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Rachoin JS, Cerceo E, Anderson TS. Things We Do for No Reason™: Intensifying antihypertensive medications for hospitalized patients at the time of discharge. J Hosp Med 2024; 19:219-222. [PMID: 37545427 DOI: 10.1002/jhm.13185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Jean-Sebastien Rachoin
- Department of Medicine, Division of Hospital Medicine, Cooper University Healthcare, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Elizabeth Cerceo
- Department of Medicine, Division of Hospital Medicine, Cooper University Healthcare, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Bhat A, Mahajan V, Wolfe N. Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke. J Clin Neurosci 2021; 85:27-35. [PMID: 33581786 DOI: 10.1016/j.jocn.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/02/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
Stroke is a leading cause of morbidity and mortality worldwide. Although the majority of strokes affect the elderly, the incidence of stroke in young patients is on the rise. Prompt recognition of stroke symptoms and time critical therapies play a key role in management and prognosis of this condition. This is especially critical in young stroke patients, for whom delays in early recognition and treatment can result in many years of disability with associated social and financial burden. Misdiagnosis and unwarranted variation in treatment of stroke in young patients is problematic. Clinician implicit bias, the unconscious and unintentional process of judgement in healthcare decision-making, is a contributor to the short-falls in outcomes in this population. Interventions in this process have been shown to improve clinical outcomes in young stroke patients and represent an active area of study.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, NSW 2148, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, NSW 2148, Australia
| | - Nigel Wolfe
- Department of Neurology, Blacktown Hospital, Sydney, NSW 2148, Australia
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Abstract
Background and purpose After an initial stroke, the risk of recurrent stroke is high. Models that implement best-practice recommendations for risk factor management in stroke survivors to prevent stroke recurrence remain elusive. We examined a model which focuses on vascular risk factor management to prevent stroke recurrence in survivors returning to their primary care physicians. This model is coordinated from the stroke unit, integrates specialist stroke services with primary care physicians, and directly involves patients and carers in risk factor management. It is underpinned by the shared care principle in which there is joint participation of specialists as well as primary care physicians in a planned, integrated delivery of care with ongoing involvement of patients and carers, a structure which encourages implementation of best-practice recommendations as well as transferability and sustainability. We hypothesized that an integrated, multimodal intervention based on a shared-care model which supports joint participation of stroke specialists and primary care physicians would improve the implementation of best-practice recommendations for risk factor management in stroke survivors returning to the community. Methods We undertook a double-blind randomized controlled trial, testing the model in three Australian cities using stroke survivors admitted to stroke units and discharged from hospital to return to their primary care physicians. The model was a shared care, multifaceted integrated program which included bidirectional feedback between general practitioner and specialist unit, education, and engagement of patient and carer in self-management with ongoing input from a multidisciplinary team. The primary endpoint was improvement or abolition of risk factors such as raised blood pressure, diabetes, hyperlipidemia, the modification of adverse life-style factors such as lack of exercise, smoking and alcohol abuse and adherence to preventive medication at one year. Intermediate measurement points were scheduled at three monthly intervals. Analysis was by intention to treat, evaluated by covariance or a linear model adjusting for confounding factors or variance of base-line risk factors. The study was registered as ACTRN = 1261100026498. Results The study population was as follows: intervention ( n = 112), control ( n = 137). At baseline, there was no statistical difference between the groups for any variable. At the 12-month evaluation, there was a significant decrease in systolic blood pressure from baseline in the intervention group of 5.2 mmHg ( p < 0.01). This change was not observed in the control group ( p = 0.29). Moreover, at 12 months the mean systolic blood pressure in the intervention group was 129.4 mmHg (SD 14.7), a result which was not obtained in controls. Fasting total cholesterol as well as triglycerides was reduced significantly in the intervention group (both p < 0.01) but this was not the case in the control group ( p = 0.11 and p = 0.27, respectively). At 12 months, there was no change in BMI in the intervention group but there was a significant increase in BMI ( p = 0.02) in the control group. At 12 months in the intervention group, the mean distance walked with ease compared to the baseline measurements was increased by a mean distance of 600 m while in the control group the distance walked with ease was reduced compared to that measured at baseline. At 12 months, the Barthel index in the intervention group demonstrated improved function ( p = 0.01), but no change was observed in controls. At 12 months in the intervention group, there was a significant decrease in number of standard alcoholic drinks consumed per week compared to the baseline ( p = 0.04). This was not observed in the control group ( p = 0.34). Conclusion In stroke survivors, the ICARUSS (Integrated Care for the Reduction of Secondary Stroke) model is superior to usual care with respect to best-practice recommendations for traditional risk factors as well as behavioral and functional outcomes.
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Abstract
AbstractBackgroundIn 2010, we published our stroke prevention clinic’s performance as compared to Canadian stroke prevention guidelines. We now compare our clinic’s adherence with guidelines to our previous results, following the implementation of an electronic documentation form.MethodsAll new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008–2010) regarding vascular risk management and treatment.ResultsThree hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04–2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.ConclusionsOur study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.
