Appropriate secondary prevention of stroke and transient ischaemic attack with antithrombotics: an audit in general practice

2020 ◽  
Vol 70 (suppl 1) ◽  
pp. bjgp20X711641
Author(s):  
Isabelle Williams ◽  
William Smith ◽  
Edward Nash ◽  
Ajay Patel
Keyword(s):  
Secondary Prevention ◽  
Transient Ischaemic Attack ◽  
Antithrombotic Therapy ◽  
Current Practice ◽  
Bleeding Risk ◽  
Haemorrhagic Stroke ◽  
Patient Records ◽  
Risk Of Bleeding ◽  
The Past ◽  
Ischaemic Attack

BackgroundStroke is a major cause of death and disability worldwide. Major advances have occurred in secondary prevention of stroke/transient ischaemic attack (TIA) during the past three decades. Primary care is a critical point of contact with patients in the implementation of secondary prevention, with the majority of patients with past stroke/TIA being managed in the community.AimTo assess current practice at the New Queen Street and Stanground Surgeries, Peterborough, in reference to the National Institute for Health and Care Excellence guidelines on secondary prevention of stroke/TIA.MethodAn audit at the above practices was undertaken by searching the SystmOne computer system for adult patients with previous stroke/TIA (311), excluding those with haemorrhagic stroke and those on aspirin. The patient records of the remaining group (37) were investigated to find whether they were on appropriate antithrombotic therapy and, if not, why.ResultsOf post-stroke/TIA patients, 234/236 were receiving antithrombotic therapy unless contraindicated. For those not on antithrombotics, risk of bleeding was the reason given in 10/13 of cases, though many of these patients did not have active bleeding (exact number unclear due to poor documentation). In 2/13 cases there was no documented reason given and informed dissent in one of the 13 cases.ConclusionIt was found that both practices implemented the guidelines to a satisfactory degree. However, to further improve secondary prevention outreach, bleeding risk should be assessed using a tool such as S2TOP-BLEED before withholding antithrombotic therapy, as, on balance, antithrombotic therapy may still be preferable. In addition, accurate and detailed documentation of the indications/contraindications to anticoagulation is paramount for such assessment.

Complex antithrombotic therapy and bleeding risk in patients with peripheral arterial disease

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Tseng ◽  
S Bhatt ◽  
M Girardo ◽  
D Liedl ◽  
P Wennberg ◽  
...  
Keyword(s):  
Peripheral Arterial Disease ◽  
Triple Therapy ◽  
Major Bleeding ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Arterial Disease ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Peripheral Arterial

Abstract Introduction Antiplatelet therapy is the cornerstone of treatment for many atherosclerotic vascular pathologies including peripheral arterial disease (PAD). Patients with PAD often have comorbid conditions that require complex antithrombotic therapy, i.e. combined antiplatelet and anticoagulation. Methods All adult patients undergoing ankle brachial index (ABI) measurements were included in the study. ABI values between 1.00 and 1.40 were considered normal, and values below 1.00 or above 1.40 were considered PAD. Demographic, comorbidity and outcome data were obtained using diagnostic codes from the electronic health record. Three medication classes were analyzed: aspirin, non-aspirin oral antiplatelets (e.g. P2Y12 inhibitors) and oral anticoagulants (warfarin and the direct oral anticoagulants). Medication use was determined for patients who had been on a medication for at least one year. Cox proportional hazard analysis for the time to first bleeding event was analyzed. Bleeding was defined as any bleeding requiring medical evaluation (including clinically-relevant non-major bleeding and major bleeding). Results In all, 40,144 patients were included in the analysis (mean age 66±15, 43% female). Patients with PAD were more likely to be on double therapy (one antiplatelet with anticoagulation) (28% vs 19%) and triple therapy (dual antiplatelet with anticoagulation) (10% vs 4%). Unadjusted hazard ratios for bleeding risk showed increased risk of bleeding for patients with PAD (1.18, 95% confidence interval [CI]: 1.08–1.29), though the association is no longer present after adjustment for antithrombotic therapy. Adjusting for age, sex and PAD class, compared to no antithrombotic therapy, there was increased risk of bleeding for monotherapy (1.91, 95% CI: 1.61–2.26), double therapy (3.40, 95% CI: 2.89–4.00) and triple therapy (5.00, 95% CI: 4.21–5.96). Among medications, aspirin and anticoagulant use was independently associated with the greatest increase in risk of bleeding. Conclusion Patients in PAD are at increased risk of bleeding secondary to antithrombotic therapy. Complex antithrombotic therapy with double or triple therapy confer additional bleeding risk, particularly regimens containing aspirin and oral anticoagulants. Funding Acknowledgement Type of funding source: None

