Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses

Effectiveness of motivational interviewing on medication adherence for the prevention of recurrent stroke or transient ischemic attack: Systematic review of randomized controlled trials

BACKGROUND AND PURPOSE

This systematic review examines the effectiveness of motivational interviewing (MI) on medication adherence for preventing recurrent stroke and transient ischemic attack (TIA).

METHODS

MEDLINE (via PubMed), CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov were searched from inception to 12 June 2023. Randomized controlled trials comparing MI with usual care or interventions without MI in participants with any stroke type were identified and summarized descriptively. Primary outcome was medication adherence. Secondary outcomes were quality of life (QoL) and different clinical outcomes. We assessed risk of bias with RoB 2 (revised Cochrane risk-of-bias tool) and intervention complexity with the iCAT_SR (intervention Complexity Assessment Tool for Systematic Reviews).

RESULTS

We screened 691 records for eligibility and included four studies published in five articles. The studies included a total of 2751 participants, and three were multicentric. Three studies had a high risk of bias, and interventions varied in complexity. Two studies found significantly improved medication adherence, one at 9 (96.9% vs. 88.2%, risk ratio = 1.098, 95% confidence interval = 1.03-1.17) and one at 12 months (97.0% vs. 95.0%, p = 0.026), but not at other time points, whereas two other studies reported no significant changes. No significant differences were found in QoL or clinical outcomes.

CONCLUSIONS

Evidence on MI appears inconclusive for improving medication adherence for recurrent stroke and TIA prevention, with no benefits on QoL and clinical outcomes. There is a need for robustly designed studies and process evaluations of MI as a complex intervention for people with stroke.

REGISTRATION

PROSPERO (CRD42023433284).

Reducing risk behaviours after stroke: An overview of reviews interrogating primary study data using the Theoretical Domains Framework

BACKGROUND

Lifestyle changes, in addition to preventive medications, optimise stroke secondary prevention. Evidence from systematic reviews support behaviour-change interventions post-stroke to address lifestyle-related risk. However, understanding of the theory-driven mediators that affect behaviour-change post-stroke is lacking.

METHODS

Electronic databases MEDLINE, Embase, Epistemonikos and Cochrane Library of Systematic Reviews were searched to March 2023 for systematic reviews addressing behaviour-change after stroke. Primary studies from identified systematic reviews were interrogated for evidence supporting theoretically-grounded interventions. Data were synthesized in new meta-analyses examining behaviour-change domains of the Theoretical Domains Framework (TDF) and secondary prevention outcomes.

RESULTS

From 71 identified SRs, 246 primary studies were screened. Only 19 trials (N = 2530 participants) were identified that employed theoretically-grounded interventions and measured associated mediators for behaviour-change. Identified mediators mapped to 5 of 14 possible TDF domains. Trial follow-up ranged between 1-12 months and no studies addressed primary outcomes of recurrent stroke or cardiovascular mortality and/or morbidity. Lifestyle interventions targeting mediators mapped to the TDF Knowledge domain may improve the likelihood of medication adherence (OR 6.08 [2.79, 13.26], I2 = 0%); physical activity participation (OR 2.97 [1.73, 5.12], I2 = 0%) and smoking cessation (OR 10.37 [3.22, 33.39], I2 = 20%) post-stroke, supported by low certainty evidence; Lifestyle interventions targeting mediators mapping to both TDF domains of Knowledge and Beliefs about Consequences may improve medication adherence post-stroke (SMD 0.36 [0.07, 0.64], I2 = 13%, very low certainty evidence); Lifestyle interventions targeting mediators mapped to Beliefs about Capabilities and Emotions domains may modulate low mood post-stroke (SMD -0.70 [-1.28, -0.12], I2 = 81%, low certainty evidence).

CONCLUSION

Limited theory-based research and use of behaviour-change mediators exists within stroke secondary prevention trials. Knowledge, Beliefs about Consequences, and Emotions are the domains which positively influence risk-reducing behaviours post-stroke. Behaviour-change interventions should include these evidence-based constructs known to be effective. Future trials should address cardiovascular outcomes and ensure adequate follow-up time.

Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2)

Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.

Age and Aspirin Dosing in Secondary Prevention of Atherosclerotic Cardiovascular Disease

BACKGROUND

In patients with atherosclerotic cardiovascular disease, increasing age is concurrently associated with higher risks of ischemic and bleeding events. The objectives are to determine the impact of aspirin dose on clinical outcomes according to age in atherosclerotic cardiovascular disease.

METHODS AND RESULTS

In the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) trial, patients with atherosclerotic cardiovascular disease were randomized to daily aspirin doses of 81 mg or 325 mg. The primary effectiveness end point was death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke. The primary safety end point was hospitalization for bleeding requiring transfusion. A total of 15 076 participants were randomized to aspirin 81 mg (n=7540) or 325 mg (n=7536) daily (median follow-up: 26.2 months; interquartile range: 19.0-34.9 months). Median age was 67.6 years (interquartile range: 60.7-73.6 years). Among participants aged <65 years (n=5841 [38.7%]), a primary end point occurred in 226 (7.54%) in the 81 mg group, and in 191 (6.80%) in the 325 mg group (adjusted hazard ratio [HR], 1.23 [95% CI, 1.01-1.49]). Among participants aged ≥65 years (n=9235 [61.3%]), a primary end point occurred in 364 (7.12%) in the 81 mg group, and in 378 (7.96%) in the 325 mg group (adjusted HR, 0.95 [95% CI, 0.82-1.10]). The age-dose interaction was not significant (P=0.559). There was no significant interaction between age and the randomized aspirin dose for the secondary effectiveness and the primary safety bleeding end points (P>0.05 for all).

CONCLUSIONS

Age does not modify the impact of aspirin dosing (81 mg or 325 mg daily) on clinical end points in secondary prevention of atherosclerotic cardiovascular disease.

Health risk factors in Australian Stroke Survivors: A latent class analysis

ISSUES ADDRESSED

To (i) determine the prevalence of health risk factors (physical activity, diet, alcohol, smoking, blood pressure medication use and mental health) in community-dwelling stroke survivors; and (ii) examine how these health risk factors cluster, and identify associations with physical functioning, independent living, or sociodemographic factors.

METHODS

A secondary analysis of data obtained during a national randomised controlled trial. Participants had experienced stroke and completed a baseline telephone survey on demographic and stroke characteristics, health risk factors, physical functioning and independence in activities of daily living. A latent class analysis was performed to determine health risk profiles. Univariate logistic regressions were performed to identify if participant characteristics were associated with resulting classes.

RESULTS

Data analysed from 399 participants. Two classes of health risk factors were identified: Low Mood, Food & Moves Risk (16% of participants) and Alcohol Use Risk (84% of participants). The Low Mood, Food & Moves Risk group had poorer diet quality, lower physical activity levels and higher levels of depression and anxiety. Lower levels of independence and physical functioning were predictor variables for this group. In contrast, the Alcohol Use Risk group had better physical activity and diet scores, significantly lower probability of depression and anxiety, but a higher probability of risky drinking.

CONCLUSIONS

We identified two distinct health risk factor groups in our population. SO WHAT?: Future interventions may benefit from targeting the specific needs and requirements of people who have experienced stroke based on their distinct risk group. Alcohol consumption in poststroke populations requires further attention.

Disability Status and Secondary Prevention Among Survivors of Stroke: A Cross-Sectional Analysis of the 2011 to 2018 National Health and Nutrition Examination Survey

BACKGROUND

Among survivors of stroke, adherence to secondary prevention care is associated with decreased risk of recurrent stroke. However, not all survivors of stroke use secondary stroke prevention treatment. We examined the association between the disability status of survivors of stroke and their treatment and control of diabetes, hyperlipidemia, and hypertension.

