Abstract
People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Evidence-based strategies for secondary stroke prevention have been established. However, the implementation of prevention strategies could be improved. To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events. We searched the Cochrane Stroke Group Trials Register (April 2013), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013), CENTRAL (The Cochrane Library 2013, issue 3), MEDLINE (1950 to April 2013), EMBASE (1981 to April 2013) and 10 additional databases. We located further studies by searching reference lists of articles and contacting authors of included studies. We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention. Two review authors selected studies for inclusion and independently extracted data. One review author assessed the risk of bias for the included studies. We sought missing data from trialists. This review included 26 studies involving 8021 participants. Overall the studies were of reasonable quality, but one study was considered at high risk of bias. Fifteen studies evaluated predominantly organisational interventions and 11 studies evaluated educational and behavioural interventions for patients. Results were pooled where appropriate, although some clinical and methodological heterogeneity was present. The estimated effects of organisational interventions were compatible with improvements and no differences in the modifiable risk factors mean systolic blood pressure (mean difference (MD) -2.57 mmHg; 95% confidence interval (CI) -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68), blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64) and mean body mass index (MD -0.68 kg/m(2); 95% CI -1.46 to 0.11). There were no significant effects of organisational interventions on lipid profile, HbA1c, medication adherence or recurrent cardiovascular events. Educational and behavioural interventions were not generally associated with clear differences in any of the review outcomes, with only two exceptions. Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes. The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors. We identified a large number of ongoing studies, suggesting that research in this area is increasing. The use of standardised outcome measures would facilitate the synthesis of future research findings.
Highlights
People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events
We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors or reduce the incidence of recurrent cardiovascular events
People who experience a stroke or TIA are at risk of future stroke
Summary
People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Transient ischaemic attack (TIA) is an expression used traditionally to describe comparable neurological deficits lasting for fewer than 24 hours (Albers 2002). Secondary prevention strategies aim to prevent recurrent events by improving modifiable risk factor control. National stroke guidelines identify clinical conditions (hypertension, hyperlipidaemia, atrial fibrillation, diabetes, and obesity) and lifestyle factors (smoking, physical inactivity, unhealthy diet, and excess alcohol consumption) as significant modifiable risk factors that should be targeted for secondary prevention (Canadian Stroke Best Practices 2017; ESO 2008; Kernan 2014; National Stroke Foundation 2017; SIGN 2008; Stroke Audit 2016). The evidence for lifestyle interventions such as improving control of diabetes, weight loss, smoking cessation, and alcohol reduction relies on observational studies (Hankey 2014)
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