Secondary preventive medication persistence and adherence 1 year after stroke

Importance of blood pressure lowering in patients with direct oral anticoagulant-associated intracerebral haemorrhage in the acute phase and for secondary prevention

PURPOSE

Intracerebral haemorrhage (ICH) is an important complication of direct oral anticoagulation (DOAC) therapy, where risks and prognosis are potentially modified by effective blood pressure (BP) control, both in the acute phase and for secondary prevention. Herein, we review BP management in the context of general anticoagulation associated ICH and specifically in DOAC-ICH, considering current evidence and highlighting outstanding questions.

METHOD

Narrative review.

FINDINGS

Pooled analyses of major trials of BP lowering in acute ICH patients without anticoagulants demonstrate a reduction in the risk of haematoma expansion. As anticoagulant-associated ICH patients tend to be older, have more co-morbidities, and larger haematomas at baseline with a greater risk of expansion, the risks and benefits of intensive BP lowering treatment might both be higher. Small observational studies of DOAC-ICH patients suggest that lower achieved BP is associated with less expansion, lower mortality, and better functional outcomes. Care bundles including both anticoagulant reversal and intensive BP lowering might reduce the risk of death and disability in DOAC-ICH. Optimal control of BP in survivors of ICH reduces the risk of both ischaemic and haemorrhagic stroke but whether this modulates the risks and benefits of restarting a DOAC is unknown.

DISCUSSION

Limited evidence suggests that BP should be well managed in DOAC-ICH patients, in the same way as ICH patients not on anticoagulants, both in the hyperacute phase and for secondary prevention. Hypothetical differences in the effects of BP lowering treatment in DOAC-ICH need to be tested in clinical trials.

Cognition and influencing factors of secondary prevention in patients with ischemic stroke 1 year after discharge in Southwest China: a cross-sectional survey

Although the risk of recurrent stroke is very high in patients with ischemic stroke (IS), the implementation of secondary prevention of IS has not received enough attention. Therefore, we aimed to investigate the cognition and compliance status of secondary prevention in patients with IS in southwest China and explore the factors affecting compliance with secondary prevention 1 year after discharge. We conducted a cross-sectional survey of patients with IS 1 year after discharge in southwest China through convenience sampling. Factors affecting the compliance of secondary prevention in patients with IS after discharge were analysed. A total of 1,041 patients were included in our study. Nearly one-third of patients did not follow secondary prevention measures according to the guidelines, and an improvement in lifestyle was even less likely. Living with or without children did not significantly affect patient compliance (odds ratio 1.11; 95% confidence interval 0.83-1.49; p = 0.47). Furthermore, no significant differences were observed in the probability of treatment acceptance between patients experiencing one or two of the following conditions: hypertension, diabetes, and hyperlipidemia, and those with all three conditions. Thus, patients with IS have insufficient compliance with secondary prevention and there is a particular lack of emphasis on lifestyle improvement. Further interventions are needed to improve compliance with secondary prevention in patients with IS, especially patients with all three conditions of hypertension, diabetes, and hyperlipidemia.

Untangling areas of improvement in secondary prevention of ischemic stroke in patients with atrial fibrillation

Improvement of post-stroke outcomes relies on patient adherence and appropriate therapy maintenance by physicians. However, comprehensive evaluation of these factors is often overlooked. This study assesses secondary stroke prevention by differentiating patient adherence to antithrombotic treatments (ATT) from physician-initiated interruptions or switches. We analyzed a population-based retrospective cohort (n = 10,343) of post-stroke patients with atrial fibrillation using the VID database (2010-2017). Secondary prevention was evaluated based on patients' primary and secondary adherence to ATT at two years (percentage of days covered-PDC-and persistence/discontinuation) and physician prescription patterns (initiation, interruption, switching, restart). E-prescription and dispensing data were linked. Three ATT strategies were identified: oral anticoagulants (OAC), antiplatelets (APT), or combination therapy (OAC + APT), prescribed to 54%, 23%, and 17% of patients, respectively. Primary adherence was high for all ATTs (≈90%). OAC discontinuation was highest (16%), but frequently restarted (73.4%). APT treatment was interrupted the most (14%) and restarted the least (38.5%) by physicians, followed by OAC (interrupted in 11%, restarted in 65%). Overall, 17% of patients switched treatments, with OAC + APT being switched the most (76%), mainly to OAC (53.8%). Identifying areas for improvement in secondary stroke prevention requires considering both patient adherence and physician prescription patterns (initiation, interruptions, and restarts).

Sex Differences in Nonadherence to Secondary Stroke Prevention Medications Among Patients With First-Ever Ischemic Stroke

BACKGROUND

More women than men experience recurrent strokes. Medication adherence is critical to prevent recurrence; however, studies investigating sex differences are limited. We examined sex differences in poststroke medication adherence, overall and by drug class, and identified influencing factors.

METHODS AND RESULTS

Patients with first-ever ischemic stroke were identified from a population-based study (2008-2019). At 90 days after a stroke, self-reported medication adherence was defined as never or rarely missing a dose in a typical week for each secondary stroke prevention medication (antihypertensives, cholesterol-lowering drugs, antiplatelets, anticoagulants). We generated prevalence ratios (PRs) using modified Poisson models to assess sex differences with and without adjustment for potential confounding factors, including demographics, social factors, health system-related, lifestyle-related, health condition-related, prestrokehealth-related, and stroke-related factors. Among 1324 participants (48.4% women, 58.0% Mexican American individuals), women were more likely to report nonadherence to cholesterol-lowering drugs (PR, 1.80 [95% CI, 1.14-2.84]) and antiplatelets (PR, 1.53 [95% CI, 1.003-2.34]). Adjusting for obesity attenuated while adjusting for age, marital status, access to care, smoking, and alcohol consumption accentuated sex differences. Race and ethnicity modified the sex difference in nonadherence to cholesterol-lowering drugs (Pinteraction=0.054) such that the sex difference was larger in Mexican American individuals (PR, 3.00 [95% CI, 1.65-5.48]) than in non-Hispanic White individuals (PR, 1.30 [95% CI, 0.52-3.27). No significant sex differences were found for nonadherence to antihypertensives and overall nonadherence.

CONCLUSIONS

Poststroke medication nonadherence was more prevalent among women than men. This was partially due to the confounding effects of lifestyle, marital status, and access to care, suggesting potential subgroups for interventions to improve adherence.

Management of people after stroke in 383 Victorian general practices, 2014-2018: analysis of linked stroke registry and general practice data

OBJECTIVE

To evaluate the management in Victorian general practice of people who have been hospitalised with stroke or transient ischaemic attacks (TIA).

STUDY DESIGN

Retrospective observational study; analysis of linked Australian Stroke Clinical Registry (AuSCR) and general practice data.

SETTING

383 general practices in the Eastern Melbourne, South Eastern Melbourne, and Gippsland primary health networks (Victoria), 1 January 2014 - 31 December 2018.

PARTICIPANTS

Adults who had been hospitalised with acute stroke or TIA and had at least two encounters with the same general practice during the observation period (7-18 months after the acute event).

MAIN OUTCOME MEASURES

Assessment of cardiometabolic risk factors (blood pressure, serum lipids, blood glucose, urinary protein); prescribing of guideline-recommended prevention medications (blood pressure-, lipid-, or glucose-lowering, antithrombotic agents); attainment of guideline targets for cardiometabolic risk factors at final assessment during observation period.

RESULTS

During 2014-2018, 3376 eligible AuSCR registrants (1465 women, 43.4%) had at least two encounters with one of the 383 general practices during the observation period; median age at stroke onset was 73.9 (interquartile range, 64.4-81.9) years, 737 events were TIAs (21.8%). Blood pressure was assessed in 2718 patients (80.5%), serum lipids in 1830 (54.2%), blood glucose in 1708 (50.6%). Prevention medications were prescribed for 2949 patients (87.4%), including lipid-lowering (2427, 71.9%) and blood pressure-lowering agents (2363, 70.0%). Blood glucose targets had been achieved by 1346 of 1708 patients assessed for this risk factor (78.8%), blood pressure targets by 1935 of 2717 (71.2%), and serum lipid targets by 765 of 1830 (41.8%). The incidence of having risk factors assessed was lower among patients aged 60 years or younger (incidence rate ratio [IRR], 0.97; 95% confidence interval [CI], 0.92-1.03) and those over 80 years of age (IRR, 0.92; 95% CI 0.88-0.97) than for those aged 61-80 years, and for women (IRR, 0.91; 95% CI, 0.87-0.95) and people with dementia (IRR, 0.89; 95% CI, 0.81-0.98). The likelihood of having classes of prevention medication prescribed was lower for patients aged 60 years or younger (IRR, 0.92; 95% CI, 0.88-0.97) and those over 80 years of age (IRR, 0.96; 95% CI, 0.92-0.997) than for patients aged 61-80 years, and for women (IRR, 0.95; 95% CI, 0.91-0.98) and people with dementia (IRR, 0.88; 95% CI, 0.78-0.98).

CONCLUSIONS

The general practice management of people who have been hospitalised with stroke or TIA could be improved. Effective monitoring of cardiometabolic risk factors will enable general practitioners to optimise care for people who need careful attention to prevent adverse secondary events.

Hypertension Prevalence, Treatment, and Control 90 Days After Acute Stroke Among Mexican American and Non-Hispanic White Adults

BACKGROUND

High blood pressure (BP) increases recurrent stroke risk.