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Mendyk AM, Duhamel A, Bejot Y, Leys D, Derex L, Dereeper O, Detante O, Garcia PY, Godefroy O, Montoro FM, Neau JP, Richard S, Rosolacci T, Sibon I, Sablot D, Timsit S, Zuber M, Cordonnier C, Bordet R. Controlled Education of patients after Stroke (CEOPS)- nurse-led multimodal and long-term interventional program involving a patient's caregiver to optimize secondary prevention of stroke: study protocol for a randomized controlled trial. Trials 2018; 19:137. [PMID: 29471839 PMCID: PMC5824577 DOI: 10.1186/s13063-018-2483-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 01/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Setting up a follow-up secondary prevention program after stroke is difficult due to motor and cognitive impairment, but necessary to prevent recurrence and improve patients' quality of life. To involve a referent nurse and a caregiver from the patient's social circle in nurse-led multimodal and long-term management of risk factors after stroke could be an advantage due to their easier access to the patient and family. The aim of this study is to compare the benefit of optimized follow up by nursing personnel from the vascular neurology department including therapeutic follow up, and an interventional program directed to the patient and a caregiving member of their social circle, as compared with typical follow up in order to develop a specific follow-up program of secondary prevention of stroke. METHODS/DESIGN The design is a randomized, controlled, clinical trial conducted in the French Stroke Unit of the Strokavenir network. In total, 410 patients will be recruited and randomized in optimized follow up or usual follow up for 2 years. In both group, patients will be seen by a neurologist at 6, 12 and 24 months. The optimized follow up will include follow up by a nurse from the vascular neurology department, including therapeutic follow up, and a training program on secondary prevention directed to the patient and a caregiving member of their social circle. After discharge, a monthly telephone interview, in the first year and every 3 months in the second year, will be performed by the nurse. At 6, 12 and 24 month, the nurse will give the patient and caregiver another training session. Usual follow up is only done by the patient's general practitioner, after classical information on secondary prevention of risk factors during hospitalization. The primary outcome measure is blood pressure measured after the first year of follow up. Blood pressure will be measured by nursing personnel who do not know the group into which the patient has been randomized. Secondary endpoints are associated mortality, morbidity, recurrence, drug side-effects and medico-economic analysis. DISCUSSION The result of this trial is expected to provide the benefit of a nurse-led optimized multimodal and long-term interventional program for management of risk factors after stroke, personalizing the role of the nurse and including the patient's caregiver. TRIAL REGISTRATION ClinicalTrials.gov, NCT 02132364. Registered on 7 May 2014. EUDRACT, A 00473-40.
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Affiliation(s)
- Anne-Marie Mendyk
- University Lille, Inserm, CHU, U1171 'Degenerative and vascular cognitive disorders', F-59000, Lille, France
| | - Alain Duhamel
- University Lille, CHU, EA2694, F-59000, Lille, France
| | - Yannick Bejot
- University Hospital and Medical School of Dijon, University of Burgundy, Digon, France
| | - Didier Leys
- University Lille, Inserm, CHU, U1171 'Degenerative and vascular cognitive disorders', F-59000, Lille, France
| | - Laurent Derex
- Department of Stroke Medicine, Université Lyon 1, Lyon, France
| | - Olivier Dereeper
- Stroke Unit, Neurology Department, Calais Hospital, Calais, France
| | - Olivier Detante
- Université Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, Grenoble, France
| | - Pierre-Yves Garcia
- Stroke Unit, Neurology Department, Compiègne Hospital, Compiègne, France
| | - Olivier Godefroy
- Department of Neurology and Functional Neuroscience Laboratory EA 4559, Amiens University Medical Center, Amiens, France
| | | | - Jean-Philippe Neau
- Department of Neurology, CHU of Poitiers, University of Poitiers, Poitiers, France
| | - Sébastien Richard
- Stroke unit, Department of Neurology, CHU of Nancy, Lorraine University, Nancy, France
| | - Thierry Rosolacci
- Stroke Unit, Neurology Department, Maubeuge Hospital, Maubeuge, France
| | - Igor Sibon
- Department of Neurology, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Denis Sablot
- Stroke Unit, Neurology Department, Perpignan Hospital, Perpignan, France
| | - Serge Timsit
- CHRU Brest, Department of Neurology and Stroke Unit, Université de Bretagne Occidentale, Brest, France
| | - Mathieu Zuber
- Department of Neurology, Saint-Joseph Hospital Center, AP - HP, Université Paris-Descartes, INSERM UMR S 919, Paris, France
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU, U1171 'Degenerative and vascular cognitive disorders', F-59000, Lille, France
| | - Régis Bordet
- University Lille, Inserm, CHU, U1171 'Degenerative and vascular cognitive disorders', F-59000, Lille, France.
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Andrew NE, Kim J, Thrift AG, Kilkenny MF, Lannin NA, Anderson CS, Donnan GA, Hill K, Middleton S, Levi C, Faux S, Grimley R, Gange N, Geraghty R, Ermel S, Cadilhac DA. Prescription of antihypertensive medication at discharge influences survival following stroke. Neurology 2018; 90:e745-e753. [PMID: 29386279 DOI: 10.1212/wnl.0000000000005023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the risk of death from cardiovascular disease between patients who were and were not prescribed antihypertensive medication following stroke or TIA. METHODS This was a large cohort study using routinely collected prospective data from the Australian Stroke Clinical Registry. Patients registered between 2009 and 2013 who were discharged to the community or rehabilitation were included. Cases were linked to the National Death Index to determine the date and cause of death. Propensity score matching with stratification was utilized to compare between similar subgroups of patients. Multivariable competing risks regression, with noncardiovascular death as a competing risk, was conducted to investigate the association between the prescription of antihypertensive medications and cardiovascular death at 180 days after admission. RESULTS Among 12,198 patients from 40 hospitals, 70% were prescribed antihypertensive medications. Patients who were older, were treated in a stroke unit, and had better socioeconomic position were more often discharged from hospital with an antihypertensive medication. Including only patients within propensity score quintiles with acceptable levels of balance in covariates between groups (n = 8,786), prescription of antihypertensive medications was associated with a 23% greater reduction in the subhazard of cardiovascular death compared to those who were not prescribed these agents (subhazard ratio 0.77; 95% confidence interval 0.61 to 0.97). CONCLUSIONS People who are prescribed antihypertensive medications at discharge from hospital after a stroke or TIA demonstrate better cardiovascular and all-cause survival outcomes than those not prescribed these agents.
