Agnete is a
Mai Bang Poulsen, MD, PhD Department of Neurology Nordsjællands Hospital Dyrehavevej 29 3400 Hillerød Denmark
ClinicalTrials.gov NCT03782857.
None.
In Denmark 25% of hospital admissions with stroke are recurrent strokes. With thrombolytic treatment more patients survive with only minor disability. This promising development should be followed up by intensive secondary prevention. Hypertension is the most important target. We aimed at testing the hypotheses that early follow up in a preventive clinic would result in 1) A higher proportion of patients with blood pressure at target, 2) Time to stroke recurrence, myocardial infarction and death would be longer in the intervention group compared to controls.
Eligible patients admitted to the stroke unit of Herlev Hospital were randomized shortly before discharge to intervention or control group. Of 78 included participants data from 73 was available for follow up nine months after inclusion. Patients in the intervention group were seen in the clinic within one week. In case of hypertension treatment was initiated or supplied with a new drug. We used individual targets for blood pressure according to diagnosis of stroke and patients’ comorbidity. Patients in the intervention group had a median of five visits to the preventive clinic.
Wiley Generico
In the intervention group blood pressure was treated to target in 25 patients (69%) versus 14 (38%) in the control group (
Treatment of hypertension to individual targets after stroke is feasible. It may postpone recurrent stroke and death in stroke survivors.
The is the third and last part of the volume devoted to solubility data of rare earth metal chlorides in water and in ternary and quaternary aqueous systems. Compilations of all available experimental data are introduced for each rare earth metal chloride with a corresponding critical evaluation. This part covers chlorides of Gd, Tb, Dy, Ho, Er, Tm, Yb, and Lu, with coverage of the literature through the middle of 2008.
Il s'agit de la troisième et dernière partie du volume consacrée aux données de solubilité des chlorures de métaux des terres rares dans l'eau et dans les systèmes aqueux ternaires et quaternaires. Une compilation de toutes les données expérimentales disponibles est présentée pour chaque chlorure de métaux des terres rares, accompagnée de l'évaluation critique correspondante. Cette partie couvre les chlorures de Gd, Tb, Dy, Ho, Er, Tm, Yb et Lu, avec une couverture de la littérature jusqu'à mi-2008.
simple image
caption
test paragraph
It is a far, far better thing that I do now than I have ever done.
A standard pullquote.
A half-left pullquote.
A half-right pullquote.
pullquote without content-type
blockquote
Over the last two decades continuous development of thrombolytic treatment of acute ischemic stroke (IS) has improved safety and functional outcome in treated patients
Hypertension is an important risk factor for stroke recurrence.
Observational studies have demonstrated the difficulties in lowering BP after stroke with rates of BP treated to target ranging from 28% to 73%
The aim of the present study was to test the hypotheses that follow up after stroke in a specialized nurse led physician supervised clinic with stepwise escalation of BP- and lipid lowering treatment would result in
Secondary endpoints: A greater reduction of BP A greater proportion of participants with LDL-cholesterol treated to target A greater reduction of LDL-cholesterol Longer time to recurrence of stroke, MI and death in the intervention group compared to controls
The benefits of geriatric day hospital care have been controversial for many years.
This systematic review of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care.
Day hospitals had a possible advantage over no comprehensive care in terms of death or poor outcome, disability, and use of resources.
The costs of day hospital care may be partly offset by a reduced use of hospital beds and institutional care among survivors.
Hello World!
The benefits of geriatric day hospital care have been controversial for many years.
This systematic review of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care.
Day hospitals had a possible advantage over no comprehensive care in terms of death or poor outcome, disability, and use of resources.
The costs of day hospital care may be partly offset by a reduced use of hospital beds and institutional care among survivors.
Before the initiation of the study the authors attended a three-day course in treatment of hypertension arranged by the Danish Society of Hypertension. The recommendations of our national guidelines regarding BP targets were in line with those given by the American Stroke Association in force at the time of initiation of the study: “An absolute target BP level and reduction are uncertain and should be individualized.”
