Transient Ischemic Attack Survivors Research Articles

Expert opinion of the Heart Rhythm Association of the Polish Cardiac Society and the Polish Neurological Society on evidence-driven implementation of implantable loop recorders in Poland.

Implantable loop recorders (ILR) are considered increasingly helpful in diagnosing cardio-neurological conditions, especially if arrhythmic events are of high clinical importance but are unlikely to be captured by standard methods of electrocardiogram recording due to the low frequency of events and short duration of a single event. The compelling evidence from randomized trials and observational studies strongly supports ILR utilization in patients after cryptogenic stroke or transient ischemic attack and in patients with recurrent transient loss of consciousness of unknown origin. These two groups of patients are expected to gain the most from initiating ILR-driven clinically effective management strategies. Stroke or transient ischemic attack survivors with detected subclinical atrial fibrillation can be switched from antiplatelets to anticoagulants, whilst patients with recurrent syncope may avoid severe injuries and/or substantial impairment of their quality of life. This joint opinion of the Heart Rhythm Association of the Polish Cardiac Society and experts from the Polish Neurological Society summarizes the up-to-date rationale for using ILR in everyday clinical practice and describes the road map for implementing this technology in Poland. Special emphasis is placed on the most recent guidelines issued by both cardiological and neurological scientific societies.

Exercise prescription, intervention, dissemination, and implementation following transient ischemic attack or stroke: advancing the field through interdisciplinary science.

Lay Summary Research has demonstrated that both exercise, and a reduction in cardiovascular disease (CVD) risk factors (i.e., high blood sugar, blood lipids, and blood pressure), following a stroke or transient ischemic attack (TIA) are beneficial for reducing risk of recurrent stroke or TIA and for improving overall quality of life. Despite this evidence, many stroke and TIA survivors remain inactive and sedentary and present with multiple CVD risk factors. The purpose of this commentary is to highlight gaps in the current literature in regard to exercise and behavior interventions for the stroke and TIA populations, present ideas for intervention design, and discuss the dissemination and implementation of research findings. The future research ideas presented in this commentary are based on current research findings, as well as the professional experience of the article authors. Professional experience spans occupational therapy in neurorehabilitation, clinical exercise physiology in rehabilitation, creation and implementation of stroke rehabilitation clinics, stroke and TIA research, and behavioral and implementation science.

Returning to Leisure Activity Post-Stroke: Barriers and Facilitators to Engagement.

To identify barriers and facilitators to engagement when returning to, or participating in, leisure activity post-stroke or Transient Ischemic Attack (TIA). Sequential explanatory, mixed methods study. 21 hospital sites across England, Wales and Northern Ireland. Adults with a clinical diagnosis of first/recurrent stroke or TIA. Patients approaching end of life were excluded. Participants were recruited as in-patients or at first clinic appointment and a baseline questionnaire was completed. A 6-month follow-up questionnaire was sent to participants for self-completion. Open-text questions were asked about barriers and facilitators when returning to, or participating in, leisure activity. Responses were thematically analysed and explored by participant characteristics, including type of leisure activity undertaken. Characteristics also included measures of socioeconomic deprivation, mood, fatigue and disability. 2000 participants returned a 6-month follow-up questionnaire (78% stroke, 22% TIA); 1045 participants responded to a question on barriers and 820 on facilitators. Twelve themes were identified and the proportion of responses were reported (%). Barriers: physical difficulties (69%), lower energy levels (17%), loss of independence (11%), psychological difficulties (10%), hidden disabilities (7%), and delay or lack of healthcare provision (3%). Facilitators: family support (35%), healthcare support (27%), well-being and fitness (22%), friendship support (20%), self-management (19%), and returning to normality (9%). 'Physical difficulties' was the most reported barrier across all participant characteristics and activity types. Family support was the most reported facilitator except for those with greater disability, where it was healthcare support and those without fatigue where it was well-being and exercise. Physical difficulties and lack of energy are problematic for stroke and TIA survivors who want to return to or participate in leisure activity. Healthcare support alone cannot overcome all practical and emotional issues related to leisure activity engagement. Family support and improving well-being are important facilitators and future research should explore these mechanisms further.

