Abstract
Post-stroke dysphagia is common, associated with poor outcome and often requires non-oral feeding/fluids. The relationship between route of feeding and outcome, as well as treatment with glyceryl trinitrate (GTN), was studied prospectively. The Efficacy of Nitric Oxide in Stroke (ENOS) trial assessed transdermal GTN (5 mg versus none for 7 days) in 4011 patients with acute stroke and high blood pressure. Feeding route (oral = normal or soft diet; non-oral = nasogastric tube, percutaneous endoscopic gastrostomy tube, parenteral fluids, no fluids) was assessed at baseline and day 7. The primary outcome was the modified Rankin Scale (mRS) measured at day 90. At baseline, 1331 (33.2%) patients had non-oral feeding, were older, had more severe stroke and more were female, than 2680 (66.8%) patients with oral feeding. By day 7, 756 patients had improved from non-oral to oral feeding, and 119 had deteriorated. Non-oral feeding at baseline was associated with more impairment at day 7 (Scandinavian Stroke Scale 29.0 versus 43.7; 2p < 0.001), and worse mRS (4.0 versus 2.7; 2p < 0.001) and death (23.6 versus 6.8%; 2p = 0.014) at day 90. Although GTN did not modify route of feeding overall, randomisation ≤6 h of stroke was associated with a move to more oral feeding at day 7 (odds ratio = 0.61, 95% confidence intervals 0.38, 0.98; 2p = 0.040). As a proxy for dysphagia, non-oral feeding is present in 33% of patients with acute stroke and associated with more impairment, dependency and death. GTN moved feeding route towards oral intake if given very early after stroke.Clinical Trial RegistrationClinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN99414122.
Highlights
Dysphagia is a common complication after stroke affecting up to 65% of patients, many of whom are asymptomatic [1] or have symptoms that are not thought to be related to swallowing problems
Poststroke dysphagia (PSD) is associated with a poor outcome for multiple reasons: first, it is a manifestation of severe stroke and is associated with increased death, dependency, disability, impairment and institutionalisation; [4] second, it causes aspiration of foods, liquids and oral secretions and pneumonia [5,6,7], which in itself leads to death; [6] and third, poor recognition and management leads to dehydration and malnutrition
We report the effect of transdermal glyceryl trinitrate (GTN, a nitric oxide (NO) donor that relaxes smooth muscle) hypothesising that it might improve the oesophageal phase of swallowing and return patients to oral feeding and a normal diet [17]
Summary
Dysphagia (difficulty in swallowing) is a common complication after stroke affecting up to 65% of patients, many of whom are asymptomatic [1] or have symptoms that are not thought to be related to swallowing problems. In respect of drug treatment, a small pilot randomised trial suggested that nifedipine (a calcium channel blocker that relaxes oesophageal smooth muscle) might improve swallowing, and metoclopramide (a dopamine D2-receptor antagonist with antiemetic and gastric prokinetic activity) might reduce the incidence of pneumonia [13, 14]. We describe the natural history and outcomes of patients with feeding problems in the acute phase of stroke using data from the large ‘Efficacy of Nitric Oxide in Stroke’ (ENOS) trial [16,17,18,19]. We report the effect of transdermal glyceryl trinitrate (GTN, a nitric oxide (NO) donor that relaxes smooth muscle) hypothesising that it might improve the oesophageal phase of swallowing and return patients to oral feeding and a normal diet [17]. Since GTN might improve functional outcome if administered very early (
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