LDL-cholesterol should be < 2.5 mmol/l in patients with IS or TIA in non-diabetic patients and in case of diabetes < 2.0 mmol/l.
A sample size calculation showed that 24 patients in each group were needed to show a difference of 10 mm Hg in the development of systolic BP (80% power).
From June 2012 to February 2013 all patients diagnosed with a stroke or TIA at the stroke unit of Herlev Gentofte Hospital, University of Copenhagen were considered for inclusion in the study. Patients should be without cognitive deficits that would prevent their active participation and they should be discharged to their own home. The last author used computer-generated block randomization procedures with stratification by hypertension (1:1). The allocation sequence was concealed, and we aimed at equal numbers in the two groups. Shortly before discharge the first author approached eligible patients for oral and written information about the study. Where written informed consent to participation was achieved BP was measured before a concealed envelope administered by a secretary was opened revealing the allocation to either intervention or control group.
The research protocol was approved by the ethics committee of the Capital Region of Denmark (H-3-2011–152) and by the Danish Data Protection Agency (2012–41-0429). The study was conducted according to all common ethical standards including the rules given by the Declaration of Helsinki. Patients randomized to the control group had the usual treatment: one visit in the outpatient clinic of the stroke unit three months after discharge. Patients randomized to the intervention group had an appointment with the first author within one week after discharge. The first author undertook all visits in the preventive clinic.
BP was measured at every visit after at least five minutes rest in a sitting position in an arm chair. BP was measured simultaneously in both arms followed by two measurements with 10-min intervals using the arm with the highest systolic BP. In case of hypertension the first author would suggest initiation or intensification of antihypertensive treatment. The last author would accept or suggest an alternative and do the prescription. Patients would come to the clinic for control of BP and relevant blood tests every 3–4 weeks until BP was at target. After five weeks on lipid lowering drugs treatment was intensified if needed. Patients who did not tolerate lipid lowering medication were referred to a dietitian. In motivated patients home BP measurements were performed using patients’ own monitor or by lending patients a BP monitor between visits.
Patients in the intervention group had a mean of five visits to the clinic with addition of new drugs rather than adding more of the same drug in case of hypertension. Although we used minimum doses to prevent adverse effects, many patients had unacceptable side effects necessitating change to another class of antihypertensive drug.
Patients were informed about the importance of life-long adherence with all preventive medication. Those with elevated BP or receiving antihypertensive treatment were advised in salt reduction, smokers were advised to stop smoking and all patients were informed about the benefits of 30 min of moderate physical activity daily. Likewise, information about the risk of an intake of alcohol above seven drinks per week in women and 14 drinks in men was part of the program as well as the benefits of weight reduction in overweight patients with hypertension or diabetes.
Participants in both groups were invited to the usual follow up visit three months after discharge at the outpatient clinic of the stroke unit as well as a follow up visit in the study a median of 9 (IQR 8–11) months after inclusion.
In accordance with the protocol the final follow up visits were performed by nurses in the outpatient clinic with measurement of BP and blood-cholesterols. Patients were asked not to reveal their group allocation but blinding of the nurses was not possible. Patients were interviewed about adherence to all preventive medications as well as their present life style. For practical purposes a minority of visits were performed by the first author. To do intention to treat analyses we used last observation carried forward regarding the endpoints of the study where patients had died or did not respond to the invitation to a follow up visit. Thus, we used the last recorded values in five patients in the intervention group and in seven controls.
After a median of 65 months (IQR: 61–66) from inclusion data on vascular events and death were attained from the hospital based medical records covering all hospitals of the region.