METHODS AND RESULTS

We assessed hypertension prevalence, treatment, control, medication adherence, and predictors of uncontrolled BP 90 days after ischemic or hemorrhagic stroke among 561 Mexican American and non-Hispanic White (NHW) survivors of stroke from the BASIC (Brain Attack Surveillance in Corpus Christi) cohort from 2011 to 2014. Uncontrolled BP was defined as average BP ≥140/90 mm Hg at 90 days poststroke. Hypertension was uncontrolled BP or antihypertensive medication prescribed or hypertension history. Treatment was antihypertensive use. Adherence was missing zero antihypertensive doses per week. We investigated predictors of uncontrolled BP using logistic regression adjusting for patient factors. Median (interquartile range) age was 68 (59-78) years, 64% were Mexican American, and 90% of strokes were ischemic. Overall, 94.3% of survivors of stroke had hypertension (95.6% Mexican American versus 92.0% non-Hispanic White; P=0.09). Of these, 87.9% were treated (87.3% Mexican American versus 89.1% non-Hispanic White; P=0.54). Among the total population, 38.3% (95% CI, 34.4%-42.4%) had uncontrolled BP. Among those with uncontrolled BP prescribed an antihypertensive, 84.5% reported treatment adherence (95% CI, 78.8%-89.3%). Uncontrolled BP 90 days poststroke was less likely in patients with stroke who had a primary care physician (adjusted odds ratio [aOR], 0.45 [95% CI, 0.24-0.83]; P=0.01), greater stroke severity (aOR per-1-point-higher National Institutes of Health Stroke Scale score, 0.96 [95% CI, 0.93-0.99]; P=0.02), or more depressive symptoms (aOR per-1-point-higher Personal Health Questionnaire Depression Scale-8 score, 0.95 [95% CI, 0.92-0.99] among those with a history of hypertension at baseline; P=0.009).

CONCLUSIONS

Greater than one third of survivors of stroke have uncontrolled BP at 90 days poststroke in this population-based study. Interventions are needed to improve BP control after stroke.

Investigation of vascular risk factor control and secondary prevention medication compliance in acute ischemic stroke

Objectives

This study aimed to investigate the management of vascular risk factors, with a specific focus on understanding the various factors affecting risk factor control through an in-depth analysis of clinical data and a longitudinal follow-up of patients who have experienced ischemic strokes.

Methods

A total of 1,572 participants were included in the analysis. We assessed thresholds for blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and glycated hemoglobin (HbA1c) levels to uncover the contextual conditions and factors affecting vascular risk factor control. Moreover, the study also scrutinized medication compliance at intervals of 3, 6, and 12 months post-onset. Logistic regression was used to adjust for confounding factors.

Results

At 3, 6, and 12 months, BP,LDL, hemoglobin control targets were achieved in 50.7, 51.8, and 50.6%; 51.5, 59.4, and 50.6%; 48.1, 44.0, and 48.4%,respectively. Notably, age was associated with the achievement of BP control (odds ratio [OR], 0.96; 95% confidence intervals [CI], 0.94-0.98; p < 0.0001). Ethnic minorities (OR, 4.23; 95% CI, 1.19-15.09; p = 0.02) and individuals with coronary heart disease (OR, 0.5; 95% CI, 0.3-1.0; p = 0.05) experienced decreased BP control ratios. A previous history of stroke (OR, 1.7; 95% CI, 1.0-2.8; p = 0.03) and unrestricted alcohol consumption (OR, 3.3; 95% CI, 1.0-11.1; p = 0.05) was significantly associated with the achievement of lipid control. Furthermore, lifestyle modifications were significantly correlated with the achievement of BP control (OR, 0.19; 95% CI, 0.12-0.30; p < 0.01), blood glucose control (OR, 0.03; 95% CI, 0.01-0.08; p < 0.01), and blood lipid control (OR, 0.26; 95% CI, 0.16-0.42; p < 0.01). The absence of regular physical activity was associated with lower rates of glycemic (OR, 0.14; 95% CI, 0.06-0.36; p < 0.01) and lipid controls (OR, 0.55; 95% CI, 0.33-0.90; p = 0.01). Over time, overall medication compliance declined.

Conclusion

Within the cohort of patients under medication, the compliance rate concerning vascular risk factors remains unsatisfactory. Attention should be paid to compliance with secondary prevention medications and enhance the control of vascular risk factors, as compliance emerges as the key to effective prevention.

Trends in the Use of Medications for Secondary Ischemic Stroke Prevention in Denmark, 2005-2021

BACKGROUND AND OBJECTIVES

Understanding trends in the use of medications for secondary stroke prevention is crucial for identifying areas for improvement in stroke care. We examined the use of lipid-lowering, antihypertensive, glucose-lowering, oral anticoagulant, and antiplatelet medications after ischemic stroke hospitalization, from 2005 to 2021.

METHODS

Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a first-time or recurrent ischemic stroke (N = 150,744). Stratified by calendar year, we ascertained the 180-day probability of filling a prescription for the abovementioned medications after discharge. We further assessed factors associated with medication use.

RESULTS

From 2005 to 2021, lipid-lowering medication use increased from 58.3% to 82.0%; atorvastatin use rose from 2.1% to 64.8% and simvastatin use decreased from 55.7% to 8.6%. Antihypertensive medication use remained stable, at approximately 89%, and various antihypertensive classes were used comparably. Glucose-lowering medication use increased from 71.5% in 2005 to 84.1% in 2021, driven primarily by an increase in metformin use (from 28.0% to 59.5%). Use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors continually increased (from 1.7% to 17.5% and from 0.5% to 17.3%, respectively) between 2015 and 2021. Anticoagulant medication use rose from 45.9% in 2005 to 87.0% in 2021, primarily because of increased use of direct oral anticoagulant medications starting around 2010 and a decline in warfarin use. Antiplatelet use remained consistently high, at approximately 95%. Trends were consistent across subgroups of interest; however, overall medication use was lower in older patients (65 years and older), patients with severe stroke, and patients with neurologic and psychiatric comorbidities.

DISCUSSION

Despite increasing trends in the use of 3 of 5 medication classes, the overall use of lipid-lowering, glucose-lowering, and oral anticoagulant medications was somewhat lower than expected according to clinical guidelines, particularly among older patients with more severe stroke and other comorbidities. The relatively low use in these subgroups may signify appropriate clinical decision making in consideration of frequent contraindications and reduced life expectancy or highlight potential areas of improvement for the care of patients with recent ischemic stroke.

Antiplatelet Treatment Patterns and Outcomes for Secondary Stroke Prevention in the United Kingdom

INTRODUCTION

Stroke is a leading cause of death and disability worldwide. Antiplatelet therapies are recommended to reduce the risk of recurrent stroke in patients with ischemic stroke/transient ischemic attack (IS/TIA). This study evaluated outpatient antiplatelet treatment patterns and outcomes for secondary stroke prevention (SSP) among UK adults without atrial fibrillation who were hospitalized for IS/TIA.

METHODS

This retrospective observational study utilized data from the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics data (01/01/2011-30/06/2019). Treatment patterns included type and duration of treatments. Treatment outcomes included IS, myocardial infarction, major bleeding, and cardiovascular-related and all-cause mortality. Descriptive statistics were reported.

RESULTS

Of 9270 patients, 13.9% (1292) might not receive antithrombotic therapy within 90 days of hospital discharge. Of 7978 patients who received antiplatelet therapies, most used clopidogrel (74.8%) or aspirin (16.7%) single antiplatelet therapy and clopidogrel + aspirin dual antiplatelet therapy (DAPT, 5.9%). At 1-year post-hospitalization, 36.9, 43.3, and 35.1% of those receiving these treatments discontinued them, respectively, and of the patients initiating DAPT, 62.3% switched to single antiplatelet therapy. At 1-year post-discharge, the incidence rate (per 100 person-years) of IS, myocardial infarction, major bleeding, cardiovascular-related mortality, and all-cause mortality among the treated were 6.5, 0.7, 4.1, 5.0, and 7.3, respectively, and among the untreated were 14.9, 0.7, 8.6, 28.1, and 39.8, respectively.

CONCLUSIONS

In the United Kingdom, 13.9% of patients hospitalized for stroke might not have any antiplatelet treatment to prevent secondary stroke; among the treated, clopidogrel, aspirin, and DAPT were commonly used. These study findings suggest that improved anti-thrombotic therapies for long-term SSP treatment are needed, which may lead to higher treatment and persistence rates and, therefore, improved outcomes in this population.

The machine learning methods to analyze the using strategy of antiplatelet drugs in ischaemic stroke patients with gastrointestinal haemorrhage

BACKGROUND

For ischaemic stroke patients with gastrointestinal haemorrhage, stopping antiplatelet drugs or reducing the dose of antiplatelet drugs was a conventional clinical therapy method. But not a study to prove which way was better. And the machinery learning methods could help to obtain which way more suit for some patients.

METHODS

Data from consecutive ischaemic stroke patients with gastrointestinal haemorrhage were prospectively collected. The outcome was a recurrent stroke rate, haemorrhage events, mortality and favourable functional outcome (FFO). We analysed the data using conventional logistic regression methods and a supervised machine learning model. We used unsupervised machine learning to group and analyse data characters.

