Pub Date: Thursday, Jul 15, 2021
Author: Deborah A. Levine MD, MPH
Affiliation: Department of Internal Medicine and Cognitive Health Services Research Program, Department of Neurology and Stroke Program, and Institute for Healthcare Policy and Innovation, University of Michigan
Suffering a stroke is devastating. Individuals with stroke face four challenges simultaneously: 1) understand the stroke etiology/mechanism; 2) manage complications; 3) recover functioning; and 4) prevent recurrent stroke. Individuals with stroke often ask: Why did I have a stroke? Will I get better? Will I be able to do the things I could do before the stroke? How can I prevent another stroke? After hospital discharge, primary care providers lead these efforts and work with the patient, their care partners, and other health care providers to address each of these challenges optimally. Now, primary care providers have a roadmap.
In the American Heart Association Scientific Statement, “Primary Care of Adult Patients After Stroke”, Kernan and colleagues provide primary care providers with a practical guide of goal-directed, evidence-based strategies to care for the individual with stroke and address each of the four challenges.1 It is a superlative document. The report summarizes the literature and guidelines into one easy-to-read, useable document for the busy primary care provider. They use a holistic approach to the whole individual with stroke and emphasize patient-centered care. The report gives helpful questions to focus primary care providers’ actions.
Recurrent strokes are more lethal, disabling, and costly than first strokes.2 While up to 80% of recurrent strokes are preventable,3 many individuals with stroke have uncontrolled, modifiable risk factors, increasing their risk for recurrent stroke. Vascular risk factors such as hypertension and tobacco smoking are increasing in Americans with stroke.4 One in 2 individuals with stroke has uncontrolled high blood pressure.5 Tremendous opportunities to prevent recurrent stroke are missed in those with stroke, putting individuals with stroke at substantial risk.
The article by Kernan et al.1 acknowledges the lack of evidence regarding smoking cessation and secondary stroke prevention. Randomized controlled trials have not demonstrated that smoking cessation reduces secondary stroke prevention. These trials likely will not be done. This situation is similar to that of another practical intervention, parachute use.6 However, experts estimate that smoking cessation can reduce recurrent stroke risk by 33% using the best available observational evidence.3 They estimate that treating 43 individuals with transient ischemic attack and stroke would avoid one stroke per year, a number lower than that for cholesterol-lowering drugs.3 From 2004 to 2014, the smoking prevalence increased by 70% among Americans hospitalized with ischemic stroke, driven by increased smoking rates in adults younger than 60.4 Among Americans hospitalized with ischemic stroke in 2014, 30-40% of those aged 18-59 and nearly 20% of those aged 60-79 smoked cigarettes.4 New guidelines recommend that providers start treatment with varenicline in individuals with tobacco dependence rather than wait until they are ready to stop tobacco use.7,8
Kernan et al.1 justifiably recommend cognitive impairment screening over the short-term and long-term in patients with stroke. Not only does stroke cause early cognitive dysfunction, but stroke is also associated with persistent, accelerated cognitive decline9 and increased dementia risk for 5+ years.10 Clinical practice guidelines and experts recommend cognitive assessments in all individuals with stroke before and after hospital discharge.11-14 Screening is important because individuals with stroke might lack insight and available care partners to identify cognitive impairment. Guidelines recommend a neuropsychological evaluation to identify cognitive strengths and weaknesses when screening reveals cognitive deficits.12
The article by Kernan et al is a significant contribution to the field. It provides clear, structured, and actionable information for primary care providers to deliver high-quality care to individuals with stroke. Still, we need policy and health system-level interventions to ensure that all individuals with stroke get high-quality care and reduce the burden on individual primary care providers. Like other individuals with disabilities, individuals with stroke frequently have problems accessing and getting high-quality health care.15 Some Americans with stroke, particularly those under 65 and racial/ethnic minorities, face barriers to care including lack of health insurance, lack of transportation, and inability to get appointments.16,17 Their insurance might limit services (e.g., capping the number of therapy visits) and medical equipment (e.g., home blood pressure monitors).15 Telemedicine has improved access for some individuals with stroke who cannot attend in-person visits. More improvements are needed. We need to raise our voices and advocate to guarantee that all individuals with stroke have access to the high-quality care recommended in this outstanding article.
