Date of Award

2014

Document type

Thesis

Degree Name

MD (Medical Doctor)

First Supervisor

Professor David Williams

Second Supervisor

Professor Anne Hickey

Funder/Sponsor

ASPIRE-S research grant awarded by the Health Board of Ireland (2011)

Abstract

Stroke is a leading cause o f death and disability in all countries and results in substantial personal and healthcare costs. Approximately one third of strokes occur in individuals with a previous transient ischaemic attack and one half occur in individuals with previous vascular events of any kind. The significant disease burden and the high recurrence rates of stroke emphasize the importance of both primary and secondary preventive strategies amongst all patients at high risk for stroke. In recent years numerous policies and guidelines on the secondary prevention o f stroke have been published and updated (nationally and internationally) that summarize important evidence based practice in stroke care which aim to improve cardiovascular disease and stroke outcomes, with resultant beneficial effects for healthcare systems and populations. However, few studies to date have assessed the adequacy o f secondary prevention after ischaemic stroke outside the trial setting. This study, Action on Secondary Prevention Interventions and Rehabilitation in Stroke (the ASPIRE-S study) aimed to prospectively assess the secondary prevention (and rehabilitation) profiles of over 300 patients six months following hospital admission for ischaemic stroke in Dublin across key dimensions of quality care, patient safety effective care and patient experience. This thesis focuses on the secondary prevention component o f ASPIRE-S.

Results of this cross-sectional study revealed suboptimal control of many stroke risk factors. Office blood pressure was <140/90 in 37% and <130/80 in 16% of patients. On ambulatory blood pressure monitoring, more people had their blood pressure controlled by day than by night (66% versus 44%). Lipid control was suboptimal, with one quarter of patients failing to meet total cholesterol (<4.5mmol/L) and LDL (<2.5mmol/L) targets. In diabetic patients, 28% had HbAlc> 7%. Many patients (68%) had an increased body mass index, were still smoking (16%) and were in the high (29%) or moderate risk (60%) category when the SCORE risk assessment tool was applied. Abnormal scores for anxiety (32%) and depression (22%) were detected in substantial proportions o f patients. Furthermore knowledge o f stroke risk factors and recall o f lifestyle advice received by patients were particularly poor at six months post stroke. The prescription o f secondary preventive medications (including anti-thrombotic (97%) and lipid-lowering (95%) medications) was, however, good in this cohort and self-reported medication adherence was excellent with a mean MARS score of 24.2/25.

These results promote awareness of the importance of ongoing surveillance of cardiovascular risk after ischaemic stroke and support the need for re-evaluation of local secondary prevention programmes. Given the notable advances in the evidence base supporting the use o f secondary preventive therapies over the last two decades and the recent implementation of the national stroke clinical care programme in Ireland (resulting in substantially improved services for patients with stroke) it is imperative that programmes o f care secondary prevention (including assessment of risk factors and patient education) be optimised. Future initiatives should include the development of policies which support more effective, comprehensive, multidisciplinary patient education and risk factor management programmes for all patients with ischaemic stroke in Ireland.

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Comments

A thesis submitted for the degree of Doctor of Medicine from the Royal College of Surgeons in Ireland in 2014.

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