RESULTS

The patients of stopping antiplatelet drugs had a lower rate of bleeding events (p = 0.125), mortality (p = 0.008), rate of recurrence of stroke (p = 0.161) and distribution of severe patients (mRS 3-6) (p = 0.056). For Logistic regression, stopping antiplatelet drugs (OR = 2.826, p = 0.030) was related to lower mortality. The stopping antiplatelet drugs in the supervised machine learning model related to mortality (AUC = 0.95) and FFO (AUC = 0.82). For group by unsupervised machine learning, the patients of better prognosis had more male (p < 0.001), younger (p < 0.001), had lower NIHSS score (p < 0.001); and had a higher value of serum lipid level (p < 0.001).

CONCLUSIONS

For ischemic stroke patients with gastrointestinal haemorrhage, stopping antiplatelet drugs had a better prognosis. Patients who were younger, male, with lesser NIHSS scores at admission, with the fewest history of a medical, higher value of diastolic blood pressure, platelet, blood lipid and lower INR could have a better prognosis.

Relationships between beliefs about statins and non-adherence in inpatients from Northwestern China: a cross-sectional survey

Background: Studies have identified patients' beliefs about medicines as an important determinant of non-adherence. However, scant data are available on the possible association between patients' beliefs and statin non-adherence among adult patients in China. The objectives of this study are to assess the prevalence of statin non-adherence, and to identify the factors associated with statin non-adherence, especially the association between inpatients' beliefs about statins and non-adherence in a tertiary hospital in the Northwestern China. Methods: A cross-sectional questionnaire-based survey was carried out in the department of cardiology and neurology between February and June 2022. The Beliefs about Medicine Questionnaire (BMQ) was used to assess patients' beliefs about statins. The Adherence to Refills and Medications Scale (ARMS) was used to assess statin adherence. Logistic regression analyses were performed to identify the factors associated with statin non-adherence. Receiver operator characteristic (ROC) was conducted to assess the performance of the logistic regression model in predicting statin non-adherence. Results: A total of 524 inpatients participated and finished the questionnaire, 426 (81.3%) inpatients were non-adherent to statin, and 229 (43.7%) inpatients expressed strong beliefs about the stain treatment necessity, while 246 (47.0%) inpatients expressed strong concerns about the potential negative effects. We found that the low necessity beliefs about statin (adjusted odds ratio [OR] and 95% confidence interval [CI], 1.607 [1.019, 2.532]; p = 0.041), prescribed rosuvastatin (adjusted OR 1.820 [1.124, 2.948]; p = 0.015) and ex-drinker (adjusted OR 0.254 [0.104, 0.620]; p = 0.003) were independent determinants of statin non-adherence. Conclusion: Statin adherence was poor in this study. The findings indicated a significant association between inpatients' lower necessity beliefs and statin non-adherence. More attention should be focused on statin non-adherence in China. Nurses and pharmacists could play an important role in patient education and patient counseling in order to improve medication adherence.

Medication self-management interventions for persons with stroke: A scoping review

The use of multiple medications is common following a stroke for secondary prevention and management of co-occurring chronic conditions. Given the use of multiple medications post-stroke, optimizing medication self-management for this population is important. The objective of this scoping review was to identify and summarize what has been reported in the literature on interventions related to medication self-management for adults (aged 18+) with stroke. Electronic databases (Ovid Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO, Web of Science) and grey literature were searched to identify relevant articles. For inclusion, articles were required to include an adult population with stroke undergoing an intervention aimed at modifying or improving medication management that incorporated a component of self-management. Two independent reviewers screened the articles for inclusion. Data were extracted and summarized using descriptive content analysis. Of the 56 articles that met the inclusion criteria, the focus of most interventions was on improvement of secondary stroke prevention through risk factor management and lifestyle modifications. The majority of studies included medication self-management as a component of a broader intervention. Most interventions used both face-to-face interactions and technology for delivery. Behavioural outcomes, specifically medication adherence, were the most commonly targeted outcomes across the interventions. However, the majority of interventions did not specifically or holistically target medication self-management. There is an opportunity to better support medication self-management post-stroke by ensuring interventions are delivered across sectors or in the community, developing an understanding of the optimal frequency and duration of delivery, and qualitatively exploring experiences with the interventions to ensure ongoing improvement.

Effectiveness of Remote Interventions to Improve Medication Adherence in Patients after Stroke: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Stroke affects more than 30 million people every year, but only two-thirds of patients comply with prescribed medication, leading to high stroke recurrence rates. Digital technologies can facilitate interventions to support treatment adherence.

PURPOSE

This study evaluates the effectiveness of remote interventions and their mechanisms of action in supporting medication adherence after stroke.

METHODS

PubMed, MEDLINE via Ovid, Cochrane CENTRAL, the Web of Science, SCOPUS, and PsycINFO were searched, and meta-analysis was performed using the Review Manager Tool. Intervention content analysis was conducted based on the COM-B model.

RESULTS

Ten eligible studies were included in the review and meta-analysis. The evidence suggested that patients who received remote interventions had significantly better medication adherence (SMD 0.49, 95% CI [0.04, 0.93], and p = 0.03) compared to those who received the usual care. The adherence ratio also indicated the interventions' effectiveness (odds ratio 1.30, 95% CI [0.55, 3.10], and p = 0.55). The systolic and diastolic blood pressure (MD -3.73 and 95% CI [-5.35, -2.10])/(MD -2.16 and 95% CI [-3.09, -1.22]) and cholesterol levels (MD -0.36 and 95% CI [-0.52, -0.20]) were significantly improved in the intervention group compared to the control. Further behavioural analysis demonstrated that enhancing the capability within the COM-B model had the largest impact in supporting improvements in adherence behaviour and relevant clinical outcomes. Patients' satisfaction and the interventions' usability were both high, suggesting the interventions' acceptability.

CONCLUSION

Telemedicine and mHealth interventions are effective in improving medication adherence and clinical indicators in stroke patients. Future studies could usefully investigate the effectiveness and cost-effectiveness of theory-based and remotely delivered interventions as an adjunct to stroke rehabilitation programmers.

Polypill Programs to Prevent Stroke and Cut Costs in Low Income Countries: Moving From Clinical Efficacy to Pragmatic Implementation

Current projections are that the already overwhelming burden of strokes and atherosclerotic cardiovascular diseases in low- and middle-income countries (LMICs) will continue to rise over the coming decades as the prevalence of traditional vascular risk factors burgeon in these countries. Cardiovascular polypills containing combinations of antihypertensive(s), a statin, with or without aspirin or folic acid in the form of a single pill, represent a viable strategy for both primary and secondary prevention of atherosclerotic cardiovascular diseases in LMICs. Large multicenter trials in LMIC and high-income country (HIC) settings have now clearly demonstrated the beneficial effects of the cardiovascular polypill versus placebo (or usual care) in reducing primary stroke risk by 50%. For survivors of a recent myocardial infarction residing in HICs, the polypill reduced risk of major cardiovascular events by 25% due to improved treatment adherence. Data on the clinical efficacy of the polypill for secondary stroke prevention are scanty both in HICs and LMICs. Cost-effectiveness analyses data from LMICs suggest cost savings with the polypill for primary and secondary prevention of stroke and atherosclerotic cardiovascular diseases. However, major contextual barriers in LMICs need to be surmounted through mixed methods research and hybrid clinical trials to assess its real-world effectiveness, before the adoption of the polypill for primary and secondary atherosclerotic cardiovascular disease prevention in routine clinical practice.

Factors and Behaviors Related to Successful Transition of Care After Hospitalization for Ischemic Stroke

BACKGROUND

Our objective is to describe adoption of the posthospitalization behaviors associated with successful transition of care and related baseline characteristics.

METHODS

This study includes 550 participants in the Transition of Care Stroke Disparities Study, a prospective observational cohort derived from the Florida Stroke Registry. Participants had an ischemic stroke (2018-2021), discharged home or to rehabilitation, with modified Rankin Scale score=0-3 (44% women, 24% Black, 48% White, 26% Hispanic, 35% foreign-born). We collected baseline sociodemographic and clinical characteristics. A structured telephone interview at 30-day postdischarge evaluated outcomes including medication adherence, medical appointment attendance, outpatient therapy, exercise, diet modification, toxic habit cessation, and a calculated composite adequate transition of care measure. Multivariable analyses assessed the association of baseline characteristics with 30-day behaviors.

RESULTS

At 30 days, medication adherence was achieved by 89%, medical appointments by 82%, outpatient therapy by 76%, exercise by 71%, diet modification by 68%, toxic habit cessation by 35%, and adequate transition of care measure by 67%. Successful adequate transition of care participants were more likely to be used full-time (42% versus 31%, P=0.02), live with a spouse (60% versus 47%, P=0.01), feel close to ≥3 individuals (84% versus 71%, P<0.01), have history of dyslipidemia (45 versus 34%, P=0.02), have thrombectomy (15% versus 8%, P=0.02), but less likely to have a history of smoking (17% versus 32%, P<0.001), coronary artery disease (14% versus 21%, P=0.04), and heart failure (3% versus 11%, P<0.01). Multivariable logistic regression analyses revealed that multiple socio-economic factors and prestroke comorbid diseases predicted fulfillment of transition of care measures. There was no difference in outcomes during the Covid-19 pandemic (2020-2021) compared with prepandemic years (2018-2019).

CONCLUSIONS

One in 3 patients did not attain adequate 30-day transition of care behaviors. Their achievement varied substantially among different measures and was influenced by multiple socioeconomic and clinical factors. Interventions aimed at facilitating transition of care from hospital after stroke are needed.