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Affiliation(s)
- Nadine E Andrew
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Joosup Kim
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Amanda G Thrift
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Monique F Kilkenny
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Natasha A Lannin
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Craig S Anderson
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Geoffrey A Donnan
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Kelvin Hill
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Sandy Middleton
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Christopher Levi
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Steven Faux
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Rohan Grimley
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Nisal Gange
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Richard Geraghty
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Sharan Ermel
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia
| | - Dominique A Cadilhac
- From Stroke & Ageing Research (N.E.A., J.K., A.G.T., M.F.K., R.G., D.A.C.), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton; Department of Medicine (N.E.A), Peninsula Clinical School, Central Clinical School, Monash University, Frankston; Florey Institute of Neuroscience and Mental Health (J.K., M.F.K., G.A.D., D.A.C.), University of Melbourne, Heidelberg; School of Allied Health (Occupational Therapy) (N.A.L.), La Trobe University, Bundoora; Occupational Therapy Department (N.A.L.), Alfred Health, Melbourne; Faculty of Medicine (C.S.A.), The University of New South Wales, Sydney; Stroke Foundation (K.H.), Melbourne; Nursing Research Institute (S.M.), St Vincent's Health Australia, Sydney and Australian Catholic University, Sydney; University of New South Wales and the Partnership for Health Education, Research and Enterprise (SPHERE) (C.L.), Sydney; Faculty of Medicine (S.F.), The University of New South Wales, Sydney and St Vincent's Health Australia, Sydney; Statewide Stroke Clinical Network (R.G.), Queensland Health, Brisbane; Sunshine Coast Clinical School (R.G), The University of Queensland, Birtinya; Toowoomba Hospital (N.G.), Toowoomba; Redcliffe Hospital (R.G.), Brisbane; and Bendigo Health (S.E.), Bendigo, Australia.
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Jiang Y, Yang X, Li Z, Pan Y, Wang Y, Wang Y, Ji R, Wang C. Persistence of secondary prevention medication and related factors for acute ischemic stroke and transient ischemic attack in China. Neurol Res 2017; 39:492-497. [PMID: 28420316 DOI: 10.1080/01616412.2017.1312792] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Yue Jiang
- School of General Practice and Continuing Education, Capital Medical University, Beijing, China
- Department of General Practice, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Xiaomeng Yang
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Tiantan Clinical Trial and Research Center for Stroke, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Tiantan Clinical Trial and Research Center for Stroke, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Ruijun Ji
- Vascular Neurology, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Chen Wang
- School of General Practice and Continuing Education, Capital Medical University, Beijing, China
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Blecker S, Meisel T, Dickson VV, Shelley D, Horwitz LI. "We're Almost Guests in Their Clinical Care": Inpatient Provider Attitudes Toward Chronic Disease Management. J Hosp Med 2017; 12:162-167. [PMID: 28272592 PMCID: PMC5520967 DOI: 10.12788/jhm.2699] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Many hospitalized patients have at least 1 chronic disease that is not optimally controlled. The purpose of this study was to explore inpatient provider attitudes about chronic disease management and, in particular, barriers and facilitators of chronic disease management in the hospital. METHODS We conducted a qualitative study of semi-structured interviews of 31 inpatient providers from an academic medical center. We interviewed attending physicians, resident physicians, physician assistants, and nurse practitioners from various specialties about attitudes, experiences with, and barriers and facilitators towards chronic disease management in the hospital. Qualitative data were analyzed using constant comparative analysis. RESULTS Providers perceived that hospitalizations offer an opportunity to improve chronic disease management, as patients are evaluated by a new care team and observed in a controlled environment. Providers perceived clinical benefits to in-hospital chronic care, including improvements in readmission and length of stay, but expressed concerns for risks related to adverse events and distraction from the acute problem. Barriers included provider lack of comfort with managing chronic diseases, poor communication between inpatient and outpatient providers, and hospital-system focus on patient discharge. A strong relationship with the outpatient provider and involvement of specialists were facilitators of inpatient chronic disease management. CONCLUSIONS Providers perceived benefits to in-hospital chronic disease management for both processes of care and clinical outcomes. Efforts to increase inpatient chronic disease management will need to overcome barriers in multiple domains. Journal of Hospital Medicine 2017;12:162-167.
