Family Perceptions of Barriers and Facilitators of Treatment Protocols for Secondary Stroke Prevention in Children with Sickle Cell Disease

Abstract Abstract 4805 Children with sickle cell anemia (SCA) and a primary overt stroke are at high risk of recurrent (secondary) stroke. Chronic blood transfusion (CBT) dramatically reduces but does not eliminate this high risk, and results in transfusion-related hemosiderosis. We previously reported the use of hydroxyurea/phlebotomy as an alternative to CBT to reduce the risk of secondary stroke and improve management of iron overload (Ware et al. J Pediatr 2004). This study examines the caregiver and child experience with secondary stroke prevention. Individual semi-structured interviews were conducted with primary caregivers and children/adolescents (age > 5 years) recruited from the Duke Pediatric Sickle Cell Program. The interviewer (E.P.) asked about perceptions of risk of recurrent stroke and iron overload with and without therapy and facilitators and barriers of therapy. Interviews were coded and analyzed independently by two investigators (E.P and C.T.). The sample included 14 youth (10 males) with a median age of 12.5 years (range 3–17). All primary caregivers were female. Twelve children had a history of overt stroke and 2 had a history of silent stroke. All children had experience with CBT and 9 were receiving CBT at the time of the interview. Eleven children had experience taking hydroxyurea and 5 were taking hydroxyurea at the time of the interview. All caregivers agreed that their child was at risk of recurrent stroke, identified benefit of current treatment and reported high motivation to adhere to treatment protocols. They noted significant impact that stroke had on school functioning, attention, personality, participation in sports and overall quality of life. Caregiver-reported barriers to CBT and hydroxyurea fell into three main categories: (1) missed work and school and related consequences; (2) unexpected resource-related challenges; and (3) inconvenience of clinic appointments, all of which contributed to burden on the family and sometimes missed clinic appointments and treatments. There were higher levels of concern expressed by caregivers of children on CBT related to the higher frequency and longer length of medical appointments compared with those taking hydroxyurea. The primary child-reported barrier was dislike of needles or shots (although this decreased with age as expected); those taking hydroxyurea also noted that they sometimes forgot to take the medication if they were busy with other activities or fell asleep. Caregiver-reported facilitators of CBT and hydroxyurea included: (1) understanding importance of stroke prevention and connection to consistent treatment; (2) ancillary benefits of treatments in addition to stroke prevention; (3) link between treatment and long-term benefits. Caregivers were able to overcome treatment barriers via the following: (1) logistical supports including appointment and medication reminders; (2) shared responsibility with other family members including the child; (3) trust in medical staff; and (4) faith. Although children disliked needles and shots, many enjoyed the clinic visits due to fun activities in the clinic setting and rewards. In addition, iron overload was a significant concern for caregivers. For those with children on CBT, knowledge of the risks of iron overload motivated adherence with oral iron chelation. Automatic refills facilitated adherence with chelation therapy, but the taste of the medication was a major barrier to adequate iron chelation. Caregivers of children taking hydroxyurea noted the benefit of avoiding iron overload. Of those who had undergone phlebotomy, in-home phlebotomy was noted as a facilitator, though requirement for IV contributed to negative perception. In summary, as clinicians review options for secondary stroke prevention with families, they should discuss family perceptions and individual barriers and facilitators which may impact adherence with therapy and long-term outcome. Future research should also investigate whether these family perceptions predict actual adherence to protocols and treatment outcomes. Disclosures: Off Label Use: Hydroxyurea for secondary stroke prevention in sickle cell disease.

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Stroke with Transfusions Changing to Hydroxyurea (SWiTCH): A Phase 3 Randomized Clinical Trial for Treatment of Children with Sickle Cell Anemia, Previous Stroke, and Iron Overload

Blood ◽

10.1182/blood.v116.21.844.844 ◽

2010 ◽

Vol 116 (21) ◽

pp. 844-844 ◽

Cited By ~ 2

Author(s):

Russell E. Ware ◽

Ronald W Helms

Keyword(s):

Clinical Trial ◽

Iron Overload ◽

Recurrence Rate ◽

Sickle Cell ◽

Sickle Cell Anemia ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Secondary Stroke Prevention ◽