REGISTRATION

URL: https://clinicaltrials.gov/; Unique identifier: NCT03452813.

Predictors of long-term medication adherence in stroke survivors: A multicentre, prospective, longitudinal study

BACKGROUND

Although the optimal use of prescribed medications for stroke survivors is critical for preventing secondary stroke, longitudinal observations of the natural course of medication persistence and adherence in Korean stroke survivors are rare. Furthermore, studies are needed to identify strong predictors influencing medication adherence and to determine whether these predictors change over time.

AIMS AND OBJECTIVES

To evaluate the longitudinal medication persistence and adherence at 3 months and 1 year after discharge in all stroke patients and to identify predictors of long-term medication adherence in patients who can self-medicate.

DESIGN

A multicentre, prospective, longitudinal descriptive study.

METHODS

A total of 600 consecutive ischaemic stroke patients were recruited from three stroke centres across Korea, from 1 September, 2017 to 28 February, 2019. Various factors related to medication adherence suggested by the World Health Organisation were investigated through face-to-face interviews at each centre during hospitalisation. Medication persistence and adherence were assessed at 3 months and 1 year after discharge using the eight-item Morisky Medication Adherence Scale through telephone interviews.

RESULTS

Of 537 survivors at 3 months, 526 (98.0%) were persistent and 472 (89.7%) were adherent. Of 493 survivors at 1 year, 477 (96.8%) were persistent and 392 (82.2%) were adherent. Medication belief, income and health literacy were statistically significant predictors of three-month medication adherence, which predicted one-year medication adherence with older age and low income.

CONCLUSIONS

Among Korean stroke survivors, three-month and one-year medication persistence and adherence were relatively good. Medication beliefs and three-month medication adherence were important and modifiable factors predicting three-month adherence and one-year adherence, respectively.

RELEVANCE TO CLINICAL PRACTICE

To increase long-term adherence to medication, various strategies are needed to improve beliefs about medication, taking into account the patient's age and level of knowledge. These interventions need to be initiated during hospitalisation to form early medication habits after discharge.

Health-related quality of life using WHODAS 2.0 and associated factors 1 year after stroke in Korea: a multi-centre and cross-sectional study

BACKGROUND

Little is known about the self-perceived level of disability of stroke survivors in the community. We aimed to characterise Health-related quality of life (HRQoL) 1 year after stroke and investigate how sociodemographic and stroke-related factors and medical adherence explain the self-perceived level of disability in a Korean stroke population.

METHODS

This was a multicentre cross-sectional study. A total of 382 ischaemic stroke survivors at 1 year after onset from 11 university hospitals underwent a one-session assessment, including socioeconomic variables, the modified Rankin Scale (mRS), various neurological sequelae, the Morisky, Green and Levin-Medication Adherence Questionnaire (MGL), and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 36-items. The relationship between disability and different variables was analysed using ordinal logistic regression.

RESULTS

The prevalence of disability based on global WHODAS 2.0 was 62.6% (mild, 41.6%; moderate, 16.0%; severe, 5.0%). The prevalence of severe disability was higher in participation in society (16.8%) and getting around (11.8%) than in other domains. Low MGL- motivation was the only factor determining a significant association between all six domains of disability after adjustment. Different predictors for specific domains were age, mRS, dysarthria, trouble seeing, cognition problems, and MGL-motivation for understanding and communicating; age, recurrent stroke, mRS, hemiplegia, facial palsy, general weakness, and MGL-motivation for getting around; age, education, mRS, hemiplegia, and MGL-motivation for self-care; education, recurrent stroke, hemiplegia, dysarthria, and MGL-motivation for getting along with people; age, education, income, mRS, hemiplegia, dysarthria, MGL-knowledge, and MGL-motivation for life activities; living without a spouse, mRS, hemiplegia, dysarthria, trouble seeing, cognition problems, general weakness, and MGL-motivation for participation in society.

CONCLUSIONS

Self-perceived disability according to the WHODAS 2.0 at 1 year after stroke was highly prevalent. Each disability domain showed a different prevalence and associated factors. Interventions promoting medical adherence to motivation seemed to help achieve high HRQoL in all domains.

Quality of Care Among Patients with Diabetes and Cerebrovascular Disease. Insights from The Diabetes Collaborative Registry

BACKGROUND

Although secondary cardiovascular prevention is a focus among patients with type 2 diabetes (T2D) and coronary artery disease (CAD) or peripheral artery disease (PAD), the application of guideline-recommended therapy in T2D patients and isolated cerebrovascular disease (CeVD) remains unknown.

METHODS

In a US outpatient registry, T2D patients with established cardiovascular disease from 2014-2018 were categorized as: isolated CeVD, CeVD plus CAD or PAD, or isolated CAD/PAD. In each group, we determined the proportion with optimal secondary prevention (hemoglobin [Hb]A_1C <8%, blood pressure <130/80 mm Hg, use of antithrombotics, use of statins, non-smoking/cessation counseling, and use of glucose-lowering medications with cardioprotective effects (sodium-glucose cotransporter [SGLT]-2 inhibitors, glucagon-like peptide [GLP]-1 receptor agonists, thiazolidinediones [TZDs]). Hierarchical Poisson regression was used to estimate relative rate of achieving each target across groups, adjusted for age and chronic kidney disease (where relevant).

RESULTS

Our study included 727,467 T2D outpatients with cardiovascular disease (isolated CeVD [n = 99,777], CeVD plus CAD/PAD [n = 158,361], isolated CAD/PAD [n = 469,329]). Compared with isolated CAD/PAD patients, isolated CeVD patients more often had an HbA_1c <8% (adjusted relative risk [aRR] 1.10; 95% confidence interval [CI], 1.08-1.11) but less often had a blood pressure of ≤130/80 mm Hg (aRR 0.93; 95% CI, 0.92-0.94) or were prescribed antithrombotics (0.84; 95% CI, 0.83-0.85), statins (0.86; 95% CI, 0.85-0.87), GLP-1 agonists (0.75; 95% CI, 0.73-0.78), SGLT2 inhibitors (0.73; 95% CI, 0.71-0.76), and TZDs (aRR 0.76; 95% CI, 0.73-0.78).

CONCLUSION

Among T2D patients, those with isolated CeVD had the lowest rates of secondary cardiovascular prevention goals attainment. More focus is needed on secondary prevention in patients with CeVD.

Racial differences in persistence to secondary prevention medication regimens after ischemic stroke

BACKGROUND

Prior stroke is one of the biggest risk factors for future stroke events. Effective secondary prevention medication regimens can dramatically reduce recurrent stroke risk. Guidelines recommend the use of antithrombotic, antihypertensive and lipid-lowering medications after stroke. Medication adherence is known to be better in the presence of a caregiver but long-term adherence after stroke is unknown and disparities may persist.

METHODS

We examined the effects of race and sex on baseline prescription and maintenance of secondary prevention regimens in the presence of a caregiver using the Caring for Adults Recovering from the Effects of Stroke (CARES) study, an ancillary study of the national REasons for Geographic and Racial Differences in Stroke (REGARDS).

RESULTS

Incident ischemic stroke survivors (N = 172; 36% Black) with family caregivers had medications recorded at hospital discharge and on average 9.8 months later during a home visit. At discharge, antithrombotic prescription (95.9%), lipid-lowering medications (78.8%) and antihypertensives (89.9%) were common and there were no race or sex differences in discharge prescription rates. One year later, medication persistence had fallen to 86.6% for antithrombotics (p = 0.002) and 69.8% for lipid lowering (p = 0.008) but increased to 93.0% for antihypertensives (p = 0.30). Blacks were more likely to have discontinued antithrombotics than Whites (18.3% v 7.7%, p = 0.04). No significant differences in persistence were seen with age, sex, income, depression, or cognitive impairment.

CONCLUSIONS

Medication persistence was high in this sample, likely due to the presence of a caregiver. In our cohort, despite similar prescription rates at the time of hospital discharge, Black stroke survivors were more than twice as likely to stop antithrombotics than Whites. The effect of changes in patterns of medication usage on health outcomes in Black stroke survivors warrants continued investigation.

Pharmacy program to improve care for veterans with transient ischaemic attack: a pilot implementation evaluation

Background

Early evaluation and effective communication to manage transient ischaemic attacks (TIA) may lead to a reduction of up to 70% in recurrent events for patients with TIA/minor stroke, along with reduced costs and lengths of hospital stay.

Methods

We conducted a single site pilot evaluation of a clinical pharmacy programme to improve medication management among TIA patients. The programme included a structured protocol, online identification tool, and a templated discharge checklist. Primary effectiveness measures were change in systolic blood pressure (SBP) 90 days post discharge and prescription of high/moderate potency statins. Contextual aspects and clinical perspectives on the implementation process were evaluated through prospective semistructured interviews with key informants.

Results

The analysis included 75 patients in the preimplementation group and 61 in the postimplementation group. The mean SBP at 90 days post discharge was significantly lower in the post implementation period (pre implementation, 133.3 mm Hg (SD 17.8) vs post implementation, 126.8 mm Hg (16.6); p=0.045). The change in SBP from discharge to 90 days post discharge was greater in the postimplementation period (15.8 mm Hg (20.5) vs 24.8 mm Hg (23.2); p=0.029). The prescription of high/moderate potency statins were similar across groups (pre implementation, 66.7% vs post implementation, 77.4%; p=0.229). Front-line clinicians involved in the pilot study reported positively on the acceptability, appropriateness and feasibility of implementing the protocol without additional cost and within current scope of practice.