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Affiliation(s)
- Saul Blecker
- Department of Population Health, New York University School of Medicine, New York, New York
- Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center, New York, New York
- Department of Medicine, New York University School of Medicine, New York, New York
- Address for correspondence and reprint requests: Saul Blecker, MD, MHS, New York University School of Medicine, 227 E. 30th St., Room 648, New York, NY 10016; Telephone: 646-501-2513; Fax: 646-501-2706;
| | - Talia Meisel
- Department of Population Health, New York University School of Medicine, New York, New York
| | | | - Donna Shelley
- Department of Population Health, New York University School of Medicine, New York, New York
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Leora I. Horwitz
- Department of Population Health, New York University School of Medicine, New York, New York
- Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center, New York, New York
- Department of Medicine, New York University School of Medicine, New York, New York
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Al AlShaikh S, Quinn T, Dunn W, Walters M, Dawson J. Multimodal Interventions to Enhance Adherence to Secondary Preventive Medication after Stroke: A Systematic Review and Meta-Analyses. Cardiovasc Ther 2017; 34:85-93. [PMID: 26820710 DOI: 10.1111/1755-5922.12176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Nonadherence to secondary preventative medications after stroke is common and is associated with poor outcomes. Numerous strategies exist to promote adherence. We performed a systematic review and meta-analysis to describe the efficacy of strategies to improve adherence to stroke secondary prevention. METHODS We created a sensitive search strategy and searched multiple electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and Web of Knowledge) for studies of interventions that aimed to enhance adherence to secondary preventative medication after stroke. We assessed quality of included studies using the Cochrane tool for assessing risk of bias. We performed narrative review and performed meta-analysis where data allowed. RESULTS From 12,237 titles, we included seventeen studies in our review. Eleven studies were considered to have high risk of bias, 3 with unclear risk, and 3 of low risk. Meta-analysis of available data suggested that these interventions improved adherence to individual medication classes (blood pressure-lowering drugs - OR, 2.21; 95% CI (1.63, 2.98), [P < 0.001], lipid-lowering drugs - OR, 2.11; 95% CI (1.00, 4.46), [P = 0.049], and antithrombotic drugs - OR, 2.32; 95% CI (1.18, 4.56, [P = 0.014]) but did not improve adherence to an overall secondary preventative medication regimen (OR, 1.96; 95% CI (0.50, 7.67), [P = 0.332]). CONCLUSION Interventions can lead to improvement in adherence to secondary preventative medication after stroke. However, existing data is limited as several interventions, duration of follow-up, and various definitions were used. These findings need to be interpreted with caution.
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Affiliation(s)
- Sukainah Al AlShaikh
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - William Dunn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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11
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Kleinig T. Antihypertensive treatment should be commenced in hospital after stroke: Pro. Int J Stroke 2016; 12:121-122. [DOI: 10.1177/1747493016674958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The most important intervention to lower stroke recurrence rates is to ensure that every eligible patient adheres to antihypertensive therapy guidelines. Although there is no strong evidence that acute in-hospital antihypertensive treatment is either beneficial or harmful, there is robust evidence that long-term adherence is promoted by antihypertensive prescription in-hospital or at discharge.
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Affiliation(s)
- Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
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Abstract
BACKGROUND Few studies have assessed the performance of stroke prevention clinics. In particular, limited information exists on patient compliance, achievement of therapeutic targets, and related occurrence of vascular events. METHODS We compared our clinical practice to recommendations from published guidelines in newly referred patients for transient ischemic attack (TIA) or ischemic stroke between 2008 and 2010. We monitored our cohort for at least 1 year and assessed for adequacy of vascular risk factor management, drug adherence, and occurrence of nonlethal vascular outcomes. RESULTS Of 408 patients, 57.8% had a stroke and 42.2% a TIA. The mean age was 68±13 years, and 52% male. Average follow-up was 15.8 months. During follow-up, 253 patients (70.3%) completely achieved their blood pressure target, 151 (45.5%) achieved their low-density lipoprotein (LDL) cholesterol target, and 407 (99.8%) were on antithrombotics. Eighty-nine patients (21.8%) attained optimal therapy status, defined as reaching targets for LDL cholesterol, blood pressure, and antithrombotic use. Adherence to drug therapy was associated with attainment of optimal therapy status (p=0.01). Diabetes was associated with lower probability of attaining optimal therapy status (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.20-0.66) and blood pressure targets (OR, 0.09; 95% CI, 0.05-0.17). During follow-up, 52 (12.7%) patients had a nonlethal vascular event. CONCLUSION Our study shows good attainment of therapeutic goals associated with adherence to drug therapy. However, optimal therapy status and blood pressure targets were more difficult to attain in patients with diabetes; therefore, more intensive preventive efforts may be required for these individuals.
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Emergency Department Management of Transient Ischemic Attack: A Survey of Emergency Physicians. J Stroke Cerebrovasc Dis 2016; 25:1517-23. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.02.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/19/2016] [Indexed: 11/23/2022] Open
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Al AlShaikh S, Quinn T, Dunn W, Walters M, Dawson J. Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses. Eur Stroke J 2016; 1:65-75. [PMID: 29900404 PMCID: PMC5992740 DOI: 10.1177/2396987316647187] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Sukainah Al AlShaikh
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - William Dunn
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Bustamante A, García-Berrocoso T, Rodriguez N, Llombart V, Ribó M, Molina C, Montaner J. Ischemic stroke outcome: A review of the influence of post-stroke complications within the different scenarios of stroke care. Eur J Intern Med 2016; 29:9-21. [PMID: 26723523 DOI: 10.1016/j.ejim.2015.11.030] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 09/28/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022]
Abstract
Stroke remains one of the main causes of death and disability worldwide. The challenge of predicting stroke outcome has been traditionally assessed from a general point of view, where baseline non-modifiable factors such as age or stroke severity are considered the most relevant factors. However, after stroke occurrence, some specific complications such as hemorrhagic transformations or post stroke infections, which lead to a poor outcome, could be developed. An early prediction or identification of these circumstances, based on predictive models including clinical information, could be useful for physicians to individualize and improve stroke care. Furthermore, the addition of biological information such as blood biomarkers or genetic polymorphisms over these predictive models could improve their prognostic value. In this review, we focus on describing the different post-stroke complications that have an impact in short and long-term outcome across different time points in its natural history and on the clinical-biological information that might be useful in their prediction.