Data were entered into Excel and imported into SAS. Statistical analyses were performed by the first author according to a pre-established statistical analysis plan. We used Chi square test (for the primary outcome) or Fisher’s exact test as appropriate for comparison of proportions, and for change from baseline we used McNemar’s test. For continuous variables we used t-test or Mann-Whitney’s test*. Change from baseline was analyzed by the paired t-test or Wilcoxon signed rank sum test* (*where data were not normally distributed). We used SAS 9.4 for Windows and
We included 78 patients in the study. Due to revision of stroke diagnoses in four participants and as one participant never turned up for the intervention, data on 73 participants were available for follow up (
Flow chart of participants
Characteristics | All( | Intervention ( | Control ( | P |
|---|---|---|---|---|
Sex, female | 29 (40) | 15 (42) | 14 (38) | 0.74 |
Age (years), mean ± SD | 66 ± 12 | 63 ± 13 | 68 ± 11 | 0.08 |
Length of education< 10 years10 – 12 years> 12 years | 12 (17)22 (30)38 (53) | 6 (17)10 (29)19 (54) | 6 (16)12 (33)19 (51) | 0.95 |
Diagnosis of strokeIschemic StrokeTIAHemorrhagic stroke | 63 (87)9 (12)1 (1) | 33 (92)3 (8) | 30 (81)6 (16)1 (3) | 0.60a |
Recurrent stroke | 11 (15) | 5 (14) | 6 (16) | 1.00a |
Modified Rankin Scale score > 2 | 5 (6) | 1 (3) | 4 (11) | 0.36a |
Antihypertensive medication before stroke | 39 (53) | 15 (42) | 24 (65) | 0.047 |
Antihypertensive medication at discharge | 46 (63) | 20 (56) | 26 (70) | 0.19 |
Cholesterol lowering medication before stroke | 25 (34) | 11 (31) | 14 (38) | 0.51 |
Cholesterol lowering medication at discharge | 65 (89) | 35 (97) | 30 (81) | 0.03 |
Diabetes at baseline | 14 (19) | 5 (14) | 9 (24) | 0.37a |
Diabetes at discharge | 16 (22) | 6 (17) | 10 (27) | 0.29 |
Atrial fibrillation at baseline | 7 (10) | 3 (8) | 4 (11) | 1.00a |
Atrial fibrillation at discharge | 12 (16) | 6 (16) | 6 (17) | 1.00 |
Unhealthy dietingb | 59 (82) | 25 (71) | 34 (92) | 0.03 |
Current smoking | 19 (26) | 11 (31) | 8 (22) | 0.62 |
Alcohol above limitsc | 23 (32) | 12 (34) | 11 (30) | 0.68 |
Sedentary lifestyled | 17 (24) | 9 (26) | 8 (22) | 0.68 |
BMI ≥ 25 | 46 (63) | 24 (67) | 22 (59) | 0.52 |
Self-rated health: fair, poor, or very poor | 34 (47) | 15 (43) | 19 (51) | 0.47 |
Values are expressed as frequencies (%) or as mean ± standard deviations
Fisher’s exact test. b Less than 600 g of fruit and vegetables per day, fish for dinner less than twice per week. c More than 7 drinks per week in women/more than 14 drinks per week in men. d Less than 30 min of moderate physical activity per day.
