The second edition of the Royal College of Physicians’ National Clinical Guidelines for Stroke 1 was published in June 2004. A two page concise version for GPs has now been produced2 (see below) and can be downloaded free of charge from www.rcplondon.ac.uk.
Primary care has the lead role in the identification of transient ischaemic attacks (TIAs), secondary prevention, and the organisation and provision of long-term rehabilitation, although the acute care of stroke should be predominantly the responsibility of secondary care.
The average GP will see only three or four new cases of stroke each year, despite the fact that it is the third most common cause of death in the United Kingdom3 and one of the most important causes of significant disability in adults. Keeping abreast of current research and maintaining clinical skills in stroke is therefore likely to be extremely challenging. The Primary Care Concise Guidelines for Stroke 2004 2 have been produced to help overcome these difficulties and improve the quality of care patients receive.
Progress in stroke management
It is only recently that stroke has started to be taken seriously and appropriate treatment offered. Thirty years ago it was seen as a largely untreatable condition; there was little teaching on stroke in the undergraduate curriculum and patients were managed passively on general and geriatric wards until they got better, died or could be discharged into the community.
Even 15 years ago, patients with stroke could be scattered between different wards and managed by whichever physician they happened to have been admitted under. Coordinated multidisciplinary care may have taken place on geriatric wards but younger patients in particular often received poor care.
The inclusion of a section on stroke in the National Service Framework for Older People, published in 2001, 4 was a major turning point in improving the organisation of stroke care, as it set the target of every hospital providing a specialist stroke service by April 2004. Although this has not been achieved in all hospitals, the latest National Sentinel Stroke Audit,5 published in August 2004, shows that 82% of hospitals in England now have a stroke unit.
Less progress has been made in the delivery of community stroke services 5 and this should be one of the major targets for the coming years.
We know from previous audits that effective secondary prevention, particularly the management of hypertension and hyperlipidaemia, is sporadic,6 and that the treatment of TIA is often slow, with the likelihood that this results in unnecessary strokes. 5 One of the major complaints of patients discharged from hospital after stroke is that they feel abandoned and do not receive the amount of rehabilitation they need.
Neurovascular clinics are becoming more widely available, but to maintain their effectiveness it is important that they are not filled with inappropriate referrals. Most clinics report that fewer than half of the patients referred to them actually have cerebrovascular disease.7 When confronted by a patient who may have had a TIA it is worth asking four questions before booking them into a clinic:8
- Are the neurological symptoms focal?
- Are the neurological symptoms negative rather than positive?
- Was the onset of the focal neurological symptoms sudden?
- Were the focal neurological symptoms maximal in onset rather than progressing over a period?
If the answer to all four questions is yes, the symptoms are almost certainly caused by vascular pathology. If even one of the answers is no, cerebrovascular disease is much less likely and alternative diagnoses should be considered.
Non-focal symptoms such as faintness, dizziness, light-headedness, confusion, mental disorientation, incontinence and syncope are all very unlikely to be caused by TIA. Positive motor or sensory phenomena such as abnormal movements are more likely to be caused by epilepsy. Migraine often produces focal neurological symptoms but, again, they are usually positive symptoms developing over minutes, rather than the sudden onset typical of TIA.
If the patient is likely to have had a TIA it is important that he or she is seen and investigated urgently. Patients who suffer a hemispheric TIA have up to a 20% chance of developing a stroke within a month.2 The guidelines recommend that patients have the diagnosis and cause established as far as possible within seven days of the event to minimise the risk of progressing to stroke. Unless there are reasons suggesting the possibility of cerebral haemorrhage the guidelines recommend starting aspirin 300 mg daily pending investigation. Patients with more than one TIA in a week should be investigated in hospital immediately.
|Figure 1: First page of the primary care concise guidelines|
|Figure 2: Second page of the primary care concise guidelines|
|Reproduced with the kind permission of the Royal College of Physicians|
Management of stroke
Any patient with persistent symptoms should be rapidly referred to hospital with the expectation of admission to a stroke unit. All patients with suspected stroke should call for an ambulance and go straight to hospital rather than contact primary care services. There will be a few patients for whom admission is inappropriate, such as those receiving palliative care where the diagnosis of stroke is not relevant to their overall clinical management, but these should be the exception.
One of the reasons why many stroke patients do not receive adequate secondary prevention may be a lack of clarity over which medical team, primary or secondary, is responsible for care after discharge from hospital. This should be clarified within each primary care trust. In most cases it is likely that management by the GP will be most appropriate.
A further problem is the failure to empower patients to take control of their own stroke prevention, by not providing them with sufficient information about the cause of their stroke, their target blood pressure and cholesterol level and the lifestyle changes that they should make. A patient version of the guidelines 2 has been developed to help inform patients and carers, and is available free of charge from the Stroke Association (0845 30 33 100). It can also be downloaded from the RCP website.
Function can continue to improve for many months and even years after the initial event. It makes no sense for all treatment to be concentrated in the first few weeks and for there to be nothing available when patients are attempting to adapt to life back in the community.
Patients should receive as much rehabilitation as they can tolerate while they are continuing to benefit from it, and the guidelines recommend that they should continue to have access to specialist stroke care and rehabilitation after leaving hospital.
Any patient with reduced activity at 6 months or later after stroke should be assessed for a period of further targeted rehabilitation. Patients and their carers should have their individual psychosocial and support needs reviewed regularly.
However, independence should be encouraged. As patients become more active, consideration should be given to withdrawal of physical and psychological support. There comes a time when cessation of therapy and withdrawal of personal care support may be appropriate as part of the process of helping people to accept and live with the function they have, rather than putting their lives on hold pending recovery that may never happen.
Management of chronic disease is most appropriately coordinated by primary care. Apart from during the acute stage of the disease when admission to hospital and management by specialists should be the norm, GPs should be closely involved in the organisation and delivery of care. It is hoped that these guidelines will aid that process and contribute towards a transformation of the quality of care that stroke patients receive.
- Intercollegiate Stroke Working Party, Royal College of Physicians. National Clinical Guidelines for Stroke. Second edition. London: Royal College of Physicians, 2004. www.rcplondon.ac.uk/pubs/books/stroke/index.htm
- Action for Stroke Group and Royal College of Physicians. Primary Care Concise Guidelines for Stroke 2004. London: Royal College of Physicians, 2004. www.rcplondon.ac.uk/pubs/books/stroke/index.htm
- Wolfe C, Rudd T, Beech R (Eds). Stroke Services and Research. London: Stroke Association, 1996.
- Department of Health. National Service Framework for Older People. London: Department of Health, 2001.
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London. National Sentinel Stroke Audit. Organisational audit 2004 (Concise report). London: Royal College of Physicians of London, August 2004. www.rcplondon.ac.uk
- Rudd AG, Lowe D, Hoffman A et al. Secondary prevention for stroke in the United Kingdom: results from the National Sentinel Audit of Stroke Age Ageing 2004; 33(3): 280-6.
- Personal communication.
- Warlow CP, Dennis MS, van Gijn J et al. Stroke: a practical guide to management, 2nd Edition. Oxford: Blackwell Science Ltd, 2000.
- The Stroke Association and Royal College of Physicians. Care after stroke and transient ischaemic attack: information for patients and their carers. London:Royal College of Physicians, 2004. www.rcplondon.ac.uk/pubs/books/stroke/index.htm