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Affiliation(s)
- Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodriguez
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Victor Llombart
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Guignard B, Bonnabry P, Perrier A, Dayer P, Desmeules J, Samer CF. Drug-related problems identification in general internal medicine: The impact and role of the clinical pharmacist and pharmacologist. Eur J Intern Med 2015; 26:399-406. [PMID: 26066400 DOI: 10.1016/j.ejim.2015.05.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients admitted to general internal medicine wards might receive a large number of drugs and be at risk for drug-related problems (DRPs) associated with increased morbidity and mortality. This study aimed to detect suboptimal drug use in internal medicine by a pharmacotherapy evaluation, to suggest treatment optimizations and to assess the acceptance and satisfaction of the prescribers. METHODS This was a 6-month prospective study conducted in two internal medicine wards. Physician rounds were attended by a pharmacist and a pharmacologist. An assessment grid was used to detect the DRPs in electronic prescriptions 24h in advance. One of the following interventions was selected, depending on the relevance and complexity of the DRPs: no intervention, verbal advice of treatment optimization, or written consultation. The acceptance rate and satisfaction of prescribers were measured. RESULTS In total, 145 patients were included, and 383 DRPs were identified (mean: 2.6 DRPs per patient). The most frequent DRPs were drug interactions (21%), untreated indications (18%), overdosages (16%) and drugs used without a valid indication (10%). The drugs or drug classes most frequently involved were tramadol, antidepressants, acenocoumarol, calcium-vitamin D, statins, aspirin, proton pump inhibitors and paracetamol. The following interventions were selected: no intervention (51%), verbal advice of treatment optimization (42%), and written consultation (7%). The acceptance rate of prescribers was 84% and their satisfaction was high. CONCLUSION Pharmacotherapy expertise during medical rounds was useful and well accepted by prescribers. Because of the modest allocation of pharmacists and pharmacologists in Swiss hospitals, complementary strategies would be required.
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Affiliation(s)
- Bertrand Guignard
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland; Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Arnaud Perrier
- Service of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Jules Desmeules
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Caroline Flora Samer
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland; Swiss Centre for Applied Human Toxicology, University of Geneva, Geneva, Switzerland
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Irewall AL, Bergström L, Ogren J, Laurell K, Söderström L, Mooe T. Implementation of telephone-based secondary preventive intervention after stroke and transient ischemic attack - participation rate, reasons for nonparticipation and one-year mortality. Cerebrovasc Dis Extra 2014; 4:28-39. [PMID: 24715896 PMCID: PMC3975210 DOI: 10.1159/000358121] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 12/17/2013] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose Patients who experience a stroke or transient ischemic attack (TIA) are known to be at high risk of subsequent vascular events, underscoring the need for secondary preventive intervention. However, previous studies have indicated insufficiency in the implementation of secondary prevention, emphasizing the need to develop effective methods of follow-up. In the present study, we examined the potential of implementing a telephone-based, nurse-led, secondary preventive follow-up in stroke and TIA patients on a population level by analyzing the participation rate, reasons for nonparticipation, and one-year mortality. Methods Between January 1, 2010 and December 31, 2011, all patients admitted to Östersund hospital, Sweden, and diagnosed with either stroke or TIA were considered for inclusion into the secondary preventive follow-up. Baseline data were collected at the hospital, and reasons for nonparticipation were documented. Multivariate logistic regression was performed to identify predictors of the patient decision not to participate and to explore independent associations between baseline characteristics and exclusion. A one-year follow-up of mortality was also performed; the survival functions of the three groups (included, excluded, declining participation) was calculated using the Kaplan-Meier estimator. Results From a total of 810 identified patients, 430 (53.1%) were included in the secondary preventive follow-up, 289 (35.7%) were excluded mainly due to physical or cognitive disability, and 91 (11.2%) declined participation. Age ≥85 years, ischemic and hemorrhagic stroke, modified Rankin scale score >3, body mass index ≥25, congestive heart failure, and lower education level were independently associated with exclusion, whereas lower education level was the only factor independently associated with the patient decision not to participate. Exclusion was associated with a more than 12 times higher risk of mortality within the first year after discharge. Conclusion Population-based implementation of secondary prevention in stroke and TIA patients is limited by the high prevalence of comorbidity and a considerable degree of disability. In our study, a large proportion of patients were unable to participate even in this simple form of secondary preventive follow-up. Exclusion was associated with substantially higher one-year mortality, and education level was independently associated with physical ability as well as the motivation to participate in the secondary preventive follow-up program.