Study Enrollment

Abstract Abstract 844 Stroke occurs in 5–10% of children with sickle cell anemia (SCA) and has a very high (50-90%) risk of recurrence without therapy. Chronic monthly erythrocyte transfusions are administered to prevent recurrent stroke, but their long term use is limited by incomplete protection and serious side effects, including alloimmunization and iron overload. An alternative to transfusion for secondary stroke prevention in SCA is needed, ideally one that also improves the management of transfusional iron overload. Stroke With Transfusions Changing to Hydroxyurea (SWiTCH) was an NHLBI-sponsored Phase III multicenter randomized controlled clinical trial for children with SCA, stroke, and iron overload (NCT00122980). The primary goal of SWiTCH was to compare 30 months of alternative therapy (hydroxyurea and phlebotomy) with standard therapy (transfusions and chelation) for the prevention of secondary stroke and reduction of transfusional iron overload. SWiTCH had several distinctive study features with novel methodological and design components, including a composite primary endpoint containing both stroke recurrence rate and iron burden, a transfusion overlap period in the alternative arm to reduce the risk of recurrent stroke until a stable hydroxyurea dose was reached, and an inclusive independent stroke adjudication process for all suspected new neurological events. An increased number of recurrent stroke events were predicted to occur in the alternative arm compared to the standard arm, but this risk would be balanced by improved management of transfusional iron burden by repeated phlebotomy. A total of 161 pediatric subjects (83 male, 78 female) with SCA, documented stroke, and iron overload were enrolled in SWiTCH between October 2006 and April 2009; after screening 133 were randomized and received study treatment (67 participants in the alternative arm, 66 in the standard arm). The average age at enrollment was 12.9 ± 4.0 years with an average of 7.0 ± 3.7 years of chronic transfusions for secondary stroke prevention; 12% had already suffered a recurrent stroke before study enrollment. The average baseline liver iron concentration (LIC) by biopsy was 15.5 ± 10.1 mg Fe per gm dry weight liver and most subjects were receiving oral chelation treatment at the time of study enrollment. At study enrollment, 28% of subjects had previously known RBC alloantibodies (most within the CDE-Kell antigen systems) and 16% had previous RBC autoantibody formation. Baseline laboratory and clinical parameters were well-balanced between treatment arms, although a higher number of subjects with moya-moya were randomized to hydroxyurea/phlebotomy. A scheduled interim data analysis was performed after 1/3 of the subjects had completed all exit studies. This analysis (which occurred with ∼80% of all patient-years of study treatment completed) concluded that the LIC was not statistically different between the two treatment arms so no increased stroke risk was justified. Accordingly, following review by the Data and Safety Monitoring Board, the NHLBI terminated the SWiTCH trial in May 2010; at that time, the on-study stroke recurrence rate was 7 of 67 participants in the alternative arm compared to 0 of 66 participants in the standard arm. At the completion of all study treatment, the recurrent stroke events remained at 7 versus 0 (alternative versus standard arm), while TIA events occurred in 6 and 9 subjects respectively, and deaths were equivalent (1 and 1, both unrelated to treatment). SWiTCH primary and secondary endpoint analyses are currently in progress and details of the study results will be presented. Disclosures: Off Label Use: Hydroxyurea is used to reduce complications of sickle cell anemia.

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Transfusional iron overload in children with sickle cell anemia on chronic transfusion therapy for secondary stroke prevention

American Journal of Hematology ◽

10.1002/ajh.22228 ◽

2011 ◽

Vol 87 (2) ◽

pp. 221-223 ◽

Cited By ~ 14

Author(s):

Janet L. Kwiatkowski ◽

Alan R. Cohen ◽

Julian Garro ◽

Ofelia Alvarez ◽

Ramamorrthy Nagasubramanian ◽

...