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

2021 ◽  
pp. svn-2020-000471
Author(s):  
Lei Zhang ◽  
Junfeng Shi ◽  
Yuesong Pan ◽  
Zixiao Li ◽  
Hongyi Yan ◽  
...  
Keyword(s):  
Secondary Prevention ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Transient Ischaemic Attack ◽  
Recurrent Stroke ◽  
Medication Persistence ◽  
Level Ii ◽  
Composite Events ◽  
Ischaemic Attack ◽  
Level I

IntroductionThe 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.MethodsPatients 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.Results18 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).ConclusionsPersistence 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.

scholarly journals Usability and Acceptability of a Novel Secondary Prevention Initiative Targeting Physical Activity for Individuals after a Transient Ischaemic Attack or “Minor” Stroke: A Qualitative Study

2020 ◽  
Vol 17 (23) ◽  
pp. 8788
Author(s):  
Neil Heron ◽  
Sean R. O’Connor ◽  
Frank Kee ◽  
Jonathan Mant ◽  
Margaret E. Cupples ◽  
...  
Keyword(s):  
Physical Activity ◽  
Secondary Prevention ◽  
Transient Ischaemic Attack ◽  
Recurrence Risk ◽  
Relevant Information ◽  
Minor Stroke ◽  
Group Discussions ◽  
Self Evaluation ◽  
Ischaemic Attack ◽  
Optimal Approach

Behavioural interventions that address cardiovascular risk factors such as physical inactivity and hypertension help reduce recurrence risk following a transient ischaemic attack (TIA) or “minor” stroke, but an optimal approach for providing secondary prevention is unclear. After developing an initial draft of an innovative manual for patients, aiming to promote secondary prevention following TIA or minor stroke, we aimed to explore views about its usability and acceptability amongst relevant stakeholders. We held three focus group discussions with 18 participants (people who had experienced a TIA or minor stroke (4), carers (1), health professionals (9), and researchers (4). Reflexive thematic analysis identified the following three inter-related themes: (1) relevant information and content, (2) accessibility of format and helpful structure, and (3) strategies to optimise use and implementation in practice. Information about stroke, medication, diet, physical activity, and fatigue symptoms was valued. Easily accessed advice and practical tips were considered to provide support and reassurance and promote self-evaluation of lifestyle behaviours. Suggested refinements of the manual’s design highlighted the importance of simplifying information and providing reassurance for patients early after a TIA or minor stroke. Information about fatigue, physical activity, and supporting goal setting was viewed as a key component of this novel secondary prevention initiative.

Abstract 14763: Patients With a Perceived High-bleeding Risk in a Randomized Controlled Trial of Alert-based Computerized Decision Support for Stroke Prevention in Atrial Fibrillation: An Af-Alert Substudy

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Gregory Piazza ◽  
Shelley Hurwitz ◽  
Brett Carroll ◽  
Samuel Z Goldhaber
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Stroke Prevention ◽  
Antithrombotic Therapy ◽  
Controlled Trial ◽  
Bleeding Risk ◽  
Computerized Decision Support ◽  
Risk Of Bleeding ◽  
Randomized Controlled ◽  
Risk For Bleeding