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Affiliation(s)
- Anna-Lotta Irewall
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Lisa Bergström
- Department of Public Health and Clinical Medicine at Östersund, Umeå University, Umeå, Sweden
| | - Joachim Ogren
- Department of Public Health and Clinical Medicine at Östersund, Umeå University, Umeå, Sweden
| | - Katarina Laurell
- Department of Pharmacology and Clinical Neuroscience at Östersund, Umeå University, Umeå, Sweden
| | - Lars Söderström
- Department of Unit of Clinical Research Center, County Council of Jämtland, Östersund Hospital, Östersund, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine at Östersund, Umeå University, Umeå, Sweden
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Gorelick PB. Primary and comprehensive stroke centers: history, value and certification criteria. J Stroke 2013; 15:78-89. [PMID: 24324943 PMCID: PMC3779669 DOI: 10.5853/jos.2013.15.2.78] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 01/24/2013] [Accepted: 01/24/2013] [Indexed: 01/28/2023] Open
Abstract
In the United States (US) stroke care has undergone a remarkable transformation in the past decades at several levels. At the clinical level, randomized trials have paved the way for many new stroke preventives, and recently, several new mechanical clot retrieval devices for acute stroke treatment have been cleared for use in practice by the US Federal Drug Administration. Furthermore, in the mid 1990s we witnessed regulatory approval of intravenous recombinant tissue plasminogen activator for administration in acute ischemic stroke. In the domain of organization of medical care and delivery of health services, stroke has transitioned from a disease dominated by neurologic consultation services only to one managed by vascular neurologists in geographical stroke units, stroke teams and care pathways, primary stroke center certification according to The Joint Commission, and most recently comprehensive stroke center designation under the aegis of The Joint Commission. Many organizations in the US have been involved to enhance stroke care. To name a few, the American Heart Association/American Stroke Association, Brain Attack Coalition, and National Stroke Association have been on the forefront of this movement. Additionally, governmental initiatives by the US Centers for Disease Control and Prevention and legislative initiatives such as the Paul Coverdell National Acute Stroke Registry program have paved the way to focus on stroke prevention, acute treatment and quality improvement. In this invited review, we discuss a brief history of organized stroke care in the United States, evidence to support the value of primary and comprehensive stroke centers, and the certification criteria and process to become a primary or comprehensive stroke center.
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Affiliation(s)
- Philip B Gorelick
- Translational Science and Molecular Medicine, Michigan State College of Human Medicine, Michigan, USA. ; Hauenstein Neuroscience Center, Saint Mary's Health Care, Michigan, USA
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Paul NLM, Koton S, Simoni M, Geraghty OC, Luengo-Fernandez R, Rothwell PM. Feasibility, safety and cost of outpatient management of acute minor ischaemic stroke: a population-based study. J Neurol Neurosurg Psychiatry 2013; 84:356-61. [PMID: 23172867 PMCID: PMC5321491 DOI: 10.1136/jnnp-2012-303585] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Outpatient management safely and effectively prevents early recurrent stroke after transient ischaemic attack (TIA), but this approach may not be safe in patients with acute minor stroke. OBJECTIVE To study outcomes of clinic and hospital-referred patients with TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) in a prospective, population-based study (Oxford Vascular Study). RESULTS Of 845 patients with TIA/stroke, 587 (69%) were referred directly to outpatient clinics and 258 (31%) directly to inpatient services. Of the 250 clinic-referred minor strokes (mean age 72.7 years), 237 (95%) were investigated, treated and discharged on the same day, of whom 16 (6.8%) were subsequently admitted to hospital within 30 days for recurrent stroke (n=6), sepsis (n=3), falls (n=3), bleeding (n=2), angina (n=1) and nursing care (n=1). The 150 patients (mean age 74.8 years) with minor stroke referred directly to hospital (median length-of-stay 9 days) had a similar 30-day readmission rate (9/150; 6.3%; p=0.83) after initial discharge and a similar 30-day risk of recurrent stroke (9/237 in clinic patients vs 8/150, OR=0.70, 0.27-1.80, p=0.61). Rates of prescription of secondary prevention medication after initial clinic/hospital discharge were higher in clinic-referred than in hospital-referred patients for antiplatelets/anticoagulants (p<0.05) and lipid-lowering agents (p<0.001) and were maintained at 1-year follow-up. The mean (SD) secondary care cost was £8323 (13 133) for hospital-referred minor stroke versus £743 (1794) for clinic-referred cases. CONCLUSION Outpatient management of clinic-referred minor stroke is feasible and may be as safe as inpatient care. Rates of early hospital admission and recurrent stroke were low and uptake and maintenance of secondary prevention was high.
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Affiliation(s)
- Nicola L M Paul
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
| | - Silvia Koton
- Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Michela Simoni
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
| | - Olivia C Geraghty
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK, OX3 9DU
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Goldfinger JZ, Kronish IM, Fei K, Graciani A, Rosenfeld P, Lorig K, Horowitz CR. 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. Contemp Clin Trials 2012; 33:1065-73. [PMID: 22710563 PMCID: PMC3408803 DOI: 10.1016/j.cct.2012.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 05/10/2012] [Accepted: 06/08/2012] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Judith Z Goldfinger
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA.
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Heeley E, Anderson C, Patel A, Cass A, Peiris D, Weekes A, Chalmers J. Disparities between Prescribing of Secondary Prevention Therapies for Stroke and Coronary Artery Disease in General Practice. Int J Stroke 2011; 7:649-54. [DOI: 10.1111/j.1747-4949.2011.00613.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Extensive evidence exists regarding the effectiveness of secondary prevention measures in patients with cardiovascular disease. Aim We aimed to examine the management and risk perceptions of cardiovascular events in people with established cardiovascular disease. Methods We analyzed data on 1453 patients, ≥55 year old, with a history of cardiovascular disease, from the Australian Hypertension and Absolute Risk Study. Results Compared with those 533 patients with stroke/transient ischemic attack, the 743 patients with coronary artery disease were twice as likely to have been prescribed secondary prevention therapies even after adjustment for potential confounding variables (adjusted relative risks 1·85; 95% confidence interval 1·56–2·19, 42% vs. 73% for use of the combination of blood pressure-lowering, lipid-lowering and antiplatelet therapies) and to have better control of lipid and blood pressure levels. General practitioners estimated that only 27% of patients with stroke/transient ischemic attack – 38% of those with coronary artery disease and 41% of those with both conditions – were at a high risk (≥15%) of a recurrent event. Patients similarly underestimated their risk of recurrent cardiovascular events, with only 8% of stroke/transient ischemic attack, 11% of coronary and 15% of combination disease patients rating themselves at ‘high’ or‘very-high’ risk. Conclusions This study reaffirms the large treatment gap in the uptake of secondary prevention for cardiovascular disease in primary care settings, being much greater for patients with cerebral compared with cardiac cardiovascular disease. This appears to be related to differential perceptions of cardiovascular risk across different vascular territories in both patients and doctors.
