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Recurrent events and secondary prevention after acute cerebrovascular disease
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.ORCID iD: 0000-0003-4768-3710
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Patients who experience a stroke or transient ischemic attack (TIA) are at high risk of recurrent stroke, but little is known about temporal trends in unselected populations. Reports of low adherence to recommended treatments indicate a need for enhanced secondary preventive follow-up to achieve the full potential of evidence-based treatments. In addition, socioeconomic factors have been associated with poor health outcomes in a variety of contexts. Therefore, it is important to assess the implementation and results of secondary prevention in different socioeconomic groups.

Aims The aims of this thesis were to assess temporal trends in ischemic stroke recurrence and evaluate the implementation and results of a nurse-led, telephone-based follow-up program to improve blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels after stroke/TIA.

Methods In study I, we collected baseline data for unique patients with an ischemic stroke event between 1998 and 2009 (n=196 765) from the Swedish Stroke Register (Riksstroke). Recurrent ischemic stroke events within 1 year were collected from the Swedish National Inpatient Register (IPR) and the cumulative incidence was compared between four time periods using the Kaplan-Meier survival analysis and the logrank test. Implementation (study II) and 1-year results (study III-IV) for the secondary preventive follow-up were studied in the NAILED (Nurse-based Age-independent Intervention to Limit Evolution of Disease) study. Between 1 Jan 2010 and 31 Dec 2013, the baseline characteristics of consecutive patients admitted to Östersund Hospital for acute stroke or TIA were collected prospectively (n=1776). Consenting patients in a condition permitting telephone-based follow-up were randomized to nurse-led, telephone-based follow-up or follow-up according to usual care. Follow-up was cunducted at 1 and 12 months after discharge and the intervention included BP and LDL-C measurements, titration of medication, and lifestyle counseling. In study II, we analyzed factors associated with non-participation in the randomized phase of the NAILED study, including association with education level. In addition, we compared the 1-year prognosis in terms of cumulative survival between participants and non-participants. In study III, we compared differences in BP and LDL-C levels between the intervention and control groups during the first year of follow-up and, in study IV, in relation to level of education (low, ≤10 years; high, >10 years).

Results The cumulative 1-year incidence of recurrent ischemic stroke decreased from 15.0% to 12.0%. Among surviving stroke and TIA patients, 53.1% were included for randomization, 35.7% were excluded mainly due to physical or cognitive disability, and 11.2% declined participation in the randomized phase. A low level of education was independently associated with exclusion, as well as the patient’s decision to abstain from randomization. Excluded patients had a more than 12-times higher risk of death within 1 year than patients who were randomized. After 1 year of follow-up, the mean systolic BP, diastolic BP, and LDL-C levels were 3.3 mmHg (95% CI 0.3 to 6.3), 2.3 mmHg (95% CI 0.5 to 4.2), and 0.3 mmol/L (95% CI 0.1 to 0.4) lower in the intervention group than among controls. Among participants with values above the treatment goal at baseline, the differences in systolic BP and LDL-C levels were more pronounced (8.0 mmHg, 95% CI 4.0 to 12.1; 0.6 mmol/L, 95% CI 0.4 to 0.9). In the intervention group, participants with a low level of education achieved similar or larger improvements in BP and LDL-C than participants with a high level of education. In the control group, BP remained unaltered and the LDL-C levels increased among participants with a low level of education.

Conclusion The 1-year risk of ischemic stroke recurrence decreased in Sweden between 1998 and 2010. Nurse-led, telephone-based secondary preventive follow-up is feasible in just over half of the survivors of acute stroke and TIA and achieve better than usual care in terms of BP and LDL-C levels, and equality in BP improvements across groups defined by education level. However, a large proportion of stroke survivors are in a general condition precluding this form of follow-up, and their prognosis in terms of 1-year survival is poor. Patients with a low education level are over-represented within this group and among patients declining randomization for secondary preventive follow-up. 

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 77 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1876
Keyword [en]
stroke, transient ischemic attack, secondary prevention, socioeconomic position, prognosis, randomized controlled trial
National Category
Neurology
Identifiers
URN: urn:nbn:se:umu:diva-130505ISBN: 978-91-7601-624-4 (print)OAI: oai:DiVA.org:umu-130505DiVA: diva2:1067348
Public defence
2017-02-16, Hörsalen Snäckan, Östersunds sjukhus, Östersund, 14:11 (Swedish)
Opponent
Supervisors
Available from: 2017-01-26 Created: 2017-01-20 Last updated: 2017-02-06Bibliographically approved
List of papers
1. One-year incidence, time trends, and predictors of recurrent ischemic stroke in Sweden from 1998-2010: An observational study
Open this publication in new window or tab >>One-year incidence, time trends, and predictors of recurrent ischemic stroke in Sweden from 1998-2010: An observational study
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(English)Manuscript (preprint) (Other academic)
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-130498 (URN)
Available from: 2017-01-20 Created: 2017-01-20 Last updated: 2017-02-06
2. Implementation of telephone-based secondary preventive intervention after stroke and transient ischemic attack - participation rate, reasons for nonparticipation and one-year mortality
Open this publication in new window or tab >>Implementation of telephone-based secondary preventive intervention after stroke and transient ischemic attack - participation rate, reasons for nonparticipation and one-year mortality
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2014 (English)In: Cerebrovascular diseases extra, ISSN 1664-5456, Vol. 4, no 1, 28-39 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE: Patients who experience a stroke or transient ischemic attack (TIA) are known to be at high risk of subsequent vascular events, underscoring the need for secondary preventive intervention. However, previous studies have indicated insufficiency in the implementation of secondary prevention, emphasizing the need to develop effective methods of follow-up. In the present study, we examined the potential of implementing a telephone-based, nurse-led, secondary preventive follow-up in stroke and TIA patients on a population level by analyzing the participation rate, reasons for nonparticipation, and one-year mortality.

