ratio (HR) for non-persistence and the corresponding 95 % confidence interval (CI) by potential determinants, including a stroke risk score (ABCD2 score). Adherence during follow-up [80 % medication possession ratio (MPR80)] was calculated for antiplatelets, statins and antihypertensive drugs.

RESULTS

The cohort comprised 594 (84 % evaluated as in-patients) TIA patients. During follow-up (median 1.7 years, interquartile range 0.9-3.0 years), 140 (23.6 %) patients became non-persistent. Non-persistence was associated with younger age (<55 years: HR 1.9, 95 % CI 1.3-2.8) and delay between TIA onset and neurological evaluation (7+ days: HR 2.0, 95 % CI 1.0-4.1). Among admitted patients, a higher ABCD2 score (4+: HR 1.3, 95 % CI 0.8-2.1) was also indicative of non-persistence. Non-persistent users were less adherent to other preventive medication (MPR80: statins 31.8 vs. 75.3 %, p value < 0.001; antihypertensives 64.3 vs. 79.5 %, p value: 0.02) than persistent users.

CONCLUSION

Long-term antiplatelet non-persistence was most pronounced in patients of younger age, those with delayed evaluation of symptoms and those at greater risk of stroke. It was also associated with a lower adherence to preventive medication in general.

Periodontal disease and recurrent vascular events in stroke/transient ischemic attack patients

Periodontal disease (PD) has been shown to be associated with incident stroke. We investigated whether PD is independently associated with recurrent vascular events and certain inflammatory markers in stroke/transient ischemic attack (TIA) patients. In this prospective, longitudinal, hospital-based cohort study, PD was assessed in stroke/TIA patients. High periodontal disease (HPD) was defined as the highest tertile of extent (% of sites) with an attachment loss of 5 mm or more. Serum interleukin-6 (IL-6), high-sensitivity C-reactive protein, and soluble intracellular adhesion molecule 1 (s-ICAM) were measured. The patients were followed for recurrent vascular events-stroke, TIA, myocardial infarction, and vascular death. In the 106 patients who were evaluated, 40 (38%) showed HPD and 27 (26%) had recurrent vascular events over a median of 24 months (range, 12-24 months). HPD patients had higher levels of IL-6 (P=.01) and s-ICAM (P=.03). HPD was associated with recurrent vascular events before (log-rank P=.01; hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.2-5.7) and after adjustment for significant confounders-age and stroke status (HR, 2.5; 95% CI, 1.1-5.5; P=.03); adjustment for possible confounders-age, male, years of education, and cardioembolic strokes (HR, 2.8; 95% CI, 1.2-6.5; P=.02); and adjustment for propensity score that accounted for all potential measured confounders (HR, 2.8; 95% CI, 1.2-6.5; P=.02). There is an independent association between HPD and recurrent vascular events in stroke/TIA patients. HPD is also associated with higher serum levels of IL-6 and s-ICAM.

Utility of a post-hospitalization stroke prevention program managed by nurses

GOAL

Evidence-based guidelines exist for the prevention and treatment of patients with cerebral ischemia. Despite these guidelines, there are gaps in clinical practice. Our study aimed to determine if a physician-directed, nurse-case-management program could reduce individual patient vascular risk factors.

METHODS

Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke (hypertension, tobacco use, dyslipidemia, diabetes) were eligible to enroll in our study. Patients were randomized to management by the nurse-prevention program or usual care. Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year. Patients in the usual-care group underwent further follow-up by primary care and/or neurology as recommended during their hospitalization or outpatient visit. Patients assigned to the prevention group received individualized education, motivational interviewing, and were aided in setting up their risk-factor modification goal plan. Additional education was tailored to each patient based on individualized risk factors. Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist. The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year.

RESULTS

At 1-year post-hospitalization, patients in the nurse-care-management group were 42% more likely to have met the primary endpoint (n = 18; 61% nurse-managed patients) compared with 33% (n = 18) of patients undergoing usual care (P = 0.09). There was no significant reduction in minor risk factors for either patient group. Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels (-38 vs -4; P = 0.0083), changes in cardiovascular risk score (-5.2 vs 1.3; P = 0.0033), and had a greater reductions in systolic blood pressure (-12.2 vs -0.105; P = 0.07) than their usual-care counterparts (changes shown respectively). Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group (50% vs 7%, respectively; P = 0.0070) and maintain an exercise program (83% vs 33%, respectively; P = 0.0018).