Post-traumatic Stress Disorder Following Acute Stroke

Stroke is a devastating event that annually affects over 800,000 million individuals in the USA and is associated with significant individual and social costs. In this narrative review, we summarize current evidence regarding post-traumatic stress disorder (PTSD) following acute stroke. In addition to the long-term physical consequences, it is increasingly recognized that psychological distress is common after stroke and transient ischemic attack (TIA). Nearly 1 in 4 survivors of TIA and stroke report elevated symptoms of PTSD in the first year following their cerebrovascular event. Those individuals with PTSD symptoms are at elevated risk for not only sustained psychological distress but also increased risk for non-adherence to medication. Factors in the emergency department, such as crowding, may influence the development of PTSD following acute stroke and TIA. We also summarize the rationale and clinical importance of developing and implementing quantitative predictive models of post-stroke PTSD symptoms in the ED setting. The potential of promising early interventions to prevent PTSD critically hinges on the accurate and precise identification of patients at risk for PTSD. Predictive modeling of PTSD risk may greatly facilitate the prospective management of mental health care in ED patients after stroke.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work. A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N>2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N=1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD. Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery.

Incidence and Etiologies of Stroke Mimics After Incident Stroke or Transient Ischemic Attack.

Background and Purpose- Stroke mimics (SM) pose a common clinical challenge, but the burden of SM in patients with previous ischemic stroke (IS) or transient ischemic attack is unknown. The objective of this study was to calculate the incidence of SM in IS survivors, compare it with the incidence of recurrent stroke in the same population, and explore the time-dependent patterns of SM etiologies. Methods- This prospective cohort study registered SM events and etiologies among 1872 IS and transient ischemic attack survivors diagnosed with index stroke at Haukeland University Hospital stroke unit from 2007 to 2013 by review of medical records. Cumulative incidences of SM were estimated with a competing risks Cox model and compared with incidence of recurrent stroke in the same population. Results- During 8172 person-years of follow-up, 339 patients had 480 SM events. The cumulative incidence rate of SM during follow-up was 58.7 per 1.000 person-years (95% CI, 53.7-64.2) compared with 34.0 per 1.000 person-years (95% CI, 30.2-38.2) for recurrent stroke in the same time period. The risks of SM and recurrent stroke were highest the first year after index IS or transient ischemic attack. The most frequent SM diagnoses were sequelae of cerebral infarction (19.8%), medical observation, and evaluation for suspected cerebrovascular disease (15.6%) and infections (14.0%). The 2 most frequent and unspecific diagnoses (sequelae of cerebral infarction and medical observation) were clustered in the first months after index stroke. Conclusions- SM after IS or transient ischemic attack are more frequent than recurrent stroke and the risk is especially high in the early period. SMs are multietiological and unspecific diagnoses are most frequent early after index stroke.

Women have a poorer very long-term functional outcome after stroke among adults aged 18-50years: the FUTURE study.

Due to their young age young stroke survivors have to cope with a dramatic impact on their life for the decades to come. We investigated the sex-specific very long-term functional outcome after transient ischemic attack (TIA) and ischemic stroke (IS) in adults aged 18–50 years. This study is part of a cohort study among 619 first-ever young ischemic stroke patients, admitted to our department between January 1, 1980 and November 1, 2010. Functional outcome was assessed during follow-up in 2009–2011 and in 2014–2015 with the modified Rankin Scale (mRS) and instrumental Activities of Daily Living scale (iADL). Risk factors for a poor functional outcome (mRS > 2 and iADL < 8) were calculated by logistic regression analysis. After a mean follow-up of 13.9 (SD 8.2) years, 24.5 % of TIA patients and 44.7 % of IS patients had a poor functional outcome (mRS > 2). When assessing the survivors, 15.2 % of TIA patients and 22.9 % of IS patients had a poor outcome as assessed by iADL. The strongest baseline predictors of poor outcome were female sex (OR 2.7, 95 % CI 1.5–5.0) and baseline NIHSS (OR 1.1, 95 % CI 1.1–1.2 per point increase). In conclusion, 14 years after an ischemic cerebrovascular event in young adults, one out of five IS survivors and one out of ten TIA survivors is still dependent in daily life, with a two to threefold higher risk of a poor outcome in women. This includes a period of life, during which important decisions regarding work and family life have to be made.

Depressive symptoms following stroke and transient ischemic attack: is it time for a more intensive treatment approach? results from the TABASCO cohort study.