METHODS AND RESULTS

In a cross-sectional analysis of the 2011 to 2018 National Health and Nutrition Examination Survey, we compared diabetes, hyperlipidemia, and hypertension treatment and control rates among self-reported survivors of stroke age ≥20 years with and without disability. Disability was defined as self-reporting any of 5 physical or 4 functional domains assessed using a structured questionnaire. Logistic regression models adjusted for age, sex, race and ethnicity, and history of medical conditions were used to estimate associations between disability status and risk factor treatment and control. The mean age of survivors of stroke was 65.1 years, and 55.5% were female; 76% (95% CI, 72.7%-79.3%) self-reported at least 1 disability. Age-standardized treatment rates for diabetes, hyperlipidemia, and hypertension were 33.1% (95% CI, 26.9%-39.2%), 67.5% (95% CI, 62.6%-72.3%), and 78.4% (95% CI, 74.6%-82.2%), respectively. Age-standardized control rates for diabetes, hyperlipidemia, and hypertension were 86.8% (95% CI, 83.8%-89.8%), 20.5% (95% CI, 15.0%-25.9%), and 47.1% (95% CI, 42.6%-51.7%), respectively. In adjusted models, those with and without disabilities had similar odds of risk factor treatment and control.

CONCLUSIONS

In the United States, three-quarters of survivors of stroke self-reported a disability, and these patients had similar odds of diabetes, hyperlipidemia, and hypertension treatment and control compared with those without disability.

Improving health literacy of antibiotic use in people with cystic fibrosis (CF)-comparison of the readability of patient information leaflets (PILs) from the EU, USA and UK of 23 CF-related antibiotics used in the treatment of CF respiratory infections

Background

Antibiotic adherence is poor amongst people with cystic fibrosis (CF). Low-quality patient information leaflets (PILs), which accompany prescription antibiotics, with poor readability may contribute to poor antibiotic adherence, with the potential for antimicrobial resistance (AMR) development. The aim of this study was to examine the readability of antibiotic PILs used to treat CF lung infections.

Methods

CF-related antibiotics (n = 23; seven classes: aminoglycosides, β-lactams, fluoroquinolones, macrolides/lincosamides, oxazolidinones, tetracyclines, trimethoprim/sulfamethoxazole) were investigated. Readability of PILs (n = 141; 23 antibiotics) from the EU (n = 40), USA (n = 42) and UK (n = 59) was calculated.

Results

Mean [± standard error of mean (SEM)] values for the Flesch Reading Ease (FRE) for EU, USA and UK were 50.0 ± 1.1, 56.2 ± 1.3 and 51.7 ± 1.1, respectively (FRE target ≥60). Mean (± SEM) values for the Flesch Kinkaid Grade Level (FKGL) for the EU, USA and UK were 9.0 ± 0.2, 7.5 ± 0.2 and 9.6 ± 0.2, respectively (FKGL target ≤8). US PILs were significantly shorter (P < 0.0001) in words (mean ± SEM = 1365 ± 52), than either UK or EU PILs, with fewer sentences (P < 0.0001), fewer words per sentence (P < 0.0001) and fewer syllables per word. The mean ( ± SEM) reading time of UK PILs (n = 59) was 12.7 ± 0.55 mins .

Conclusions

Readability of antibiotic PILs is poor. Improving PIL readability may lead to improved health literacy, which may translate to increased antibiotic adherence and AMR avoidance. Authors preparing written materials for the lay/patient CF community are encouraged to employ readability calculators, so that final materials are within recommended readability reference parameters, to support the health (antibiotic) literacy of their readers.

[Inclisiran in patients with acute ischemic stroke: first data]

AIM

To evaluate the effect of inclisiran therapy on parameters of lipid metabolism in hospitalized patients with acute ischemic stroke.

MATERIAL AND METHODS

A prospective, observational, non-randomized study was performed. The study included 12 patients with acute ischemic stroke prescribed with a combination lipid-lowering therapy with inclisiran (284 mg as a single dose). At 15 days after the start of therapy, changes in blood lipid composition were assessed. For quantitative variables, median, maximum and minimum values were determined. The significance of differences between related samples in quantitative variables was assessed using the Mann-Whitney test.

RESULTS

Before the start of combination lipid-lowering therapy, total cholesterol (TC) was 7.33 mmol/l and low-density lipoprotein C (LDL-C) was 5.23 mmol/l. At 15 days after the start of inclisiran therapy, TC significantly decreased by 52.1 % and LDL-C decreased by 71.1 %. The proportion of patients who reached the LDL-C goal was 66.7 %. There were no adverse events considered by the investigators to be related with the therapy.

CONCLUSION

The strategy of early administration of inclisiran (or its combination with a statin) in patients with ischemic stroke allows safe achievement of a significant reduction in LDL-C already in 15 days after the start of therapy.

User-Centered Mobile Applications for Stroke Survivors (MAPPS): A Mixed-Methods Study of Patient Preferences

OBJECTIVE

Investigate stroke survivors' (SS) preferences for a hypothetical mHealth app for post-stroke care and to study the influence of demographic variables on these preferences.

DESIGN

Mixed-methods, sequential, observational study.

SETTING

Focus groups (phase 1) were conducted to identify SS perceptions and knowledge of mHealth applications (apps). Using grounded theory approach, recurring themes were identified. A multiple-choice questionnaire of 5 desired app features was generated using these themes and mailed to SS (national survey, phase 2). SS' demographics and perceived usefulness (yes/no) for each feature were recorded. In-person usability testing (phase 3) was conducted to identify areas of improvement in user interfaces of existing apps. Summative telephone interviews (phase 4) were conducted for final impressions supplementary to national survey.

PARTICIPANTS

SS aged >18 years recruited from study hospital, national stroke association database, stroke support and advocacy groups. Non-English speakers and those unable to communicate were excluded.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

(1) Percentage of SS (phase 2) identifying proposed app features to be useful. (2) Influence of age, sex, race, education, and time since stroke on perceived usefulness.

RESULTS

Ninety-six SS participated in focus groups. High cost, complexity, and lack of technical support were identified as barriers to adoption of mHealth apps. In the national survey (n=1194), ability to track fitness and diet (84%) and communication (70%) were the most and least useful features, respectively. Perceived usefulness was higher among younger SS (P<.001 to .006) and SS of color (African American and Hispanic) (ORs 1.73-4.41). Simple design and accommodation for neurologic deficits were main recommendations from usability testing.

CONCLUSIONS

SS are willing to adopt mHealth apps that are free of cost and provide technical support. Apps for SS should perform multiple tasks and be of simple design. Greater interest for the app's features among SS of color may provide opportunities to address health inequities.

How does the COVID-19 pandemic impact medication adherence of patients with chronic disease?: A systematic review

OBJECTIVE

To determine how the COVID-19 pandemic impacts patients with chronic disease medication adherence.

METHODS

Four electronic databases, PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text, were searched for literature between 2019 and 2021. Abstracts and later full texts were independently screened by the authors of this review using inclusion and exclusion criteria to determine relevance to our study. Joanna Briggs Institute (JBI) critical appraisal tools were used to assess the quality of included texts. Relevant information and data from the included texts were extracted into tables for data synthesis and analysis.

RESULTS

Ten studies met the study criteria, the most popular study design was cross-sectional design (n = 9, 90.0%), others were case series (n = 1, 10.0%). Barriers to medication adherence and facilitators of medication adherence were the major two themes that participants reported regarding the impact of COVID-19 on medication adherence. Moreover, these two main themes have been organized in sub-themes that are dealt with in-depth.

DISCUSSION

Our results could heighten healthcare providers, stakeholders, and policy leaders' awareness of providing appropriate support for chronic disease patients, especially regarding medication adherence. Future research incorporating programs that support patients' needs is recommended.

The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke-Findings from A Feasibility Study

The study aimed to investigate whether a structured discharge letter and the use of the person-centred communication method Teach Back for sharing information at hospital discharge could support perceived understanding and knowledge of and adherence to prescribed medication for secondary prevention after stroke. Data from a feasibility study of a codesigned care transition support for people with stroke was used. Patients who at discharge received both a structured discharge letter and participated in the person-centred communication method Teach Back (n = 17) were compared with patients receiving standard discharge procedures (n = 21). Questionnaires were used to compare the groups regarding perceived understanding of information about medical treatment, knowledge of information about medical treatment and medication adherence at 1 week and 3 months. There was a statistically significant difference in perceived understanding of information about medical treatment (p > 0.01) between the groups in favour of those who participated in Teach Back at the discharge encounter. No differences between groups were found regarding understanding health information about medical treatment and medication adherence. The results indicate that the use of Teach Back at the discharge encounter positively impacts perceived understanding of information about medical treatment in people with stroke. However, considering the nonrandomised study design and the small sample size, a large-scale trial is needed.