Conclusions

Implementation of a clinical protocol outlining medication management and provider communication to ensure rapid postdischarge treatment of TIA patients was associated with SBP improvements. The pilot evaluation demonstrates how clinical pharmacists may play a role in treating low frequency, high stakes cerebrovascular events where early treatment and follow-up are critical.

Long-term outcome of a pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack: study protocol

Background

Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of incident cardiovascular events and recurrent stroke. Despite compelling evidence about the efficacy of secondary prevention, a substantial gap exists between risk factor management in real life and that recommended by international guidelines. We conducted the STROKE-CARD trial (NCT02156778), a multifaceted pragmatic disease management program between 2014 and 2018 with follow-up until 2019. This program successfully reduced cardiovascular risk and improved health-related quality of life and functional outcome in patients with acute ischaemic stroke or TIA within 12 months after the index event. To investigate potential long-term effects of STROKE-CARD care compared to standard care, an extension of follow-up is warranted.

Methods

We aim to include all patients from the STROKE-CARD trial (n = 2149) for long-term follow-up between 2019 and 2021 with the study visit scheduled 3–6 years after the stroke/TIA event. The co-primary endpoint is the composite of major recurrent cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, and vascular death) from hospital discharge until the long-term follow-up visit and health-related quality of life measured with the European Quality of Life-5 Dimensions (EQ-5D-3L) at the final visit. Secondary endpoints include overall mortality, long-term functional outcome, and target-level achievement in risk factor management.

Discussion

This long-term follow-up will provide evidence on whether the pragmatic post-stroke/TIA intervention program STROKE-CARD is capable of preventing recurrent cardiovascular events and improving quality-of-life in the long run.

Trial registration clinicaltrials.gov: NCT04205006 on 19 December 2019.

Use of Complementary and Alternative Medicine and Adherence to Medication Therapy Among Stroke Patients: A Meta-analysis and Systematic Review

Purpose: To identify the use patterns of complementary and alternative medicine (CAM) and its impact on medication adherence among patients with stroke. Method: A systematic search through Science Direct, Google Scholar, and PubMed was performed to identify potential studies up to June 2021.The primary outcome was CAM use, and the secondary outcome was medication adherence among patients with stroke. Articles included in the review met the following criteria: 1) patients with stroke ≥18 years old on prescribed medications, and 2) medication adherence reported status. Meta-analyses were conducted to estimate the pooled prevalence of complementary and alternative medicine and adherence in stroke patients using a random-effects model. Results: A total of 1,330 studies were screened, of which 22 were included in the final analysis. The type of studies included were cross-sectional surveys, cohort studies, retrospective studies and prospective survey. The pooled prevalence of CAM usage was at 38% (29-48% CI) and medication non-adherence among stroke patients was at 29% (20-48% CI). The most common reason for inadequate stroke therapy and higher dependence on CAM was the patients' lack of knowledge and the regimen complexity of the medication. Other factors for medication non-adherence were forgetfulness, side effects, cost, and lack of doctor-patient communication. Conclusion: A low prevalence of CAM usage and non-adherence to medications was observed among patients with stroke. Studies investigating the association between CAM usage and medication adherence among patients with stroke are scarce and future researches are needed to explore the influence of CAM use on stroke medication adherence.

Multiprofessional intervention to improve adherence to medication in stroke patients: a study protocol for a randomised controlled trial (ADMED AVC study)

INTRODUCTION

Adherence to secondary preventive medications is often suboptimal in patients with stroke, exposing them to an increased risk of recurrent cerebral and/or cardiovascular events. Effective actions in the long term to improve adherence to medication are needed. The study will evaluate the efficacy of a collaborative multiprofessional patient-centred intervention conducted by a pharmacist on adherence to secondary preventive medication in stroke survivors.

METHODS AND ANALYSIS

This is a multicentre cluster-randomised controlled trial. Two groups of 91 patients (intervention vs standard care) will be recruited. The clinical pharmacist intervention targeting secondary preventive medication will consist of three parts over 1 year: (1) an individual semi-structured interview at hospital discharge; (2) follow-up telephone interviews at 3, 6 and 9 months after discharge; and (3) a final individual semi-structured interview 1 year after discharge. Information on patient follow-up will be shared with the general practitioner and the community pharmacist by sending a report of each interview. The primary outcome is adherence to medication during the 12 months after hospital discharge, assessed using a composite endpoint: the medication possession ratio associated with a self-administered questionnaire.

ETHICS AND DISSEMINATION

The local ethics committee, the national committee for use of personal data in medical research and the national data protection agency approved the study. The sponsor has no role in study design; collection, analysis and interpretation of data; or report writing.

DISCUSSION

This pharmacist-led educational programme has the potential to significantly improve adherence to medication in stroke survivors which could lead to a decrease in recurrent cerebral and/or cardiovascular events.

TRIAL REGISTRATION NUMBER

NCT02611440.

Linking the Paul Coverdell National Acute Stroke Program to commercial claims to establish a framework for real-world longitudinal stroke research

BACKGROUND

Non-interventional large-scale research on real-world patients who had a stroke requires the use of multiple data sources ensuring access to longitudinal data from large populations with clinically-detailed information. We sought to establish a framework for longitudinal research on patients hospitalised with stroke by linking information-rich, deidentified inpatient data from the Paul Coverdell National Acute Stroke Program (PCNASP) to commercial and Medicare Advantage longitudinal claims data.

METHODS

All stroke admissions in PCNASP between 2008 and 2015 were evaluated for linkage to longitudinal claims from a commercial insurer using an algorithm based on six available common data fields (patient age, gender, admission date, discharge date, discharge diagnosis and state) and a hospital match. We evaluated the linkage quality (via the percentage of unique records in the linked dataset) and the representativeness of the linked population. We also described medical history, stroke severity and patterns of medication use among the PCNASP-claims linked cohort.

RESULTS

The linkage produced uniqueness equal to 99.1%. We identified 5644 linked and 98 896 unlinked patients who had an ischaemic stroke hospitalisation in claims data. Linked patients were younger than unlinked (69.7 vs 72.5 years), but otherwise similar by medical history, prestroke medication use or lab values. Stroke severity was mild and most patients were discharged home. Prestroke and discharge use of antihypertensive and statins in the PCNASP were greater than their use as measured by filled prescriptions in claims.

CONCLUSIONS

High-quality linkage between the PCNASP and commercial claims data is feasible. This linkage identified differences between reported or recommended versus actual out-of-hospital medication utilisation, highlighting the importance of longitudinal data availability for research aimed to improve the care of patients who had a stroke.

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

Association of triglyceride-glucose index and stroke recurrence among nondiabetic patients with acute ischemic stroke

Backgroud and purpose

Triglyceride-glucose (TyG) index has been considered a surrogate marker of insulin resistance. We investigated the association between TyG index and stroke recurrence and compared the effectiveness of TyG index with homeostasis model assessment of insulin resistance (HOMA-IR) in predicting stroke recurrence and death in nondiabetic acute ischemic stroke patients.

Methods

Nondiabetic acute ischemic stroke patients from the ACROSS-China (Abnormal Glucose Regulation in Patients with Acute Stroke across China) registry were included. TyG index was performed and classified into four groups by quartiles. The outcomes were stroke recurrence and death within 1 year. The association between TyG index and the risk of stroke recurrence and death were analyzed by Cox regression models. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the prediction of TyG index and HOMA-IR for stroke recurrence and death. Delong test was used for comparing the differences between area under the curve (AUC) of TyG index and HOMA-IR.

Results

Among the 1226 patients included, the median (interquartile range) of TyG index was 5.8 (5.5–6.2). Both the third and fourth quartiles of TyG index were associated with an increased risk of stroke recurrence (adjusted hazard ratio 2.04, 95% confidence interval 1.26–3.31; adjusted hazard ratio 1.86, 95% confidence interval 1.13–3.06). Patients with fourth quartiles of TyG index were associated with a higher mortality risk (adjusted hazard ratio, 2.91; 95% confidence interval, 1.62–2.53). Regarding stroke recurrence within 1 year, the AUC (95% confidence interval) of the ROC curve for the TyG index was similar to that of the HOMA-IR[0.56 (0.52–0.61) vs 0.57 (0.52–0.61); P = 0.93]. Regarding death within 1 year, the AUCs (95% confidence interval) of the ROC curve for the TyG index and HOMA-IR were 0.55 (0.50–0.61) and 0.59 (0.53–0.64), respectively (P = 0.32).

Conclusions

Elevated TyG index was associated with an increased risk of stroke recurrence and death. However, neither of TyG nor HOMA-IR can be a qualified predictor of stroke recurrence and death in nondiabetic acute ischemic stroke patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02588-3.

[A comparative analysis of the clinical and anamnestic status of patients with chronic occlusion of the carotid arteries based on the data of observational registries]

OBJECTIVE

To study the clinical and anamnestic status of patients with chronic carotid artery occlusion (CCAO) based on the analysis of risk factors, demographic and clinical and anatomical characteristics, the dynamics of the disease; to evaluate ongoing drug therapy, the incidence of strokes (MI) and deaths (according to the local registry compared with the results of other observational studies).

MATERIAL AND METHODS

PubMed and eLibrary searches for a systematic review were performed from October 24 to December 10, 2021 independently by two investigators. Out of 870 articles, based on inclusion/exclusion criteria, 8 studies were selected and included in the systematic review.