Kernan WN, Viera AJ, Billinger SA, Bravata DM, Stark SL, Kasner SE, Kuritzky L, Towfighi A; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; and Council on Peripheral Vascular Disease. Primary care of adult patients after stroke: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print July 15, 2021]. Stroke. doi: 10.1161/STR.0000000000000382
- Kernan WN, Viera AJ, Billinger SA, Bravata DM, Stark SL, Kasner SE, Kuritzky L, Towfighi A; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; and Council on Peripheral Vascular Disease. Primary care of adult patients after stroke: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print July 15, 2021]. Stroke. doi: 10.1161/STR.0000000000000382
- Samsa GP, Bian J, Lipscomb J, Matchar DB. Epidemiology of recurrent cerebral infarction: a Medicare claims-based comparison of first and recurrent strokes on 2-year survival and cost. Stroke. 1999;30(2):338-349.
- Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet. 1999;354(9188):1457-1463.
- Otite FO, Liaw N, Khandelwal P, Malik AM, Romano JG, Rundek T, Sacco RL, Chaturvedi S. Increasing prevalence of vascular risk factors in patients with stroke: a call to action. Neurology. 2017;89(19):1985-1994.
- Razmara A, Ovbiagele B, Markovic D, Towfighi A. Patterns and predictors of blood pressure treatment, control, and outcomes among stroke survivors in the United States. J Stroke Cerebrovasc Dis. 2016;25(4):857-865.
- Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461.
- Leone FT, Zhang Y, Evers-Casey S, Evins AE, Eakin MN, Fathi J, Fennig K, Folan P, Galiatsatos P, Gogineni H, et al. Initiating pharmacologic treatment in tobacco-dependent adults: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;202(2):e5-e31.
- Jain A, Davis AM. Initiating pharmacologic treatment in tobacco-dependent adults. JAMA. 2021;325(3):301-302.
- Levine DA, Galecki AT, Langa KM, Unverzagt FW, Kabeto MU, Giordani B, Wadley VG. Trajectory of cognitive decline after incident stroke. JAMA. 2015;314(1):41-51.
- Pendlebury ST, Rothwell PM. Incidence and prevalence of dementia associated with transient ischaemic attack and stroke: analysis of the population-based Oxford Vascular Study. Lancet Neurol. 2019;18(3):248-258.
- American Academy of Neurology. Stroke and stroke rehabilitation quality measurement set update. https://www.aan.com/siteassets/home-page/policy-and-guidelines/quality/quality-measures/15strokeandrehabmeasureset_pg.pdf (PDF), 2016. Accessed May 9, 2021.
- Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98-e169.
- Eskes GA, Lanctôt KL, Herrmann N, Lindsay P, Bayley M, Bouvier L, Dawson D, Egi S, Gilchrist E, Green T, et al. Canadian stroke best practice recommendations: mood, cognition and fatigue following stroke practice guidelines, update 2015. Int J Stroke. 2015;10(7):1130-1140.
- Centers for Medicare and Medicaid Services. CARE item set and B-CARE. 2020; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE. Accessed May 9, 2021.
- Iezzoni L, O'Day B. More than ramps: A guide to improving health care quality and access for people with disabilities. New York: Oxford University Press; 2006.
- Levine DA, Burke JF, Shannon CF, Reale BK, Chen LM. Association of medication nonadherence among adult survivors of stroke after implementation of the US Affordable Care Act. JAMA Neurol. 2018;75(12):1538-1541.
- Levine DA, Neidecker MV, Kiefe CI, Karve S, Williams LS, Allison JJ. Racial/ethnic disparities in access to physician care and medications among US stroke survivors. Neurology. 2011;76(1):53-61.
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