To examine whether depressive symptoms after a stroke or a transient ischemic attack (TIA) increase the risk of cognitive impairment and functional deterioration at 2-year follow-up. Participants were survivors of first-ever, mild-to-moderate ischemic stroke or TIA from the TABASCO prospective cohort study who underwent 3T magnetic resonance imaging and were examined by a multiprofessional team 6, 12, and 24 months after the event using direct interviews, depression scales, and neurologic, neuropsychological, and functional evaluations. The main outcome was the development of cognitive impairment, either mild cognitive impairment (MCI) or dementia. MCI was diagnosed by a decline on at least 1 cognitive domain (≥ 1.5 SD) of the Montreal Cognitive Assessment score and/or on the computerized neuropsychological battery, as compared with age- and education-matched published norms. Dementia was diagnosed by a consensus forum that included senior neurologists specializing in memory disorders and a neuropsychologist. Data were obtained from 306 consecutive eligible patients (mean age: 67.1 ± 10.0 years) who were admitted to the department of emergency medicine at the Tel Aviv Medical Center from April 1, 2008, to December 1, 2011, within 72 hours from onset of symptoms of TIA or stroke. Of these patients, 51 (16.7%) developed cognitive impairment during a 2-year follow-up. Multivariate regression analysis showed that a Geriatric Depression Scale (GDS) score ≥ 6 at admission and at 6 months after the event was a significant independent marker of cognitive impairment 2 years after the stroke/TIA (OR = 3.62, 95% CI, 1.01-13.00; OR = 3.68, 95% CI, 1.03-13.21, respectively). A higher GDS score at 6 months was also related to a worse functional outcome (P < .001). Our results support depression screening among stroke and TIA survivors as a tool to identify patients who are prone to have a worse cognitive and functional outcome. These patients may benefit from closer medical surveillance and a more intensive treatment approach. ClinicalTrials.gov identifier: NCT01926691.

Stroke and TIA survivors’ cognitive beliefs and affective responses regarding treatment and future stroke risk differentially predict medication adherence and categorised stroke risk

Cognitive beliefs and affective responses to illness and treatment are known to independently predict health behaviours. The purpose of the current study is to assess the relative importance of four psychological domains – specifically, affective illness, cognitive illness, affective treatment and cognitive treatment – for predicting stroke and transient ischemic attack (TIA) survivors’ adherence to stroke prevention medications as well as their objective, categorised stroke risk. We assessed these domains among stroke/TIA survivors (n = 600), and conducted correlation and regression analyses with concurrent and prospective outcomes to determine the relative importance of each cognitive and affective domain for adherence and stroke risk. As hypothesised, patients’ affective treatment responses explained the greatest unique variance in baseline and six-month adherence reports (8 and 5%, respectively, of the variance in adherence, compared to 1–3% explained by other domains). Counter to hypotheses, patients’ cognitive illness beliefs explained the greatest unique variance in baseline and six-month objective categorised stroke risk (3 and 2%, respectively, compared to 0–1% explained by other domains). Results indicate that domain type (i.e. cognitive and affective) and domain referent (illness and treatment) may be differentially important for providers to assess when treating patients for stroke/TIA. More research is required to further distinguish between these domains and their relative importance for stroke prevention.

Effect of peer education on stroke prevention: the prevent recurrence of all inner-city strokes through education randomized controlled trial.

Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success. We aimed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors. Between 2009 and 2012, we enrolled 600 stroke or transient ischemic attack survivors from diverse, low-income communities in New York City into a 2-arm randomized clinical trial that compared a 6 week (1 session/week), peer-led, community-based, stroke prevention self-management group workshop (N=301) to a wait-list control group (N=299). The primary outcome was the proportion with a composite of controlled blood pressure (<140/90 mm Hg), low-density lipoprotein cholesterol <100 mg/dL, and use of antithrombotic medications at 6 months. Secondary outcomes included control of the individual stroke risk factors. All analyses were by intent-to-treat. There was no difference in the proportion of intervention and control group participants achieving the composite outcome (34% versus 34%; P=0.98). The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group (76% versus 67%; P=0.02). This corresponded to a greater change in systolic blood pressure in the intervention versus control group (-3.63 SD, 19.81 mm Hg versus +0.34 SD, 23.76 mm Hg; P=0.04). There were no group differences in the control of cholesterol or use of antithrombotics. A low-cost peer education self-management workshop modestly improved blood pressure, but not low-density lipoprotein cholesterol or antithrombotic use, among stroke and transient ischemic attack survivors from vulnerable, predominantly minority urban communities. http://www.clinicaltrials.gov/show/NCT0102727. Unique identifier: NCT01027273.