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Affiliation(s)
- Emma Heeley
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Craig Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Anushka Patel
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Alan Cass
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Andrew Weekes
- Servier Laboratories (Australia) Pty Ltd, Hawthorn, Vic., Australia
| | - John Chalmers
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
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Palamuthusingam D, Quigley F, Golledge J. Implications of the finding of no significant carotid stenosis based on data from a regional Australian vascular unit. Ann Vasc Surg 2011; 25:1050-6. [PMID: 21831585 DOI: 10.1016/j.avsg.2011.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 01/30/2011] [Accepted: 05/24/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to assess the long-term clinical outcomes in terms of vascular events in patients who showed no significant or mild carotid stenosis (<50%) and thus in whom surgical intervention was not planned. Patients were recruited through referrals to a vascular laboratory between January 2000 and June 2000. One hundred thirty-two of 316 (42%) patients referred for carotid duplex scan were identified to have mild carotid artery disease. METHODS A retrospective observational study of patients identified to have mild carotid artery stenosis from a regional vascular unit in Australia was carried out. Patients were followed up over an 8-year period. Outcomes were assessed in relation to the patients' presenting complaint and risk factor profile. Outcomes included the following: (1) combined cardiovascular events (fatal and nonfatal strokes, fatal and nonfatal myocardial infarctions, and cardiac admissions, which included arrhythmias and angina), (2) strokes (both fatal and nonfatal strokes), and (3) all-cause mortality. RESULTS The patient sample included 75 men and 57 women. The median age of the patients was 69.9 (interquartile range: 63.4-76.7) years. There were a total of 49 vascular events in 46 of the 132 patients, including 16 nonfatal and 2 fatal myocardial infarctions, 19 admissions for cardiac reasons other than an acute coronary syndrome, and 12 nonfatal strokes. The cardiovascular and stroke rates were 33.9% and 13.0% at 7.7 years, respectively. The incidence of strokes was highest among those who presented with a previous stroke or a transient ischemic attack. CONCLUSIONS The long-term clinical outcomes of patients who were referred for duplex ultrasonography and found to have <50% stenosis were not benign. A significant number of vascular events were observed in this study group. Those who presented with a history of stroke or transient ischemic attack were at particular risk of another stroke.
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Affiliation(s)
- Dharmenaan Palamuthusingam
- Department of Medicine, Logan Hospital, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
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Abstract
PURPOSE OF REVIEW The aim is to review transient ischaemic attack (TIA) clinics, other service delivery models, and current TIA management. RECENT FINDINGS Urgent assessment of TIA patients by stroke specialist services reduces stroke risk and is cost-effective. Almost one-third of TIA patients wait more than 24 h before presenting to medical attention, with delay associated with higher stroke risk. Risk stratification following suspected TIA may be performed by clinical assessment of individual patient characteristics, combined with the validated ABCD2 score (pre-investigation), and the ABCD3-I score (postinvestigation) in secondary care settings. Brain MRI and transcranial Doppler ultrasound add information related to vascular territory, TIA mechanism, and prognosis. Variability in systolic blood pressure in treated and untreated patients is an important predictor of stroke risk, independently of mean blood pressure. SUMMARY Daily specialist-provided TIA services delivered in clinic or inpatient settings have proven efficacy for stroke prevention. In addition, a rapid-access, clinic-based service is associated with cost savings and reduced hospital bed-day utilization after TIA.
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Abstract
Stroke is a leading cause of mortality and long-term disability in the western world, accounting for 5% of the UK health budget. Consequently, it has been the major focus of recent healthcare advances. Physiological disturbances are common following an acute stroke, chiefly blood pressure (BP) abnormalities (high and 'relatively' low BP), which indicate adverse prognosis. While pilot studies suggest that early intervention to moderate both extremes of BP may improve outcomes, definitive evidence is awaited from ongoing research. Long-term elevated BP is the most prevalent risk factor for future stroke, with a comprehensive evidence base supporting BP reduction to reduce the risk of vascular events, including stroke. However, adherence to secondary preventive medications, including antihypertensive agents, remains poor. This article summarizes the current understanding of the role of BP in stroke, focusing on the management of BP for secondary prevention. Further emphasis is placed on identifying deficiencies in long-term management; barriers to improved application and potential interventions to overcome these barriers are summarized.