Keyword(s):

Iron Overload ◽

Sickle Cell ◽

Sickle Cell Anemia ◽

Stroke Prevention ◽

Secondary Stroke Prevention ◽

Transfusion Therapy

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Therapeutic Phlebotomy in Children with Sickle Cell Anemia, Stroke, and Iron Overload: The SWiTCH Experience

Blood ◽

10.1182/blood.v118.21.1044.1044 ◽

2011 ◽

Vol 118 (21) ◽

pp. 1044-1044 ◽

Cited By ~ 1

Author(s):

Banu Aygun ◽

Nicole A Mortier ◽

Karen Kesler ◽

Willliam H Schultz ◽

Ofelia A. Alvarez ◽

...

Keyword(s):

Adverse Events ◽

Iron Overload ◽

Sickle Cell ◽

Sickle Cell Anemia ◽

Recurrent Stroke ◽

Venous Access ◽

Study Entry ◽

Liver Iron ◽

History Of ◽

The Mean

Abstract Abstract 1044 Background: Stroke With Transfusions Changing to Hydroxyurea (SWiTCH Clinical Trials.gov NCT00122980), an NHLBI-sponsored Phase III multicenter trial, compared chronic blood transfusions/chelation to hydroxyurea/phlebotomy for the reduction of recurrent stroke and improvement in iron overload management in children with sickle cell anemia (SCA) and history of overt stroke. To date, however, phlebotomy to manage iron overload has not been commonly performed in children, especially those with SCA. Objective: To describe the experience with SWiTCH phlebotomy procedures, including success rate, associated adverse events, and effect on liver iron stores. Methods: Quantitative liver iron concentration (LIC) was measured by liver biopsy at study entry. Only subjects with LIC > 5 mg Fe/gram dry weight liver (DWL) were eligible for randomization. Those randomized to hydroxyurea/phlebotomy received decreasing volumes of monthly transfusion during hydroxyurea dose escalation, which lasted 4–9 months. Phlebotomy was performed every 4±1 weeks after discontinuation of transfusions. The prescribed phlebotomy volume was 10 mL/kg (maximum 500 mL) for Hb ≥ 8.0 gm/dL, and 5 mL/kg for Hb 7.0–7.9 gm/dL. Phlebotomy was held if Hb was <7.0 gm/dL. Phlebotomy was performed over 30 minutes with immediate normal saline replacement, typically using peripheral venous access. Exit LIC by liver biopsy was obtained in those completing 30 months of therapy. Ferritin was monitored monthly in all subjects using a centralized laboratory. Results: Sixty-seven children (mean age 13.0 ± 4.0 years; range 5.2–19.0 years) with history of previous stroke and transfusion therapy for an average of 7.4 ± 3.8 years (range 1.5–15.5 years) were randomized to the hydroxyurea/phlebotomy arm. Most of them had also received chelation therapy: 47 (71%) with deferoxamine for an average of 4.8 ± 3.2 years, and 57 (86%) with deferasirox for 1.5 ± 0.8 years prior to study entry. Their average entry LIC was 16.5 ± 9.4 mg/gram DWL. Sixty of 67 children (90%) successfully transitioned to hydroxyurea after 7.2 ± 2.4 months of transfusion overlap; one subject had a stroke during overlap and six failed to demonstrate adequate response/compliance to hydroxyurea to safely discontinue transfusions. These 60 subjects received an average of 8 ± 3 transfusions providing 63 ± 44 mL/kg PRBCs before completing transition and commencing phlebotomy, and 3 ± 3 transfusions providing 19 ± 20 mL/kg PRBCs after starting phlebotomy, for various clinical indications. During the course of the study, a total of 935 phlebotomies were performed (mean 16 per subject) removing an average total volume of 127 ± 74 mL/kg per subject. The mean pre-phlebotomy Hb level on hydroxyurea (9.1 gm/dL) was not significantly different than the mean pre-transfusion Hb during the transfusion overlap period (9.0 gm/dL). Mean ferritin for these 60 subjects on the hydroxyurea/phlebotomy arm decreased from 3523 ± 2150 ng/mL at study entry to 2227 ± 1646 ng/mL (p<0.0001) at exit; and decreased in 50 of 60 subjects. For the 23 patients on the hydroxyurea/phlebotomy arm who completed 30 months of study treatment, the average LIC was unchanged (18.5 mg Fe/gram DWL at entry compared to 18.1 mg Fe/gram at exit, p=0.817). However, average ferritin level for these subjects was significantly lower at exit (4216 ± 2799 ng/mL vs 2356 ± 2032 ng/mL, respectively, p=0.0003). Of 968 protocol-directed phlebotomy procedures, 935 (97%) were performed; 94% of which were at full prescribed volume. Of the 33 phlebotomy procedures that were not performed, 11 were held due to Hb < 7.0 gm/dL and 9 due to poor venous access. There were only 33 grade 2 adverse events (3.5% prevalence) reported in 12 subjects and no serious adverse events. The most common complication was hypotension (9 events; 5 subjects) followed by dizziness, syncope, headache and weakness. Six subjects had a recurrent stroke but there was no temporal relationship to the phlebotomy procedures. Conclusions: Therapeutic phlebotomies were well-tolerated and did not result in worsening anemia or stroke recurrence in this cohort of children with SCA and previous stroke switched to hydroxyurea. Although ferritin levels decreased significantly, we did not demonstrate an overall decrease in LIC in this heavily iron overloaded cohort, most likely due to continued iron loading with transfusions in the overlap period and subsequent short duration of phlebotomy. Disclosures: Off Label Use: Use of hydroxyurea in children with sickle cell anemia.