Prevalence and determinants of unmet needs for hypertension care among the older population in Selangor: cross-sectional study

BACKGROUND

Hypertension is a major cause of morbidity and mortality worldwide. Although multiple studies have assessed the prevalence of hypertension among older people, no study has examined the unmet need for hypertension care among older people in Malaysia. This study uses the hypertension care cascade to identify the prevalence of unmet needs for hypertension care and their determinants among the older population in Selangor.

METHODS

This is a cross-sectional study involving a total of 1204 participants recruited from different areas in Selangor. A face-to-face interview was conducted using the Bahasa Malaysia version of the Japan Gerontological Evaluation Study questionnaire. The inclusion criteria were Malaysians aged ≥ 60 years who could converse in Bahasa Malaysia.

RESULTS

Among the 637 participants with hypertension, 18% (117) had not been previously screened but were found to have BP ≥ 140/90 mmHg, 21% (136) were undiagnosed, 3% (17) were untreated, 42% (267) were treated with antihypertensive medication but still had high blood pressure, and 16% (100) had hypertension that was controlled with medication. The hypertension care cascade demonstrates that 18% (117) of those with hypertension had never been screened for hypertension; 26% (136/520) of those who were screened never received a diagnosis; 4% (17/384) of those who were diagnosed did not receive treatment; and 73% (267/367) of those who were treated did not reach the threshold for control. The prevalence of total unmet needs was 84% (537/637). Statistically significant determinants of having any unmet need for hypertension care were smoking status and medical history, with adjusted odds ratios and 95% confidence intervals (CIs) in the multivariate analysis of 0.5 (95% CI: 0.3-0.9) for being a smoker, 2.8 (95% CI: 1.1-6.9) for having a history of stroke and 1.6 (95% CI: 1.0-2.5) for having a history of diabetes mellitus.

CONCLUSIONS

The prevalence of unmet need for hypertension care among the older population in Selangor is 84% (537/637), which is alarmingly high. This study highlights where and how much of the loss of care for hypertension happens in the care cascade and provides insight into the efforts required to improve effective service coverage to manage the increasing burden of hypertension associated with population ageing.

Medication non-adherence and associated factors among older adult stroke survivors in China

Aim: Medication non-adherence has remained a common and costly global health issue of growing importance among older adults. This study aims to determine the prevalence and associated factors related to medication non-adherence among older adult stroke survivors in China. Methods and results: In this cross-sectional study, a total of 402 older adult stroke survivors were recruited from three tertiary hospitals in China. The results of the survey showed that 61.4% exhibited medication non-adherence. The chances of medication non-adherence among older adult stroke survivors who had primary school or less educational levels were higher than those who had senior secondary and junior college educational levels [OR (95% CI) = 0.440(0.249, 0.778)] as well as those who had a bachelor's degree or above educational levels [OR (95%CI) = 0.367(0.202, 0.667)]. Moreover, the probability of medication non-adherence with 4-5 and ≥6 types of total prescription medications per day increased by 1.993 times [OR (95% CI) = 1.993(1.190, 3.339))] and 2.233 times [OR (95%CI) = 2.233(1.159, 4.300)], respectively, as compared to when there were ≤3 types. Furthermore, medication non-adherence decreased with the increase in health literacy scores (β = -0.641 (95% CI; (0.913, 0.965)) and BMQ specific-necessity scores (β = -0.131 (95% CI; 0.806, 0.995)). On the other hand, when the BMQ specific-concerns score increased by one unit, medication non-adherence increased by 11.1% [OR (95% CI) = 1.111(1.044, 1.182)]. Conclusion: The present study found that patient medication adherence among older adult stroke survivors in China is problematic and associated with educational levels, total prescribed drugs per day, beliefs about medication, and health literacy scores. This indicates that measures should be taken to enhance medication adherence among such higher-risk populations.

Lived experiences of stroke survivors in India: A phenomenological study

BACKGROUND

Stroke is a major cause of long-term disability and has a potentially enormous emotional and socio-economic impact on patients, their families, and health services. Perceptions of patients with stroke have already been studied worldwide, which are unique in terms of their cultural background. However, in India, there is a lack of studies about the experience of the disease by stroke survivors and their perspectives of understanding the situation.

OBJECTIVE

This study aimed to explore lived experience of stroke survivors in India.

METHODS

A phenomenological study design was used. In-depth interviews were conducted with a purposive sample of ten stroke survivors who had experienced post-stroke deficits three months to one year after stroke. Data were analyzed using Diekelmann's hermeneutical approach to identify underlying themes.

RESULTS

Two main themes emerged: (1) emergence of stroke (actual occurrence, mental perception, and recognition of illness) and (2) therapeutic concerns (enhanced and weakened recovery).

CONCLUSION

Recognizing how patients experience the illness is crucial in planning care for stroke survivors. Strengthening factors enhancing recovery and limiting the hindering factors through effective therapeutic management is a necessity. The findings might also contribute to refining existing interventions and designing holistic multi-component rehabilitation programs that facilitate easy recovery. The study also highlights the need for providing information to general public on recognizing warning signs of stroke.

High non-adherence rates to secondary prevention by chemical adherence testing in patients with TIA

INTRODUCTION

Transient ischaemic attack (TIA) clinics are important for secondary prevention of fatal or disabling stroke. Non-adherence to prescribed medications is an important reason for treatment failure but difficult to diagnose. This study ascertained the utility of a novel biochemical tool in the objective biochemical diagnosis of non-adherence.

METHODS

One-hundred consecutive urine samples collected from patients attending the TIA clinic, at a tertiary centre, were analysed for presence or absence of prescribed cardiovascular medications using liquid chromatography-mass spectrometry (LC-MS/MS). Patients were classified as adherent or non-adherent, respectively. Demographic and clinical characteristics were compared between the two cohorts. Univariate regression analyses were performed for individual variables and model fitting was undertaken for significant variables.

RESULTS

The mean duration of follow-up from the index event was 31 days [standard deviation (SD): 18.9]. The overall rate of non-adherence for at least one medication was 24%. In univariate analysis, the number of comorbidities [3.4 (SD: 1.9) vs. 2.5 (1.9), P = 0.032] and total number of all prescribed medications [6.0 (3.3) vs 4.4 (2.1), P = 0.032] were higher in the non-adherent group. On multivariate analysis, the total number of medications prescribed correlated with increased non-adherence (odds ratio: 1.27, 95% Confidence Intervals: 1.1-1.5, P = 0.01).

CONCLUSIONS

LC-MS/MS is a clinically useful tool for the diagnosis of non-adherence. Nearly a quarter of TIA patients were non-adherent to their cardiovascular medications Addressing non-adherence early may reduce the risk of future disabling cardiovascular events.

Once versus twice daily direct oral anticoagulants in patients with recent stroke and atrial fibrillation

Background:

Data on the safety and effectiveness of once-daily (QD) versus twice-daily (BID) direct oral anticoagulants (DOAC) in comparison to vitamin K antagonists (VKA) and to one another in patients with atrial fibrillation (AF) and recent stroke are scarce.

Patients and methods:

Based on prospectively obtained data from the observational registry Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients(NOACISP)-LONGTERM (NCT03826927) from Basel, Switzerland, we compared the occurrence of the primary outcome – the composite of recurrent ischemic stroke, major bleeding, and all-cause death – among consecutive AF patients treated with either VKA, QD DOAC, or BID DOAC following a recent stroke using Cox proportional hazards regression including adjustment for potential confounders.

Results:

We analyzed 956 patients (median age 80 years, 46% female), of whom 128 received VKA (13.4%), 264 QD DOAC (27.6%), and 564 BID DOAC (59%). Over a total follow-up of 1596 patient-years, both QD DOAC and BID DOAC showed a lower hazard for the composite outcome compared to VKA (adjusted HR [95% CI] 0.69 [0.48, 1.01] and 0.66 [0.47, 0.91], respectively). Upon direct comparison, the hazard for the composite outcome did not differ between patients treated with QD versus BID DOAC (adjusted HR [95% CI] 0.94 [0.70, 1.26]). Secondary analyses focusing on the individual components of the composite outcome revealed no clear differences in the risk-benefit profile of QD versus BID DOAC.

Discussion and conclusion:

The overall benefit of DOAC over VKA seems to apply to both QD and BID DOAC in AF patients with a recent stroke, without clear evidence that one DOAC dosing regimen is more advantageous than the other.