Introduction: A perceived increased risk of bleeding is one of the most frequent reasons for failure to prescribe anticoagulation for stroke prevention in atrial fibrillation (AF). We previously conducted a randomized controlled trial of alert-based computerized decision support (CDS) to increase prescription of antithrombotic therapy in 458 high-risk hospitalized patients with AF who were not being anticoagulated. Hypothesis: We hypothesized that patients with a perceived high risk for bleeding would have a similar HAS-BLED score and rate of major and clinically-relevant non-major bleeding. Methods: To determine the clinical characteristics and outcomes of these patients determined to be high-risk for bleeding, we analyzed the 248 patients in the alert group. Results: A perceived high risk of bleeding was the most common reason (77%) for omitting antithrombotic therapy. Median HAS-BLED scores were similar in these patients compared with those who were not deemed to have an increased bleeding risk (3 vs. 3, p=0.44). Despite being categorized as too high-risk for bleeding to receive antithrombotic therapy for stroke prevention at the time of the alert, nearly 12% of these patients were ultimately prescribed anticoagulation over the ensuing 90 days. The frequency of major and clinically-relevant non-major bleeding was similar between the two groups. Conclusions: In conclusion, a perceived high risk of bleeding was the most common reason for failure to prescribe antithrombotic therapy after the CDS alert. History of a prior bleeding event or underlying bleeding disorder was not reflected in a higher HAS-BLED score. Implementation of an alert-based CDS with specific attention to assessment of bleeding risk and mitigation warrants further study to encourage adherence to evidence-based clinical practice guideline recommendations for stroke prevention in AF.

Abstract P208: Transient Ischaemic Attack: How the Patient Perceives it

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
Mary J MacLeod ◽  
Ali Abdullah
Keyword(s):  
Secondary Prevention ◽  
Transient Ischaemic Attack ◽  
Patient Adherence ◽  
Behavioural Change ◽  
Illness Perception ◽  
Personal Control ◽  
Self Report ◽  
Minor Stroke ◽  
Medical Attention ◽  
Ischaemic Attack

Background: The risk of stroke after Transient Ischaemic Attack (TIA) is 8-11 % within a month. Rapid assessment and early use of preventative therapies can reduce this risk by 80-90%. Many patients do not seek timely medical attention, and may minimise their symptoms. The purpose of this study was to assess patients' perception of the significance of TIA/ minor stroke, and their beliefs and attitudes to secondary prevention interventions. Methods: 120 patients with a recent TIA/minor stroke were given a questionnaire after clinic/ward review. This included the validated Brief Illness Perception Questionnaire (Brief-IPQ: scores 0-10), and Beliefs about Medicines Questionnaire (BMQ: scores 5-25). Patient adherence to secondary prevention medications was assessed by self-report. Results: There was a 56% return rate. Within the brief-IPQ, patients had a mid score for perceived consequences of their event (4.88 (sd2.67)). Only 22% took urgent action at the time of the event. 60% were persuaded to take action by family or friends. Patients scored the midpoint for emotional distress (4.9 (sd 3.4)) and felt they could not exert personal control (4.0(3.2)). They did believed treatment would control their condition (7.7(2.1)). The majority of patients (86.3%) believed in the necessity of medication, with mean necessity score of 18.36(3.5). 14% reported concerns about becoming dependent upon medications and the potential adverse consequences of taking medication. 78% of patients said they complied with their treatment. Conclusions: Patients may not regard TIA or minor stroke as having important implications for their future health. Many only seek medical advice as a result of external pressure. Patients do not feel they have personal control over the condition, but believe medication is necessary and beneficial. These findings will inform strategies for education and behavioural change interventions in people at risk of or who have had a TIA/minor stroke

scholarly journals Rehabilitation of patients after transient ischaemic attack or minor stroke: pilot feasibility randomised trial of a home-based prevention programme

