Two new stroke guidelines emphasise the importance of a team approach and structured care, says Dr Alan Begg
The management of stroke is at last beginning to receive the attention it deserves. Two recently published guidelines will help to improve clinical care and the quality of life of these patients.
It is apparent from the management of other diseases that structured care can result in better identification of those at risk as well as a greater effort to address risk factors and commence prevention therapy.
A two-page concise version of the RCP’s National Clinical Guidelines for Stroke has been produced for GPs, which advocates that such an approach should be taken with stroke patients. This in time should translate into improved patient outcomes. Progress in rehabilitation and social integration should be reviewed regularly allowing further intervention as necessary.
Translating recommendations into a concise format can help implementation. However, it is important that the primary care team receive explicit advice, especially in light of the emphasis the new GMS contract clinical indicators place on prevention therapy.
The benefits of blood pressure reduction in stroke prevention in patients with a history of stroke or TIA irrespective of baseline blood pressure are clear from the PROGRESS study, although trial patients treated with an ACE inhibitor alone had a stroke risk similar to placebo.1
The BHS guidelines take the view that conventional blood pressure targets do not apply and recommend achieving the lowest tolerated blood pressure. There is a growing consensus that it is the size of blood pressure reduction rather than the particular regimen used that determines the benefit of treatment.
The benefits of aspirin after an ischaemic stroke are clear,and evidence for the additional benefit of also giving modified release dipyridamole comes from the European Stroke Prevention Study 2.2 MR dipyridamole alone compared with aspirin did not give a reduction in stroke, so for patients intolerant to aspirin GPs need to consider whether an alternative antiplatelet agent which will also protect against other vascular events might be more appropriate.
The benefits of statin therapy in preventing stroke in patients at high risk of an occlusive event have been shown in the Heart Protection Study.3 However, in patients with pre-existing cerebrovascular disease there was no apparent reduction in the stroke rate.
What this guideline aptly demonstrates is how the management of stroke is an active process involving full investigation and assessment.
Further evidence for this active approach is provided by the SIGN guideline on identification and management of dysphagia in patients with stroke. This guideline highlights the need for the assessment of stroke patients to identify swallowing problems, so that complications such as aspiration pneumonia, undernutrition and dehydration can be prevented.
The guideline illustrates the need for a highly trained stroke team and a fully integrated service, although it is important that these special skills are acquired across disciplines so that stroke care is not delayed if staff resources are not available.
The primary care team may not have an active role in assessing stroke patients with dysphagia, but raising their awareness of this potential problem and the benefits of home enteral tube feeding is important.
The challenge remains to interpret the evidence appropriately and give clear and precise recommendations, allowing seamless stroke care across organisational boundaries.
- Wennberg R, Zimmermann C. The PROGRESS trial three years later: time for a balanced report of effectiveness. Br Med J 2004; 329: 968-70.
- Diener HC, Cunha L, Forbes C et al. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143: 1-13.
- Collins R, Armitage J, Parish S et al; Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004; 363: 757-67.