Commentary on the Secondary Stroke Prevention Guidelines...Pearls for Clinicians

Updated:May 19,2014

Commentary on the Secondary Stroke Prevention Guidelines...Pearls for Clinicians Caring for At-Risk Populations

Disclosure:Dr. Hepburn has nothing to disclose.
Pub Date:Thursday, March 27, 2014
Authors:Millie Hepburn, PhD(c), RN, MPhil, SCRN, ACNS-BC
Affiliation: Neurosciences, Inpatient Psychiatry, Rusk Institute of Rehabilitation
NYU Langone Medical Center, New York, NY

Citation

Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology,
and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published online ahead of print May 1, 2014] . Stroke. doi: 10.1161/STR.0000000000000024.
http://stroke.ahajournals.org/lookup/doi/10.1161/STR.0000000000000024

Article Text

It has been shown that three to four percent of all patients that experience a stroke will subsequently experience a second stroke. Assisting clinicians to prevent this occurrence of this event is the goal of this much-needed revised guideline. The new and revised recommendations are the result of strong research science, and will prove to be invaluable to clinicians to prevent stroke in a wide variety of co-morbid diseases and conditions. Although much has been accomplished to reduce the incidence of second stroke over the past 10 years, the incidence of a second stroke in some patients has not dropped significantly. This may be due to a plethora of differences in the cost, quality, and access to care, as well as differences in clinical presentation of stroke, especially among ethnic minorities and women.

While the new secondary stroke prevention guidelines are extremely comprehensive in many areas of secondary prevention (such as recommendations for: treatment of stroke in patients with aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocystememia, hypercoaguable stated, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis and pregnancy), there are gaps in many areas in terms of specific recommendations for treatment that may be encountered most commonly in clinical practice by licensed providers to specific vulnerable populations that have been shown to be most likely to experience a second stroke event.

Perhaps most striking is an absence of secondary stroke prevention in regard to blood pressure, anticoagulant, antithrombotic and other pharmacologic recommendations specific Blacks and women, although it is mentioned in the guideline that the highest percentage of strokes occur in these two groups1,2,3. Although there is discussion in the guideline in regard to gaps in care by population from the Michigan Coverdell registry, the only area in which gender/race/ethnic specific recommendations are made is in reference to the treatment of diabetes. There is, however, mention of disparities in hospital based care among Black stroke patients as well as women experiencing stroke, but precious little is mentioned in regard to recommendations to reduce these disparities4. Additionally, there is no mention of secondary stroke prevention in American Indians in the document. It seems reasonable to expand disease and condition specific recommendations for secondary stroke prevention specific to at risk populations, as they are the very patients that providers are most likely to encounter post stroke in their clinical practice.

There is a small segment devoted to the disparity of primary and secondary stroke prevention in women, and it appears to have been deposited at the end of the guideline as an afterthought, and given the higher incidence of stroke (61 percent) in women, as well as higher stroke mortality in women, this is notable, and should be thoroughly reported concurrently to treatment recommendations in each section of the document, to ensure that specific disparities and recommendations in post stroke care are addressed by clinicians. 

Lacking in this guideline is reporting in regard to research promise in the use estrogen to increase neurogenesis in post stroke recovery, as well as the role of gender relevant neurologic protection following stroke as a possible prevention measure4,5,6. The vast majority of strokes in women occur following the onset of menopause when endogenous estrogen levels are at their lowest7. Thorough reporting of preliminary findings to date in neuro-protection and in the attenuation of infarct size could ignite future research in humans.  The AHA/ASA recently published a new Guideline, Prevention of stroke in Women (Guideline by Bushnell et al 2014), and covers primary and secondary prevention. (3)

The guideline should also address the need for age-specific evidence in the prevention of second stroke in young and older patients, and given the increased prevalence of stroke in younger patients, as this could trigger clinical trials that reduce a potential life altering disability that could span several decades of life8,9,10.

In terms of medication guidelines, given a recent widespread prescribing pattern of newly approved anticoagulants (rivaroxaban, dabigatran, apixaban), specific indications for use by population and conditions should be suggested if empiric evidence is available. The current recommendations do not specify use of one anticoagulant agent over another in common clinical situations, leaving the reader with no specific clinical guidelines for anticoagulant treatment other than how to prescribe these agents concurrently with antithrombotic. There are also no recommendations for effective strategies for educating patients in regard to medications to prevent a second stroke, although there is an abundance of literature in this regard4.

Preventing a second stroke in palliative care patients is another example of an extremely vulnerable population, and should be addressed as well11.