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A Single Institution Study of Chronic Erythrocytapheresis for Secondary Stroke Prevention in Children and Young Adults with Sickle Cell Disease

Blood ◽

10.1182/blood.v120.21.4754.4754 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4754-4754

Author(s):

Nadia L Cheek ◽

Robert L Saylors ◽

Raghu Ramakrishnaiah ◽

Suzanne Saccente ◽

Xinyu Tang ◽

...

Keyword(s):

Sickle Cell Disease ◽

Iron Overload ◽

Sickle Cell ◽

Stroke Prevention ◽

Organ Damage ◽

Secondary Stroke Prevention ◽

Cell Disease ◽

End Organ Damage ◽

Children And Young Adults ◽

The Mean

Abstract Abstract 4754 Introduction: The current standard of care for secondary stroke prevention in children and young adults with sickle cell disease and cerebral infarction is chronic simple transfusion (ST). Published data indicate that at least 18% of patients treated with chronic ST will experience a second overt infarct and at least 28% will experience additional silent infarcts. Since 1996, we have used chronic erythrocytapheresis (RCE) instead of chronic ST in our hospital to treat all patients with either overt infarction or abnormal transcranial doppler (TCD) with silent infarction. Here we present clinical, radiographic, and laboratory data from this group of patients treated with chronic RCE for secondary stroke prevention. Methods: This was a retrospective study of all patients treated with chronic RCE for either overt infarction or for an abnormal TCD with silent infarction at Arkansas Children's Hospital from 1996 through 2011. We reviewed clinical records and serial MRI/MRA scans and determined the time to progression from the time of the initial diagnosis of an overt or silent infarct to the time of the second overt or silent infarct. Events were classified as overt infarcts if the MRI demonstrated acute cerebral ischemia, based on increased signal intensity on T2-weighted images and restricted diffusion on diffusion-weighted images, and abnormal neurologic findings correlated with the abnormalities identified on MRI. Events were classified as silent infarcts if the MRI demonstrated new lesions 3 mm or greater in a single dimension with increased signal intensity on T2-weighted images and there were no corresponding abnormal neurologic findings. We also studied the pre-procedure hemoglobin S concentration (%S), pre-procedure ferritin levels, volume of blood transfused per kilogram, necessity for chelation medication, and presence of end-organ damage. Results: We identified 24 patients, ranging in age from 2 to 18 years at the initiation of chronic RCE, who were treated with 2539 RCE procedures during the study period. These patients were treated with RCE every two to six weeks with the goal of maintaining their pre-RCE %S at less than 30%. Progressive cerebral infarcts occurred in 42% (10 of 24) of the patients while receiving chronic RCE (Figure 1): 3 were overt (13%) and 7 were silent (29%). There were no additional infarcts observed after patients had been on chronic RCE for greater than 5 years. Eight patients (33%) experienced increased vasculopathy and 3 patients (13%) had an improvement in vasculopathy while on therapy. The mean pre-procedure %S concentration was 29%. The mean pre-procedure ferritin was 1188 ng/ml but approximately 60% of the patients had ferritin levels under 1000 ng/ml and only three patients required chelation. Patients received a mean of 45.5 ml/kg of packed red blood cells per procedure. There was no evidence of end-organ damage secondary to iron overload. Discussion: We determined that children with sickle cell disease and cerebral infarction experience additional silent and overt strokes despite intensive treatment with chronic RCE. The proportion of patients developing new overt infarcts in our study (13%) was slightly lower than that in a recent multi-institution study (18%; Hulbert et al, Blood 117:772, 2011) but the proportion of patients developing new silent infarcts in our study (29%) was no different (28%). Although patients receiving RCE have increased blood product utilization as compared with patients receiving ST, only three patients required chelation medication and none experienced end-organ damage secondary to iron overload. We conclude that chronic RCE is no more effective than chronic ST for secondary stroke prevention, that chronic RCE prevents the iron overload and need for chelation that is common with chronic ST, and that other forms of therapy are needed to prevent the progressive accumulation of cerebral infarcts in these patients. Disclosures: No relevant conflicts of interest to declare.