Less than 20% of patients had a baseline BP treated to target (
Blood pressure and treatment of hypertension at baseline in 73 patients (%)
Follow up visits showed that 25 patients (69%) in the intervention group had a BP at target versus 14 (38%) of controls (
Blood pressure and treatment of hypertension at follow up in 73 patients (%)
Median reduction in systolic BP was 11 mm Hg (-5-19) with 14 mm Hg (IQR: 5–21) in the intervention group and 3 mm Hg (IQR -11-17) in the control group (
There was no difference between the groups regarding LDL-cholesterol treated to target with 32 patients (89%) at target in the intervention group versus 29 patients (78%) in the control group (
In 11 patients (31%) in the intervention group cholesterol lowering medication remained unchanged since discharge versus 29 (78%) of controls (
The combined endpoint of both BP and LDL-cholesterol at target was achieved in 22 (61%) of patients in the intervention group and in 10 patients (27%) in the control group (
The only significant change in lifestyle was a reduction in current smokers by four in the control group (
Characteristics | All( | Intervention( | Control( | P |
|---|---|---|---|---|
Systolic BP, mm Hg, mean ± SD | 134 ± 21 | 130 ± 17 | 137 ± 24 | 0.12 |
Diastolic BP, mm Hg, mean ± SD | 78 ± 11 | 78 ± 10 | 78 ± 12.8) | 0.94 |
Antihypertensive medication | 55 (75) | 29 (81) | 26 (70) | 0.31 |
100% compliance with AHM ( | 38 (84) | 23 (89) | 15 (79) | 0.38 |
LDL-cholesterol, mmol/l ( | 1.9 ± 0.8 | 1.9 ± 0.7 | 2.0 ± 0.8 | 0.66 |
Cholesterol lowering medication | 64 (88) | 32 (89) | 32 (86) | 0.76 |
100% compliance with CLM ( | 46 (89) | 24 (86) | 22 (92) | 0.50 |
Unhealthy dietingb | 59 (81) | 26 (72) | 33 (89) | 0.76 |
Current smoker | 15 (21) | 11 (31) | 4 (11) | 0.046a |
Alcohol > limitsc | 20 (27) | 11 (31) | 9 (24) | 0.55 |
Sedentary lifestyled | 16 (22) | 7 (20) | 9 (24) | 0.66 |
BMI ≥ 25 | 43 (59) | 21 (58) | 22 (60) | 0.92 |
Values are expressed as frequencies (%) or as mean ± standard deviations. Abbreviations: AHM, antihypertensive medication; CLM, cholesterol lowering medication.
Fisher’s exact test. b Less than 600 g of fruit and vegetables per day, fish for dinner less than twice per week. c More than 7 drinks per week in women/more than 14 drinks per week in men. d Less than 30 min of moderate physical activity per day.
Regarding vascular complications and death, we found 32 events in 22 patients after a median of 65 months. Median time to first event was 26 months (IQR: 4–49) with a median of 44 months (IQR: 11–49) in the intervention group and 19 months (IQR: 4–37) in the control group (
In this randomized clinical trial, a larger proportion of patients in the intervention group compared to controls had BP within the above-mentioned limits and the study fulfilled the aim of the primary endpoint.
A systematic review of interventions aimed at modifiable risk factor control for secondary prevention of stroke revealed improvement in achieving BP target.
In a study of integrated care with five prearranged visits to patients’ general practitioner versus usual care systolic BP at target set to 140 mm Hg was found in 75% versus 58% at 12-month follow up.
In a study where patients with minor stroke were randomized to six clinic visits by a pharmacist (intervention) or by a nurse (active control) aiming at treating both BP and LDL-cholesterol to target, 43% of patients in the pharmacist-led clinic met those two targets and so did 31% in the nurse-led clinic.
Our study has some limitations. Most participants had a minor stroke and patients had to be independent and without severe cognitive deficits, which is not representative of a general stroke population. With only 73 participants caution is called for in the drawing of conclusions from the results. Nonetheless, we decided to reorganize the outpatient clinic of our stroke unit as of October 2014 implementing strategies of the present study.
The strength of the study is the individual target for BP taking into account the diagnosis of stroke as well as important comorbidity as recommended by Boan et al.
In conclusion, the feasibility study has demonstrated that timely follow up of stroke patients in a dedicated preventive outpatient clinic may result in BP and cholesterol treated to target in most patients. To some extent it may postpone time to stroke recurrence, MI and death.
None.
The data that support the findings of this study are not available due to national privacy or ethical restrictions.
Agnete Hviid Hornnes, Email: agnete.hviid.hornnes@regionh.dk
Both authors have made substantial contributions to conception and design and acquisitions and analyses and interpretation of data and have; and been involved in writing the manuscript and given final approval of the version to be published. Both authors have participated sufficiently in the work to take public responsibility for the content; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Mai Bang Poulsen, MD, PhD Department of Neurology Nordsjællands Hospital Dyrehavevej 29 3400 Hillerød Denmark
ClinicalTrials.gov NCT03782857.
