Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II)

BACKGROUND

Reduction of blood pressure (BP) after stroke or TIA decreases stroke recurrence and is a major goal ofsecondary Stroke Prevention Clinics (SPCs). Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication.

METHODS

This multicentred, randomized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits (e.g., lack of confidence in the utility of medications, poor memory, mild cognitive impairment) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program (monthly telephone calls, motivational interviewingfor lifestyle change, plus home BP monitoring and use ofdosettes for medication administration) would improve BP measures and adherence to medications.

RESULTS

Both intervention (n=29) and usual care groups (n=27) showed a trend-for'reduced BP at six months (Median ql-q3, Systolic BR p=0.46; Diastolic BR p=0.37). Diabetic patients, irrespective of the group to which they were randomized, were less likely to meet Best Practice Guideline targets than those without diabetes (Chi Square test, p=0.0001).

CONCLUSION

Stroke and TIA patients with diabetes may require additional resources and support in order to reach BP target values.

Association between time-to-presentation and clinical outcome in patients with subarachnoid hemorrhage: an observational study

BACKGROUND

Headache is the most common presenting symptom of subarachnoid hemorrhage (SAH), ranging from mild headache to the "worst headache of my life". As headache is often non-specific, patients may not seek immediate medical attention, though prompt medical and surgical management is expected to improve clinical outcomes. In this study, we explore the independent association between duration from onset of symptoms to presentation at an emergency department (ED) and clinical outcomes after SAH.

METHODS

Participants with a primary diagnosis of nontraumatic SAH were identified from consecutive patients at 11 regional stroke centres participating in the Registry of the Canadian Stroke Network (RCSN, 2003-2005). Hunt and Hess score (H+H), and modified Rankin Scale (mRS) at discharge were collected on SAH cases by trained nurse-abstractors. For analysis, patients were categorized into patients with mild-moderate dependency (mRS 0-3) and those with severe dependence or death (mRS 4-6) at hospital discharge. Multivariable regression analyses were used to determine the association between 'time to presentation' and clinical outcomes, independent of comorbidities.

RESULTS

Of 721 SAH patients included in the RCSN, 642 (89.0%) had the interval between 'time last seen normal' and time of ED presentation recorded. Mean duration from symptom onset to ED arrival was 27.04 hours (+/- 2.02). One hundred and sixty-six patients (25.9%) presented to the ED more than 24 hours after onset of symptoms. On multivariable analysis, there was no association between time to presentation and severe disability or death at hospital discharge (OR 1.0 [95% CI 0.95-1.01]); 30-day mortality (OR 1.0 [95% CI 0.91-1.02]; or six-month mortality (OR 1.0 [95% CI 1.0-1.02]). Increasing H+H score and age were significantly associated with increased odds of death and severe dependence at hospital discharge.

CONCLUSIONS

In this observational study, duration from symptom onset to hospital presentation was not independently associated with death or severe disability at hospital discharge following SAH. Age and H+H score were independent predictors of clinical outcome after non-traumatic SAH.

Risk factors for posterior compared to anterior ischemic stroke: an observational study of the Registry of the Canadian Stroke Network

BACKGROUND

Traditional vascular risk factors appear to exert varying magnitudes of risk for different major vascular events. For example, hypercholesterolemia is a much stronger risk factor for myocardial infarction than ischemic stroke. Limited evidence also suggests that vascular risk factors may exert differing magnitudes of risk for ischemic stroke within different cerebral arterial territories. We sought to determine the association between traditional vascular risk factors and the location of ischemic stroke (posterior versus anterior).

METHODS

Consecutive patients with acute ischemic stroke who were admitted to 11 regional stroke centers within the Registry of the Canadian Stroke Network were included in the study sample. The Oxfordshire Community Stroke Project classification was used to distinguish posterior from anterior circulation ischemic stroke. Multivariable logistic regression was applied to determine the association between risk factors (age, gender, diabetes mellitus, hypercholesterolemia, hypertension, atrial fibrillation and smoking history) and posterior (compared to anterior) circulation ischemic stroke.

RESULTS

In total, 8,489 patients with acute ischemic stroke were included. On multivariable analysis, diabetes mellitus (OR = 1.14; 95% CI = 1.02-1.27) was associated with an increased odds of posterior circulation ischemic stroke, whereas age (OR = 0.86; 95% CI = 0.83-0.90), female sex (OR = 0.84; 95% CI = 0.76-0.93), atrial fibrillation (OR = 0.83; 95% CI = 0.74-0.94) and pulmonary edema (OR = 0.74; 95% CI = 0.62-0.88) were related to a reduced odds of posterior compared with anterior circulation ischemic stroke.