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Effectiveness of a top up transfusion programme in preventing cerebrovascular damage in a birth cohort of sickle cell disease

The Physician ◽

10.38192/1.6.2.24 ◽

2020 ◽

Vol 6 (2) ◽

pp. 1-8

Author(s):

Nadia Ibrahim ◽

Sabah Mahmood ◽

Sandra O'Driscoll ◽

Subarna Chakravorty

Keyword(s):

Sickle Cell Disease ◽

Iron Overload ◽

Sickle Cell ◽

Stroke Prevention ◽

Cerebrovascular Event ◽

Secondary Stroke Prevention ◽

Cell Disease ◽

Hepatic Iron Overload ◽

Significant Burden ◽

Haemoglobin S

Regular transfusions are effective in managing strokes in paediatric sickle cell patients. However, there are associated risks, including alloimmunisation and iron overload. This study evaluated the efficacy of top-up transfusions in primary and secondary stroke prevention in a single tertiary paediatric centre in Central London. Forty-seven children with sickle cell disease who received transfusions in the last decade were included. No patient on a primary stroke prevention transfusion programme had a cerebrovascular event during the study period but 9.5% on secondary stroke prevention programme did. Twenty-one per cent of patients in this cohort converted to exchange transfusions following transfer to adult services, of which 11% had subsequent strokes. Targeted pre-transfusion haemoglobin S % was not always met; 43% of HbS% readings in a 12- month period were above the set target of 30% and 37% were above the set target of 50%. About a third of patients had evidence of severe hepatic iron overload, but no significant cardiac iron. 25% of patients became alloimmunised, but not severe enough to warrant discontinuation of the transfusion programme. Although transfusions are effective for primary stroke prevention, iron overload remains a significant burden.

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Chronic Manual Exchange Transfusions Compared with Erythrocytapheresis in Children and Teens with Sickle Cell Disease

Blood ◽

10.1182/blood.v124.21.4927.4927 ◽

2014 ◽

Vol 124 (21) ◽

pp. 4927-4927

Author(s):

Debbie Woods ◽

Robert J. Hayashi ◽

Melanie E. Fields ◽

Monica L. Hulbert

Keyword(s):