None.
In Denmark 25% of hospital admissions with stroke are recurrent strokes. With thrombolytic treatment more patients survive with only minor disability. This promising development should be followed up by intensive secondary prevention. Hypertension is the most important target. We aimed at testing the hypotheses that early follow up in a preventive clinic would result in 1) A higher proportion of patients with blood pressure at target, 2) Time to stroke recurrence, myocardial infarction and death would be longer in the intervention group compared to controls.
Eligible patients admitted to the stroke unit of Herlev Hospital were randomized shortly before discharge to intervention or control group. Of 78 included participants data from 73 was available for follow up nine months after inclusion. Patients in the intervention group were seen in the clinic within one week. In case of hypertension treatment was initiated or supplied with a new drug. We used individual targets for blood pressure according to diagnosis of stroke and patients’ comorbidity. Patients in the intervention group had a median of five visits to the preventive clinic.
Wiley Generico
In the intervention group blood pressure was treated to target in 25 patients (69%) versus 14 (38%) in the control group (
Treatment of hypertension to individual targets after stroke is feasible. It may postpone recurrent stroke and death in stroke survivors.
The is the third and last part of the volume devoted to solubility data of rare earth metal chlorides in water and in ternary and quaternary aqueous systems. Compilations of all available experimental data are introduced for each rare earth metal chloride with a corresponding critical evaluation. This part covers chlorides of Gd, Tb, Dy, Ho, Er, Tm, Yb, and Lu, with coverage of the literature through the middle of 2008.
Il s'agit de la troisième et dernière partie du volume consacrée aux données de solubilité des chlorures de métaux des terres rares dans l'eau et dans les systèmes aqueux ternaires et quaternaires. Une compilation de toutes les données expérimentales disponibles est présentée pour chaque chlorure de métaux des terres rares, accompagnée de l'évaluation critique correspondante. Cette partie couvre les chlorures de Gd, Tb, Dy, Ho, Er, Tm, Yb et Lu, avec une couverture de la littérature jusqu'à mi-2008.
simple image
caption
test paragraph
It is a far, far better thing that I do now than I have ever done.
A standard pullquote.
A half-left pullquote.
A half-right pullquote.
pullquote without content-type
blockquote
Over the last two decades continuous development of thrombolytic treatment of acute ischemic stroke (IS) has improved safety and functional outcome in treated patients
Hypertension is an important risk factor for stroke recurrence.
Observational studies have demonstrated the difficulties in lowering BP after stroke with rates of BP treated to target ranging from 28% to 73%
The aim of the present study was to test the hypotheses that follow up after stroke in a specialized nurse led physician supervised clinic with stepwise escalation of BP- and lipid lowering treatment would result in
Secondary endpoints: A greater reduction of BP A greater proportion of participants with LDL-cholesterol treated to target A greater reduction of LDL-cholesterol Longer time to recurrence of stroke, MI and death in the intervention group compared to controls
The benefits of geriatric day hospital care have been controversial for many years.
This systematic review of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care.
Day hospitals had a possible advantage over no comprehensive care in terms of death or poor outcome, disability, and use of resources.
The costs of day hospital care may be partly offset by a reduced use of hospital beds and institutional care among survivors.
Hello World!
The benefits of geriatric day hospital care have been controversial for many years.
This systematic review of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care.
Day hospitals had a possible advantage over no comprehensive care in terms of death or poor outcome, disability, and use of resources.
The costs of day hospital care may be partly offset by a reduced use of hospital beds and institutional care among survivors.
Before the initiation of the study the authors attended a three-day course in treatment of hypertension arranged by the Danish Society of Hypertension. The recommendations of our national guidelines regarding BP targets were in line with those given by the American Stroke Association in force at the time of initiation of the study: “An absolute target BP level and reduction are uncertain and should be individualized.”
