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EDITORIALS: Helen Rodgers and Richard Thomson Functional status and long term outcome of stroke BMJ 2008; 0: bmj.39456.470880.80v1 [Full text]

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Educating Stroke patients and/ or their carers

Amer Jafar   (18 February 2008)

Secondary prevention in ischaemic stroke: other considerations

Mohammed A Butt, Sameer Mallick, F1 elderly care medicine, Worthing Hospital. Rajen Patel consultant physician in elderly care and stroke medicine, Worthing Hospital.   (19 February 2008)

Educating Stroke patients and/ or their carers 18 February 2008
Amer Jafar, Associate Specialist in Rehabilitation Medicine St Woolos Hospital, 131 Stow Hill, Newport, np20 4sz Send response to journal: Re: Educating Stroke patients and/ or their carers	Dear Sir, Madam; I quite agree with the editorial for this issue regarding the importance of educating the community about the risk factors for stroke and TIA (1). In fact the implications are immense on the progress of any prevention strategy with regard of stroke care. In thier research findings a team from Brazil disclosed in Feburary issue of Stroke that there is an alarming lack of knowledge about activation of emergency medical services and availability of acute stroke treatment in Brazil(2). These findings have implications for public health initiatives in the treatment of stroke and other cardiovascular emergencies. Another medical team from the Netherland investigated the knowledge of patients with a TIA or minor stroke about specific aspects of their disease 3 months after the event (3). The study concluded that the vast majority of patients with TIA or stroke lack specific knowledge about their disease, but they do have a reasonable knowledge of general vascular risk factors and treatment. Furthermore, a team from Arrow Park Hospital in Wirral, UK, wanted to assess the impact of the CareFile, an individualized information booklet, on patients' knowledge and satisfaction level after stroke (4). The team concluded that a simple education package, in the form of an individualized information booklet, resulted in a significant improvement in knowledge and recognition of risk factors for stroke. I think there is a lot to do on this side of stroke care, not only targeting the stroke patients themselves but thier carers as well. References: 1.Rodgers H and Thomson R.Functional status and long term outcome of stroke. BMJ 2008;336:337-8 2. Pontes-Neto O, Silva G S, Feitosa M R et al. Stroke awareness in Brazil.Stroke 2008;39:292-296 3.Maasland L, Koudstaal PJ, Habbema JD and Dipple DW. Knowledge and understanding of disease process, risk factors and treatment modalities in patients with a recent TIA or minor ischemic stroke.Cerebrovasc Dis.2007;23:435-40 4.Lowe DB, Sharma AK and Leathley MJ.The CareFile Project: a feasibility study to examine the effects of an individualised information booklet on patients after stroke. Age Ageing. 2007;36(1):83-9. Competing interests: None declared
Secondary prevention in ischaemic stroke: other considerations 19 February 2008
Mohammed A Butt, ST2 general medicine Worthing Hospital, West Sussex BN11 2DH, Sameer Mallick, F1 elderly care medicine, Worthing Hospital. Rajen Patel consultant physician in elderly care and stroke medicine, Worthing Hospital. Send response to journal: Re: Secondary prevention in ischaemic stroke: other considerations	Rodgers and Thompson comment in their editorial on the under treatment of hypertension, hypercholesterolaemia and atrial fibrillation (AF) in patients with ischaemic stroke prior to discharge [1]. However, their article did not explain the rationale for the under prescription of these agents. Several factors may influence the decision to start treatment and timing of treatment, often initiated after discharge. The optimal management of blood pressure in the acute phase of stroke is a matter of disagreement. There are many theoretical reasons to caution the initiation of anti-hypertensive medication during the acute phase of a stroke. Cerebral autoregulatory mechanisms regulate consistent perfusion over a variety of blood pressures. In the hypertensive individual, the autoregulatory curve shifts to a higher level such that at ‘normotensive’ blood-pressure, they are at the lower end of the curve and at an increased risk of cerebral hypoperfusion with further reduction in blood pressure [2]. An elevated blood pressure in the acute phase of stroke allows for a sufficient perfusion of the ischaemic penumbra, thus preventing any extension of the existing infarct [3]. There are reports in the literature of further neurological impairment in the acute phase of a stroke with over-zealous antihypertensive therapy [4]. Despite proven benefits in the elderly, the initiation of statin therapy in this group remains controversial. NICE guidelines state that when starting statins, clinicians should ‘take into account all factors that relate to the individual’s life expectancy and capacity to benefit from the reduction in cardiovascular events associated with statin usage’ [5]. The intended benefits of statins are often therefore not realised due to other significant co-morbidities limiting patients life expectancy. Furthermore, compliance is a significant issue with the elderly. The benefit of initiating statin treatment versus the effectiveness of prescription needs careful consideration in this age group. Although there is strong evidence to initiate warfarin therapy for AF post ischaemic stroke, many clinicians and patients still avoid anticoagulation [6]. One reason is that this particular group of patients is especially at risk of falls. The initiation of antihypertensive medication for secondary prevention in stroke may indirectly cause postural hypotension and further augment gait instability [7] increasing the likelihood of falls and risks of anticoagulation. Some authors also report as much as 40% of patients expressing a desire not to be anticoagulated with warfarin [8]. Furthermore anticoagulation for AF in patients with significant areas of cerebral infarction should be delayed 2 weeks due to the potential risk of haemorrhagic transformation [9]. Although it is clear that there is room for improvement in the UK for secondary prevention of mortality and morbidity associated with stroke, it is important to understand that some of the shortcomings in optimal management are largely due to legitimate clinical reasoning. Bibliography: 1. Rodgers H, Thomson R. Functional status and long term outcome of stroke. BMJ 2008;336;337-338 2. Mori S, Sadoshima S, Fujii K, et al. Decrease in cerebral blood flow with blood pressure reductions in patients with chronic stroke. Stroke. 1993; 24:1376 –1381 3. Hakim AM. Ischemic penumbra: the therapeutic window. Neurology. 1998;51:S44–46. 4. Fischberg GM, Lozano E, Rajamani K, et al. Stroke precipitated by moderate blood pressure reduction. J Emerg Med. 2000;19:339 –346. 5. National Clinical Guidelines for Stroke Second edition. Prepared by the Intercollegiate Stroke Working Party. Royal College of Physicians. June 2004. 6. Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. Ann Intern Med 1999;131:927-34. 7. Jones DA, Huwez F. Don't forget standing blood pressure. BMJ. 2008 Feb 16;336(7640):344 8. Protheroe J, Fahey T, Montgomery AA, Peters TJ. The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient-based decision analysis. BMJ 2000;320:1380- 4. 9. Hobbs R. Stroke prevention in atrial fibrillation. Br J Cardiol 2003;10:358–66. Competing interests: None declared