Sickle Cell Disease ◽

Iron Overload ◽

Sickle Cell ◽

Stroke Prevention ◽

Secondary Stroke Prevention ◽

Cell Disease ◽

Double Lumen ◽

Transfusion Therapy ◽

Catheter Complications ◽

Hb S

Abstract Background: Children and young adults with sickle cell disease (SCD) are at high risk of strokes and are frequently treated with red blood cell (RBC) transfusions. RBCs may be given by simple transfusion, manual exchange transfusion (ME), or erythrocytapheresis (ECP) with a goal of suppressing hemoglobin (Hb) S while minimizing transfusion-induced iron overload. There have been no formal comparisons of these modalities, and practices for transfusion management vary among institutions. We compared transfusion therapy outcomes among patients with SCD undergoing transfusion therapy for primary or secondary stroke prevention, hypothesizing that children would be more likely to achieve Hb S suppression and ferritin goals while receiving ECP. We also compared complications of transfusion therapy across transfusion modalities. Methods: This is a single-institution retrospective cohort study of 38 patients with SCD who received chronic transfusion therapy for primary or secondary stroke prevention from 1/1/2008 through 12/31/2012. Per institutional practice, younger patients receive ME for stroke prevention; they are offered ECP when their size is adequate for a large-bore double-lumen implantable port, but may choose to continue ME. The pre-transfusion Hb S goal is <30% for at least 2 years, then may be liberalized to <50% for subjects without either abnormal transcranial Doppler ultrasound or infarct recurrence. Hb S percentage and ferritin were measured prior to each transfusion. Patients on transfusion therapy for 6 or more months were included; one child who had a stroke after brain tumor biopsy was excluded. Subjects were censored at last date of follow-up or date of hematopoietic stem cell transplant. The following factors were evaluated: duration and mode of transfusion therapy, achievement of Hb S suppression goal, ferritin levels, and catheter complications. Categorical variables were compared with Fisher’s exact test and medians with the Mann-Whitney U-test in SPSS version 21 (IBM, Armonk, NY). Results: During the study period, 38 subjects (42% male) met all inclusion criteria. Of these, 5 received exclusively ECP, 17 received exclusively ME, and 16 received both modalities during the study period. For the most recent 12-month period of data for each participant, 13 received ECP and 25 received ME. There was no association between modality of transfusion and the proportion of visits during which subjects achieved their pre-transfusion Hb S goal during the 12-month period. The median proportion of visits achieving the Hb S goal was 0.80 for ECP (IQR 0.40-1.0) versus 0.50 for ME (IQR 0.28-0.90) (p=0.27). Furthermore, there was no significant difference in ferritin concentrations between transfusion modalities: median 875 ng/ml for ECP (IQR 578-2659) versus median 1527 ng/ml for ME (IQR 731-2568) (p=0.56). Children who had ever received ECP had a significantly longer total duration of transfusion therapy (median 97 months, IQR 51.5-134) than those receiving ME only (median 28 months, IQR 12.5-47) (p<0.001). Among 21 subjects who had ever received ECP, 15 (71.4%) experienced one or more catheter complications, including infection, thrombosis, catheter leakage, or venous stenosis, compared with 1/17 subjects (5.8%) who had never received ECP (OR for catheter complications 40 for subjects who had ever received ECP, 95% CI 4.29, 372.4, p <0.001). Five subjects switched from ECP to ME due to stenosis of the great vessels that precluded double-lumen port replacement. Conclusions: Children with SCD receiving ECP and ME for stroke prevention in this cohort had similar achievement of Hb S suppression goals and iron overload management. Additional patient-specific factors may be responsible for variations in pre-transfusion Hb S and ferritin concentrations. Catheter complications were significantly more common in children and adolescents receiving ECP compared with ME, likely due to the large-bore double-lumen port utilized for ECP at our center. Disclosures No relevant conflicts of interest to declare.

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Abstract P252: Discharge Antithrombotic Therapy for Ischemic Stroke Patients With Prior Aspirin Failure

Stroke ◽

10.1161/str.52.suppl_1.p252 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ying Xian ◽