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

Medication adherence early after stroke: using the Perceptions and Practicalities Framework to explore stroke survivors', informal carers' and nurses' experiences of barriers and solutions

Background

Secondary prevention medication after stroke reduces risk of recurrence, but adherence is often poor. Stroke survivors’, carers’ and nurses’ perspectives of early post-stroke medication adherence are unexplored.

Aim

The aim of this study was to explore stroke survivors’, carers’ and nurses’ views and experiences about adhering to medication early after post-stroke hospital discharge.

Methods

Qualitative individual and group interviews, utilising the Perceptions and Practicalities Framework, were employed. Nine people <2 months post-stroke, three carers and 15 nurses from one UK stroke unit participated. Interviews were digitally recorded, transcribed and thematically analysed.

Results

There were four main themes with two sub-themes. (1) Perceptions of medication taking after stroke. Factors affecting adherence included depression, imperceptible benefits and concerns about adverse effects. (2) Perceptions about those at higher risk of poor medication adherence. Nurses suggested that poor adherence might be more likely in those living alone or with previous non-adherence. (3) Practicalities of taking medication early after stroke; these included post-stroke disabilities, cognition, polypharmacy and lack of information. (4a) Practicalities of addressing poor medication adherence during the hospital stay. Solutions included multidisciplinary co-ordination, but nurses and stroke survivors described suboptimal use of opportunities to promote adherence. (4b) Practicalities of addressing poor medication adherence post-discharge. Solutions included modifications and support from carers, but stroke survivors reported difficulties in evolving systems for taking medications.

Conclusions

Stroke survivors and informal carers lack knowledge and support needed to manage medication early after discharge. Nurses’ opportunities to promote medication adherence are under-exploited. Medication adherence strategies to support stroke survivors early after discharge are needed.

Investigation of Medication Adherence and Factors Affecting It in Patients With Stroke

ABSTRACT

BACKGROUND: Medication adherence is important in reducing the rate of secondary stroke in patients previously given a diagnosis of stroke. Therefore, there is a need to examine medication adherence and the factors affecting it in these patients. This study aimed to examine medication adherence in patients with stroke and the factors affecting it. METHODS: This study adopted a descriptive and cross-sectional design carried carried out on 183 stroke patients. Data were obtained between January and December 2019 using a sociodemographic and clinical characteristics form, the Morisky's Questions - Self-Reported Measure of Medication Adherence, the Turkish translation of the Beliefs about Medicines Questionnaire, the Nottingham Extended Activities of Daily Living Scale, and the revised Turkish version of Mini-Mental State Examination. RESULTS: The proportion of patients with high medication adherence was 33.9%. The sociodemographic and clinical characteristics of patients with stroke were found as not effective factors in medication adherence. Specific concerns and general overuse in the Turkish translation of the Beliefs about Medicines Questionnaire were found as factors affecting medication adherence. The Nottingham Extended Activities of Daily Living Scale and its subscales were found to be not effective factors in medication adherence. CONCLUSION: According to the results, the proportion of patients with high medication adherence was low. Patients' concerns about the possible side effects of their prescribed medications and beliefs about the overuse of medications negatively affected their medication adherence. It is recommended that nurses evaluate patients' medication adherence and beliefs about medications during hospitalization, discharge, or home visits. Structured nurse-led intervention programs are needed to enhance patients' medication adherence and beliefs about their medications.

Mobile Health Application to Support Family Caregivers in Recurrent Stroke Prevention: Scoping Review

BACKGROUND OF THE STUDY: Caregivers play a vital role in continuum care for stroke patients. Involvement of caregivers in stroke care was important. With the advancement of information technology and the rapid growth worldwide in cell-phone use and internet connectivity, additional evidence may be needed in the use of mobile applications to support caregivers in stroke care. AIM OF THE STUDY: The aims of this review was to identify existing mobile application designed to support family caregivers of people with stroke disease. METHODOLOGY: A scoping review study framework was carried out in this study, using the EBSCO, Cochrane, PubMed, ProQuest, and Science Direct databases using search keywords: ‘family caregiver’, ‘mobile health application’,  and ‘recurrent stroke or secondary stroke prevention’. This review examined studies published between January 2011 and December 2020. Of a total of 728 papers found, 9 journals were selected. RESULTS: The results founded three categories and their attendant sub-categories. The categories was caregivers support, involvement caregivers in stroke care, and barriers. The majority of mobile application was used to provide video education for caregivers. Caregivers involved in stroke care including emotional care, nutrition, exercise, and recurrent stroke prevention. Poor connection was the most barrier in using mobile application. CONCLUSION: Mobile application can support caregivers in stroke care. Healthcare providers are expected to utilize mobile applications in helping caregivers in post-stroke care.

Long-term mortality and recurrent vascular events in lacunar versus non-lacunar ischaemic stroke: A cohort study

Introduction

Studies of differences in very long-term outcomes between people with lacunar/small vessel disease (SVD) versus other types of ischaemic stroke report mixed findings, with limited data on myocardial infarction (MI). We investigated whether long-term mortality, recurrent stroke and MI risks differ in people with versus without lacunar/SVD ischaemic stroke.

Patients and methods

We included first-ever strokes from a hospital-based stroke cohort study recruited in 2002–2005. We compared risks of death, recurrent stroke and MI during follow-up among lacunar/SVD versus other ischaemic stroke subtypes using Cox regression, adjusting for confounding factors.

Results

We included 812 participants, 283 with lacunar/SVD ischaemic stroke and 529 with other stroke. During a median of 9.2 years (interquartile range 3.1–11.8), there were 519 deaths, 181 recurrent strokes and 79 MIs. Lacunar/SVD stroke was associated with lower mortality (adjusted HR 0.79, 95% CI 0.65 to 0.95), largely due to markedly lower all-cause mortality in the first year. From one year onwards this difference attenuated, with all-cause mortality only slightly and not statistically significantly lower in the lacunar/SVD group (0.86, 95% CI 0.70 to 1.05). There was no clear difference in risk of recurrent stroke (HR 0.84, 95% CI 0.61–1.15) or MI (HR 0.83, 95% CI 0.52–1.34).

Conclusion

Long-term risks of all-cause mortality, recurrent stroke and MI are similar, or only slightly lower, in patients with lacunar/SVD as compared to other ischaemic stroke. Patients and physicians should be as vigilant in optimising short- and long-term secondary prevention of vascular events in lacunar/SVD as for other stroke types.

Factors related to patient adherence to the use of new oral anticoagulants

OBJECTIVE

To characterize the self-reported adherence of patients with cardiovascular diseases to the use of new oral anticoagulants and to identify factors related to adherence to these drugs.

METHOD

This is a descriptive, correlational, and cross-sectional study, carried out with outpatients. The collection of sociodemographic, clinical, and adherence data, through the Measurement of Adherence to Treatments, was made through telephone calls. Descriptive, correlation, and multiple linear regression analyses were used.

RESULTS

A total of 120 patients using new anticoagulants for 32.3 months, on average, participated in the study. More than half of the sample consisted of women, who were professionally inactive, with a mean age of 70.1 years and a mean family income of 6.7 minimum wages. The mean adherence score was 5.7, in a possible range between 1 and 6, indicating medication adherence. Inactive employment status, female sex, higher family income, and follow-up at a public outpatient clinic were related to greater adherence to these medications.

CONCLUSION

The patients showed high adherence to new anticoagulants. Employment status, sex, family income, and type of outpatient follow-up were related to medication adherence, and should be considered in the design of interventions for this public.

Adherence to oral anticoagulation in ischemic stroke patients with atrial fibrillation

BACKGROUND

Non-vitamin K antagonist oral anticoagulants (NOAC) have superior safety and comparable efficacy profile compared to vitamin-K antagonists (VKAs), with more convenient dosing schemes. However, issues with adherence to the NOACs remain unsolved.

AIMS

We sought to investigate the adherence to oral anticoagulation (OAC) and baseline factors associated with poor adherence after ischaemic stroke in patients with atrial fibrillation (AF).

METHODS

We recruited hospitalised patients (2013-2019) from two prospective stroke registries in Larissa and Helsinki University Hospitals and invited survived patients to participate in a telephone interview. We assessed adherence with the Adherence to Refills and Medications Scale (ARMS) and defined poor adherence as a score of over 17. In addition to demographics, individual comorbidities, and stroke features, we assessed the association of CHA2DS2-VASc and SAMe-TT2R2 scores with poor adherence.

