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Primary Community Perspective on Stroke Care

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Primary Community Perspective on Stroke Care

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    1. Jonathan Mant, Professor of Primary Care Research Primary & Community Perspective on Stroke Care

    2. Patient pathway and primary care

    3. Prevention of stroke

    4. Who is at high risk of stroke? Lifestyle factors: Obesity; physical inactivity; excessive alcohol consumption; smoking; diet Medical factors: Hypertension; atrial fibrillation; carotid artery stenosis; diabetes mellitus (Raised cholesterol) Existing disease: Previous stroke or TIA; coronary heart disease

    5. How common are these risk factors for a GP with list size 2,000?

    6. What evidence based treatments? Blood pressure lowering Agents Statins to lower cholesterol Anti-platelet agents (aspirin) Carotid endarterectomy Anticoagulation for atrial fibrillation Lifestyle intervention

    7. Vascular disease prevention strategies Much stroke prevention is same as coronary heart disease prevention Identification of people at raised cardiovascular risk & treat with cholesterol lowering therapy and blood pressure lowering therapy Current threshold 20% 10 year cardiovascular risk Stroke specific strategies (TIA; AF) Population strategies aimed at Smoking; diet; exercise

    8. Change in stroke incidence 1981-2004

    12. Stroke specific primary prevention Strategies that are stroke focussed are: Rapid treatment of transient ischaemic attack Detection and treatment of carotid artery stenosis Detection and treatment of atrial fibrillation

    13. Early treatment of TIA

    20. Express Study: before and after study of effect of urgent treatment of TIA/ minor stroke Phase 1 GP referral to daily clinic Treatment recommendations faxed to GP Patients advised to see GP asap Phase 2 No appointment required Treatment initiated immediately in clinic

    22. Express treatment protocol Aspirin 300mg given in clinic (then 75mg daily) Clopidogrel 300mg then 75mg daily if within 48 hrs Simvastatin 40mg daily BP lowering therapy if systolic BP = 130mmHg Anticoagulation if indicated Carotid imaging during following week CT scan during clinic if incomplete symptom resolution

    23. Differences in process of care from phase one to phase two in EXPRESS Speedier assessment after symptom onset (3 days to less than one day) Faster treatment (20 days to less than one day) Greater use of preventive medicines at one month follow up: Aspirin + clopidogrel: 49% v 10% Statin: 84% v 65% On BP lowering: 83% v 62% Lower BP at one month: 136/75 v 142/80

    24. Questions in TIA care Which treatments are effective in acute TIA management? Should GPs initiate treatment?

    25. Evidence base for specific therapies in acute phase of TIA/ minor stroke Aspirin v Carotid endarterectomy v Addition of second anti-platelet agent? BP lowering Long term v Early phase ? Cholesterol lowering Long term v Early phase ?

    26. Effectiveness of Endarterectomy in relation to timing of surgery Rothwell et al, Lancet 2004 (20th March)

    27. Detection and treatment of atrial fibrillation

    31. NICE guidelines: caution with warfarin Aged over 75 On anti-platelet drugs Polypharmacy Uncontrolled hypertension History of bleeding (eg peptic ulcer; cerebral haemorrhage) History of poor anticoagulation control

    34. BAFTA Results Risk of primary end point: Warfarin v aspirin 1.8% p.a v 3.8% p.a RR 0.48 (0.28-0.80) NNT: 50 for 1 year p = 0.0027

    35. BAFTA bleeding risk per annum

    36. Secondary prevention Aspirin + dipyridamole Simvastatin 40mg Blood pressure lowering Anticoagulation if indicated

    37. Effect of statin on risk of stroke and cardiovascular events Heart Protection Study, Lancet 2004 (6th March)

    39. PROGRESS – sub group analyses P value for heterogeneity: <0.001 for combination versus singleP value for heterogeneity: <0.001 for combination versus single

    42. Quality markers (1) High quality specialist rehabilitation Stroke units Early supported discharge Longer term availability in the community End of life care Responsive care with appropriate skills

    43. Quality Markers (2) Seamless transfer of care Clear discharge plan Inter-sectoral (health; social services; transport; housing) That is communicated Long term care & support Emotional and psychological factors Adaptation of environment Carer engagement and support

    44. Quality Markers (3) Assessment and review Health & social care By primary care: 6 weeks; 6 months; annual Participation in community life Local opportunities & resources Liaison with community & voluntary sector Return to work

    46. Community perspective - conclusion Significant advances in evidence base for stroke prevention in last 15 years Implementation strategies need to be in place Lots of longer term unmet need Needs multi-disciplinary and inter-sectoral approach Mustn’t be neglected Current lack of service provision Current lack of research

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