Personalising secondary prevention: different treatments for different strokes

Stroke is a syndrome caused by many different disease mechanisms rather than being a single disease. It is important to identify the underlying mechanism accurately in individual patients in order to choose the best treatment approach. This article provides practical tips to diagnose the underlying subtype of stroke, and in particular discusses non-lacunar pathologies that can present with a clinical lacunar syndrome. It also reviews the recent advances in recurrent stroke prevention, including using more intensive antiplatelet regimens in the acute phase, and the concept that undetected cardiac arrhythmias may be important in apparently cryptogenic stroke.

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Abstract TP398: Stroke prevention opportunities being missed: the Australian Stroke Clinical Registry experience.

Stroke ◽

10.1161/str.44.suppl_1.atp398 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Monique Kilkenny ◽

Helen Dewey ◽

Natasha Lannin ◽

Joyce Lim ◽

Craig Anderson ◽

...

Keyword(s):

Secondary Prevention ◽

Hospital Discharge ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Prevention Measures ◽

Post Discharge ◽

Stroke Event ◽

Clinical Registry ◽

Large Hospital ◽

Missed Opportunities

Introduction: Stroke utilizes a large portion of hospital resources. Little is known about the frequency of contacts with hospitals prior to first-ever stroke and potentially missed opportunities for stroke prevention. In addition, re-admissions may indicate failed secondary prevention. Hypothesis: Many patients have had a presentation or admission to hospital in the year prior to a first-ever stroke event. Methods: Data from the prospective, national Australian Stroke Clinical Registry (AuSCR) obtained between 15 June 2009 and 31 December 2010 from a large hospital in Melbourne, Victoria (Australia) were linked to the Victorian government emergency department (ED) and hospital discharge datasets for a 3 year ‘look-back’ period and any re-presentation up until February 2011 using stepwise deterministic linkage methods. Descriptive statistics are presented. Results: Matched linkage to ED (731/788) and hospital discharge (736/788) datasets was achieved in 93% of AuSCR registrants, of whom 513 were first-ever strokes (51% male, average age 74 [±16] years, 82% ischemic). Prior to the first-ever stroke, 221 (47%) registrants had ED presentations and 283 had a hospital admission on average 2.9 months before stroke. The mean number of ED presentations within 3 years of AuSCR registration for a first-ever event was 2.1 (SD 1.6); and 48/466 (10%) occurred in the month prior to stroke. Among first-ever stroke registrants, 200 were re-admitted on average within 5 months following discharge; 3.5% for recurrent stroke/TIA. Conclusion: Contact with hospitals was common (~50%) before first stroke, raising opportunities to screen and intervene in people at risk of stroke. As one in 5 hospital re-admissions is for recurrent stroke, a closer monitoring of secondary prevention measures in the early post-discharge period may be warranted.

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Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) study protocol

International Journal of Stroke ◽

10.1177/1747493019895653 ◽

2019 ◽

Vol 15 (1) ◽

pp. 109-115

Author(s):

Mahesh Pundlik Kate ◽

Deepti Arora ◽

Shweta Jain Verma ◽

PN Sylaja ◽

Vishnu Renjith ◽

...

Keyword(s):

Clinical Trial ◽

Coronary Artery ◽

Secondary Prevention ◽

Acute Stroke ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Standard Of Care ◽

Clinical Trial Registry ◽

Cardiovascular Morbidity And Mortality ◽

Recurrent Strokes

Rationale Recurrent stroke, cardiovascular morbidity, and mortality are important causes of poor outcome in patients with index stroke. Despite the availability of best medical management recurrent stroke occur in up to 15–20% of patients with stroke in India. Education for stroke prevention could be a strategy to prevent recurrent strokes. Hypothesis We hypothesize that a structured semi-interactive stroke prevention package can reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke at the end of one year. Design Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) is a multi-center stroke trial involving 25 centers under the Indian Stroke Clinical Trial Network. Patients with first ever sub-acute stroke within two days to three months of onset, age 18–85 years, mRS <5, showing recent stroke in imaging are included. Participants or caregivers able to read and complete tasks suggested in a stroke prevention workbook and have a cellular device for receiving short message service and watching videos. A total of 5830 stroke patients speaking 11 different languages are being randomized to intervention or control arm. Patients in the intervention arm are receiving a stroke prevention workbook, regular educational short messages, and videos. All patients in the control arm are receiving standard of care management. Summary Structured semi-interactive stroke prevention package may reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke. Trial registration This trial is registered with clinicaltrials.gov (NCT03228979) and CTRI (Clinical Trial Registry India; CTRI/2017/09/009600).

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

Journal of Stroke ◽

10.5853/jos.2020.03391 ◽

2021 ◽

Vol 23 (1) ◽

pp. 51-60

Author(s):

Yuesong Pan ◽

Zixiao Li ◽

Jiejie Li ◽

Aoming Jin ◽

Jinxi Lin ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Secondary Prevention ◽

Acute Ischemic Stroke ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Antihypertensive Agents ◽

Residual Risk ◽

Stroke Recurrence ◽

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.