RESULTS

Among 396 patients (median age 75.0 years, interquartile range [IQR] 70-80; 57% men; median time from ischaemic stroke to interview 21 months [IQR 12-33]; median ARMS score 17 [IQR 17-19]), 56% of warfarin users and 44% of NOAC users reported poor adherence. In the multivariable regression model adjusted for site, sex, and age, poor adherence was independently associated with tertiary education, absence of heart failure, smoking history, use of VKA prior to index stroke, and prior ischaemic stroke. CHA2DS2-VASc and SAMe-TT2R2 scores were not associated with poor adherence.

CONCLUSIONS

Adherence was poor in half of AF patients who survived an ischaemic stroke. Independent patient-related factors, rather than composite scores, were associated with poor adherence in these patients.KEY MESSAGESAdherence was poor in half of the atrial fibrillation patients who survived an ischaemic stroke.Independent patient-related factors rather than composite scores were associated with poor adherence.The findings support the importance of recognising adherence support as a crucial part of holistic patient care recommended by recent AF guideline.

Importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease

Stroke is a leading cause of death and disability worldwide. Women are disproportionately affected by stroke, exhibiting higher mortality and disability rates post-stroke than men. Clinical stroke research has historically included mostly men and studies were not properly designed to perform sex- and gender-based analyses, leading to under-appreciation of differences between men and women in stroke presentation, outcomes, and response to treatment. Reasons for these differences are likely multifactorial; some are due to gender-related factors (i.e. decreased social support, lack of stroke awareness), yet others result from biological differences between sexes. Unlike men, women often present with 'atypical' stroke symptoms. Lack of awareness of 'atypical' presentation has led to delays in hospital arrival, diagnosis, and treatment of women. Differences also extend to carotid atherosclerotic disease, a cause of stroke, where plaques isolated from women are undeniably different in morphology/composition compared to men. As a result, women may require different treatment than men, as evidenced by the fact that they derive less benefit from carotid revascularization than men but more benefit from medical management. Despite this, women are less likely than men to receive medical therapy for cardiovascular risk factor management. This review focuses on the importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease, summarizing the current evidence with respect to (i) stroke incidence, mortality, awareness, and outcomes, (ii) carotid plaque prevalence, morphology and composition, and gene connectivity, (iii) the role of sex hormones and sex chromosomes in atherosclerosis and ischaemic stroke risk, and (iv) carotid disease management.

Association Between Patient Activation and Medication Adherence in Patients With Stroke: A Cross-Sectional Study

Background: Medication adherence is key to secondary prevention in patients with stroke. Poor medication adherence can lead to recurrence, disability, or even death in stroke survivors. Patient activation is associated with increased healthy behaviors and improved clinical outcomes in many chronic diseases. However, the association between patient activation and medication adherence in patients with stroke remains unclear.

Objective: The study aimed to explore the influence of patient activation on the medication adherence of patients with stroke and to analyze the reasons for medication nonadherence.

Materials and Methods: A cross-sectional design with convenience sampling was used in this study. A total of 119 patients with stroke were recruited from a tertiary hospital in Guangzhou. A social-demographic and clinical data form, a self-developed medication adherence questionnaire, and the 13-item Patient Activation Measure (PAM-13) were used. Univariate analysis and multiple linear regression analysis with dummy variables were conducted to investigate the associations between medication adherence and patient activation. Data were analyzed with IBM® SPSS® version 25.0.

Results: The mean PAM-13 score in patients with stroke was 51.56 ± 12.58. A low level of patient activation was reported by up to 66.4% of the patients. The self-reported medication adherence questionnaire score was 5.59 ± 1.52. A low level of medication adherence was reported by up to 59.7% of the patients, while a moderate level was reported by 34.4%, and a high level was reported by only 5.9%. In the multiple stepwise regression analysis, patient activation was found to be an independent influencing factor of medication adherence in patients with stroke (p < 0.05).

Conclusion: Medication adherence was poor in patients in Guangzhou, China, following an ischemic stroke. Patient activation as the independent influencing factor identified in this study will support healthcare givers to develop the tailored intervention to improve medication adherence among patients with stroke in China.

Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study

BACKGROUND

We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data.

METHODS

Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months.

RESULTS

Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months.

CONCLUSIONS

The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.

van Onzenoort H, J.H.M. van Laarhoven K, Bredie SJ, van Dulmen S. Identification of Cardiovascular Patient Groups at Risk for Poor Medication Adherence: A Cluster Analysis

BACKGROUND

Poor medication adherence limits the secondary prevention of cardiovascular diseases (CVDs) and leads to increased morbidity, mortality, and costs. Identifying groups of patients at risk of poor adherence behavior could enable an intervention to be developed and target patients appropriately.

OBJECTIVE

The first aim of this study was to identify homogeneous subgroups of cardiovascular outpatients based on their cardiovascular risk factors. Subsequently, differences in medication adherence between these groups were examined.

METHODS

In this retrospective, observational study, patients with an established CVD were included. Well-known cardiovascular risk factors such as smoking, diet, exercise, blood lipid levels, blood pressure, and body mass index were collected. To identify patient subgroups, a 2-step cluster analytic procedure was performed. Differences between the groups on medication adherence were determined on the outcome of the Modified Morisky Scale. Data collection took place between October 2011 and January 2013.

RESULTS

Cardiovascular risk factors of 530 patients were included in the cluster analysis. Three groups were identified. Compared with other clusters (clusters 1 and 2), cluster 3 contained significantly fewer patients who could be classified as highly adherent and more patients classified as medium adherent (23% and 57%, respectively; P = .024). This group was characterized by a younger age (53% were <55 years old) and using a relatively low number of different medications (41% used <4 different medications). Besides, in this subgroup the most smokers (37%), unhealthy alcohol users (27%), and patients with unhealthy eating habits (14%) were present.

CONCLUSION

This study showed that cardiovascular patients who are relatively young and have an unhealthy lifestyle are at risk for nonadherent behavior.

Smart About Meds (SAM): a pilot randomized controlled trial of a mobile application to improve medication adherence following hospital discharge

Objective

The objectives of this pilot study were (1) to assess the feasibility of a larger evaluation of Smart About Meds (SAM), a patient-centered medication management mobile application, and (2) to evaluate SAM’s potential to improve outcomes of interest, including adherence to medication changes made at hospital discharge and the occurrence of adverse events.

Materials and Methods

We conducted a pilot randomized controlled trial among patients discharged from internal medicine units of an academic health center between June 2019 and March 2020. Block randomization was used to randomize patients to intervention (received access to SAM at discharge) or control (received usual care). Patients were followed for 30 days post-discharge, during which app use was recorded. Pharmacy claims data were used to measure adherence to medication changes made at discharge, and physician billing data were used to identify emergency department visits and hospital readmissions during follow-up.

Results

Forty-nine patients were eligible for inclusion in the study at hospital discharge (23 intervention, 26 control). In the 30 days of post-discharge, 15 (65.2%) intervention patients used the SAM app. During this period, intervention patients adhered to a larger proportion of medication changes (83.7%) than control patients (77.8%), including newly prescribed medications (72.7% vs 61.7%) and dose changes (90.9% vs 81.8%). A smaller proportion of intervention patients (8.7%) were readmitted to hospital during follow-up than control patients (15.4%).

Conclusion

The high uptake of SAM among intervention patients supports the feasibility of a larger trial. Results also suggest that SAM has the potential to enhance adherence to medication changes and reduce the risk of downstream adverse events. This hypothesis needs to be tested in a larger trial.

Trial registration

Clinicaltrials.gov, registration number NCT04676165.

Association between depression and medication adherence in stroke survivor older adults

AIM

This study aimed to investigate the association between depression score and medication adherence in stroke survivor older adults.

METHODS

The participants were 102 stroke survivor older adults. The outcome was medication adherence during a 6-month follow-up. The independent variable was the depression score which was assessed by the Patient Health Questionnaire-9 (PHQ-9). The confounding factors included sociodemographic data, clinical characteristics, number of comorbidities, and number of medications. We analyzed the association between depression and medication adherence using multiple linear regression analyses.

