Determining the appropriateness of selected surgical and medical management options in recurrent stroke prevention: a guideline for primary care physicians from the National Stroke Association work group on recurrent stroke prevention.
Despite a decade of successful clinical trials for stroke prevention, substantial gaps exist in the application and implementation of this information in community practice. The frequency of guideline use is low, and there remains controversy regarding the standard of practice. Patients with stroke may have multiple risk factors and concomitant stroke mechanisms, factors that are not addressed in stroke clinical trials and guideline statements. New guidelines are needed to account for these complexities and to provide primary care physicians a practical means to achieve stroke prevention. We sought to develop guidelines that can be implemented by primary care physicians to enhance the use of medical and surgical measures for recurrent stroke prevention. We sought to test the applicability of current evidence-based guidelines to daily practice with routine and complex patient case scenarios to determine whether these could be simplified into a more easily applied form for primary care physicians. We used RAND/UCLA Appropriateness Methodology to develop guidelines for the use of interventions supported by randomized controlled trials including carotid revascularization, anticoagulant therapy, antiplatelet therapy, and blood pressure management for the prevention of recurrent stroke. After a systematic literature review of randomized clinical trials we developed a comprehensive list of indications or clinical scenarios to capture decision making. A diverse multidisciplinary panel reviewed and rated each indication according to the RAND Appropriateness Method. First, panelists rated each scenario (1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate) without interaction with other panelists. "Appropriate" was defined as the expected health benefit exceeding its expected negative consequences by a sufficient margin. At a formal interactive session, panelists re-rated all indications. Overall carotid endarterectomy was rated as appropriate when there was 50% to 99% ipsilateral symptomatic carotid artery stenosis, inappropriate with <50% or 100% stenosis (total occlusion), and uncertain when the surgical risk was high. Carotid angioplasty was generally rated as of uncertain value. When there was atrial fibrillation, anticoagulation with warfarin was rated as appropriate when there was a low bleeding risk but of uncertain value when the bleeding risk was high. For patients who were not candidates for warfarin therapy, aspirin, aspirin plus extended-release dipyridamole, or clopidogrel were all rated as appropriate initial therapies. Ticlopidine was considered inappropriate and aspirin plus clopidogrel of uncertain value. With the exception of ticlopidine and aspirin, persons with a prior cerebral ischemic event while on aspirin could receive any of the aforementioned antiplatelet agents or combinations and be considered appropriately treated. The panelists rated a blood pressure of <130/80 mm Hg at 1 year after ischemic stroke as the target level and rated any of the following agents as appropriate initial therapies if there was no diabetes mellitus or proteinuria: diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin-converting enzyme receptor blockers, or combinations of a diuretic and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patient risk played a significant role in deterring the panel from recommending certain therapies; however, the presence of atrial fibrillation or large or small cerebral vessel syndromes rarely had significant influence on treatment decisions. Appropriateness was less where bleeding or surgical risk was excessive. Using consensus evidence from clinical trials, we have developed recurrent stroke prevention guidelines for routine and more complex patient scenarios according to appropriateness methodology. Broad application of these guidelines in primary practice promises to reduce the burden of recurrent stroke.
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[Show abstract][Hide abstract] ABSTRACT: Cerebrovascular disease is the third leading cause of mortality and the leading cause of long-term neurological disability in the United States. Most strokes are of ischemic origin and, other than cardioembolic or small vessel strokes, are caused by the development of platelet-fibrin thrombi on an atherosclerotic plaque. This underlying disease mechanism shares important features with coronary artery disease and peripheral artery disease, highlighting the systemic nature of atherothrombosis and the elevated cross risk in stroke patients for ischemic events in other vascular beds. It has been estimated that up to 80% of ischemic strokes could be prevented with application of currently available treatments for blood pressure, cholesterol, and antithrombotic therapies. Stroke is not, like cancer, waiting for a scientific breakthrough; stroke preventive treatments are well understood and widely available. It is only the application of these treatments to patients, many of whom do not visit physicians, that is lacking. Clearly, better education of the public and active participation of primary care physicians is essential to get the message out to all those at risk.
The Journal of the American Board of Family Practice / American Board of Family Practice 11/2005; 18(6):528-40. DOI:10.3122/jabfm.18.6.528
[Show abstract][Hide abstract] ABSTRACT: It is generally assumed that initial and recurrent strokes are of the same type, but data from South London, United Kingdom; Lausanne, Switzerland; and other studies suggest this may not be true for certain subtypes. In these studies, however, the number of recurrent strokes observed during the follow-up period was small, thereby limiting the ability of these studies to provide reliable estimates of stroke type concordance.
Using a large, diverse, inpatient database, this study sought to: (1) estimate the relative agreement (Cohen's kappa) between initial and recurrent stroke types for blacks and whites; and (2) develop a risk-adjusted logistic model for readmission stroke type, with the initial admission stroke type as the main predictor and race, other sociodemographic variables, and clinical and hospital characteristics as potential covariates.
Stroke type concordance was similar for blacks (kappa = 0.77, 95% confidence interval [CI] = 0.71-0.83) and whites (kappa = 0.77, 95% CI = 0.74-0.79). In the adjusted logistic regression models, the initial admission stroke type strongly predicted the readmission stroke type (subarachnoid hemorrhage: odds ratio [OR] = 738.31, 95% CI = 422.58-1289.93; intracerebral hemorrhage [ICH]: OR = 80.86, 95% CI = 61.57-106.19; ischemic: OR = 125.81, 95% CI = 96.12-164.67). Other patient factors, but not race, also predicted readmission stroke type (e.g., younger age increased the odds of having an subarachnoid hemorrhage readmission; atrial fibrillation increased the odds of having an ICH readmission; older age, diabetes mellitus, and heart failure increased the odds of having an ischemic stroke readmission).
This study showed that the initial stroke type and other factors were independently associated with the readmission stroke type and that patterns of stroke type concordance were similar for blacks and whites. These results may help to identify patients in high-risk subgroups who are more likely to have a recurrent hemorrhagic stroke, which could inform patient treatment decisions. For example, patients with atrial fibrillation may be at greater risk for having an ICH readmission because of the adverse effects of anticoagulant therapy, antiplatelet treatment, or both, which should be investigated further.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 11/2005; 14(6):251-60. DOI:10.1016/j.jstrokecerebrovasdis.2005.08.003 · 1.67 Impact Factor