RESULTS

A comparative analysis of the clinical and anamnestic status of patients with CCAO according to the present review showed the following data on the prevalence of the main risk factors/diseases: hypertension - 79.1%; male gender - 83.7%; smoking - 46%; diabetes mellitus - 30.5%. Of the entire of own Duplex registry group (n=2548), 7 patients were identified with CCAO (0.27%). All patients were male (mean age 71.3±9.4 years). Endpoints were recorded in 5 of 7 participants during the follow-up period (8.9 years): 5 deaths, 2 fatal MI, 1 non-fatal MI, 1 myocardial infarction. A significant impact of the fact of MI on the survival of patients was confirmed using the standard log-rank test (p=0.02 and the Cox-Mendel test (p=0.04). The incidence of MI during the prospective follow-up according to the analyzed studies ranged from 4.3% (within a month of follow-up) to 42.8% (with a follow-up of 8.9 years), and averaged 12%.

CONCLUSIONS

A comparative analysis of the clinical and anamnestic status of patients with CCAO based on data from observational registers showed that the probability of detecting this pathology is associated with age and male gender. Data obtained from prospective observation of patients with CCAO in our own study show that the development of MI is one of the main factors affecting the survival of this category of patients.

Retrospectively Collected EQ-5D-5L Data as Valid Proxies for Imputing Missing Information in Longitudinal Studies

OBJECTIVES

Studies face challenges with missing 5-level EQ-5D (EQ-5D-5L) data, often because of the need for longitudinal EQ-5D-5L data collection. There is a dearth of validated methodologies for dealing with missing EQ-5D-5L data in the literature. This study, for the first time, examined the possibility of using retrospectively collected EQ-5D-5L data as proxies for the missing data.

METHODS

Participants who had prospectively completed a 3rd month postdischarge EQ-5D-5L instrument (in-the-moment collection) were randomly interviewed to respond to a 2nd "retrospective collection" of their 3rd month EQ-5D-5L at 6th, 9th, or 12th month after hospital discharge. A longitudinal single imputation was also used to assess the relative performance of retrospective collection compared with the longitudinal single imputation. Concordances between the in-the-moment, retrospective, and imputed measures were assessed using intraclass correlation coefficients and weighted kappa statistics.

RESULTS

Considerable agreement was observed on the basis of weighted kappa (range 0.72-0.95) between the mobility, self-care, and usual activities dimensions of EQ-5D-5L collected in-the-moment and retrospectively. Concordance based on intraclass correlation coefficients was good to excellent (range 0.79-0.81) for utility indices computed, and excellent (range 0.93-0.96) for quality-adjusted life-years computed using in-the-moment compared with retrospective EQ-5D-5L. The longitudinal single imputation did not perform as well as the retrospective collection method.

CONCLUSIONS

This study demonstrates that retrospective collection of EQ-5D-5L has high concordance with "in-the-moment" EQ-5D-5L and could be a valid and attractive alternative for data imputation when longitudinally collected EQ-5D-5L data are missing. Future studies examining this method for other disease areas and populations are required to provide more generalizable evidence.

Prevention of vascular dementia via immunotherapeutic blockade of renin-angiotensin system in a rat model

INTRODUCTION

As several clinical trials have revealed that angiotensin-converting enzyme inhibitors and angiotensin II (Ang II) receptor blockers may be efficient in treating vascular dementia (VaD), the long-acting blockade of the renin-angiotensin system (RAS) would be useful considering the poor adherence of antihypertensive drugs. Accordingly, we continuously blocked RAS via vaccination and examined the effectiveness of the VaD model in rats.

METHODS

Male Wistar rats were exposed to two-vessel occlusions (2VO) after three injections of Ang II peptide vaccine. The effects of the vaccine were evaluated in the novel object recognition test, brain RAS components, and markers for oligodendrocytes.

RESULTS

In the vaccinated rats, anti-Ang II antibody titer level was increased in serum until Day 168, but not in cerebral parenchyma. Vaccinated rats showed better object recognition memory with inhibited demyelination in the corpus callosum and activation of astrocytes and microglia. Also, levels of BrdU/GSTπ-positive cells and the phosphorylation of cAMP response element binding protein was increased in vaccinated rats, indicating that the differentiation of oligodendrocyte progenitor cells to mature oligodendrocytes was accelerated. Vaccinated rats showed increased expression of fibroblast growth factor-2 (FGF2), which was observed in endothelial cells. Angiotensinogen mRNA was decreased at 7 days after 2VO but increased at 14 and 28 days.

CONCLUSION

Ang II vaccine might have promoted oligodendrocyte differentiation and inhibited astrocytic and microglial activation by stimulating FGF2 signaling in the endothelial cells-oligodendrocyte/astrocyte/microglia coupling. These data indicate the feasibility of Ang II vaccine for preventing progression of vascular dementia.

Impact of mobile health and telehealth technology on medication adherence of stroke patients: a systematic review and meta-analysis of randomized controlled trials

Background Stroke patients have low medication adherence after discharge, which leads to a high recurrence rate and poor disease control. Various strategies have been explored to enhance medication adherence in this patient population. Aim To evaluate the effects of mobile health (mHealth) and telehealth technology on medication adherence in stroke patients. Method All English studies that met the inclusion criteria published before September 2021 were obtained from PubMed, EMBASE, Web of Science, and Cochrane Library. Two researchers independently screened articles, extracted data, and evaluated the quality of the included studies. All articles were about randomized controlled trials. Medication adherence was used as the outcome index of this review. Random or fixed-effect models were used in statistical methods. I² statistics were used to evaluate heterogeneity. Results A total of ten studies met the inclusion criteria, covering 2151 stroke patients. Compared with the Usual Care group, the medication adherence scores of the mHealth technology group were better (standard mean deviation 0.67, 95% confidence interval, CI [0.49, 0.85], P < 0.001). The medication adherence ratio of the mHealth technology group was higher (odds ratio, OR, 2.81, 95% CI [1.35, 5.85], P = 0.006). Subgroup analysis showed that application and messaging interventions were more effective than the telephone call intervention (OR 4.05, 95% CI [2.10, 7.80], P < 0.001). The shorter the interval of the intervention, the better the medication adherence of patients (OR 4.24, 95% CI [2.30, 7.81], P < 0.001). Conclusion Compared with Usual Care, mHealth can effectively improve the medication adherence of stroke patients.

Hospital management of major stroke types in Chinese adults: a population-based study of 20 000 hospitalised stroke cases

OBJECTIVES

To compare hospital treatments for major stroke types in Chinese adults by stroke pathological types, sex, age, calendar year, hospital tier, region and other factors.

DESIGN

Cross-sectional analysis of medical records retrieved from 20 229 stroke cases in the China Kadoorie Biobank.

SETTING

Ten diverse areas (five urban, five rural) in China.

PARTICIPANTS

First-incident stroke cases who were recruited during an 11-year follow-up of 0.5M participants in the China Kadoorie Biobank.

METHODS

Electronic copies of medical records of stroke cases were retrieved for clinical adjudication by local neurologists. Stroke cases were classified as ischaemic stroke (IS) (including lacunar infarction (LACI) and non-LACI (non-LACI)), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) and unspecified stroke types.

RESULTS

Among 20 299 first-ever stroke cases, 17 306 (85%) had IS, 7123 had non-LACI, 6690 had LACI, 3493 had silent LACI, 2623 (13%) had ICH and 370 (2%) had SAH. Among IS cases, antiplatelet treatment was used by 64% (65% non-LACI, 66% LACI, 56% silent LACI), lipid-lowering by 50% (52% non-LACI, 53% LACI, 43% silent LACI) and blood pressure-lowering by ~42% of all IS types, with positive trends in the use of these treatments by calendar year and hospital tier. Among ICH cases, 53% used blood pressure-lowering and 10% used lipid-lowering treatments, respectively. In contrast, traditional Chinese medicines (TCMs) were used by 59% of IS (50% non-LACI, 62% LACI, 74% silent LACI), 38% of ICH and 30% of SAH cases, with positive trends by calendar year and by hospital tier.

CONCLUSIONS

Among IS cases, use of antiplatelet and lipid-lowering medications increased in recent years, but use of TCM still exceeded use of blood pressure-lowering treatment. In contrast, blood pressure-lowering treatment was widely used for ICH, but only half of all ICH cases used blood pressure-lowering treatment.

Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study

BACKGROUND

We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data.

METHODS

Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months.

RESULTS

Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months.

CONCLUSIONS

The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

Association between depression and medication adherence in stroke survivor older adults

AIM

This study aimed to investigate the association between depression score and medication adherence in stroke survivor older adults.

METHODS

The participants were 102 stroke survivor older adults. The outcome was medication adherence during a 6-month follow-up. The independent variable was the depression score which was assessed by the Patient Health Questionnaire-9 (PHQ-9). The confounding factors included sociodemographic data, clinical characteristics, number of comorbidities, and number of medications. We analyzed the association between depression and medication adherence using multiple linear regression analyses.

RESULTS

The PHQ-9 score of stroke survivor older adults at the baseline was 1.11±2.03, and at the 6-month follow-up was increased to 5.06±3.91. The medication adherence mean score at the outcome was 4.15±1.83. After full adjustment, the PHQ-9 scores at baseline and 6-month follow-up were significantly associated with medication adherence (β = -.315, 95% CI = -.483 to -.086, p = 0.006 and β = -.270, 95% CI = -.238 to -.020, p = 0.021, respectively). Other variables that affect medication adherence during a 6-month follow-up included living with others and a lower number of medications.

