Developments in secondary prevention, management of TIAs and stroke care services are reflected in the new guidelines. Dr Tony Rudd and Penny Irwin report


   

National audit1 and studies comparing processes and outcomes with those in other European countries have shown that stroke care in the UK is in need of reform.2

Although the proportion of stroke patients being treated in stroke units is increasing, the latest audit for which figures are available, in 1999, showed that 75% of stroke patients in England, Wales and Northern Ireland still do not receive specialist care. Data on implementation of effective secondary prevention likewise suggests that patients receive suboptimal treatment.3

For these reasons, the multidisciplinary Intercollegiate Working Party on Stroke, organised through the Royal College of Physicians of London, developed and published the National Clinical Guidelines for Stroke in March 2000. These have now been updated and are available on www.rcplondon.ac.uk. A paper version of the supplement should be available from June and a fully revised second edition will be available at the beginning of 2004.

Updated information

The guidelines have been expanded to include the management of transient ischaemic attack (TIA), and the next edition will also include stroke in children and subarachnoid haemorrhage.

With the publication of the National Service Framework (NSF) for Older People4 recommending that stroke care be delivered as recommended by the National Clinical Guidelines, keeping them up to date and ensuring that they are widely known and as accessible as possible become particularly important.

Over the past year there have been important developments, particularly in secondary prevention as well as in the organisation of care for patients with TIA and minor stroke who are not admitted to hospital.

Secondary prevention

The two major trials that have affected the guidelines (Table 1, below) are the HOPE5 and PROGRESS6 trials. Both trials looked at the effects of long-acting angiotensin converting enzyme (ACE) inhibitors on secondary prevention of stroke. Both support the use of ACE inhibitors, even, in the case of the PROGRESS trial, in patients without hypertension.

Table 1: Secondary prevention of stroke*

These guidelines apply to all patients with TIA and stroke, even those not admitted to hospital. Therefore they refer to patients either before discharge from hospital or before 2 weeks have passed from stroke onset, whichever is the sooner.

a. All patients should have their blood pressure checked, and hypertension persisting for more than one month should be treated. The British Hypertension Society guidelines are: optimal blood pressure treatment targets are systolic blood pressure <140mmHg and diastolic blood pressure <85mmHg; the minimum accepted level of control recommended is <150/<90mmHg. For patients with diabetes, the target level of control should be 140/85mmHg. (A)

b. Further reduction of blood pressure should be considered using a combination of long-acting ACE inhibitor (e.g. perindopril or ramipril) and a thiazide diuretic (e.g. indapamide). (A)

c. All patients with ischaemic stroke who are not on anticoagulation should be taking an antiplatelet agent, i.e. aspirin (75-325mg) daily (A), or clopidogrel, or a combination of low-dose aspirin and dipyridamole modified release (MR). Where patients are aspirin intolerant an alternative antiplatelet agent (clopidogrel 75mg daily or dipyridamole MR 200mg twice daily) should be used (A)

d. Anticoagulation:

i. should not be used after TIAs or minor strokes unless cardiac embolism is suspected (A)

ii. should not be started until brain imaging has excluded haemorrhage, and 14 days have passed from the onset of an ischaemic stroke (A)

iii. should be started in every patient in atrial fibrillation (valvular or non-valvular) unless contraindicated (A)

iv. should be considered for all patients who have ischaemic stroke associated with mitral valve disease, prosthetic heart valves, or within 3 months of myocardial infarction (C)

e. Any patient with a carotid artery area stroke, and minor or absent residual disability, should be considered for carotid endarterectomy (A)

f. Carotid endarterectomy should be considered where carotid stenosis is measured at greater than 70% (A)

g. All patients should be assessed for other vascular risk factors and be treated or advised appropriately (B)

h. Therapy with a statin should be considered for all patients with a history of ischaemic heart disease and a cholesterol >5.0mmol/l following stroke (A)

* See Table 4, below, for explanation of grading of recommendations

The principal questions that arise from the trials are:

  • Are the benefits specific to perindopril and indapamide (PROGRESS) and ramipril (HOPE), or would any (possibly cheaper) long-acting ACE inhibitor be as effective?
  • Are the effects the result of blood pressure lowering alone, or is there some other mechanism operating?

The working party believed that clinicians should preferably use the drugs that had been shown to be effective in the trials, until further evidence became available.

The target blood pressure values remain those recommended by the British Hypertension Society,7 but having achieved those values, consideration should be given to adding an ACE inhibitor and thiazide diuretic. The PROGRESS trial suggests that the lower the blood pressure that can be achieved without adverse effects the better.

Further developments in the secondary prevention of stroke can be expected over the coming months. The imminent publication of the Heart Protection Study may affect the guideline on use of statins, and the LIFE study8 has addressed the benefits of losartan, albeit in primary stroke prevention.

The MATCH trial comparing clopidogrel with the combination of clopidogrel and aspirin for stroke prevention in high-risk patients should report within the next 2 years, and there may be further data on the combination of aspirin with dipyridamole.

Management of TIAs

TIAs are a major risk factor for stroke. More than 50% of patients who go on to develop a stroke will do so within the first month after the TIA (Table 2).