RESULTS

The PHQ-9 score of stroke survivor older adults at the baseline was 1.11±2.03, and at the 6-month follow-up was increased to 5.06±3.91. The medication adherence mean score at the outcome was 4.15±1.83. After full adjustment, the PHQ-9 scores at baseline and 6-month follow-up were significantly associated with medication adherence (β = -.315, 95% CI = -.483 to -.086, p = 0.006 and β = -.270, 95% CI = -.238 to -.020, p = 0.021, respectively). Other variables that affect medication adherence during a 6-month follow-up included living with others and a lower number of medications.

CONCLUSION

This study revealed that lower depression scores were associated with high medication adherence in post-stroke older adults. Additionally, living with others and a lower number of medications were associated with medication adherence. Therefore, stroke survivor older adults should be assessed for depression and given medication, and education should be used to improve mediation adherence, especially for the ones who live alone and have polypharmacy to prevent recurrent stroke.

Pharmaceutical care program for ischemic stroke patients: a randomized controlled trial

Background Effective secondary prevention is essential for reducing stroke recurrence. Objective This parallel randomized-controlled study aimed to evaluate the impact of a pharmaceutical care program on risk factor control (blood pressure, blood glucose, lipid profile, and medication adherence) and hospital readmissions in post-stroke care. Setting The First Hospital of Hebei Medical University, China. Method Ischemic stroke patients were enrolled in the study. Upon hospital discharge, patients were randomly allocated either to a control group (CG, no pharmaceutical care) or to an intervention group (IG, monthly pharmaceutical care follow-up for 6 months). The interventions aimed to increase medication adherence and improve risk factor control through education and counseling. Medication adherence and surrogate laboratory markers of risk factors were assessed and compared between the two groups. Main outcome measures Blood pressure, blood glucose, lipid profile, and medication adherence. Results A total of 184 patients with ischemic strokes were randomly assigned, and 84 patients in IG and 82 in CG were analyzed. There were no significant differences (P > 0.05) in both groups concerning demographic and clinical characteristics. Compared to CG, at the 6-month follow-up, medication adherence rates significantly increased regarding antihypertensive drugs (92.86% versus 78.57%, P = 0.031), anti-diabetic drugs (91.67% versus 69.7%, P = 0.02), and lipid-lowering drugs (77.38% versus 60.98%, P = 0.022) in IG. Compared to CG, more patients in IG attained the goal surrogate risk factor control markers of hemoglobin A1c (87.88% vs. 52.78%, P = 0.038) and low-density lipoprotein-C (66.67% vs. 48.78%, P = 0.02). Significantly fewer patients were re-admitted to the hospital in IG than CG (7.14% vs. 18.3%, P = 0.03). Conclusion Pharmaceutical care programs can improve risk factor control for the secondary prevention of stroke recurrence in ischemic stroke patients.

Facilitators and barriers to medication adherence among stroke survivors in India

Strict compliance with medication and life style modification are integral to secondary stroke prevention. This study was undertaken to find out medication adherence among stroke survivors and factors associated with it. Cross sectional survey among stroke survivors was conducted. Interview based self-reported medication adherence was defined as consumption at least >80% of their medications for last two weeks, based on last prescription. Structured interview using pretested interview schedule was done to collect other data. Sequential step wise logistic regression analysis was done to find out the facilitators and barriers to medication adherence. Two hundred and forty stroke survivors (mean age 58.64 ± 10.96 years; 25.4% females) with a mean post-stroke period of 6.65 ± 3.36 months were participated. Overall medication adherence was 43.8% (n = 105). Medication adherence was 34.3% (n = 134), 52.6% (n = 190) and 56.7% (n = 224) for antidiabetics, antihypertensives and statins respectively and was associated with risk factor control (Diabetes: Odds Ratio (OR) = 4.85; 95% Confidence Interval (CI) 2.12-11.08, Hypertension: OR = 3.42; 95% CI 1.83-6.4, Dyslipidaemia: OR = 3.88; 95% CI 1.96-4.04). Having daily routine (OR = 2.82; 95% CI 1.52-5.25), perceived need of medication (OR = 2.33; 95% CI 1.04-5.2) and perceived poor state of health (OR = 2.65; 95% CI 1.30-5.40) were facilitators. Memory issues (OR = 0.34; 95% CI 0.16-0.71), side effects (OR = 0.24; 95% CI 0.11-0.42) and financial constraints (OR = 0.46; 95% CI 0.24-0.91) were barriers to medication adherence. Establishing daily routines, periodic reminders, financial supports to buy medicines and patient education can enhance medication adherence to prevent future strokes.

Vascular risk factor control and adherence to secondary preventive medication after ischaemic stroke

BACKGROUND

Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke.

METHODS

A total of 664 home-dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self-reporting (4-item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline-defined targets of blood pressure (BP) (<140/90 mmHg), low-density lipoprotein cholesterol (LDL-C) (<2.0 mmol L^-1 ) and haemoglobin A1c (HbA1c) (≤53 mmol mol^-1 ) and determinants of risk factor control.

RESULTS

At discharge, 97% were prescribed antithrombotics, 88% lipid-lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL-C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL-C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL-C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL-C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98).

CONCLUSION

Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies.

Non-persistence with anti-platelet therapy and long-term mortality after ischemic stroke: A nationwide study

Background

We tried to investigate the effect of non-persistence with antiplatelets after ischemic stroke on long-term all-cause mortality (ACM).

Methods and findings

We selected newly diagnosed ischemic stroke patients aged ≥20years who were newly treated with aspirin or clopidogrel from 2003–2010 Korean National Health Insurance Service-National Sample Cohort, a random sample of 2.2% of total population. Subjects were divided into two pairs of groups according to persistence with antiplatelets at 6 and 12 months: those who discontinued antiplatelets within 6 months (DA6M) and those who continued them for 6 or months or more (CA6M); and those who discontinued antiplatelets within 12 months (DA12M) and those who continued them for 12 months or more (CA12M). Those who died within 6 months among DA6M and those who died within 12 months among DA12M were excluded along with those with medication possession ratio<80% among CA6M and CA12M. Subjects were followed-up until death or December 31, 2013. Among 3,559 total subjects, DA6M were 1,080 and CA6M were 2,479 while, out of 3,628 total patients, DA12M were 1,434 and CA12M were 2,194. The risks of ACM [adjusted hazard ratio (aHR), 2.25; 95% confidence interval (CI), 1.94–2.61], cerebro-cardiovascular disease (CVD) death (aHR, 2.52; 95% CI, 1.96–3.24) and non-CVD death (aHR, 2.11; 95% CI, 1.76–2.64) of DA6M were all significantly increased compared to CA6M. DA12M also had significantly higher risks of ACM (aHR, 1.93; 95% CI, 1.65–2.25), CVD mortality (aHR, 2.13; 95% CI; 1.63–2.77) and non-CVD mortality (aHR, 1.83;95% CI 1.51–2.22) than DA12M but aHRs were lower than that between DA6M and CA6M. The difference rates of ACM, CVD death, and non-CVD death between non-persistent and persistent groups all continuously widened over time but the degree of difference was gradually decreased.

Conclusions

Maintaining antiplatelets for the first 12 months after ischemic stroke reduces long-term risks of both CVD death and non-CVD death.

Social deprivation and 1-year survival after stroke: a prospective cohort study

BACKGROUND

Social deprivation may have a deleterious influence on post-stroke outcomes, but available data in the literature are mixed.

AIM

The aim of this cohort study was to evaluate the impact of social deprivation on 1-year survival in patients with first-ever stroke.

METHODS

Social deprivation was assessed at individual level with the EPICES score, a validated multidimensional questionnaire, in 1312 patients with ischemic stroke and 228 patients with spontaneous intracerebral hemorrhage, who were prospectively enrolled in six French study centers. Baseline characteristics including stroke severity and pre-stroke functional status were collected. Multivariable Cox models were generated to evaluate the associations between social deprivation and survival at 12 months in ischemic stroke and intracerebral hemorrhage separately.