SUMMARY

A physician-directed, nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke. A larger trial is needed to verify trends noted in our study.

Impact of a better persistence with antihypertensive agents on ischemic stroke outcomes for secondary prevention

Background

The efficacy of antihypertensive (AH) treatment after stroke has been investigated in several randomized clinical trials. However, non-adherence to AH medication is common for stroke patients in “real world” setting. The purpose of this study was to assess the impact of persistence with AH agents on ischemic stroke (IS) outcomes.

Methods and Results

Using the China National Stroke Registry, we analyzed data from 8409 IS patients with hypertension. Persistence with AH therapy (high persistence ≥75%, low persistence <75%) was measured by patient self-report at 3, 6, and 12 months after stroke. Multivariate logistic regression model was used to assess the relationship between persistence and IS outcomes (stroke recurrence, combined vascular events and death) at 12 months. Of the 8409 patients in this study, 40.0% were female and the mean age at study entry was 66.7 years. 31.6% of patients had high persistence with AH drugs, and 68.4% had low persistence during 1 year after stroke onset. High persistence with AH drugs significantly decreased the risk of stroke recurrence (odds ratio, 0.78; 95% CI, 0.68 to 0.89), combined vascular events (0.71; 0.63–0.81) and death (0.44; 0.36–0.53) compared with low persistence.

Conclusions

Our study reinforces the benefits of AH medications in routine clinical practice and highlights the importance of persistence with AH therapy among IS patients known to be hypertensive within the first year of an event.

Trends in vascular risk factor treatment and control in US stroke survivors: the National Health and Nutrition Examination Surveys (1999-2010)

BACKGROUND

Treatment and control of vascular risk factors reduce the likelihood of recurrent stroke. Present nationally representative data are sparse regarding secondary prevention treatment and control rates.

METHODS AND RESULTS

We evaluated sex- and race-stratified blood pressure, cholesterol, and hemoglobin A1c levels and treatment and control rates in 1154 self-reported stroke survivors from the National Health and Nutrition Examination Surveys 1999 to 2010. We used weighted linear regression to estimate time trends. Participants were 54% to 61% women, 70% to 76% white, and had a mean age of 63 to 66 years. For blood pressure, treatment rates remained unchanged in men, but in women, treatment rates increased from 41% in 1999 to 2000 to 65% in 2009 to 2010 (P=0.03), and control rates increased from 23% to 79% (P=0.03). Treatment rates remained unchanged in non-Hispanic whites, non-Hispanic blacks, and Mexican Americans, although control rates increased in non-Hispanic whites from 50% in 1999 to 2002 to 69% in 2007 to 2010 (P=0.04). For cholesterol, treatment rates increased from 30% to 40% in men (P=0.02) and from 28% to 36% (P<0.01) in women, but control rates increased only in men, from 62% to 87% (P<0.01). Cholesterol treatment rates increased only in non-Hispanic blacks, from 18% to 37% (P=0.02). By sex and race, there was no change in dysglycemia treatment and control.

CONCLUSIONS

Despite improvements in blood pressure treatment and control and cholesterol treatment for women and cholesterol treatment and control for men, stroke secondary prevention through treatment and control of vascular risk factors remains suboptimal. Urgent action is needed to improve secondary prevention to reduce stroke morbidity and mortality in this high-risk group.

Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial

Background

Patients with recent stroke or TIA are at high risk for new vascular events. Several evidence based strategies in secondary prevention of stroke are available but frequently underused. Support programs with multifactorial risk factor modifications after stroke or TIA have not been investigated in large-scale prospective controlled trials so far. INSPiRE-TMS is a prospective, multi-center, randomized open intervention trial for intensified secondary prevention after minor stroke and TIA.

Methods/design

Patients with acute TIA or minor stroke admitted to the participating stroke centers are screened and recruited during in-hospital stay. Patients are randomised in a 1:1 ratio to intervention (support program) and control (usual care) arms. Inclusion of 2.082 patients is planned. The support program includes cardiovascular risk factor measurement and feedback, monitoring of medication adherence, coaching in lifestyle modifications, and active involvement of relatives. Standardized motivational interviewing is used to assess and enhance patients’ motivation. Primary objective is a reduction of new major vascular events defined as nonfatal stroke and myocardial infarction or vascular death. Recruitment time is planned for 3.5 years, follow up time is at least 2 years for every patient resulting in a total study time of 5 years (first patient in to last patient out).