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Affiliation(s)
- Kate Lager
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK
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Witte KK, Clark AL. NYHA class I heart failure is not 'mild'. Int J Cardiol 2011; 146:128-9. [PMID: 20970201 DOI: 10.1016/j.ijcard.2010.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 10/02/2010] [Indexed: 10/18/2022]
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Kirshner HS. Current issues in antiplatelet therapy for stroke prevention: the importance of stroke subtypes and differences between stroke and MI patients. J Neurol 2010; 257:1788-97. [DOI: 10.1007/s00415-010-5667-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 06/22/2010] [Accepted: 07/06/2010] [Indexed: 10/19/2022]
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Hornnes N, Larsen K, Boysen G. Little Change of Modifiable Risk Factors 1 Year after Stroke: a Pilot Study. Int J Stroke 2010; 5:157-62. [DOI: 10.1111/j.1747-4949.2010.00424.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Recurrent stroke accounts for about 25% of admissions for acute stroke. For the prevention of recurrent cerebro and cardiovascular disease, stroke patients are advised to change modifiable stroke risk factors before discharge from stroke units. Aims To investigate the change in modifiable risk factors 1 year after stroke and to explore the feasibility of a preventive programme aimed at stroke patients discharged from hospital. Methods From April 2004 to February 2005, 173 patients admitted to hospital with a diagnosis of stroke were consecutively included and interviewed about their medical history and modifiable risk factors before stroke. One-year follow-up with measurement of blood pressure was performed in 92% of surviving and able participants. Results One year after discharge, 121 participants were reinterviewed and 118 had their blood pressure measured. We found uncontrolled hypertension in 43 of 65 patients (66% of those receiving antihypertensive medication) and unknown hypertension in 30 of 53 patients (57% of those without antihypertensive medication). There was a reduction in the prevalence of excessive consumption of alcohol from 24 of 121 patients (20%) to 16 of 121 patients (13%) (P<005). The frequency of cigarette intake remained unchanged: 57 of 121 patients (47%) 1 year after stroke. The proportion of patients who were physically inactive increased from 36% (43 of 121 patients) before stroke to 59% (71 of 121) 1 year later ( P < 0·0001). Conclusions The change in modifiable risk factors was inadequate 1 year after stroke. The pilot study indicated that a preventive programme should focus on hypertension, smoking and physical inactivity.
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Affiliation(s)
| | - Klaus Larsen
- Department of Biostatistics, Lundbeck A/S, Ottiliavej, Valby, Denmark
| | - Gudrun Boysen
- Department of Neurology, Bispebjerg Hospital, København NV, Denmark
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Mechtouff L, Touzé E, Steg PG, Ohman EM, Goto S, Hirsch AT, Röther J, Aichner FT, Weimar C, Bhatt DL, Alberts MJ, Mas JL. Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease. J Intern Med 2010; 267:621-33. [PMID: 20210837 DOI: 10.1111/j.1365-2796.2009.02198.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Poor blood pressure (BP) control is common amongst patients with symptomatic atherothrombotic disease. It is unclear whether BP control and management differ across atherothrombotic disease subtypes. METHODS We analysed the baseline data of 44,984 patients with documented coronary artery disease (CAD) only (n = 30,414), cerebrovascular disease (CVD) only (n = 11,359) and peripheral arterial disease (PAD) only (n = 3211) from the international REduction of Atherothrombosis for Continued Health Registry and investigated the impact of atherothrombotic disease subtype on BP control and use of antihypertensive drugs. RESULTS The proportion of patients with BP controlled (<140/90 mmHg) was higher in CAD (58.1%) than in CVD (44.8%) or PAD (38.9%) patients (P < 0.001). Amongst patients with treated hypertension, CAD patients were more likely to have BP controlled than were CVD patients [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.59-1.75] or PAD (OR = 2.30; 95% CI = 2.10-2.52). These differences were smaller in women than in men and decreased with age. Amongst treated patients, CAD patients were more likely to receive > or =3-drug combination therapies than were CVD (OR = 1.73; 95% CI = 1.64-1.83) or PAD (OR = 1.64; 95% CI = 1.49-1.80) patients. Adjustment for age, gender, waist obesity, diabetes, education level and world region did not alter the results. CONCLUSIONS Coronary artery disease patients are more likely than CVD or PAD patients to have BP controlled and to receive antihypertensive drugs, particularly combination therapies. Promotion of more effective BP control through combination antihypertensive therapies could improve secondary prevention and therefore prevent complications in CVD and PAD patients.
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Affiliation(s)
- L Mechtouff
- Department of Neurology, Hôpital Sainte-Anne, Paris-Descartes University, INSERM U894, Paris, France
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Nolte CH, Jungehulsing GJ, Rossnagel K, Roll S, Haeusler KG, Reich A, Willich SN, Villringer A, Muller-Nordhorn J. Vascular risk factor awareness before and pharmacological treatment before and after stroke and TIA. Eur J Neurol 2009; 16:678-83. [PMID: 19236460 DOI: 10.1111/j.1468-1331.2009.02562.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Educating the public to screen for vascular risk factors and have them treated is a major public health issue. We assessed the vascular risk factor awareness and frequency of treatment in a cohort of patients with cerebral ischaemia. METHODS Data on awareness and pharmacological treatment of vascular risk factors before hospital admission of patients with confirmed ischaemic stroke/transient ischaemic attack (TIA) were analyzed. A follow-up questionnaire assessed the frequency of treatment 1 year after discharge and assessed non-adherence to antithrombotic medication. RESULTS At time of stroke/TIA, individual awareness regarding existing hypertension, diabetes, hyperlipidemia and atrial fibrillation (AF) was 83%, 87%, 73% and 69% respectively (n = 558). Pharmacological treatment for hypertension, diabetes, hyperlipidemia and AF was being administered in 80%, 77%, 37% and 62% of patients aware of their conditions. The follow-up was completed by 383 patients (80% recall rate): of the patients with hypertension, diabetes, hyperlipidemia and AF, 89%, 78%, 45% and 86% were receiving risk factor targeted medication. This represents a significant increase concerning AF and hyperlipidemia. Non-adherence to recommended antithrombotics (15%) was higher in patients who had had a TIA. CONCLUSIONS All risk factors leave room for improvement in screening and treatment efforts. Adherence to treatment is higher for hypertension and diabetes than for hyperlipidemia. Education efforts should bear in mind less well recognized risk factors.
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Affiliation(s)
- C H Nolte
- Department of Neurology, University Hospital Charite, Berlin, Germany
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