RESULTS

A total of 819 patients (53.2%) were socially deprived (EPICES score ≥ 30.17). In ischemic stroke, mortality at 12 months was higher in deprived than in non-deprived patients (16% vs. 11%, p = 0.006). In multivariable analyses, there was no association between deprivation and death occurring within the first 90 days following ischemic stroke (adjusted hazard ratio [aHR] 0.81, 95% CI 0.54-1.22, p = 0.32). In contrast, an excess in mortality was observed between 90 days and 12 months in deprived compared with non-deprived patients (aHR 1.97, 95% CI 1.14-3.42, p = 0.016). In patients with intracerebral hemorrhage, mortality at 12 months did not significantly differ according to deprivation status.

CONCLUSIONS

Social deprivation was associated with delayed mortality in ischemic stroke patients only and, although the exact underlying mechanisms are still to be identified, our findings suggest that deprived patients in particular may benefit from an optimization of post-stroke care.

Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke

OBJECTIVE

To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA.

METHODS

This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation.

RESULTS

Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation.

CONCLUSIONS

Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.

Mediators, confounders and effectiveness of interventions for medication adherence after stroke

After a stroke, people are left with an increased risk of recurrence. One of the primary methods of prevention is the use of a range of medications, but adherence to these is often low. This article evaluates and summarises three systematic reviews that investigate possible underlying reasons for this and how to overcome these barriers.

A Qualitative Study of Barriers and Facilitators to Adherence to Secondary Prevention Medications Among French Patients Suffering from Stroke and Transient Ischemic Attack

PURPOSE

Secondary prevention medications (SPM) reduce the risk of ischemic stroke (IS) and transient ischemic attack (TIA) recurrence. However, approximately one-third of patients are estimated to be non-adherent. This qualitative study aimed to explore barriers and facilitators to adherence to SPM after IS or TIA.

PATIENTS AND METHODS

Thirty-six face-to-face semi-structured interviews were conducted with 14 TIA patients and 22 IS patients who self-administered their treatment 12 months after IS/TIA. A thematic analysis was performed.

RESULTS

Major facilitators to good adherence to SPM were the fear of stroke recurrence and the high level of trust in the prescribing physician. Barriers included a perceived lack and/or inappropriate timing of information about SPM, practical difficulties of taking some SPM (eg, inadequate packaging) and of implementing routines into their daily life.

CONCLUSION

Information on SPM is inadequate in terms of quantity and timing both during the acute IS/TIA period and over the long term. Providing more tailor-made information at an opportune moment, in particular by promoting discussion with their general practitioner (GP) throughout the course of illness and recovery, is essential to ensure that patients are not left alone in the decision-making process regarding adherence to SPM.

Factors associated with medication persistence among ischemic stroke patients: a systematic review

OBJECTIVE

An investigation of the prevalence of medication persistence and associated factors in order to inform effective strategies for improving medication persistence.

METHODS

A systematic review of the literature from 2010 to the present was performed, using the PRISMA protocol. Primary and empirical observational studies of adult ischemic stroke or transient ischemic attack patients were included. PubMed, CINAHL, Web of Science, Cochrane Library, and PsycInfo databases were searched using the key terms stroke, ischemic stroke, medication persistence, medication adherence, and patient compliance.

RESULTS

Of four hundred twenty-eight journal articles retrieved, a final 18 articles were included. Short-term medication persistence was 46.2-96.7%, and long-term medication persistence was 41.7-93.0%. Identified hospital-related factors for medication persistence were stroke unit care, in-hospital medical complications, and early follow-up visit. Demographic factors for medication persistence were older age, and high/adequate financial status; disease-related factors were disease history, stroke subtype, and symptom severity. Age less than 75, female sex, comorbidity, antiplatelet medication switch, and polypharmacy were identified as factors of medication nonpersistence.

CONCLUSIONS

Stroke patients' medication persistence decreases over time, and persistence on antiplatelets, anticoagulants, and statin was poor. Several factors were associated with medication persistence, and these factors should be considered in future secondary preventative strategies.

Medication-taking after stroke: a qualitative meta-synthesis of the perspectives of stroke survivors, informal carers and health professionals

BACKGROUND

Lifelong secondary prevention medication is recommended after stroke or transient ischaemic attack. However, poor medication adherence and persistence, which lead to suboptimal health outcomes, are common, but the reasons for this are not well understood, mainly because there have been few studies reporting adherence barriers in stroke survivors.

OBJECTIVE

The aim of this review was to undertake a meta-synthesis of qualitative studies of medication-taking after stroke. Outcomes of interest were: lived experiences, views and beliefs, and strategies and solutions used by community-dwelling stroke and transient ischaemic attack survivors, informal carers and health care professionals in relation to medication-taking.

METHOD

The review protocol was registered on PROSPERO (CRD42018086792). A search of online bibliographic databases was performed using key search terms of stroke, persistence, adherence and medication for years 1980-2018. Citation tracking was also carried out. Studies using qualitative or mixed methods were included. Systematic data extraction and synthesis were conducted using a meta-ethnographic approach.

RESULTS

Twelve studies were eligible for inclusion, with a total of 412 participants, two-thirds of whom were stroke survivors, ranging from 1 month to over 20 years post-stroke. Third-order themes identified were 'Medicines Work'-Information Work; Health Care Work; Carer Work; Emotional Work; Practical Work and an underpinning theme of Trust. However, many studies had significant methodological weaknesses.

CONCLUSIONS

This synthesis suggests that the burden of 'medicines work' after stroke is substantial and multifaceted. Its successful undertaking depends on mutual trust between stroke survivors, carers and health care professionals and trust in the benefits of medicines themselves.

Factors Influencing 1-Year Medication Adherence of Korean Ischemic Stroke Survivors

BACKGROUND

Medication adherence is important for secondary stroke prevention. However, suboptimal adherence to medication among patients after stroke or transient ischemic attack is reportedly 30.9%. We assessed medication adherence of Korean stroke survivors within 1 year of acute ischemic stroke and identified factors that influence adherence.

METHODS

We consecutively enrolled ischemic stroke survivors who visited the Department of Neurology of a university hospital from March 9 to June 15, 2016. Data were collected by face-to-face interviews using a structured questionnaire which assessed general characteristics, clinical characteristics, medication beliefs, social support, and depression. Medication adherence was measured using the 8-item Morisky Medication Adherence Scale. Multiple logistic regression was used to identify factors independently associated with medication adherence.

RESULTS

Of the total 250 participants, 183 (73%) were in the optimal adherence group. Age (p = 0.035), smoking (p = 0.020), number of prescribed medicines (p = 0.037), frequency of daily doses (p = 0.040), and beliefs about medication (p < 0.001) were associated with medication adherence. Optimal medication adherence was associated with being a non-smoker (OR, 3.19; 95% CI, 1.29-7.87; p = 0.012), more prescribed medicines (OR, 1.27; 95% CI, 1.05-1.54; p = 0.014), less frequency of daily doses (OR, 0.37; 95% CI, 0.18-0.79; p = 0.010), and stronger beliefs about medication (OR, 1.09; 95% CI, 1.03-1.15; p = 0.004).

CONCLUSION

To improve medication adherence of stroke survivors, post-stroke care should focus on bolstering patients' belief in the necessity of medication and encouraging lifestyle modifications, such as quitting smoking, as well as prescribing medicine with simple regimens.

Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) study protocol

RATIONALE

Recurrent stroke, cardiovascular morbidity, and mortality are important causes of poor outcome in patients with index stroke. Despite the availability of best medical management recurrent stroke occur in up to 15-20% of patients with stroke in India. Education for stroke prevention could be a strategy to prevent recurrent strokes.

HYPOTHESIS

We hypothesize that a structured semi-interactive stroke prevention package can reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke at the end of one year.

DESIGN

Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) is a multi-center stroke trial involving 25 centers under the Indian Stroke Clinical Trial Network. Patients with first ever sub-acute stroke within two days to three months of onset, age 18-85 years, mRS <5, showing recent stroke in imaging are included. Participants or caregivers able to read and complete tasks suggested in a stroke prevention workbook and have a cellular device for receiving short message service and watching videos. A total of 5830 stroke patients speaking 11 different languages are being randomized to intervention or control arm. Patients in the intervention arm are receiving a stroke prevention workbook, regular educational short messages, and videos. All patients in the control arm are receiving standard of care management.

SUMMARY

Structured semi-interactive stroke prevention package may reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke.

TRIAL REGISTRATION

This trial is registered with clinicaltrials.gov (NCT03228979) and CTRI (Clinical Trial Registry India; CTRI/2017/09/009600).