Stroke survivors’ endorsement of a “stress belief model” of stroke prevention predicts control of risk factors for recurrent stroke

Perceptions that stress causes and stress-reduction controls hypertension have been associated with poorer blood pressure (BP) control in hypertension populations. The current study investigated these “stress-model perceptions” in stroke survivors regarding prevention of recurrent stroke and the influence of these perceptions on patients’ stroke risk factor control. Stroke and transient ischemic attack survivors (N = 600) participated in an in-person interview in which they were asked about their beliefs regarding control of future stroke; BP and cholesterol were measured directly after the interview. Counter to expectations, patients who endorsed a “stress-model” but not a “medication-model” of stroke prevention were in better control of their stroke risk factors (BP and cholesterol) than those who endorsed a medication-model but not a stress-model of stroke prevention (OR for poor control = .54, Wald statistic = 6.07, p = .01). This result was not explained by between group differences in patients’ reported medication adherence. The results have implications for theory and practice, regarding the role of stress belief models and acute cardiac events, compared to chronic hypertension.

Correlates of Post-traumatic Stress Disorder in Stroke Survivors

Post-traumatic stress disorder (PTSD) can occur after life-threatening events, including illness, but correlates of PTSD after stroke or transient ischemic attack (TIA) have not been well described. We measured the prevalence of stroke-induced PTSD with the PTSD Checklist Specific for stroke (PCL-S) in adults who had a stroke or TIA within 5 years. A PCL-S score of 50 or more indicated likely PTSD. We tested for potential predictors of stroke-associated PTSD, including demographics, stroke history, disability, medical comorbidities, depression, and emotional support and then examined the association between poststroke PTSD and measures of physical and mental health. Of 535 participants, 95 (18%) had a PCL-S score of 50 or more; the mean score was 35.4±13.7 (range 17-80 of 85). In logistic regression analysis, low income (odds ratio [OR] 1.98, 95% confidence interval [CI] 1.01-3.61), recurrent stroke or TIA (OR 1.86, 1.10-3.16), more disability (OR 1.79, 1.43-2.23), and increased comorbidities (OR 1.90, 1.05-3.45) were independently associated with PTSD. Older age (OR .93, .90-.95), marriage or partnership (OR .52, .28-.98), and having emotional support (OR .25, .11-.54) were protective against developing PTSD. Participants with likely PTSD had worse physical andmental health. In this racially and ethnically diverse cohort ofstroke and TIA survivors, stroke-induced PTSD was associated with younger age, recurrent strokes, greater disability, and comorbidities. PTSD was associated with a substantially increased physical, mental, and quality of life burden in this already vulnerable population. Having social support was protective, suggesting a potential target for intervention.

Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review

Background and PurposePosttraumatic stress disorder (PTSD) is common in survivors of acute life-threatening illness, but little is known about the burden of PTSD in survivors of stroke and transient ischemic attack (TIA). This study estimated the prevalence of stroke or TIA-induced posttraumatic stress disorder (PTSD) using systematic review and meta-analysis.MethodsPotentially relevant peer-reviewed journal articles were identified by searching the Ovid MEDLINE, PsycINFO, PILOTS Database, The Cochrane Library and Scopus from inception to January 2013; all searches were conducted on January 31, 2013. Observational cohort studies that assessed PTSD with specific reference to a stroke or TIA that occurred at least 1 month prior to the PTSD assessment were included. PTSD rates and characteristics of the study and sample were abstracted from all included studies. The coding of all articles included demographics, sample size, study country, and method and timing of PTSD assessment.ResultsNine studies (N = 1,138) met our inclusion criteria. PTSD rates varied significantly across studies by timing of PTSD assessment (i.e., within 1 year of stroke/TIA versus greater than 1 year post-stroke/TIA; 55% of heterogeneity explained; Q 1 = 10.30; P = .001). Using a random effects model, the estimated rate of PTSD following stroke or TIA was 23% (95% CI, 16%–33%) within 1 year of the stroke or TIA and 11% (95% CI, 8%–14%) after 1 year.ConclusionsAlthough PTSD is commonly thought to be triggered by external events such as combat or sexual assault, these results suggest that 1 in 4 stroke or TIA survivors develop significant PTSD symptoms due to the stroke or TIA. Screening for PTSD in a large population-based prospective cohort study with cardiovascular outcome assessments is needed to yield definitive prevalence, and determine whether stroke or TIA-induced PTSD is a risk factor for subsequent cardiovascular events or mortality.