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Abstract W P374: Population-Based Eligibility for a Stroke Prevention Trial Evaluating Novel Anticoagulants and Embolic Strokes of Uncertain Etiology: Similar Eligibility as for IV Rt-PA

Stroke ◽

10.1161/str.46.suppl_1.wp374 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Dawn Kleindorfer ◽

Scott Kasner ◽

Charles J Moomaw ◽

Kathleen Alwell ◽

Opeolu Adeoye ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Population Based ◽

Vascular Imaging ◽

Stroke Patients ◽

Exclusion Criteria ◽

The Us ◽

Uncertain Etiology

Introduction: The RESPECT-ESUS trial is proposed to evaluate the best stroke prevention strategy for patients with strokes of uncertain etiology. This trial will compare a novel anticoagulant with antiplatelet agents to prevent recurrent stroke among cryptogenic stroke patients. We sought to evaluate the eligibility for this trial within a large, biracial population representative of the US. Methods: All adult ischemic stroke patients in 2010 among residents of the 5-county Greater Cincinnati/Northern Kentucky region (population 1.3 million) were ascertained from all local hospitals via ICD-9 codes 430-436. Inclusion and exclusion criteria supplied by the corporate sponsor as of 6/30/14 were applied to the ischemic stroke population. Per trial protocol, a complete workup was defined as brain and both intra- and extracranial vascular imaging, ECHO, telemetry, and EKG. Results: Of 1894 ischemic stroke patients without hemorrhagic transformation who survived the hospital stay (and not sent to hospice), 138 (7.4%) would have been eligible for RESPECT-ESUS. Inclusion and exclusion criteria are listed in the Table. If we were to assume that every stroke patient received a complete workup and no further etiologies were identified, the “hypothetical” eligibility could be as high as 18.7%. Discussion: We found that the potential eligibility for the RESPECT-ESUS trial to be low, and in fact is similar to population-based estimates of rt-PA eligibility (6%-8%). Extrapolation of eligibility across the US would be further limited by presentation to an enrolling center and consent refusal rates. Our estimates are based on information obtained during hospitalization, which may over- or underestimate eligibility within the 3-6 month post-event enrollment window. It is likely that centers that participate in the trial will have more complete diagnostic workups, which was a major exclusion in our population, especially the requirement for intracranial vascular imaging.

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Factors Affecting Non-Adherence to Secondary Stroke Prevention Therapy in Ischemic Stroke Patients

JURNAL MANAJEMEN DAN PELAYANAN FARMASI (Journal of Management and Pharmacy Practice) ◽

10.22146/jmpf.34434 ◽

2018 ◽

Vol 8 (2) ◽

pp. 90

Author(s):

Zakky Cholisoh ◽

Hidayah Karuniawati ◽

Tanti Azizah ◽

Zaenab Zaenab ◽

Laila Nur Hekmah

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Antihypertensive Agents ◽

Heart Association ◽

Secondary Stroke Prevention ◽

Stroke Patients ◽

Factors Affecting ◽

Prevention Therapy

Stroke is cardiovascular disease that causes the world's highest disability and is the most prevalence disease after heart disease and cancer. Stroke is caused by circulatory disorders with 80% of the sufferers are diagnosed with ischemic stroke and 20% of them are diagnosed with hemorrhagic stroke. Patients who survive from the first stroke have high risk to have recurrent stroke. American Heart Association/American Stroke Association and Perhimpunan Dokter Spesialis Syaraf Indonesia recommend secondary stroke prevention therapy including antiplatelet/anticoagulant, antihypertensive agents, and antidislipidemia to minimalize the risk of recurrent stroke. Secondary stroke prevention therapy is only the first step. Patients need to be adhere to those therapies. The non-adherence will increase the risk of recurrent stroke. The study aimed to determine factors which causing the non-adherence to secondary prevention therapy in patients with ischemic stroke. This was a case control study with concecutive sampling method by interviewing patients who met the inclusion criterias i.e., had been diagnosed and were inpatients due to ischemic stroke, but in the time of interview patients were outpatients, patients were able to communicate and agree to participate in the study.Data was analized by bivariate / chi square test and multivariate logistic regression test. During the study period, 184 respondents met the inclusion criterias. Factors affecting non-adherence in the use of secondary prevention therapy were No one reminded to take medicine p = 0.03; OR 4.51, denial of the disease p = 0,036 OR 214, and tired of taking medicine p = 0,045 OR 1,97.

