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How PCPs can help patients prevent second ischemic stroke
Within 5 years of a first stroke, 42% of men and 24% of women will have another one, according to the National Stroke Association.
Primary care physicians play a critical role in reducing the odds of a second stroke, according to Seuli Brill, MD, clinical associate professor of internal medicine at The Ohio State University Wexner Medical Center.
“PCPs have a really unique vantage point over a cardiologist or neurologist in secondary stroke prevention in that they know how the patient’s health has evolved over time, and thus, they have a more holistic view of the patient,” she said in an interview.
Healio Primary Care Today asked Brill and other experts to discuss how PCPs can reduce their patients’ risk for subsequent strokes.
Assessing patient’s risk
One way PCPs can gauge a patient’s risk for second stroke is to ask several questions to ascertain recurrent stroke risk, J. David Spence, MD, FRCPC, FAHA, of the Robarts Research Institute at Western University in Canada, told Healio Primary Care Today.
“Was the [first] stroke cardioembolic? The patient should be anticoagulated and if possible a direct-acting oral anticoagulant should be used,” he said.
“Was the [first] event hemorrhagic or ischemic? This is best answered with a CT scan to rule out hemorrhage. If ischemic, the most common mistake doctors make in this situation is to double the aspirin if the patient was already taking it; this is wrong because low-dose aspirin is more effective than high doses,” Spence continued, adding that the following questions should be asked if the event was ischemic.
“Was the event due to large artery atherosclerosis such as carotid stenosis? A carotid ultrasound would be appropriate, and urgent endarterectomy would be indicated (or stenting in selected cases, but stenting carries a higher risk of stroke, particularly in the elderly).
“Was the event a hypertensive lacune? In that case the blood pressure would be high, and the infarction would be in the internal capsule, basal ganglia, thalamus or brainstem; the primary treatment would be to control the hypertension.
“Was the event due to giant cell arteritis? This is an emergency and should be treated with high-dose prednisone pending further investigation — the patient would have a high C-reactive protein and usually a history of fatigue, headache, maybe jaw claudication and scalp tenderness,” Spence added.
Another way PCPs may be able to ascertain risk for second stroke 1 year after transient ischemic attack or minor stroke, is by using the ABCD score. This score, described in an NEJM article, allocates patients one point for each of the following criteria they meet: aged older than 60 years; BP of 140 mm Hg/90 mm Hg or higher; clinical finding of unilateral weakness or speech impairment; duration of stroke’s sudden symptoms) of 10 to 59 minutes and has diabetes. Symptom duration of 60 minutes or more is assigned two points. Higher scores usually, but not always, connotate risk for second stroke, Pierre Amarenco, MD, wrote on behalf of the TIAregistry.org investigators, in the NEJM article.
A third method, called the Recurrent Risk Estimator and described in JAMA Neurology, may predict early stroke recurrence after an acute ischemic stroke. Like the ABCD score, patients get one point for each of the following: previous transient ischemic attack or stroke within the preceding month; first stroke was caused by large artery atherosclerosis or arterial dissection, prothombotic disorders or vasculitis; more than one acute infarct; acute infarcts in both hemispheres or in both anterior and posterior circulations at the same time; multiple infarcts of different ages for combination of acute and subacute infarcts); and isolated cortical location. The higher the score, the higher one’s risk for second stroke, E. Murat Arsava, MD, of the department of neurology at Hacettepe University Faculty of Medicine in Turkey and colleagues wrote in JAMA Neurology.
Medication considerations
Once a patient’s risk has been identified, the patient will likely begin a medication regimen, Pravin George, DO, of Cleveland Clinic, said in an interview. Patients must be treated for hypertension regardless of whether they were before the stroke, with a goal of getting the patient’s BP to 140 mm Hg/90 mm Hg or lower. If the patient’s LDL cholesterol is 100 mg/dL or higher, even if there is no evidence of other clinical atherosclerotic cardiovascular disease, they should start statin therapy.
There are several regimens patients can start to reach the LDL-cholesterol and BP goals, according to articles published by the American Heart Association and American Family Physician: 50 mg to 325 mg of aspirin daily; 25 mg/200 mg of aspirin/dipyridamole twice daily; aspirin and clopidogrel within 24 hours of a minor ischemic stroke or transient ischemic attack and for up to 21 days after the event; or, if the patient is allergic to aspirin, 75 mg of clopidogrel monotherapy daily.
Spence said that adding ezetimibe more than doubles the effect of statins with less adverse events than high doses of statins, and that evidence has shown adding ezetimibe to statin therapy reduces stroke risk.
“Patients with large artery disease should probably take statin and ezetimibe regardless of the baseline LDL-C. In high-risk patients, it is recommended to lower the LDL-C by half,” Spence said.