LDL-cholesterol should be < 2.5 mmol/l in patients with IS or TIA in non-diabetic patients and in case of diabetes < 2.0 mmol/l.
A sample size calculation showed that 24 patients in each group were needed to show a difference of 10 mm Hg in the development of systolic BP (80% power).
From June 2012 to February 2013 all patients diagnosed with a stroke or TIA at the stroke unit of Herlev Gentofte Hospital, University of Copenhagen were considered for inclusion in the study. Patients should be without cognitive deficits that would prevent their active participation and they should be discharged to their own home. The last author used computer-generated block randomization procedures with stratification by hypertension (1:1). The allocation sequence was concealed, and we aimed at equal numbers in the two groups. Shortly before discharge the first author approached eligible patients for oral and written information about the study. Where written informed consent to participation was achieved BP was measured before a concealed envelope administered by a secretary was opened revealing the allocation to either intervention or control group.
The research protocol was approved by the ethics committee of the Capital Region of Denmark (H-3-2011–152) and by the Danish Data Protection Agency (2012–41-0429). The study was conducted according to all common ethical standards including the rules given by the Declaration of Helsinki. Patients randomized to the control group had the usual treatment: one visit in the outpatient clinic of the stroke unit three months after discharge. Patients randomized to the intervention group had an appointment with the first author within one week after discharge. The first author undertook all visits in the preventive clinic.
BP was measured at every visit after at least five minutes rest in a sitting position in an arm chair. BP was measured simultaneously in both arms followed by two measurements with 10-min intervals using the arm with the highest systolic BP. In case of hypertension the first author would suggest initiation or intensification of antihypertensive treatment. The last author would accept or suggest an alternative and do the prescription. Patients would come to the clinic for control of BP and relevant blood tests every 3–4 weeks until BP was at target. After five weeks on lipid lowering drugs treatment was intensified if needed. Patients who did not tolerate lipid lowering medication were referred to a dietitian. In motivated patients home BP measurements were performed using patients’ own monitor or by lending patients a BP monitor between visits.
Patients in the intervention group had a mean of five visits to the clinic with addition of new drugs rather than adding more of the same drug in case of hypertension. Although we used minimum doses to prevent adverse effects, many patients had unacceptable side effects necessitating change to another class of antihypertensive drug.
Patients were informed about the importance of life-long adherence with all preventive medication. Those with elevated BP or receiving antihypertensive treatment were advised in salt reduction, smokers were advised to stop smoking and all patients were informed about the benefits of 30 min of moderate physical activity daily. Likewise, information about the risk of an intake of alcohol above seven drinks per week in women and 14 drinks in men was part of the program as well as the benefits of weight reduction in overweight patients with hypertension or diabetes.
Participants in both groups were invited to the usual follow up visit three months after discharge at the outpatient clinic of the stroke unit as well as a follow up visit in the study a median of 9 (IQR 8–11) months after inclusion.
In accordance with the protocol the final follow up visits were performed by nurses in the outpatient clinic with measurement of BP and blood-cholesterols. Patients were asked not to reveal their group allocation but blinding of the nurses was not possible. Patients were interviewed about adherence to all preventive medications as well as their present life style. For practical purposes a minority of visits were performed by the first author. To do intention to treat analyses we used last observation carried forward regarding the endpoints of the study where patients had died or did not respond to the invitation to a follow up visit. Thus, we used the last recorded values in five patients in the intervention group and in seven controls.
After a median of 65 months (IQR: 61–66) from inclusion data on vascular events and death were attained from the hospital based medical records covering all hospitals of the region.
