Functional status and long term outcome of strokeBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39456.470880.80 (Published 14 February 2008) Cite this as: BMJ 2008;336:337
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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
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.
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
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
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: No competing interests
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 . 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
. 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 . There are reports in the literature
of further neurological impairment in the acute phase of a stroke with
over-zealous antihypertensive therapy .
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’
. 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 . 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  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 . 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 .
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.
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.
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.
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
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-
9. Hobbs R. Stroke prevention in atrial fibrillation. Br J Cardiol
Competing interests: No competing interests