METHODS: Between January 1, 2010 and December 31, 2011, all patients admitted to Östersund hospital, Sweden, and diagnosed with either stroke or TIA were considered for inclusion into the secondary preventive follow-up. Baseline data were collected at the hospital, and reasons for nonparticipation were documented. Multivariate logistic regression was performed to identify predictors of the patient decision not to participate and to explore independent associations between baseline characteristics and exclusion. A one-year follow-up of mortality was also performed; the survival functions of the three groups (included, excluded, declining participation) was calculated using the Kaplan-Meier estimator.

RESULTS: From a total of 810 identified patients, 430 (53.1%) were included in the secondary preventive follow-up, 289 (35.7%) were excluded mainly due to physical or cognitive disability, and 91 (11.2%) declined participation. Age ≥85 years, ischemic and hemorrhagic stroke, modified Rankin scale score >3, body mass index ≥25, congestive heart failure, and lower education level were independently associated with exclusion, whereas lower education level was the only factor independently associated with the patient decision not to participate. Exclusion was associated with a more than 12 times higher risk of mortality within the first year after discharge.

CONCLUSION: Population-based implementation of secondary prevention in stroke and TIA patients is limited by the high prevalence of comorbidity and a considerable degree of disability. In our study, a large proportion of patients were unable to participate even in this simple form of secondary preventive follow-up. Exclusion was associated with substantially higher one-year mortality, and education level was independently associated with physical ability as well as the motivation to participate in the secondary preventive follow-up program.

National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-100849 (URN)10.1159/000358121 (DOI)24715896 (PubMedID)
Available from: 2015-03-11 Created: 2015-03-11 Last updated: 2017-02-13Bibliographically approved
3. Nurse-Led, Telephone-Based, Secondary Preventive Follow-Up after Stroke or Transient Ischemic Attack Improves Blood Pressure and LDL Cholesterol: Results from the First 12 Months of the Randomized, Controlled NAILED Stroke Risk Factor Trial
Open this publication in new window or tab >>Nurse-Led, Telephone-Based, Secondary Preventive Follow-Up after Stroke or Transient Ischemic Attack Improves Blood Pressure and LDL Cholesterol: Results from the First 12 Months of the Randomized, Controlled NAILED Stroke Risk Factor Trial
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2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 10, e0139997Article in journal (Refereed) Published
Abstract [en]

Background: Enhanced secondary preventive follow-up after stroke or transient ischemic attack (TIA) is necessary for improved adherence to recommendations regarding blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels. We investigated whether nurse-led, telephone-based follow-up was more efficient than usual care at improving BP and LDL-C levels at 12 months after hospital discharge.

Methods: We randomized 537 patients to either nurse-led, telephone-based follow-up (intervention) or usual care (control). BP and LDL-C measurements were performed at 1 month (baseline) and 12 months post-discharge. Intervention group patients who did not meet target values at baseline received additional follow-up, including titration of medication and lifestyle counselling, to reach treatment goals (BP < 140/90 mmHg, LDL-C < 2.5 mmol/L).

Results: At 12 months, mean systolic BP, diastolic BP and LDL-C was 3.3 (95% CI 0.3 to 6.3) mmHg, 2.3 mmHg (95% CI 0.5 to 4.2) and 0.3 mmol/L (95% CI 0.1 to 0.4) lower in the intervention group compared to controls. Among participants with values above the treatment goal at baseline, the difference in systolic BP and LDL-C was more pronounced (8.0 mmHg, 95% CI 4.0 to 12.1, and 0.6 mmol/L, 95% CI 0.4 to 0.9). A larger proportion of the intervention group reached the treatment goal for systolic BP (68.5 vs. 56.8%, p = 0.008) and LDL-C (69.7% vs. 50.4%, p < 0.001).

Conclusions: Nurse-led, telephone-based secondary preventive follow-up, including medication adjustment, was significantly more efficient than usual care at improving BP and LDL-C levels by 12 months post-discharge.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-111483 (URN)10.1371/journal.pone.0139997 (DOI)000363185500019 ()26474055 (PubMedID)
Available from: 2015-12-01 Created: 2015-11-13 Last updated: 2017-02-13Bibliographically approved
4. Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a prospective cohort study
Open this publication in new window or tab >>Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a prospective cohort study
Show others...
(Swedish)Manuscript (preprint) (Other academic)
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-130496 (URN)
Available from: 2017-01-20 Created: 2017-01-20 Last updated: 2017-02-06

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