Associations between depressive symptoms, cigarette smoking, and cardiovascular health: Longitudinal results from CARDIA

INTRODUCTION

Depression is associated with increased risk of incident and recurrent cardiovascular disease, while the association between depression and cardiovascular health (CVH) remains unknown. Because the natural course of depression varies widely, different patterns of depression, as well as co-occurring factors such as cigarette smoking, may influence this relationship. We examined potential interactions between longitudinal patterns of depression and smoking with CVH.

METHODS

Using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, we modeled trajectories of depression (Center for Epidemiologic Studies Depression scale scores; Years 5, 10, 15, 20) and smoking (cigarettes/day; Years 0, 2, 5, 7, 10, 15, 20). We calculated a modified American Heart Association (AHA) CVH Score (weight, blood glucose, cholesterol, blood pressure, physical activity, and diet; Year 20); higher scores indicate better CVH. Generalized linear models evaluated associations between depression trajectories, smoking trajectories, and their interaction with CVH Score.

RESULTS

The depression trajectory x smoking trajectory interaction was not associated with CVH Score, but main effects of depression trajectory (p < .001) and smoking trajectory (p < .001) were observed. Participants with patterns of subthreshold depression (β = -0.26, SE=0.08), increasing depression (β = -0.51 SE = 0.14), and high depression (β = -0.65, SE = 0.32) had lower CVH Scores than those without depression. Compared to never smokers, participants who quit smoking had higher CVH Scores (β = 0.38, SE = 0.11), while participants with the greatest smoking exposure had lower CVH Scores (β = -0.49, SE = 0.22).

LIMITATIONS

CVH Scores were adapted from the AHA guidelines based on the available CARDIA data.

CONCLUSIONS

Deleterious depression and smoking trajectories are independently but not synergistically associated with worse CVH.

Cognitive impairment and medication adherence post-stroke: A five-year follow-up of the ASPIRE-S cohort

BACKGROUND

Control of vascular risk factors is essential for secondary stroke prevention. However, adherence to secondary prevention medications is often suboptimal, and may be affected by cognitive impairment. Few studies to date have examined associations between cognitive impairment and medication adherence post-stroke, and none have considered whether adherence to secondary prevention medications might affect subsequent cognitive function. The aim of this study was to explore prospective associations between cognitive impairment and medication non-adherence post-stroke.

METHODS

A five-year follow-up of 108 stroke survivors from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) prospective observational cohort study. Cognitive function was assessed using the Montreal Cognitive Assessment at 6 months, and a neuropsychological test battery at 5 years. Adherence to antihypertensive, antithrombotic and lipid-lowering medications was assessed using prescription refill data.

RESULTS

The prevalence of cognitive impairment at five years was 35.6%. The prevalence of non-adherence ranged from 15.1% for lipid-lowering agents to 30.2% for antithrombotics. There were no statistically significant associations between medication non-adherence in the first year post-stroke and cognitive impairment at 5 years, nor between cognitive impairment at 6 months and non-adherence at 5 years. Stroke survivors with cognitive impairment were significantly more likely to report receiving help with taking medications [OR (95% CI): 4.84 (1.17, 20.07)].

CONCLUSIONS

This is the first study to explore the potential impact of non-adherence to secondary prevention medications on cognitive impairment in stroke survivors. Findings highlight the role of family members and caregivers in assisting stroke survivors with medication administration, particularly in the context of deficits in cognitive function. Involving family members and caregivers may be a legitimate and cost-effective strategy to improve medication adherence in stroke survivors.

The role of single pill combination therapy in the prevention of ischaemic stroke

BACKGROUND AND AIMS

The role of single pill combination therapy for stroke prevention remains to be established. We explored the perspectives of stroke survivors and healthcare professionals on single pill combination therapy for stroke prevention.

METHODS

We conducted focus groups involving stroke survivors and healthcare professionals.

RESULTS

We recruited six stroke survivors: four (67%) were female and mean age was 70 ± 12 years; and eight healthcare professionals (three Stroke Consultants, two Nurse Specialists, three General Practitioners). Improved adherence is the main perceived benefit of single pill combination therapy, although concerns exist surrounding less individualised care, unsuitability for use in the acute setting, reduced ability to titrate doses and difficulty identifying the cause of side effects. The clinical stability of patients, alongside single pill combination therapy efficacy, cost, side effect profile and evidence base for impact on risk factors and clinical outcomes are key factors influencing acceptability. Stroke survivors and healthcare professionals feel single pill combination therapy is most suitable for stable patients, although there is no evidence base for its use in this context.

CONCLUSION

Stroke healthcare professionals and stroke survivors are most amenable to using single pill combination therapy for stable patients, although its role in this context should be evaluated in studies with risk factor targets and clinical outcomes as endpoints.

Protocol for MAAESTRO: Electronic Monitoring and Improvement of Adherence to Direct Oral Anticoagulant Treatment-A Randomized Crossover Study of an Educational and Reminder-Based Intervention in Ischemic STROke Patients Under Polypharmacy

Background: Non-adherence to direct oral anticoagulants (DOACs) remains a matter of concern, especially for patients with a recent stroke. However, data on electronically monitored adherence and adherence-improving interventions are scarce. Aims: We aim to use electronic monitoring in DOAC-treated stroke patients to (i) evaluate the effect of an educational, reminder-based adherence-improving intervention, (ii) investigate predictors of non-adherence, (iii) identify reliable self-report measures of adherence, and (iv) explore the association of non-adherence with clinical outcomes. Methods: Single-center, randomized, crossover, open-label study. Adherence to DOACs of polymedicated patients self-administering their medication will be monitored electronically throughout the 12-month-long study following hospitalization for ischemic stroke. After a 6-month observational phase, patients will receive pharmaceutical counseling with feedback on their intake history and be given a multi-compartment pillbox for the subsequent 6-month interventional phase. The pillbox will provide intake reminders either during the first or the last three interventional-phase months. Patients will be randomly allocated to reminders-first or reminders-last. Study outcomes: Primary: non-optimal timing adherence; Secondary: non-optimal taking adherence; timing adherence; taking adherence; self-reported adherence; clinical outcomes including ischemic and hemorrhagic events; patient-reported device usability and satisfaction. Sample size estimates: A sample of 130 patients provides 90% power to show a 20% improvement of the primary adherence outcome with intake reminders. Discussion: MAAESTRO will investigate various aspects of non-adherence and evaluate the effect of an adherence-improving intervention in DOAC-treated patients with a recent stroke using electronic monitoring. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT03344146, Swiss National Clinical Trials Portal SNCTP000002410.

Resveratrol Delivery by Albumin Nanoparticles Improved Neurological Function and Neuronal Damage in Transient Middle Cerebral Artery Occlusion Rats

Human serum albumin (HSA) is an intrinsic protein and important carrier that transports endogenous as well as exogenous substances. It is demonstrated in this study that the regional accumulation of albumin in the ischemia-reperfusion (I/R) brain may lead in the application of HSA based nanoparticles in the study of cerebral I/R injury. Resveratrol (RES) is potential in the treatment of cerebral I/R injury but is restricted for its water insolubility and short half-life in vivo. In our study, RES loaded HSA nanoparticles (RES-HSA-NPs) were prepared to facilitate the application of RES in protection from cerebral I/R injury. RES-HSA-NPs demonstrated spherical shape, a diameter about 100 nm, a highest RES encapsulation efficiency of 60.9 ± 5.07%, and controlled release pattern with the maximum release ratio of 50.2 ± 4.91% [in pH = 5.0 phosphate buffered saline (PBS)] and 26. 2 ± 2.73% (in pH = 7.4 PBS), respectively, after 90 h incubation at 37°C. After intravenous injection into transient middle cerebral artery occlusion (tMCAO) rats, RES-HSA-NPs improved neurological score and decreased infarct volume at 24 h after tMCAO in a dose dependent manner. A single dose of 20 mg/kg RES-HSA-NPs via tail vein improved neurological outcomes and decreased infarct volume at 24 and 72 h in tMCAO rats. I/R increased oxidative stress (indicated by products of lipid peroxidation, MDA) and neuronal apoptosis (indicated by yellow-brown TUNEL-positive cells), RES-HSA-NPs significantly attenuated oxidative stress and neuronal apoptosis. These results demonstrated the potential of RES-HSA-NPs in the therapy of cerebral I/R injury.