PCPs must consider a patient’s other medications when making these treatment decisions for secondary stroke prevention, according to Ryan R. Bailey, PhD, MSCI, OTR/L, a postdoctoral research scholar at the Washington University School of Medicine in Saint Louis,
“Although risk factor management through pharmacological intervention is often necessary, polypharmacy can result in a high treatment burden for people with stroke and carries added risk for morbidity and mortality,” he wrote in the American Journal of Lifestyle Medicine while with the VA Medical Center in Atlanta.
PCPs can avoid polypharmacy by considering adherence, adequate directions, adverse events, alternatives to current therapy, appropriateness of medication reviewed at least annually, clinical response, interaction, complexity of medication, compliance with guidance, contraindication, and dose/route/formulation/frequency indication made available, according to a systematic review in BMC Medicine.
Lifestyle changes
More than medication is needed to reduce a patient’s risk for a second stroke, Brill and George told Healio Primary Care Today.
PCPs must screen patients for diabetes and obesity, recommend polysomnography, discourage smoking and heavy alcohol use, and encourage patients who can participate in physical activity to perform 40 minutes of moderate to vigorous intensity aerobic physical exercise a minimum of three to four times weekly, according to George.
Spence added that eating healthy foods like those in the Mediterranean diet is an important, but sometimes overlooked, component of avoiding a second stroke.
“Diet is far more important than most physicians (and the public) suppose,” he wrote in F1000 Research. “In the Lyon Diet Heart Study, there was a greater than 60% reduction of stroke and myocardial infarction over 4 years in secondary prevention. This was approximately twice the effect of simvastatin in the contemporaneous Scandinavian Simvastatin Survival Study.
Other clinical pearls
When discussing secondary stroke prevention, Brill said it is important that both lifestyle changes and medication management be discussed in tandem, with no clinical bias towards one or the other.
“It would be irresponsible after a patient has had a stroke to tell them to solely rely on lifestyle or solely rely on medication. Patients who have had a stroke are not likely to make instantaneous lifestyle interventions or start taking medications that they didn’t take or prioritize in the past,” she said in an interview.
“Therefore, you must find a way to engage the patient in two-way conversations that provide practical ways to make those changes, otherwise you’re missing a golden opportunity to improve their physical and mental well-being,” Brill added.
Bailey agreed that the conversation must involve the people on both sides of the examining room table.
“Ask the patient what the pros and cons are of both changing a behavior for the better as well as not changing the behavior at all. Sometimes this is enough to get patients to think about the consequences of their behavior and at least be willing to consider modifying their behaviors,” he said in an interview.
Brill added PCPs who can relate to the patient’s concerns and can go slow and steady with treatment from the first stroke will likely have the most success in secondary stroke prevention.
“I had a patient who was reluctant to take some of her medications. During our talk, the patient disclosed the medicine I had recommended had been associated with the death of her loved one. So instead of pushing the issue by referring to guidelines, I found another treatment option, and she is slowly starting to bring her blood sugar under control,” she said.
“I also tell my patients it is better for them to make a small change rather than some big, grandiose one and a few days later, feel overwhelmed by the commitment you made. I would rather negotiate a goal with the patient and then chip away at changes to achieve it, rather than scare them with a whole litany of medical society recommendations that are just too much to institute at one time,” Brill added. – by Janel Miller
References:
Amarenco P, et al. NEJM. 2016;doi:10.1056/NEJMoa1412981.
American Heart Association. “Top ten things to know. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack.” Accessed Feb. 13, 2019. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_462212.pdf
Arsava EM, et al. JAMA Neurol. 2016;doi:10.1001/jamaneurol.2015.4949.
Bailey RR. Am J Lifestyle Med. 2016;doi:10.1177/1559827616633683.
Burt J, et al. BMC Med. 2018;doi:10.1186/s12916-018-1078-7.
National Stroke Association. “Preventing another stroke.” https://www.stroke.org/we-can-help/survivors/stroke-recovery/first-steps-to-recovery/preventing-another-stroke/. Accessed Feb. 13, 2019.
NIH. “Stroke information page.” https://www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page. Accessed Feb. 13, 2019.
Oza R, et al. Am Fam Physician. 2017;96(7):436-440.
Spence JD. F1000Res. 2017;doi:10.12688/f1000research.11597.1
Spence JD, Barnett HJM. “Stroke prevention, treatment and rehabilitation.” McGraw-Hill Medical 2012.
Disclosures: Bailey reports no relevant financial disclosures. Spence reports receiving lecture fees from Bristol-Myers Squibb and Pfizer and serving a consultant to Amgen and Orphan Technologies. Healio Primary Care Today was unable to determine Brill and George’s relevant financial disclosures prior to publication.