In some of these areas, the empiric evidence to make the aforementioned secondary stroke prevention recommendations is lacking, and this should be clearly identified within the guideline, thereby guiding researchers to create clinical trials to build evidence, among vulnerable, high-risk patients.

Feasibility of the new recommendations is also a consideration. New for 2014 is a recommendation to perform a sleep study for all patients with sleep apnea, and while there is strong evidence to support this, sleep studies are an expensive diagnostic tool that may not be feasible for many patients, especially among the uninsured or underinsured. Future guidelines should be inclusive of feasibility in all patients, and alternative diagnostics and treatment should be addressed12.

The future of health care demands guidelines based in empiric evidence that support treatment recommendations to assist practitioners to offer the state of the science, most feasible options to promote health and reduce the risk of  a second stroke in vulnerable populations that entrust their care to them.

Reference

  1. White, C., Pergola, Pablo, Szychowski, J., Talbert, R., Cervantes-Arriaga, A., Clark, H., Del Brutto, O., Godoy, I., Hill, M., Pelegri, A., Sussman, C., Taylor, A., Valdivia, J., ANdeson, D., Conwit, R., Benavente, O. (2013). Blood Pressure after Recent Stroke: Baseline Findings from the Secondary Prevention of Small Subcortical Strokes Trial, American Journal of Hypertension, (26)9, 1114-1122.
  2.  Lager KE, Wilson AD, Mistri AK, Khunti K. Stroke services for risk reduction in the secondary prevention of stroke (Protocol). Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD009103. DOI: 10.1002/14651858.CD009103.
  3. Lee, M., Saver, J., Hong,K., Rao, N., Ovbiagele, B. (2013). Risk-benefit profile of long-term dual-versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis, Annals Internal Medicine, 159(7), 463-470.
  4. Bushnell, C, et al (2014).  Guidelines for the Prevention of Stroke in Women. Stroke; http://stroke.ahajournals.org/content/early/2014/02/06/01.str.0000442009.06663.48
  5. Sides, E., Zimmer, L., Bushnell, C. (2012). Medication coaching program for patients with minor stroke or TIA, BMC Public Health, 12, 549.
  6. Li, Jun, Siegel, M. Yuan, M., Zeng, Z., Finnucan, L., Perskey, R., Hurn, P., McCullough, L. (2011). Estrogen enhances neurogenesis and behavioral recovery after stroke, Journal of Cerebral Blood Flow & Metabolism, 31, 413-425.
  7. Simpkins, J., Richardson, T., Yi, K., Perez, E., Covey, D. (2013). Neuroprotection with non-feminizing estrogen analogues: An overlooked possible therapeutic strategy, Hormones and Behavior, 63(2), 278-283.
  8. Ritzel, R., Capozzi, L., McCullough, D. (2013). Sex, stroke and inflammation: The potential for estrogen-mediated immunoprotection in stroke, Hormones and Behavior, (63)2, 238-253.
  9. Pandya A, Gaziano TA, Weinstein MC, et al. More Americans living longer with cardiovascular disease will increase costs while lowering quality of life. Health Affairs 2013;32(10):1706-1714.
  10. George, M., Tong,X., Kuklina, E., Labarthe, D., Trends in stroke hospitalizations and associated risk factors among children and young adults, 1995-2008, Annals of Neurology, 70(5), 713-721.
  11. Fleg JL, et al; on behalf of the American Heart Association Committees on Older Populations and Exercise Cardiac Rehabilitation and Prevention of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Lifestyle and Cardio-metabolic Health. Secondary prevention of atherosclerotic cardiovascular disease in older adults: a scientific statement from the American Heart Association. Circulation. 2013: published online before print October 28 2013, 10.1161/01.cir.0000436752.99896.22.
  12. Chen, S., Simon, J., Hill, M. (2014). There is Always something we can do—Palliative and End of Life Care in Stroke, Science News, American Heart Association, Retrieved from: http://my.americanheart.org/professional/ScienceNews/There-is-Always-Something-We-Can-Do----Palliative-and-End-of-Life-Care-in-Stroke_UCM_461984_Article.jsp
  13. Reynolds, M. (2014). Future ACC/AHA Guidelines to incorporate Cost/Value Considerations, Science News, American Heart Association, retrieved from; http://my.americanheart.org/professional/ScienceNews/Future-ACCAHA-Guidelines-to-Incorporate-CostValue-Considerations_UCM_462283_Article.jsp.

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association. -- 
 

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