Haolin Xu ◽

Deepak L Bhatt ◽

Gregg C Fonarow ◽

Eric E Smith ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Prevention ◽

Antithrombotic Therapy ◽

Recurrent Stroke ◽

Oral Anticoagulants ◽

The United States ◽

Future Research ◽

Large Artery ◽

Secondary Stroke Prevention ◽

Stroke Registry

Introduction: Aspirin is one of the most commonly used medications for cardiovascular disease and stroke prevention. Many older patients who present with a first or recurrent stroke are already on aspirin monotherapy, yet little evidence is available to guide antithrombotic strategies for these patients. Method: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we described discharge antithrombotic treatment pattern among Medicare beneficiaries without atrial fibrillation who were discharged alive for acute ischemic stroke from 1734 hospitals in the United States between October 2012 and December 2017. Results: Of 261,634 ischemic stroke survivors, 100,016 (38.2%) were on prior aspirin monotherapy (median age 78 years; 53% women; 79.4% initial stroke and 20.6% recurrent stroke). The most common discharge antithrombotics (Figure) were 81 mg aspirin monotherapy (20.9%), 325 mg aspirin monotherapy (18.2%), clopidogrel monotherapy (17.8%), and dual antiplatelet therapy (DAPT) of 81 mg aspirin and clopidogrel (17.1%). Combined, aspirin monotherapy, clopidogrel monotherapy, and DAPT accounted for 86.8% of discharge antithrombotics. The rest of 13.2% were discharged on either aspirin/dipyridamole, warfarin or non-vitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotics at all. Among patients with documented stroke etiology (TOAST criteria), 81 mg aspirin monotherapy (21.2-24.0%) was the most commonly prescribed antithrombotic for secondary stroke prevention. The only exception was those with large-artery atherosclerosis, in which, 25.3% received DAPT of 81 mg aspirin and clopidogrel at discharge. Conclusion: Substantial variations exist in discharge antithrombotic therapy for secondary stroke prevention in ischemic stroke with prior aspirin failure. Future research is needed to identify best management strategies to care for this complex but common clinical scenario.

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Physical activity in secondary stroke prevention

Swiss Sports & Exercise Medicine ◽

10.34045/ssem/2019/33 ◽

2019 ◽

Vol 67 (4) ◽

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Activities Of Daily Living ◽

Brain Function ◽

Stroke Prevention ◽

Daily Living ◽

Recurrent Stroke ◽

Treatment Strategies ◽

Secondary Stroke Prevention

After having a stroke the main challenges are reducing the risk of recurrent stroke, improving impaired brain function, quality of life, independence in activities of daily living and reintegration into the community. [1] Lesion-induced impairment of brain function also has, besides its effects on e.g. motor, sensory, visual and speech function, an influence on e.g. cognition and mood, all of which are determinants of post-stroke physical activity. The evidence for a benefit of physical activity in secondary stroke prevention is increasing and treatment strategies aimed at factors which are limiting physical activity are more and more recognized.

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Abstract 77: Intensity of Blood Pressure Reduction and Secondary Stroke Prevention: A Systematic Review and Meta-regression Analysis of Randomized Clinical Trials

Stroke ◽

10.1161/str.48.suppl_1.77 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Georgios Tsivgoulis ◽

Aristeidis H Katsanos ◽

Angeliki Filippatou ◽

Efstathios Manios ◽

Spyridon Deftereos ◽

...

Keyword(s):

Systematic Review ◽

Stroke Prevention ◽

Lower Risk ◽

Antihypertensive Treatment ◽

Recurrent Stroke ◽

Cardiovascular Death ◽

Secondary Stroke Prevention ◽

Regression Analyses ◽

Meta Regression ◽

Meta Regression Analysis

Background & Purpose: Current recommendations do not specifically address the optimal blood pressure (BP) cut-off for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and meta-regression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized-controlled clinical trials (RCTs) of secondary stroke prevention. Methods: For all reported events during each eligible study period we calculated the corresponding risk ratios (RRs) to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. Based on the reported BP values, we performed univariate meta-regression analyses according to achieved BP values under the random-effects model (Method of Moments) for those outcome events reported in ≥10 total subgroups of included RCTs. Results: In pairwise meta-analyses of 14 RCTs comprising 42,736 patients antihypertensive treatment lowered the risk for recurrent stroke (RR=0.73, 95%CI: 0.62-0.87, p<0.001), disabling or fatal stroke (RR=0.71, 95%CI: 0.59-0.85, p<0.001) and cardiovascular death (RR=0.85, 95%CI: 0.75-0.96, p=0.010). In meta-regression analyses systolic BP reduction was linearly related to lower risk of recurrent stroke (p=0.049; Figure A), myocardial infarction (p=0.024), death from any cause (p=0.001) and cardiovascular death (p<0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke (p=0.026; Figure B) and all-cause mortality (p=0.009). Funnel plot inspection and Egger’s statistical test revealed no evidence of publication bias. Conclusion: The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebro- and cardio-vascular events. Strict and aggressive BP control appears to be essential for effective secondary stroke prevention.

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