The impact of intensive blood pressure management in the post-thrombolysis setting: a real-world observational study.

AIM: Systolic blood pressure (SBP) >180mmHg following stroke thrombolysis has been associated with increased bleeding and poorer outcome. Aiming for the guideline SBP of <180mmHg often leads to SBP overshoot, as treatment is only triggered if this threshold is passed. We tested whether a lower target would result in fewer high SBP protocol violations. METHOD: This is a single-centre, sequential comparison of two blood pressure protocols. Between 2013 and 2017, the guideline-based post-thrombolysis SBP target of <180mmHg was compared with a new protocol aiming for 140-160mmHg. The primary outcome was rate of patients with SBPs >180mmHg. Secondary outcomes included rates of SBP <120 mmHg, antihypertensive infusion use, symptomatic intracerebral haemorrhage (sICH) and 3-month functional independence (modified Rankin Score [mRS] 0-2). Results were adjusted for age, baseline function and stroke severity using regression analysis. RESULTS: During the 23 months preceding and 18 months following the transition to the new protocol, 68 and 100 patients were thrombolysed respectively. Baseline characteristics were similar between groups. The odds of one or more SBPs >180mmHg trended lower in the intensive group (adjusted odds ratio [aOR] 0.61; 95% confidence interval [CI] 0.32-1.17; p=0.14). There was a higher rate of SBPs <120mmHg (aOR 3.09; 95% CI 1.49-6.40; p=0.002) in the intensive BP protocol group. sICH rate and 3-month mRS 0-2 were similar between groups. CONCLUSIONS: The more intensive post-thrombolysis BP protocol was associated with a significant increase in sub-optimally low BP events, with a non-significant trend toward fewer high BP protocol violations and unaffected patient outcomes.

Atrial fibrillation and anticoagulation in patients hospitalised for stroke in the REGIONS Care Study.

AIM: To describe atrial fibrillation (AF) patient characteristics and anticoagulation patterns in stroke patients in Aotearoa. METHODS: Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke (REGIONS) Care study is a prospective, nation-wide observational study of consecutive adult stroke patients admitted to hospital between 1 May and 31 October 2018. AF and anticoagulation prescribing, intracerebral haemorrhage (ICH) and differences by Maori ethnicity and hospital location are described. RESULTS: Of 2,379 patients, 807 (34.3%) had a diagnosis of AF. AF patients were older than non-AF patients (mean 79.9 [SD 11] versus 72.5 [14.2], p<0.0001). AF was diagnosed before stroke in 666 patients (82.5%), of whom 442 (66.4%) were taking an anticoagulant. The most common documented reasons for non-anticoagulation were prior bleeding (20.5%), patient preference (18.1%), frailty, comorbidities/side effects (13.2%) and falls (6.8%). The ICH rate was similar for AF patients on versus not on an anticoagulant (adjusted odds ratio [aOR] 0.99, 95% confidence interval [CI] 0.55-1.80). Rates and reasons for oral anticoagulant non-prescribing were similar for Maori, non-Maori, urban and non-urban populations. CONCLUSIONS: Although anticoagulation prescribing in AF has improved, one third of stroke patients with known AF were not taking an anticoagulant prior to admission and the majority did not appear to have an absolute contraindication offering a multidisciplinary opportunity for improvement. There were no significant differences for Maori and non-urban populations in anticoagulant prescribing.

Barriers to optimal stroke service care and solutions: a qualitative study engaging people with stroke and their whanau.

AIM: The aim of this study was to explore the perspectives of people with stroke and their whanau on barriers to accessing best practice care across Aotearoa, and to brainstorm potential solutions. METHOD: We conducted ten focus groups nationwide and completed a thematic analysis. RESULTS: Analysis of the data collected from the focus groups identified five themes: (1) inconsistencies in stroke care; (2) importance of effective communication; (3) the role of whanau support; (4) the need for more person rather than stroke centred processes; and (5) experienced inequities. Participants also identified potential solutions. CONCLUSION: Key recommendations include the need for improved access to stroke unit care for rural residents, improved post-discharge support and care coordination involving the whanau, improved communication across the patient journey, and a concerted effort to improve culturally safe care. Next step is to implement and monitor these recommendations.