Key Barriers to Medication Adherence in Survivors of Strokes and Transient Ischemic Attacks

Even though medications can greatly reduce the risk of recurrent stroke, medication adherence is suboptimal in stroke survivors. To identify key barriers to medication adherence in a predominantly low-income, minority group of stroke and transient ischemic attack (TIA) survivors. Cross-sectional study. Six hundred stroke or TIA survivors, age ≥ 40 years old, recruited from underserved communities in New York City. Medication adherence was measured using the 8-item Morisky Medication Adherence Questionnaire. Potential barriers to adherence were assessed using validated instruments. Logistic regression was used to test which barriers were independently associated with adherence. Models were additionally controlled for age, race/ethnicity, income, and comorbidity. Forty percent of participants had poor self-reported medication adherence. In unadjusted analyses, compared to adherent participants, non-adherent participants had increased concerns about medications (26 % versus 7 %, p < 0.001), low trust in their personal doctor (42 % versus 29 %, p = 0.001), problems communicating with their doctor due to language (19 % versus 12 %, p = 0.02), perceived discrimination from the health system (42 % versus 22 %, p < 0.001), difficulty accessing health care (16 % versus 8 %, p = 0.002), and inadequate continuity of care (27 % versus 20 %, p = 0.05). In the fully adjusted model, only increased concerns about medications [OR 5.02 (95 % CI 2.76, 9.11); p < 0.001] and perceived discrimination [OR 1.85 (95 % CI 1.18, 2.90); p = 0.008] remained significant barriers. Increased concerns about medications (related to worry, disruption, long-term effects, and medication dependence) and perceived discrimination were the most important barriers to medication adherence in this group. Interventions that reduce medication concerns have the greatest potential to improve medication adherence in low-income stroke/TIA survivors.

Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia

PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack. Within one-year of hospital discharge, up to one-third of patients no longer adhere to secondary prevention behaviors. Adherence rates are lower in minority-underserved groups, contributing to health disparities. In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals. In these groups, low literacy, limited healthcare access, and sparse community resources may reduce adherence. Lay community health workers (navigators) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services. PROTECT DC is a Phase II, single-blind, randomized, controlled trial comparing in-hospital education plus stroke navigators to usual care. Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington, DC hospitals. Navigators meet with participants during the index hospitalization, perform home visits, and meet by phone. They focus on stroke education, medication compliance, and overcoming practical barriers to adherence. The interventions are driven by the theories of reasoned action and planned behavior. The primary dependent measure is a summary score of four objective measures of stroke risk factor control: systolic blood pressure, low-density lipoprotein, hemoglobin Hb A1C, and antiplatelet agent pill counts. Secondary outcomes include stroke knowledge, exercise, dietary modification, and smoking cessation. PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted.

Perception of Recurrent Stroke Risk among Black, White and Hispanic Ischemic Stroke and Transient Ischemic Attack Survivors: The SWIFT Study

Objectives: Risk modification through behavior change is critical for primary and secondary stroke prevention. Theories of health behavior identify perceived risk as an important component to facilitate behavior change; however, little is known about perceived risk of vascular events among stroke survivors. Methods: The SWIFT (Stroke Warning Information and Faster Treatment) study includes a prospective population-based ethnically diverse cohort of ischemic stroke and transient ischemic attack survivors. We investigate the baseline relationship between demographics, health beliefs, and knowledge on risk perception. Regression models examined predictors of inaccurate perception. Results: Only 20% accurately estimated risk, 10% of the participants underestimated risk, and 70% of the 817 study participants significantly overestimated their risk for a recurrent stroke. The mean perceived likelihood of recurrent ischemic stroke in the next 10 years was 51 ± 7%. We found no significant differences by race-ethnicity with regard to accurate estimation of risk. Inaccurate estimation of risk was associated with attitudes and beliefs [worry (p < 0.04), fatalism (p < 0.07)] and memory problems (p < 0.01), but not history or knowledge of vascular risk factors. Conclusion: This paper provides a unique perspective on how factors such as belief systems influence risk perception in a diverse population at high stroke risk. There is a need for future research on how risk perception can inform primary and secondary stroke prevention.