Discussion

Given the high risk for vascular re-events in acute stroke and the available effective strategies in secondary prevention, the INSPIRE-TMS support program has the potential to lead to a relevant reduction of recurrent events and a prolongation of the event-free survival time. The trial will provide the basis for the decision whether an intensified secondary prevention program after stroke should be implemented into regular care. A cost-effectiveness evaluation will be performed.

Trial registration

clinicaltrials.gov: 01586702

Concerns about medications mediate the association of posttraumatic stress disorder with adherence to medication in stroke survivors

OBJECTIVES

Post-traumatic stress disorder (PTSD) can be a consequence of acute medical events and has been associated with non-adherence to medications. We tested whether increased concerns about medications could explain the association between PTSD and non-adherence to medication in stroke survivors.

DESIGN

We surveyed 535 participants aged 40 years or older who had at least one stroke or transient ischaemic attack in the previous 5 years.

METHODS

We assessed PTSD using the PTSD checklist-specific for stroke, medication adherence with the Morisky Medication Adherence Questionnaire, and beliefs about medications with the Beliefs about Medicines Questionnaire. We used logistic regression to test whether concerns about medications mediated the association between stroke-induced PTSD and non-adherence to medication. Covariates for adjusted analyses included age, sex, race, comorbid medical conditions, stroke-related disability, years since last stroke/TIA, and depression.

RESULTS

Symptoms of PTSD were correlated with greater concerns about medications (r = 0.45; p < .001), and both were associated with medication non-adherence. Adjustment for concerns about medications attenuated the relationship between PTSD and non-adherence to medication, from an odds ratio [OR] of 1.04 (95% confidence interval [CI], 1.01-1.06; OR, 1.63 per 1 SD) to an OR of 1.02 (95% CI, 1.00-1.05; OR, 1.32 per 1 SD), and increased concerns about medications remained associated with increased odds of non-adherence to medication (OR, 1.17; 95% CI, 1.10-1.25; OR, 1.72 per 1 SD) in this fully adjusted model. A bootstrap mediation test suggested that the indirect effect was statistically significant and explained 38% of the association of PTSD to medication non-adherence, and the direct effect of PTSD symptoms on medication non-adherence was no longer significant.

CONCLUSION

Increased concerns about medications explain a significant proportion of the association between PTSD symptoms and non-adherence to medication in stroke survivors.

The NAILED stroke risk factor trial (nurse based age independent intervention to limit evolution of disease after stroke): study protocol for a randomized controlled trial

BACKGROUND

Secondary prevention after stroke and transient ischemic attack (TIA) is essential in order to reduce morbidity and mortality. Secondary stroke prevention studies have, however, been fairly small, or performed as clinical trials with non-representative patient selection. Long-term follow-up data is also limited. A nurse-led follow-up for risk factor improvement may be effective but the evidence is limited. The aims of this study are to perform an adequately sized, nurse-led, long-term secondary preventive follow-up with a population-based inclusion of stroke and TIA patients. The focus will be on blood pressure and lipid control as well as tobacco use and physical activity.

METHODS

A randomized, controlled, long-term, population-based trial with two parallel groups. The patients will be included during the initial hospital stay. Important outcome variables are sitting systolic and diastolic blood pressure, LDL cholesterol and total cholesterol. Outcomes will be measured after 12, 24 and 36 months of follow-up. Trained nurses will manage the intervention group with a focus on reaching set treatment goals as soon as possible. The control group will receive usual care. At least 200 patients will be included in each group, in order to reliably detect a difference in mean systolic blood pressure of 5 mmHg. This sample size is also adequate for detection of clinically meaningful group differences in the other outcomes.

DISCUSSION

This study will test the hypothesis that a nurse-led, long-term follow-up after stroke with a focus on reaching set treatment goals as soon as possible, is an effective secondary preventive method. If proven effective, this method could be implemented in general practice at a low cost.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN23868518.