CONCLUSION

This study revealed that lower depression scores were associated with high medication adherence in post-stroke older adults. Additionally, living with others and a lower number of medications were associated with medication adherence. Therefore, stroke survivor older adults should be assessed for depression and given medication, and education should be used to improve mediation adherence, especially for the ones who live alone and have polypharmacy to prevent recurrent stroke.

Development of anti-thrombotic vaccine against human S100A9 in rhesus monkey

In post-stroke patients, a decreased adherence to antiplatelet drugs is a major challenge in the prevention of recurrent stroke. Previously, we reported an antiplatelet vaccine against S100A9 in mice, but the use of Freund’s adjuvant and the difference in amino acid sequences in epitopes between mice and humans were problematic for clinical use. Here, we redesigned the S100A9 vaccine for the common sequence in both humans and monkeys and examined its effects in cynomolgus monkeys with Alum adjuvant. First, we assessed several candidate epitopes and selected 102 to 112 amino acids as the suitable epitope, which could produce antibodies. When this peptide vaccine was intradermally injected into 4 cynomolgus monkeys with Alum, the antibody against human S100A9 was successfully produced. Anti-thrombotic effects were shown in two monkeys in a mixture of vaccinated serum and fresh whole blood from another cynomolgus monkey. Additionally, the anti-thrombotic effects were partially inhibited by the epitope peptide, indicating the feasibility of neutralizing anti-thrombotic effects of produced antibodies. Prolongation of bleeding time was not observed in vaccinated monkeys. Although further studies on increasing the effect of vaccine and safety are necessary, this vaccine will be a promising approach to improve adherence to antiplatelet drugs in clinical settings.

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review

BACKGROUND

Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions.

SUMMARY

The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

Pharmacist medication instructions are associated with continued medication self-management in older adults: a retrospective observational study

Background

Various factors are related to self-management of medication. However, few reports comprehensively examine the factors related to patients, medication levels, and other factors related to the recuperative environment, such as family support. The aim of this study was to investigate factors affecting the continuation of medication self-management among hospitalized older adults receiving convalescent rehabilitation.

Methods

We conducted a retrospective observational study with 274 consecutive patients newly admitted to the convalescent rehabilitation wards at a single hospital in Japan between January 2017 and May 2018. Participants who were assessed for their ability to take their medication using the Japanese Regimen Adherence Capacity Tests, were deemed to be self-manageable, and were able to successfully continue to self-manage their medication from admission to discharge were categorized as the “continuation group,” and those who were not able to continue were categorized as the “non-continuation group.” We analyzed the groups’ demographic data, laboratory data, and Functional Independence Measure. The primary outcome was the continuation of medication self-management from admission to discharge.

Results

After enrollment, 134 patients (median age 82 years; 62.7% women) were included in the final analysis. Some 60.4% of eligible patients were able to maintain medication self-management during their hospitalization. The multiple logistic regression analysis for the continuation of medication self-management during hospitalization after adjusting for confounding factors revealed that pharmacist medication instructions were independently and positively correlated with successful continuation of medication self-management (odds ratio: 1.378; 95% confidence interval 1.085–1.831; p = 0.0076).

Conclusion

Successful continuation of medication self-management is associated with pharmacist medication instructions among hospitalized older adults undergoing rehabilitation.

Trail registration

The Ethics Committee’s registration number is “TGE01216–066”.

Management characteristics and prognosis after stroke in China: findings from a large nationwide stroke registry

BACKGROUND AND PURPOSE

There is limited nationwide evidence about the standard management characteristics of stroke types and prognosis in China. This study aimed to assess clinical characteristics, in-hospital and after-discharge management characteristics and prognosis for stroke types in China.

METHODS

A nationwide registry recruited 14 244 imaging-confirmed first-ever incident strokes from 132 hospitals across 31 provinces of China during 2007-2008, recording presenting characteristics, diagnostic procedures and in-hospital treatment. After hospital discharge, patients were followed up for 6 months. Conventional statistical methods were used to examine the patterns of management and prognosis.

RESULTS

Overall, 68.7%, 26.9% and 4.4% were ischaemic stroke (IS), intracerebral haemorrhage (ICH), and subarachnoid haemorrhage (SAH), respectively. Only 20% were managed in a dedicated stroke unit. Among IS, 1.3% received thrombolysis within 3 hours after symptom onset, whereas the proportions of receiving in-hospital antiplatelet therapy, neuroprotective agents and traditional Chinese medicines (TCM) were 88.4%, 69.7% and 70.6%, respectively. For ICH, 63.3% and 36.3% received neuroprotective agents and TCM in hospital, respectively. At discharge, 70.7% and 38.0% of the patients with IS were given antiplatelet and statin therapies, respectively, decreasing to 64.8% and 23.9%, respectively, at 6 months. In-hospital mortality was 3.2%, 9.3% and 10.1% for IS, ICH and SAH, respectively, with a further 8.6%, 18.2% and 22.0%, respectively, died by 6 month. Meanwhile, in-hospital recurrence rate was 2.6%, 1.9% and 7.2% for IS, ICH and SAH, respectively, with a further 8.0%, 5.1% and 7.5%, respectively, recurred by 6 month.

CONCLUSIONS

In China, the mortality rate of stroke is lower than that reported from west populations, though most strokes are not managed in specialised stroke unit. There is widespread use of some unproven therapies but limited proven treatments, especially after discharge, leading to unnecessary recurrent risks.

Vascular risk factor control and adherence to secondary preventive medication after ischaemic stroke

BACKGROUND

Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke.

METHODS

A total of 664 home-dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self-reporting (4-item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline-defined targets of blood pressure (BP) (<140/90 mmHg), low-density lipoprotein cholesterol (LDL-C) (<2.0 mmol L^-1 ) and haemoglobin A1c (HbA1c) (≤53 mmol mol^-1 ) and determinants of risk factor control.

RESULTS

At discharge, 97% were prescribed antithrombotics, 88% lipid-lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL-C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL-C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL-C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL-C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98).

CONCLUSION

Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies.

Association of Black Race With Early Recurrence After Minor Ischemic Stroke or Transient Ischemic Attack: Secondary Analysis of the POINT Randomized Clinical Trial

Importance

Stroke incidence is higher among black than white individuals in the United States. It is unclear whether black individuals have a higher risk of stroke recurrence after a minor ischemic stroke or transient ischemic attack (TIA), a high-risk setting in which focused preventive efforts can be effective.

Objective

To examine the association between black race and early ischemic stroke recurrence.

Design, Setting, and Participants

This cohort study analyzed data from the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial conducted at 269 sites from May 28, 2010, to December 19, 2017. The trial enrolled 4881 adults within 12 hours of onset of a minor ischemic stroke (National Institutes of Health Stroke Scale score, 0-3) or high-risk TIA (ABCD2 score, ≥4). For this analysis, we excluded 598 patients enrolled outside the United States and 239 US patients with missing race/ethnicity data.

Main Outcomes and Measures

The primary outcome for this analysis was ischemic stroke within 90 days after randomization. Covariates included age, sex, Hispanic ethnicity, study assignment to take clopidogrel vs placebo, index stroke vs TIA, vascular risk factors, statin use, study drug adherence, and index event etiological subtype.

Results

Among 4044 patients included in the analysis, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race (hazard ratio, 1.6; 95% CI, 1.1-2.3). Findings were similar in subgroup analyses and in analyses limited to sites that enrolled black patients.

Conclusions and Relevance

Among US participants in the POINT trial, black individuals faced a higher risk of early stroke recurrence after a minor ischemic stroke or TIA. Our findings support research into black-white racial differences in the underlying mechanisms of recurrent stroke. In the meantime, extra effort should be made to ensure that black patients have access to proven secondary prevention measures.

Trial Registration

clinicaltrials.gov Identifier: NCT00991029.

Non-persistence with anti-platelet therapy and long-term mortality after ischemic stroke: A nationwide study

BACKGROUND

We tried to investigate the effect of non-persistence with antiplatelets after ischemic stroke on long-term all-cause mortality (ACM).

METHODS AND FINDINGS

We selected newly diagnosed ischemic stroke patients aged ≥20years who were newly treated with aspirin or clopidogrel from 2003-2010 Korean National Health Insurance Service-National Sample Cohort, a random sample of 2.2% of total population. Subjects were divided into two pairs of groups according to persistence with antiplatelets at 6 and 12 months: those who discontinued antiplatelets within 6 months (DA6M) and those who continued them for 6 or months or more (CA6M); and those who discontinued antiplatelets within 12 months (DA12M) and those who continued them for 12 months or more (CA12M). Those who died within 6 months among DA6M and those who died within 12 months among DA12M were excluded along with those with medication possession ratio<80% among CA6M and CA12M. Subjects were followed-up until death or December 31, 2013. Among 3,559 total subjects, DA6M were 1,080 and CA6M were 2,479 while, out of 3,628 total patients, DA12M were 1,434 and CA12M were 2,194. The risks of ACM [adjusted hazard ratio (aHR), 2.25; 95% confidence interval (CI), 1.94-2.61], cerebro-cardiovascular disease (CVD) death (aHR, 2.52; 95% CI, 1.96-3.24) and non-CVD death (aHR, 2.11; 95% CI, 1.76-2.64) of DA6M were all significantly increased compared to CA6M. DA12M also had significantly higher risks of ACM (aHR, 1.93; 95% CI, 1.65-2.25), CVD mortality (aHR, 2.13; 95% CI; 1.63-2.77) and non-CVD mortality (aHR, 1.83;95% CI 1.51-2.22) than DA12M but aHRs were lower than that between DA6M and CA6M. The difference rates of ACM, CVD death, and non-CVD death between non-persistent and persistent groups all continuously widened over time but the degree of difference was gradually decreased.