Data were entered into Excel and imported into SAS. Statistical analyses were performed by the first author according to a pre-established statistical analysis plan. We used Chi square test (for the primary outcome) or Fisher’s exact test as appropriate for comparison of proportions, and for change from baseline we used McNemar’s test. For continuous variables we used t-test or Mann-Whitney’s test*. Change from baseline was analyzed by the paired t-test or Wilcoxon signed rank sum test* (*where data were not normally distributed). We used SAS 9.4 for Windows and
We included 78 patients in the study. Due to revision of stroke diagnoses in four participants and as one participant never turned up for the intervention, data on 73 participants were available for follow up (
Flow chart of participants
Characteristics | All( | Intervention ( | Control ( | P |
|---|---|---|---|---|
Sex, female | 29 (40) | 15 (42) | 14 (38) | 0.74 |
Age (years), mean ± SD | 66 ± 12 | 63 ± 13 | 68 ± 11 | 0.08 |
Length of education< 10 years10 – 12 years> 12 years | 12 (17)22 (30)38 (53) | 6 (17)10 (29)19 (54) | 6 (16)12 (33)19 (51) | 0.95 |
Diagnosis of strokeIschemic StrokeTIAHemorrhagic stroke | 63 (87)9 (12)1 (1) | 33 (92)3 (8) | 30 (81)6 (16)1 (3) | 0.60a |
Recurrent stroke | 11 (15) | 5 (14) | 6 (16) | 1.00a |
Modified Rankin Scale score > 2 | 5 (6) | 1 (3) | 4 (11) | 0.36a |
Antihypertensive medication before stroke | 39 (53) | 15 (42) | 24 (65) | 0.047 |
Antihypertensive medication at discharge | 46 (63) | 20 (56) | 26 (70) | 0.19 |
Cholesterol lowering medication before stroke | 25 (34) | 11 (31) | 14 (38) | 0.51 |
Cholesterol lowering medication at discharge | 65 (89) | 35 (97) | 30 (81) | 0.03 |
Diabetes at baseline | 14 (19) | 5 (14) | 9 (24) | 0.37a |
Diabetes at discharge | 16 (22) | 6 (17) | 10 (27) | 0.29 |
Atrial fibrillation at baseline | 7 (10) | 3 (8) | 4 (11) | 1.00a |
Atrial fibrillation at discharge | 12 (16) | 6 (16) | 6 (17) | 1.00 |
Unhealthy dietingb | 59 (82) | 25 (71) | 34 (92) | 0.03 |
Current smoking | 19 (26) | 11 (31) | 8 (22) | 0.62 |
Alcohol above limitsc | 23 (32) | 12 (34) | 11 (30) | 0.68 |
Sedentary lifestyled | 17 (24) | 9 (26) | 8 (22) | 0.68 |
BMI ≥ 25 | 46 (63) | 24 (67) | 22 (59) | 0.52 |
Self-rated health: fair, poor, or very poor | 34 (47) | 15 (43) | 19 (51) | 0.47 |
Values are expressed as frequencies (%) or as mean ± standard deviations
Fisher’s exact test. b Less than 600 g of fruit and vegetables per day, fish for dinner less than twice per week. c More than 7 drinks per week in women/more than 14 drinks per week in men. d Less than 30 min of moderate physical activity per day.