Patterns and predictors of antihypertensive medication used 1 year after ischemic stroke or TIA in urban China

BACKGROUND

Antihypertensive treatment is recommended for secondary prevention in patients with ischemic stroke or transient ischemic attack. Prescription of and persistence with antihypertensives for secondary prevention is high in developed countries; whether this is true in China is unclear. The aim of this study was to describe the patterns of antihypertensive medication use, and factors associated with its use, 1 year after stroke in China.

METHODS

A total of 7880 hypertensive patients diagnosed with ischemic stroke or transient ischemic attack in the China National Stroke Registry were analyzed. Multivariate logistic regression was used to identify factors associated with antihypertensive medication use at discharge and 12 months.

RESULTS

Antihypertensive medication was used by 4458 (56.6%) participants at discharge and 2927 (37.1%) at 12 months. Calcium channel blockers were the most common among five classes of antihypertensive medication prescribed at discharge, and participants prescribed this class had the highest 1-year persistence. In-hospital health education was the strongest predictor of antihypertensive medication use at discharge; age and stroke severity were the strongest negative predictors of use at 12 months.

CONCLUSION

Use of antihypertensive medication 1 year after stroke is extremely low in China. Intervention is needed to improve adherence to antihypertensive medication, especially for the elderly and severe stroke patients.

Secondary prevention after minor stroke and TIA - usual care and development of a support program

Background

Effective methods of secondary prevention after stroke or TIA are available but adherence to recommended evidence-based treatments is often poor. The study aimed to determine the quality of secondary prevention in usual care and to develop a stepwise modeled support program.

Methods

Two consecutive cohorts of patients with acute minor stroke or TIA undergoing usual outpatient care versus a secondary prevention program were compared. Risk factor control and medication adherence were assessed in 6-month follow-ups (6M-FU). Usual care consisted of detailed information concerning vascular risk factor targets given at discharge and regular outpatient care by primary care physicians. The stepwise modeled support program additionally employed up to four outpatient appointments. A combination of educational and behavioral strategies was employed.

Results

168 patients in the observational cohort who stated their openness to participate in a prevention program (mean age 64.7 y, admission blood pressure (BP): 155/84 mmHg) and 173 patients participating in the support program (mean age 67.6 y, BP: 161/84 mmHg) were assessed at 6 months. Proportions of patients with BP according to guidelines were 50% in usual-care and 77% in the support program (p<0.01). LDL<100 mg/dl was measured in 62 versus 71% (p = 0.12). Proportions of patients who stopped smoking were 50 versus 79% (p<0.01). 72 versus 89% of patients with atrial fibrillation were on oral anticoagulation (p = 0.09).

Conclusions

Risk factor control remains unsatisfactory in usual care. Targets of secondary prevention were met more often within the supported cohort. Effects on (cerebro-)vascular recurrence rates are going to be assessed in a multicenter randomized trial.

Nonvitamin-K-Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and Previous Stroke or Transient Ischemic Attack

Background and Purpose—

To assess whether the combined analysis of all phase III trials of nonvitamin-K-antagonist (non-VKA) oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack shows a significant difference in efficacy or safety compared with warfarin.

Methods—

We searched PubMed until May 31, 2012, for randomized clinical trials using the following search items: atrial fibrillation, anticoagulation, warfarin, and previous stroke or transient ischemic attack. Studies had to be phase III trials in atrial fibrillation patients comparing warfarin with a non-VKA currently on the market or with the intention to be brought to the market in North America or Europe. Analysis was performed on intention-to-treat basis. A fixed-effects model was used as more appropriate than a random-effects model when combining a small number of studies.

Results—

Among 47 potentially eligible articles, 3 were included in the meta-analysis. In 14 527 patients, non-VKAs were associated with a significant reduction of stroke/systemic embolism (odds ratios, 0.85 [95% CI, 074–0.99]; relative risk reduction, 14%; absolute risk reduction, 0.7%; number needed to treat, 134 over 1.8–2.0 years) compared with warfarin. Non-VKAs were also associated with a significant reduction of major bleeding compared with warfarin (odds ratios, 0.86 [95% CI, 075–0.99]; relative risk reduction, 13%; absolute risk reduction, 0.8%; number needed to treat, 125), mainly driven by the significant reduction of hemorrhagic stroke (odds ratios, 0.44 [95% CI, 032–0.62]; relative risk reduction, 57.9%; absolute risk reduction, 0.7%; number needed to treat, 139).