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Stroke Prevention: Managing Modifiable Risk Factors

Stroke Research and Treatment ◽

10.1155/2012/391538 ◽

2012 ◽

Vol 2012 ◽

pp. 1-15 ◽

Cited By ~ 1

Author(s):

Silvia Di Legge ◽

Giacomo Koch ◽

Marina Diomedi ◽

Paolo Stanzione ◽

Fabrizio Sallustio

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Secondary Prevention ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Lifestyle Changes ◽

Thrombin Inhibitors ◽

Modifiable Risk Factors ◽

Vascular Events

Prevention plays a crucial role in counteracting morbidity and mortality related to ischemic stroke. It has been estimated that 50% of stroke are preventable through control of modifiable risk factors and lifestyle changes. Antihypertensive treatment is recommended for both prevention of recurrent stroke and other vascular events. The use of antiplatelets and statins has been shown to reduce the risk of recurrent stroke and other vascular events. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are indicated in stroke prevention because they also promote vascular health. Effective secondary-prevention strategies for selected patients include carotid revascularization for high-grade carotid stenosis and vitamin K antagonist treatment for atrial fibrillation. The results of recent clinical trials investigating new anticoagulants (factor Xa inhibitors and direct thrombin inhibitors) clearly indicate alternative strategies in stroke prevention for patients with atrial fibrillation. This paper describes the current landscape and developments in stroke prevention with special reference to medical treatment in secondary prevention of ischemic stroke.

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Antithrombotic Therapy in the Prevention of Stroke

Biomedicines ◽

10.3390/biomedicines9121906 ◽

2021 ◽

Vol 9 (12) ◽

pp. 1906

Author(s):

Shyamal Bir ◽

Roger E. Kelley

Keyword(s):

Secondary Prevention ◽

Antiplatelet Therapy ◽

Anticoagulant Therapy ◽

Stroke Prevention ◽

Antithrombotic Therapy ◽

Dual Antiplatelet Therapy ◽

Recurrent Stroke ◽

Oral Anticoagulants ◽

Minor Stroke ◽

Potential Clinical Benefit

Overview: Ischemic stroke is a leading cause of death and disability throughout the world. Antithrombotic therapy, which includes both antiplatelet and anticoagulant agents, is a primary medication of choice for the secondary prevention of stroke. However, the choices vary with the need to incorporate evolving, newer information into the clinical scenario. There is also the need to factor in co-morbid medical conditions as well as the cost ramifications for a particular patient as well as compliance with the regimen. Pertinent Updates: In the acute setting, dual antiplatelet therapy from three weeks to up to three months has become recognized as a reasonable approach for patients with either minor stroke or transient ischemic attack or those with symptoms associated with higher-grade intracranial stenosis. This approach is favored for non-cardioembolic stroke as a cardiogenic mechanism tends to be best managed with attention to the cardiac condition as well as anticoagulant therapy. Risk stratification for recurrent stroke is important in weighing potential risk versus benefits. For example, prolonged dual antiplatelet therapy, with a combination such as aspirin and clopidogrel or aspirin and ticagrelor, tends to have negation of the potential clinical benefit of stroke prevention, over time, by the enhanced bleeding risk. Anticoagulant choices are now impacted by newer agents, initially identified as novel oral anticoagulants (NOACs), which also became associated with “non-vitamin K” agents as they are no longer considered novel. Alternatively, they are now often identified as direct oral anticoagulants (DOACs). They tend to be viewed as superior or non-inferior to warfarin with the caveat that warfarin is still viewed as the agent of choice for stroke prevention in patients with mechanical heart valves. Conclusion: Based upon cumulative information from multiple clinical trials of secondary prevention of stroke, there is an increasing array of approaches in an effort to provide optimal management. Antithrombotic therapy, including in combination with anticoagulant therapy, continues to evolve with the general caveat that “one size does not fit all”. In view of this, we desire to provide an evidence-based approach for the prevention of stroke with antithrombotic agents.

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Primary and secondary prevention of stroke

Oxford Textbook of Geriatric Medicine ◽

10.1093/med/9780198701590.003.0118 ◽

2017 ◽

pp. 913-920

Author(s):

Lisa Manning ◽

Man Yee Lam ◽

Thompson G. Robinson

Keyword(s):

Secondary Prevention ◽

Stroke Prevention ◽

Acute Treatment ◽

Recurrent Stroke ◽

Evidence Based ◽

Secondary Stroke Prevention ◽

Prevention Strategies ◽

Specialist Care ◽

Causes Of Mortality ◽

Ischaemic Attack

Stroke is one of the leading causes of mortality, morbidity, and disability worldwide. Stroke and transient ischaemic attack survivors are at risk of recurrent stroke, which is often more severe and disabling. Despite the success in acute treatment and rehabilitation of stroke, prevention remains the most effective way to reduce the global burden of the disease. Since preventative strategies have early effectiveness, prompt recognition of symptoms, specialist assessment and diagnosis, and initiation of these secondary prevention strategies are of utmost importance in stroke prevention. This chapter provides an overview of current primary and secondary stroke prevention strategies, highlighting the importance of rapid recognition, urgent specialist care, and evidence-based interventions, which are the cornerstones of effective management.

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