Less than 20% of patients had a baseline BP treated to target (
Blood pressure and treatment of hypertension at baseline in 73 patients (%)
Follow up visits showed that 25 patients (69%) in the intervention group had a BP at target versus 14 (38%) of controls (
Blood pressure and treatment of hypertension at follow up in 73 patients (%)
Median reduction in systolic BP was 11 mm Hg (-5-19) with 14 mm Hg (IQR: 5–21) in the intervention group and 3 mm Hg (IQR -11-17) in the control group (
There was no difference between the groups regarding LDL-cholesterol treated to target with 32 patients (89%) at target in the intervention group versus 29 patients (78%) in the control group (
In 11 patients (31%) in the intervention group cholesterol lowering medication remained unchanged since discharge versus 29 (78%) of controls (
The combined endpoint of both BP and LDL-cholesterol at target was achieved in 22 (61%) of patients in the intervention group and in 10 patients (27%) in the control group (
The only significant change in lifestyle was a reduction in current smokers by four in the control group (
Characteristics | All( | Intervention( | Control( | P |
|---|---|---|---|---|
Systolic BP, mm Hg, mean ± SD | 134 ± 21 | 130 ± 17 | 137 ± 24 | 0.12 |
Diastolic BP, mm Hg, mean ± SD | 78 ± 11 | 78 ± 10 | 78 ± 12.8) | 0.94 |
Antihypertensive medication | 55 (75) | 29 (81) | 26 (70) | 0.31 |
100% compliance with AHM ( | 38 (84) | 23 (89) | 15 (79) | 0.38 |
LDL-cholesterol, mmol/l ( | 1.9 ± 0.8 | 1.9 ± 0.7 | 2.0 ± 0.8 | 0.66 |
Cholesterol lowering medication | 64 (88) | 32 (89) | 32 (86) | 0.76 |
100% compliance with CLM ( | 46 (89) | 24 (86) | 22 (92) | 0.50 |
Unhealthy dietingb | 59 (81) | 26 (72) | 33 (89) | 0.76 |
Current smoker | 15 (21) | 11 (31) | 4 (11) | 0.046a |
Alcohol > limitsc | 20 (27) | 11 (31) | 9 (24) | 0.55 |
Sedentary lifestyled | 16 (22) | 7 (20) | 9 (24) | 0.66 |
BMI ≥ 25 | 43 (59) | 21 (58) | 22 (60) | 0.92 |
Values are expressed as frequencies (%) or as mean ± standard deviations. Abbreviations: AHM, antihypertensive medication; CLM, cholesterol lowering medication.
Fisher’s exact test. b Less than 600 g of fruit and vegetables per day, fish for dinner less than twice per week. c More than 7 drinks per week in women/more than 14 drinks per week in men. d Less than 30 min of moderate physical activity per day.
Regarding vascular complications and death, we found 32 events in 22 patients after a median of 65 months. Median time to first event was 26 months (IQR: 4–49) with a median of 44 months (IQR: 11–49) in the intervention group and 19 months (IQR: 4–37) in the control group (
In this randomized clinical trial, a larger proportion of patients in the intervention group compared to controls had BP within the above-mentioned limits and the study fulfilled the aim of the primary endpoint.
A systematic review of interventions aimed at modifiable risk factor control for secondary prevention of stroke revealed improvement in achieving BP target.
In a study of integrated care with five prearranged visits to patients’ general practitioner versus usual care systolic BP at target set to 140 mm Hg was found in 75% versus 58% at 12-month follow up.
In a study where patients with minor stroke were randomized to six clinic visits by a pharmacist (intervention) or by a nurse (active control) aiming at treating both BP and LDL-cholesterol to target, 43% of patients in the pharmacist-led clinic met those two targets and so did 31% in the nurse-led clinic.
Our study has some limitations. Most participants had a minor stroke and patients had to be independent and without severe cognitive deficits, which is not representative of a general stroke population. With only 73 participants caution is called for in the drawing of conclusions from the results. Nonetheless, we decided to reorganize the outpatient clinic of our stroke unit as of October 2014 implementing strategies of the present study.
The strength of the study is the individual target for BP taking into account the diagnosis of stroke as well as important comorbidity as recommended by Boan et al.
In conclusion, the feasibility study has demonstrated that timely follow up of stroke patients in a dedicated preventive outpatient clinic may result in BP and cholesterol treated to target in most patients. To some extent it may postpone time to stroke recurrence, MI and death.
None.
The data that support the findings of this study are not available due to national privacy or ethical restrictions.
Agnete Hviid Hornnes, Email: agnete.hviid.hornnes@regionh.dk
Both authors have made substantial contributions to conception and design and acquisitions and analyses and interpretation of data and have; and been involved in writing the manuscript and given final approval of the version to be published. Both authors have participated sufficiently in the work to take public responsibility for the content; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.