Conclusions—

In the context of the significant limitations of combining the results of disparate trials of different agents, non-VKAs seem to be associated with a significant reduction in rates of stroke or systemic embolism, hemorrhagic stroke, and major bleeding when compared with warfarin in patients with previous stroke or transient ischemic attack.

Systematic stroke prevention

PURPOSE OF REVIEW

: This review summarizes the systematic approaches that can be used to optimize secondary stroke prevention. Systematic secondary stroke prevention involves not only prescribing stroke patients the appropriate medications to manage risk factors, but also optimizing the effectiveness of those drugs by focusing on medication adherence. Medication adherence is defined as the extent to which patients take their medications as prescribed by their providers.

RECENT FINDINGS

: Many potential barriers to adherence exist, including relationships among patient, provider, and the health system. Medication reconciliation at discharge and early follow-up are steps that may increase medication adherence, decrease medication errors, and improve the transition to home. In addition, inclusion of the primary provider or stroke specialist in decisions regarding the management of antithrombotic therapy for procedures is important, as discontinuing these medications is often associated with recurrent ischemic events.

SUMMARY

: Prevention of recurrent stroke should be a priority for patients, caregivers, providers, and health systems. Medication-taking behavior should be considered from all of these perspectives in order to optimize adherence.

Peer education for secondary stroke prevention in inner-city minorities: design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial

BACKGROUND

The highest risk for stroke is among survivors of strokes or transient ischemic attacks (TIA). However, use of proven-effective cardiovascular medications to control stroke risk is suboptimal, particularly among the Black and Latino populations disproportionately impacted by stroke.

METHODS

A partnership of Harlem and Bronx community representatives, stroke survivors, researchers, clinicians, outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial. Using data from focus groups with stroke survivors, they tailored a peer-led, community-based chronic disease self-management program to address stroke risk factors. PRAISE will test, in a randomized controlled trial, whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control, lipid control, and use of antithrombotic medications.

RESULTS

Of the 582 survivors of stroke and TIA enrolled thus far, 81% are Black or Latino and 56% have an annual income less than $15,000. Many (33%) do not have blood pressures in the target range, and most (66%) do not have control of all three major stroke risk factors.

CONCLUSIONS

Rates of stroke recurrence risk factors remain suboptimal in the high risk, urban, predominantly minority communities studied. With a community-partnered approach, PRAISE has recruited a large number of stroke and TIA survivors to date, and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities.

Regional Variation in Recommended Treatments for Ischemic Stroke and TIA

Background and Purpose—

Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get With The Guidelines-Stroke.

Methods—

Receipt of 8 guideline-recommended treatments (intravenous tissue-type plasminogen activator, antihypertensives, antithrombotics, anticoagulants for atrial fibrillation, deep vein thrombosis prophylaxis, lipid-lowering medications at discharge, smoking cessation counseling, weight loss education) and defect-free care were compared in 4 US regions among eligible patients with ischemic stroke and transient ischemic attack; there was adjustment for patient demographics, medical history, and hospital characteristics.

Results—

Among 991 995 admissions (South, 37%; Northeast, 27.6%; Midwest, 19.3%; West, 15.9%). Receipt varied regionally for tissue-type plasminogen activator (58.2%–67.8%), lipid-lowering medications (72.5%–75.7%), antihypertensives (80.1%–83.6%), antithrombotics (95.6%–96.8%), deep vein thrombosis prophylaxis (88.0%–91.4%), weight loss education (49.3%–54.7%), and defect-free care (72.1%–76.5%). In adjusted analyses, patients in the South had lower odds of use of intravenous tissue-type plasminogen activator (OR [95% CI]; 0.82 [0.69–0.97]), antihypertensives (0.82 [0.67–0.99]), and defect-free care (0.83 [0.75–0.92]); but, they were more likely to receive lipid-lowering medications (1.28 [1.05–1.54]) compared with those in the Northeast. Patients in the Midwest had lower odds of intravenous tissue-type plasminogen activator administration (0.82 [0.68–0.99]) and defect-free care (0.81 [0.72–0.92]). Those in the West had lower odds of antihypertensives (0.81 [0.67–0.99]), but had greater odds of receiving lipid-lowering medications (1.26 [1.03–1.53]).