Table 2: Management of transient ischaemic attack (TIA)*

a. Patients first seen in the community with TIA, or with a stroke but having made a good recovery when seen, should be assessed and investigated in a specialist neurovascular clinic within 14 days of onset. They do not need admission to hospital unless:

i. The patient cannot be seen in a specialist neurovascular clinic within 2 weeks (C)

ii. An underlying cause requiring urgent treatment is suspected (C)

iii. The patient has had more than one TIA within a short period (crescendo TIA) (C)

b. Patients with hemispheric TIA should have brain imaging to exclude arteriovenous malformation, subdural haematoma and tumours (C)

* See Table 4, below, for explanation of grading of recommendations

It is therefore essential to organise local services so that patients can be seen and investigated rapidly and appropriate prevention measures can be implemented. Although there is a paucity of evidence on how such services should be organised, the working party felt that a consensus statement should be made to guide primary care and acute trusts as to the standards that should be developed.

Organisation of care

The most effective intervention in terms of reducing both morbidity and mortality after stroke is the provision of specialist 'stroke unit care' (Table 3). There is no drug for acute treatment that even begins to approach the magnitude of the stroke unit effect.

Table 3: Organisation of stroke care*

a. Every organisation involved in the care of stroke patients over the first 6 months should ensure that all stroke patients are the responsibility of services specialising in stroke and rehabilitation (A). Any patient with moderate or severe symptoms should be referred to hospital with the expectation of admission to a stroke unit. Exceptions may include those relatively few patients for whom the diagnosis will make no difference to management. The stroke service should comprise:

i. a geographically identified unit (A)

ii. a coordinated multidisciplinary team (A)

iii. staff with specialist expertise in stroke and rehabilitation (A)

iv. educational programmes for staff, patients and carers (A)

v. agreed protocols for common problems (A)

vi. a neurovascular clinic for the rapid assessment of transient ischaemic attack (TIA) and minor stroke (C)

vii. access to brain and vascular imaging services (C)

b. Patients should only be managed at home if:

i. care services are able to provide adequate and flexible support within 24 hours (C)

ii. the services delivered at home are part of a specialist stroke service (A)

c. Specialist stroke services can be delivered to patients, after the acute phase, equally effectively in hospital or in the community, provided that the patient can transfer from bed to chair before going home and provided that the patient continues to be seen by a specialised multidisciplinary stroke team.(A)

d. Specialist day hospital rehabilitation or specialist domiciliary rehabilitation can be offered to outpatients with equal effect (A)

* See Table 4, below, for explanation of grading of recommendations

For this reason the major pressure being applied to commissioners of healthcare and central government is to develop stroke units of adequate size for the stroke population in all hospitals. GPs who do not get their patients admitted to a stroke unit should be making their displeasure known to those responsible for delivering services locally.

The NSF for Older People requires all hospitals to have plans for specialist stroke services by April 2002, and to have implemented them by April 2004. If these deadlines are met then truly a revolution in stroke care will have been achieved.

Conclusion

Stroke is a rapidly developing field. Many aspects of management fall to GPs to deliver, but unfortunately GPs are overburdened with guidelines and targets. However, if the structures are in place to identify appropriate patients, to enable rapid access to specialist inpatient and outpatient services and to deliver high quality rehabilitation and secondary prevention in the community, the benefits to patients and society will be huge.The key is close collaborative working between primary and secondary care.

Table 4: Guideline strength: level of evidence and grade of recommendation
Level of evidence Type of evidence Grade of recommendation
Ia Meta-analysis of randomised controlled trials (RCTs) A
Ib At least one RCT A
IIa At least one well-designed, controlled study but without randomisation B
IIb At least one well-designed, quasi-experimental study B
III At least one well-designed, non-experimental descriptive study (e.g. comparative studies, correlation studies, case studies) B

IV

Expert committee reports, opinions and/or experience of respected authorities C
  • The National Clinical Guidelines for Stroke are available on the Royal College of Physicians' website: www.rcplondon.ac.uk

References

  1. Rudd AG, Lowe D, Irwin P, et al. National Stroke Audit: a tool for change? Quality in Health Care 2001; 10: 141-51.
  2. Wolfe CD, Tilling K, Beech R, Rudd AG. Variations in case fatality and dependency from stroke in western and central Europe. The European BIOMED Study of Stroke Care Group. Stroke 1999; 30: 350-6.
  3. Hillen T, Dundas R, Lawrence E et al. Antithrombotic and antihypertensive management 3 months after ischemic stroke: a prospective study in an inner city population. Stroke 2000; 31: 469-75.
  4. Department of Health. The National Service Framework for Older People. London: Department of Health, 2001.
  5. Heart Outcomes Prevention Evaluation Study Investigators (HOPE). Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000a; 342: 145-53.
  6. PROGRESS Collaborative Group. Randomized trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033-41.
  7. Ramsay LE, Williams B, Johnston DG et al. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens 1999; 13: 569-92.
  8. Dahlof B, Devereux RB, Kjeldsen SE et al for the LIFE study group. Cardiovascular morbidity and mortality in the Losartan Intervention for Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359: 995-1003.

Guidelines in Practice, June 2002, Volume 5(6)
© 2002 MGP Ltd
further information | subscribe