Does care in a specialised stroke prevention clinic improve poststroke blood pressure control: a protocol for a randomised comparative effectiveness study

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

A randomized controlled trial of brain and heart health manager-led mHealth secondary stroke prevention

Background

This study explores the effect of brain and heart health manager (BHHM)-led stroke secondary prevention on blood pressure, and in improving the self-management ability of stroke patients. The BHHM has not been reported.

Methods

A total of 200 stroke patients, who were discharged from our hospital, were randomized into two groups at a 1:1 ratio: intervention group and control group. Patients in the control group were followed up for six months via telephone, while patients in the experimental group were followed up for six months using the BHHM-led mHealth follow-up. The primary outcomes were systolic blood pressure (BP) and self-management ability at 3, 6, 9 and 12 months, while the secondary outcomes included medication adherence, the body mass index (BMI), and blood low-density lipoprotein.

Results

The systolic BP between these two groups at four time points (F_time =8.734, F_group =172.075, and F_interaction =11.363) was statistically significant (P<0.05). The self-health management ability at four time points during follow-up period (F_time =115.09, F_group =1,185.50, and F_interaction =108.22) was also significantly different between these two groups. Furthermore, there was a statistically significant difference in compliance with medication at six months (χ²=37.616, P=0.000). However, after one year, there were no significant differences in BMI (t=0.214, P=0.644), total cholesterol (t=0.56, P=0.837), and low-density lipoprotein (t=0.042, P=0.455).

Conclusions

The BHHM-led mHealth follow-up is an effective method for managing BP and improving the self-care ability. Furthermore, this approach has no obvious effect on the management of BMI and blood low-density lipoprotein. A potential signal of efficacy with the intervention was observed.

Assessment of the Progression of Poststroke Depression in Ischemic Stroke Patients Using the Patient Health Questionnaire-9

BACKGROUND

Poststroke depression (PSD) affects one-third of stroke patients and is linked with higher stroke morbidity, mortality, and recurrence. Current guidelines do not direct when to screen for PSD, and predictors of PSD are not well understood. We sought to understand progression of PSD symptoms early after ischemic stroke, identify predictors of PSD, and describe the use of antidepressants in PSD.

METHODS

We collected demographic, clinical, and PSD (Patient Health Questionnaire-9; PHQ-9) data from ischemic stroke patients hospitalized at our Comprehensive Stroke Center and followed up in our clinic. PHQ-9 was obtained during hospitalization and again in clinic within 180 days of discharge. We performed univariate analysis and logistic regression to detect variables associated with PSD.

RESULTS

Among 201 patients, PSD symptoms (PHQ-9 > 4) were identified in 30% of patients during hospitalization and 46% during follow-up (54% of which had no symptoms during hospitalization). At follow-up, 36% were worse by PHQ-9 category. In univariate analysis, follow-up modified Rankin Scale (mRS) greater than or equal to 2 (P = .03) and antidepressant prescription (P < .001) were associated with worsening PHQ-9 category. In logistic regression analysis, follow-up mRS greater than or equal to 2 (P = .02), posterior circulation stroke (P = .03), and antidepressant prescription (P < .01) were associated with worsening PHQ-9 category.

CONCLUSIONS

Almost half of ischemic stroke patients develop PSD symptoms and more than one-third worsen between hospitalization and follow-up. Poststroke disability (mRS ≥ 2) and posterior circulation stroke were associated with worsening PSD. Worsening PSD symptoms prompted treatment change in 29% of patients. Screening for PSD during hospitalization should be repeated during early follow-up.