CONCLUSIONS

Maintaining antiplatelets for the first 12 months after ischemic stroke reduces long-term risks of both CVD death and non-CVD death.

Secondary prevention medication persistence and prognosis of acute ischaemic stroke or transient ischaemic attack

Introduction

The risk of disability and mortality is high among recurrent stroke, which highlights the importance of secondary prevention measures. We aim to evaluate medication persistence for secondary prevention and the prognosis of acute ischaemic stroke or transient ischaemic attack (TIA) in China.

Methods

Patients with acute ischaemic stroke or TIA from the China National Stroke Registry II were divided into 3 groups based on the percentage of persistence in secondary prevention medication classes from discharge to 3 months after onset (level I: persistence=0%, level II: 0%<persistence<100%, level III: persistence=100%). The primary outcome was recurrent stroke. The secondary outcomes included composite events (stroke, myocardial infarction or death from cardiovascular cause), all-cause death and disability (modified Rankin Scale score=3–5) from 3 months to 1 year after onset. Recurrent stroke, composite events and all-cause death were performed using Cox regression model, and disability was identified through logistic regression model using the generalised estimating equation method.

Results

18 344 patients with acute ischaemic stroke or TIA were included, 315 (1.7%) of whom experienced recurrent strokes. Compared with level I, the adjusted HR of recurrent stroke for level II was 0.41 (95% CI 0.31 to 0.54) and level III 0.37 (0.28 to 0.48); composite events for level II 0.41 (0.32 to 0.53) and level III 0.38 (0.30 to 0.49); all-cause death for level II 0.28 (0.23 to 0.35) and level III 0.20 (0.16–0.24). Compared with level I, the adjusted OR of disability for level II was 0.89 (0.77 to 1.03) and level III 0.82 (0.72 to 0.93).

Conclusions

Persistence in secondary prevention medications, especially in all classes of medications prescribed by the physician, was associated with lower hazard of recurrent stroke, composite events, all-cause death and lower odds of disability in patients with acute ischaemic stroke or TIA.

Residual Risk and Its Risk Factors for Ischemic Stroke with Adherence to Guideline-Based Secondary Stroke Prevention

Background and Purpose

Despite administration of evidence-based therapies, residual risk of stroke recurrence persists. This study aimed to evaluate the residual risk of recurrent stroke in acute ischemic stroke or transient ischemic attack (TIA) with adherence to guideline-based secondary stroke prevention and identify the risk factors of the residual risk.

Methods

Patients with acute ischemic stroke or TIA within 7 hours were enrolled from 169 hospitals in Third China National Stroke Registry (CNSR-III) in China. Adherence to guideline-based secondary stroke prevention was defined as persistently receiving all of the five secondary prevention medications (antithrombotic, antidiabetic and antihypertensive agents, statin and anticoagulants) during hospitalization, at discharge, at 3, 6, and 12 months if eligible. The primary outcome was a new stroke at 12 months.

Results

Among 9,022 included patients (median age 63.0 years and 31.7% female), 3,146 (34.9%) were identified as adherence to guideline-based secondary prevention. Of all, 864 (9.6%) patients had recurrent stroke at 12 months, and the residual risk in patients with adherence to guidelinebased secondary prevention was 8.3%. Compared with those without adherence, patients with adherence to guideline-based secondary prevention had lower rate of recurrent stroke (hazard ratio, 0.85; 95% confidence interval, 0.74 to 0.99; P=0.04) at 12 months. Female, history of stroke, interleukin-6 ≥5.63 ng/L, and relevant intracranial artery stenosis were independent risk factors of the residual risk.

Conclusions

There was still a substantial residual risk of 12-month recurrent stroke even in patients with persistent adherence to guideline-based secondary stroke prevention. Future research should focus on efforts to reduce the residual risk.

Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke

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.

Stroke patients' support: evaluation of knowledge, practices and training needs of French community pharmacists

Background Stroke represents a major Public Health issue in industrialized countries because of its frequency and severity. In secondary stroke prevention, treatment efficacy is correlated to medication adherence. However, it remains suboptimal in stroke patients. Community pharmacists, in light of their positioning in the care pathway and proximity to patients, can play an essential role in patient support and improving treatment adherence. However, it is currently unknown whether pharmacists are ready to perform this task. Objective Evaluate knowledge, practices and training needs for community pharmacists in therapeutic stroke management to improve long term care for stroke patients. Setting Community pharmacies in the Rhone Alpes region (France). Method We conducted a cross sectional study via a standardized self-assessment questionnaire consisting of 40 questions divided into three parts. The latter was designed by a multidisciplinary team and distributed electronically to community pharmacists of the Rhône-Alpes region (France). Main outcome measure (a) global knowledge score on the pathology, risk factors and clinical care management, (b) description of the support practices for stroke patients, (c) training needs for pharmacists. Results The 104 participants presented a moderate level of knowledge (global score: 12/20 ± 3). Topics best mastered were: pathophysiology, target blood pressure and place of antiplatelets in the therapeutic strategy. Knowledge items that needed improvement were: warning signs correctly identified by 44% of participants, time delay for thrombolysis for which 14% answered correctly, target glycated hemoglobin levels were correct for 41%, and the 3 recommended antihypertensive drug classes were only identified by 5% of participants. Patient education received from pharmacists concerned dosage (89%), treatment adherence (88%), benefits (66%) and administration modalities of medicines (64%), management of risk factors (75% for diet, 73% for physical activity, 70% for smoking and 53% for alcohol). All pharmacists wanted additional training on risk factors and clinical management guidelines. Conclusion Based on this small study, the fragmented knowledge and varied practices promote the need for further training for pharmacists to optimize support of stroke patients. This study promotes the elaboration of training systems adapted to pharmacists' needs. This will help support the development of a targeted pharmaceutical care approach for stroke patients.

Quality of Stroke Patient Information Applied in Randomized Controlled Trials-Literature Review

Background: Strokes have a huge impact on patients' quality of life. Although there are potentially effective secondary preventions and treatment options for stroke patients, adherence is mostly low. Low disease and treatment-related knowledge and, consequently, a lack of informed decision-making in stroke patients may contribute to this problem. However, stroke patient information did not seem to have relevant effects on patients' knowledge in randomized controlled trials. One contributing factor may be the lack of thoroughly developed patient information materials.

Methods: We aimed to evaluate the quality of patient information materials for stroke patients by using randomized controlled trials, applying quality criteria for evidence-based patient information (EBPI). We conducted a literature search (MEDLINE, Embase, CINAHL, PsycINFO, and CENTRAL). To be included in the review, research had to be randomized controlled trials that provided stroke patient information, were published in English, and had knowledge assessed as the primary endpoint. Authors of primary studies were contacted and asked for information materials applied.

Results: We screened 15,507 hits and identified 30 eligible studies. Information materials were available for only eight studies. Analyses revealed that all available materials had important shortcomings concerning EBPI quality criteria [concerning, for example, structural information (e.g., reporting conflicts of interest), content information (e.g., reporting sources of information), or comprehensive descriptions of treatment effects and side effects]. Frequently, treatment effects were reported only narratively without providing absolute numbers, values, or frequencies.

Conclusion: Quality of materials differed, but none sufficiently fulfilled EBPI quality criteria. Unsatisfactory trial results concerning patient knowledge and patient involvement in decision-making may at least partially be explained by limitations of the provided materials. Future patient information should consider EBPI quality criteria.

Progress of Gene Therapy in Cardiovascular Disease

Gene therapy has been extensively studied in peripheral and cardiac ischemia, heart and vein graft failure, and dyslipidemia, but most clinical trials failed to show their efficacies despite good outcomes in preclinical studies. So far, 2 gene therapies for dyslipidemia and one for critical limb ischemia in peripheral artery disease have been approved. In critical limb ischemia, gene therapy using proangiogenic factors has emerged as a novel therapeutic modality for promoting angiogenesis. Initial researches mainly focused on vascular endothelial growth factor, fibroblast growth factor, or hepatocyte growth factor. After the favorable results of basic research, several phase I and II clinical trials of these proangiogenic factors have shown promising results. However, only a phase III clinical trial of the intramuscular injection of hepatocyte growth factor plasmid DNA has shown successful outcomes, and it was recently approved in Japan for treating patients with critical limb ischemia who have ulcers and for whom no alternative therapeutic options are available. DNA vaccine is another promising modality of gene therapy. An antitumor vaccine suppressing angiogenesis through the inhibition of proangiogenic factors and an antihypertensive vaccine inhibiting the renin–angiotensin system are representative DNA vaccines. The advantage of DNA vaccine is its long-term effectiveness with a few vaccinations; however, the benefits and risks, such as adverse T-cell reaction against self-antigen or long-term side effects, of DNA vaccines should be carefully evaluated. In this review, we discuss the recent advances in proangiogenic gene therapy for critical limb ischemia and DNA vaccine for hypertension.