2019 ◽  
Vol 69 (687) ◽  
pp. e706-e714 ◽  
Author(s):  
Neil Heron ◽  
Frank Kee ◽  
Jonathan Mant ◽  
Margaret E Cupples ◽  
Michael Donnelly
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Secondary Prevention ◽  
Cardiovascular Risk Factors ◽  
Transient Ischaemic Attack ◽  
Standard Care ◽  
Minor Stroke ◽  
Home Based ◽  
Ischaemic Attack

BackgroundAlthough the importance of secondary prevention after transient ischaemic attack (TIA) or minor stroke is recognised, research is sparse regarding novel, effective ways in which to intervene in a primary care context.AimTo pilot a randomised controlled trial (RCT) of a novel home-based prevention programme (The Healthy Brain Rehabilitation Manual) for patients with TIA or ‘minor’ stroke.Design and settingPilot RCT, home-based, undertaken in Northern Ireland between May 2017 and March 2018.MethodPatients within 4 weeks of a first TIA or ‘minor’ stroke received study information from clinicians in four hospitals. Participants were randomly allocated to one of three groups: standard care (control group) (n = 12); standard care with manual and GP follow-up (n = 14); or standard care with manual and stroke nurse follow-up (n = 14). Patients in all groups received telephone follow-up at 1, 4, and 9 weeks. Eligibility, recruitment, and retention were assessed; stroke/cardiovascular risk factors measured at baseline and 12 weeks; and participants’ views were elicited about the study via focus groups.ResultsOver a 32-week period, 28.2% of clinic attendees (125/443) were eligible; 35.2% of whom (44/125) consented to research contact; 90.9% of these patients (40/44) participated, of whom 97.5% (39/40) completed the study. After 12 weeks, stroke risk factors [cardiovascular risk factors, including blood pressure and measures of physical activity] improved in both intervention groups. The research methods and the programme were acceptable to patients and health professionals, who commented that the programme ‘filled a gap’ in current post-TIA management.ConclusionFindings indicate that implementation of this novel cardiac rehabilitation programme, and of a trial to evaluate its effectiveness, is feasible, with potential for clinically important benefits and improved secondary prevention after TIA or ‘minor’ stroke.

scholarly journals Prevention of stroke in patients with chronic coronary syndromes or peripheral arterial disease

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M26-M34
Author(s):  
William A E Parker ◽  
Diana A Gorog ◽  
Tobias Geisler ◽  
Gemma Vilahur ◽  
Dirk Sibbing ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Stroke Risk ◽  
Density Lipoprotein ◽  
Bleeding Risk ◽  
Haemorrhagic Stroke ◽  
Major Adverse Cardiovascular Events ◽  
Full Dose ◽  
Increased Risk ◽  
Coronary Syndromes

Abstract Stroke is a common and devastating condition caused by atherothrombosis, thromboembolism, or haemorrhage. Patients with chronic coronary syndromes (CCS) or peripheral artery disease (PAD) are at increased risk of stroke because of shared pathophysiological mechanisms and risk-factor profiles. A range of pharmacological and non-pharmacological strategies can help to reduce stroke risk in these groups. Antithrombotic therapy reduces the risk of major adverse cardiovascular events, including ischaemic stroke, but increases the incidence of haemorrhagic stroke. Nevertheless, the net clinical benefits mean antithrombotic therapy is recommended in those with CCS or symptomatic PAD. Whilst single antiplatelet therapy is recommended as chronic treatment, dual antiplatelet therapy should be considered for those with CCS with prior myocardial infarction at high ischaemic but low bleeding risk. Similarly, dual antithrombotic therapy with aspirin and very-low-dose rivaroxaban is an alternative in CCS, as well as in symptomatic PAD. Full-dose anticoagulation should always be considered in those with CCS/PAD and atrial fibrillation. Unless ischaemic risk is particularly high, antiplatelet therapy should not generally be added to full-dose anticoagulation. Optimization of blood pressure, low-density lipoprotein levels, glycaemic control, and lifestyle characteristics may also reduce stroke risk. Overall, a multifaceted approach is essential to best prevent stroke in patients with CCS/PAD.

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