Evaluation of Antihypertensive Therapy Among Ischemic Stroke Survivors: Impact of Ischemic Heart Disease

Hypertension and ischemic heart disease (IHD) are among the most prevalent modifiable risk factors for stroke. Clinical trial evidence suggests that antihypertensive medications are recommended for prevention of recurrent ischemic stroke in hypertensive and normotensive patients. The objectives of this study were to analyze and evaluate the utilization of antihypertensive medication for acute ischemic stroke (AIS) or transient ischemic attack (TIA) survivors in relation to recent recommendations and guidelines and to compare their use among patients with or without IHD. This was a retrospective cohort study of all patients with AIS/TIA attending the hospital from July 1, 2008 to December 31, 2008. Demographic data, clinical characteristics, different classes of antihypertensive medications, and different antihypertensive combinations prescribed to AIS/TIA survivors were analyzed among patients with and without IHD. Statistical Package for Social Sciences (SPSS) program version 15 was used for data analysis. In all, 383 AIS/TIA survivors were studied, of which 66 (19.5%) had a documented history of IHD. Three quarters (n = 260; 76.9%) of AIS or TIA survivors received antihypertensive medication, mostly as monotherapy, at discharge. The majority of patients (n = 201, 59.5%) were prescribed angiotensin-converting enzyme inhibitors (ACEIs). Patients with IHD were significantly prescribed more β-blockers than patients without IHD (P = .003). A history of hypertension, a history of diabetes mellitus, and age were significantly associated with prescription of antihypertensive medications at discharge (P < .001, P < .001, and P < .001, respectively). Patterns of antihypertensive therapy were commonly but not adequately consistent with international guidelines. Screening stroke survivors for blood pressure control, initiating appropriate antihypertensive medications, and decreasing the number of untreated patients might help reduce the risk of recurrent strokes and increase survival.

The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788

BackgroundSurvivors of transient ischemic attack (TIA) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk. However, vascular risk factors, especially hypertension and high cholesterol, are not managed optimally even in those patients seen in specialized clinics. This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes. In this study, we will be testing a pharmacist case manager for delivery of stroke prevention services. We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes.MethodsWe will conduct a prospective, randomized, controlled open-label with blinded ascertainment of outcomes (PROBE) trial. Treatment allocation will be concealed from the study personnel, and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient's clinical care or trial participation and who are masked to baseline measurements. Patients will be randomized to control or a pharmacist case manager treating vascular risk factors to guideline-recommended target levels. Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton, Alberta after an ischemic stroke or TIA who have uncontrolled hypertension (defined as systolic blood pressure (BP) > 140 mm Hg) or dyslipidemia (fasting LDL-cholesterol > 2.00 mmol/L) and who are not cognitively impaired or institutionalized. The primary outcome will be the proportion of subjects who attain 'optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L) at six months compared to baseline; 12-month data will also be collected for analyses of sustainability of any effects. A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected.ConclusionsNearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year. If our intervention improves the provision of secondary prevention therapies in these patients, the clinical (and financial) implications will be enormous.

Current Blood Pressure Self-Management: A Qualitative Study

Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors. Each participant completed a questionnaire regarding current BP management. We analyzed and coded qualitative transcripts from the focus groups and found four emergent themes that were supported by questionnaire results. The four self-management themes include: (1) external support for BP self-management is helpful; (2) BP self-management strategies include medication adherence, routine development, and BP monitoring; (3) BP risk factor management involves diet, exercise, and stress reduction; and (4) taking advantage of the"teachable moment" may be advantageous for behavior change to self-manage BP. This research provides key elements for the development of a successful BP self-management program.

Causal Attributions and Health Behavior Choices Among Stroke and Transient Ischemic Attack Survivors

To reduce the risk of a recurring event in patients who have suffered an initial stroke or transient ischemic attack (TIA), nurses are challenged with implementing and promoting changes in lifestyle and adherence to treatment regimens. Assessing patients' beliefs about the cause of the stroke or TIA is important to understanding their subsequent health behaviors. This study describes the causal attributions and health behavior choices of 9 participants following a stroke or TIA. Attributions were categorized as internal or external and cross-tabulated by controllability. The attributions were compared with health behavior choices. All participants attempted to make causal attributions, both internal (e.g., anxiety, hypertension, lifestyle) and external (e.g., stress, fate). Those making external attributions demonstrated poorer health behavior choices than those making internal attributions; controllability had no influence on behavior. Patients diagnosed more than 6 months before the study tended to make more external attributions. The results can help nurses understand the beliefs that drive the health behavior choices made by stroke and TIA survivors and guide them in tailoring prevention strategies and engaging patients in preventive activities.