Secondary risk factor management 5-years post ischaemic stroke - The ASPIRE-S2 study
Creators: name: Gaynor, Eva
Publisher: name: Royal College of Surgeons in Ireland
Year: 2020
Subjects: subject: 119999 Medical and Health Sciences not elsewhere classified
subject: FOS: Other medical sciences
subject: FOS: Other medical sciences

description: Numerous guidelines have been published outlining evidence-based best<br>practice in secondary stroke prevention, including optimal target control of risk<br>factors. Despite these guidelines failure to achieve these recommendations in<br>clinical practice is common. This study, ASPIRE-S2 is a 5-year follow-up study<br>of the ASPIRE-S Study (Action on Secondary Prevention Interventions and<br>Rehabilitation in Stroke). The primary aim of this study was to prospectively<br>assess secondary prevention profiles of Irish ischaemic stroke patients at 5-<br>years and compare them to that measured at 6-months. Secondary outcomes<br>at 5-years (cognitive impairment, recurrent stroke events and mortality) and<br>their association with secondary risk factors measured at 6-months post-stroke<br>are also reported. The secondary aims of this thesis were to review blood<br>pressure profiles at 6-months post-stroke among the original ASPIRE-S cohort.<br>This included examining the prevalence of inter-arm blood pressure difference<br>and to investigate its associated risk factors. Ambulatory blood pressure profiles<br>and their association with cognitive impairment 6-months post-stroke was also<br>reviewed.<br>Numerous secondary risks were measured at 5-year review including blood<br>pressure (both clinic and ABPM), fasting risks (lipids and glucose and HBA1C in<br>diabetics), anticoagulation control in patients on warfarin therapy, and physical<br>measurements (weight, waist circumference, height). Lifestyle risk factors<br>(alcohol and smoking) were documented. These were compared to those<br>measured in the same patient group at 6-months. Secondary end-points at 5-<br>years post-stroke that were reviewed included death, cognitive impairment,<br>vulnerability and psychological wellbeing. Association of secondary risk factors<br>measured at 6-months with mortality at 5-years was analysed. Blood pressure<br>analysis including inter-arm blood pressure analysis in a post-stroke population<br>and ambulatory blood pressure patterns associated with cognitive impairment<br>post-stroke included those patients from the original ASPIRE-S study with<br>measurements taken at 6-months post-stroke.<br>Results of this follow-up study revealed that secondary risk factor management<br>remains suboptimal among stroke survivors at 5-years post-ischaemic stroke<br>with a substantial proportion of patients not reaching recommended target<br>control for secondary risks, especially in relation to blood pressure control.<br>Comparative analysis of risk factors between the two time-points (6-months and<br>5-years post-stroke) showed an increase in the prevalence of cardiovascular<br>risk factors (ex: hypertension, hypercholesterolaemia, atrial fibrillation) at 5-year<br>review. There was no statistically significant improvement in secondary risk<br>factor control (blood pressure, lipid, diabetic management) at 5-years poststroke<br>when compared to that measured at 6-months. Analysis of secondary<br>risk factors measured at 6-months showed that atrial fibrillation, high TC/HDL<br>ratio, cognitive impairment and vulnerability were associated with mortality at 5-<br>years.<br>Results from our blood pressure analysis at 6-months post-stroke showed that<br>there was a high prevalence of inter-arm blood pressure difference among this<br>patient population. 40.3% had an intra-arm systolic blood pressure difference<br>(IASBP) of &gt;10mmHg and 20.6% had a difference of &gt;15mmHg. A history of<br>alcohol excess was associated with an increased IASBP &gt;15mmHg.<br>Review of nocturnal blood pressure profiles at 6-months and their association<br>with cognitive impairment was performed. A reduction in normal systolic dipping<br>at night-time predicted the presence of cognitive decline (MOCA &lt;26) at 6-<br>months post-stroke (OR 1.06 CI 1.01-1.11 p=0.02).<br>The results from this study reveals that secondary risk factor control continues<br>to be suboptimal in long-term follow-up. This research aims to highlight the<br>importance for increased vigilance among healthcare professionals in managing<br>secondary cardiovascular risks in high-risk patient populations. The need for<br>continued audit of clinical practise should be encouraged to ensure guidelines<br>are met. Public health bodies should promote healthy lifestyle advise and<br>secondary prevention strategies so to encourage patient involvement and to<br>further the education on secondary stroke prevention.<br>