CONCLUSIONS

Some traditional vascular risk factors for ischemic stroke appear to exert different magnitudes of risk for posterior compared to anterior circulation ischemic stroke.

Gastrointestinal bleeding after acute ischemic stroke

OBJECTIVE

Recent studies report that major bleeding is associated with a significant increase in mortality after acute coronary syndrome. Major bleeding has also been reported to be common after ischemic stroke, most often gastrointestinal, but its association with clinical outcome is less certain. We sought to describe the incidence, risk factors, and association with clinical outcomes of gastrointestinal bleeding following acute ischemic stroke.

METHODS

Consecutive patients with acute ischemic stroke, who were admitted to 11 Ontario hospitals, were identified from the Registry of the Canadian Stroke Network (2003-2006). Stroke severity was measured using the Canadian Neurological Scale. Dependence was measured with the modified Rankin Scale (mRS), and categorized into strokes with no or mild-moderate dependency (mRS 0-3) and those with severe dependence or death (mRS 4-6). Multivariable logistic regression was used to determine the association between gastrointestinal bleeding and clinical outcome (death or severe dependence at hospital discharge and 6-month mortality), independent of comorbidities and in-hospital medical complications.

RESULTS

In total, 6,853 patients with acute ischemic stroke were included. One hundred (1.5%) patients experienced gastrointestinal hemorrhage during hospitalization, of which 36 (0.5%) required blood transfusion. On multivariable analyses, previous history of peptic ulcer disease, cancer, and stroke severity were independent predictors of gastrointestinal bleeding. Gastrointestinal hemorrhage was independently associated with death or severe dependence at discharge (OR 3.3; 95% CI 1.9-5.8) and mortality at 6 months (HR 1.5; 95% CI 1.1-2.0).

CONCLUSIONS

Gastrointestinal hemorrhage is relatively uncommon after acute ischemic stroke but is associated with increased odds of death and severe dependence.

Preadmission antithrombotic treatment and stroke severity in patients with atrial fibrillation and acute ischaemic stroke: an observational study

BACKGROUND

Vitamin K antagonists (eg, warfarin) substantially reduce the risk of ischaemic stroke in patients with atrial fibrillation. Additionally, therapeutic anticoagulation at time of acute stroke admission might reduce in-hospital mortality and disability. We assessed the association between preadmission antithrombotic treatment and initial stroke severity, neurological deterioration, major vascular events during hospital stay, and death or disability at discharge in patients with acute ischaemic stroke and atrial fibrillation.

METHODS

We identified consecutive patients with acute ischaemic stroke and atrial fibrillation, admitted to 11 hospitals in Ontario, Canada, from the Registry of the Canadian Stroke Network (2003-05). Logistic regression was used to assess the association between antiplatelet treatment, subtherapeutic warfarin treatment (admission international normalised ratio [INR] < 2), therapeutic warfarin treatment (admission INR > or = 2), and clinical outcome. Stroke severity was measured using the Canadian neurological scale (CNS) and was categorised into mild (CNS > 7) and severe stroke (CNS < or = 7). Disability was measured with the modified-Rankin scale (mRS) and was categorised into strokes associated with no or mild-moderate dependency (mRS 0-3) and with severe dependency or death (mRS 4-6).

RESULTS

Of 948 patients, 306 (32%) were not on antithrombotic treatment, 292 (31%) were receiving antiplatelet treatment, 238 (25%) were receiving warfarin with a subtherapeutic INR, and 112 (12%) were receiving warfarin with a therapeutic INR on admission. Compared with those not receiving antithrombotic therapy, antiplatelet therapy (odds ratio 0.7; 95% CI 0.5-0.995) and therapeutic warfarin (0.4; 0.2-0.6) were associated with a reduction in severe stroke at admission. Therapeutic warfarin was also associated with a reduction in the odds of severe disability or death at discharge (0.5; 0.3-0.9).

INTERPRETATION

Therapeutic warfarin is associated with reduced severity of ischaemic stroke at presentation and reduced disability or death at discharge in patients with atrial fibrillation. Antiplatelet treatment is associated with a more modest reduction than warfarin in baseline stroke severity.