Conclusions—

Despite relatively high rates of adherence to stroke-related therapies in Get With The Guidelines-Stroke hospitals, regional variations exist, with over one quarter of patients receiving suboptimal care. Systematic improvements may lead to better patient outcomes.

Posttraumatic stress disorder and adherence to medications in survivors of strokes and transient ischemic attacks

BACKGROUND AND PURPOSE

Posttraumatic stress disorder (PTSD) can be triggered by life-threatening medical events such as strokes and transient ischemic attacks (TIAs). Little is known regarding how PTSD triggered by medical events affects patients' adherence to medications.

METHODS

We surveyed 535 participants, age ≥40 years old, who had at least 1 stroke or TIA in the previous 5 years. PTSD was assessed using the PTSD Checklist-Specific for stroke; a score ≥50 on this scale is highly specific for PTSD diagnosis. Medication adherence was measured using the 8-item Morisky scale. Logistic regression was used to test whether PTSD after stroke/TIA was associated with increased risk of medication nonadherence. Covariates for adjusted analyses included sociodemographics, Charlson comorbidity index, modified Rankin Scale score, years since last stroke/TIA, and depression.

RESULTS

Eighteen percent of participants had likely PTSD (PTSD Checklist-Specific for stroke ≥50), and 41% were nonadherent to medications according to the Morisky scale. A greater proportion of participants with likely PTSD were nonadherent to medications than other participants (67% versus 35%, P<0.001). In the adjusted model, participants with likely PTSD were nearly 3 times more likely (relative risk, 2.7; 95% CI, 1.7-4.2) to be nonadherent compared with participants without PTSD (PTSD Checklist-Specific for stroke <25) even after controlling for depression, and there was a graded association between PTSD severity and medication nonadherence.

CONCLUSION

PTSD is common after stroke/TIA. Patients who have PTSD after stroke or TIA are at increased risk for medication nonadherence.

Long-term use of antiplatelet drugs by stroke patients: a follow-up study based on prescription register data

PURPOSE

Treatment with antiplatelet drugs is a key element of secondary stroke prevention. We investigated long-term antiplatelet drug use in stroke patients with a focus on non-persistence.

METHODS

Population-based prescription register data were used to determine antiplatelet drug use in a cohort of stroke patients discharged from a Danish neurology department. The antiplatelet drugs comprised acetylsalicylic acid (ASA), clopidogrel and dipyridamole (if combined with ASA use). Non-persistence was defined as failure to present a prescription for antiplatelet drugs within 180 days after the dosage of a previous prescription had run out, or within 180 days after discharge. Cox regression was used to identify risk factors for non-persistence.

RESULTS

The cohort comprised 503 patients with ischaemic stroke discharged in 1999-2001. During follow-up (median 2.8 years, interquartile range 0.8-7.8 years), 486 of the subjects presented prescriptions for antiplatelets. Most subjects used a dual regimen of ASA and dipyridamole (N = 320). Of 110 non-persistent subjects in this group, 64 stopped using ASA, but continued to use dipyridamole in monotherapy. Overall, 181 patients (36 %) were non-persistent. Stroke severity was inversely associated with the risk of non-persistence [NIHSS score on admission 0-3 (reference); 4-6: hazard risk (HR) 0.87, 95 % confidence interval (CI) 0.61-1.25; 7+: HR 0.47, 95 % CI 0.29-0.74].

CONCLUSIONS

Long-term non-persistence with antiplatelet treatment was high and more pronounced in our patients with less severe stroke. Our findings on the use of ASA and dipyridamole indicate that non-persistence may in part be amenable to simple intervention measures.

Is there a future for endovascular treatment of intracranial atherosclerotic disease after Stenting and Aggressive Medical Management for Preventing Recurrent Stroke and Intracranial Stenosis (SAMMPRIS)?

The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke and Intracranial Stenosis (SAMMPRIS) trial, a randomized clinical trial comparing aggressive medical management to stenting with aggressive medical management for symptomatic intracranial stenosis, was prematurely halted when a high rate of periprocedural events was found in the stent arm. The trial also demonstrated a high rate of stroke with medical management. This article explores possible reasons for these outcomes and discusses some weaknesses of the trial. Against this background endovascular therapy should continue to be explored in the treatment of this disease.