Impact of heart rate on admission on mortality and morbidity in acute ischaemic stroke patients - results from VISTA.

BACKGROUND AND PURPOSE: Elevated heart rate (HR) is associated with worse outcomes in patients with cardiovascular disease. Its predictive value in acute stroke patients is less well established. We investigated the effects of HR on admission in acute ischaemic stroke patients. METHODS: Using the Virtual International Stroke Trials Archive (VISTA) database, the association between HR in acute stroke patients without atrial fibrillation and the pre-defined composite end-point of (recurrent) ischaemic stroke, transient ischaemic attack (TIA), myocardial infarction (MI) and vascular death within 90 days was analysed. Pre-defined secondary outcomes were the composite end-point components and any death, decompensated heart failure and degree of functional dependence according to the modified Rankin Scale after 90 days. HR was analysed as a categorical variable (quartiles). RESULTS: In all, 5606 patients were available for analysis (mean National Institutes of Health Stroke Scale 13; mean age 67 years; mean HR 77 bpm; 44% female) amongst whom the composite end-point occurred in 620 patients (11.1%). Higher HR was not associated with the composite end-point. The frequencies of secondary outcomes were 3.2% recurrent stroke (n = 179), 0.6% TIA (n = 35), 1.8% MI (n = 100), 6.8% vascular death (n = 384), 15.0% any death (n = 841) and 2.2% decompensated heart failure (n = 124). Patients in the highest quartile (HR> 86 bpm) were at increased risk for any death [adjusted hazard ratio (95% confidence interval) 1.40 (1.11-1.75)], decompensated heart failure [adjusted hazard ratio 2.20 (1.11-4.37)] and worse modified Rankin Scale [adjusted odds ratio 1.29 (1.14-1.52)]. CONCLUSIONS: In acute stroke patients, higher HR (>86 bpm) is linked to mortality, heart failure and higher degree of dependence after 90 days but not to recurrent stroke, TIA or MI.

Dysphagia therapy in stroke: a survey of speech and language therapists.

BACKGROUND: Dysphagia is common after stroke, leading to adverse outcome. There is a paucity of high-quality evidence for dysphagia therapy, thus making it difficult to determine the best approaches to treatment. Clinical decisions are often based on usual practice, however no formal method of monitoring practice patterns exists. AIMS: To determine speech and language therapists' (SLTs) approaches to direct dysphagia therapy with stroke patients in the UK and Ireland. METHODS & PROCEDURES: A 24-item questionnaire was developed, piloted and delivered in a web-based cross-sectional survey targeting all SLTs working with stroke patients in the UK and Ireland. OUTCOMES & RESULTS: A total of 138 SLTs responded from a range of clinical settings and levels of experience. There was variation in the responses to all questions. Respondents reported treating patients a median of once a day, 3 days a week for 15 min. The most commonly recommended direct exercises were supervised swallow trials (recommended 'frequently or always' by 73%). Despite most respondents having access to an instrumental swallowing assessment, over half reported rarely or never conducting one before recommending exercises. Most (93%) did not use a protocol for systematically progressing patients' exercises and only 37% reported using standardized outcome measures. CONCLUSIONS & IMPLICATIONS: This survey gives valuable insight into the direct dysphagia therapy practices of SLTs based in the UK and Ireland working in stroke. It highlights discrepancies between reported approaches and recommendations from existing evidence and clinical guidelines. The variation in responses indicates a need to develop a consensus statement and further research to guide practice.

Peripheral endothelial function and arterial stiffness in women with migraine with aura: a case-control study.

BACKGROUND: Vascular dysfunction may be involved in migraine pathophysiology and contribute to the increased risk of ischemic stroke in migraine, particularly in women with migraine with aura (MA). However, data on endothelial function in MA are controversial. Here, we investigated whether systemic endothelial function and arterial stiffness are altered in women with MA, using a novel peripheral arterial tonometry device for the first time. METHODS: Twenty-nine female MA patients without comorbidities and 30 healthy women were included, and carotid intima-media thickness was assessed by a standardized procedure. Endothelial function was assessed using peripheral arterial tonometry. Reactive hyperaemic response of digital pulse amplitude was measured following 5 minutes of forearm occlusion of the brachial artery. Arterial stiffness was assessed by fingertip tonometry derived and heart-rate-adjusted augmentation index. RESULTS: No differences were found in peripheral arterial tonometry ratio (2.3 ± 0.6 vs 2.2 ± 0.8; p = 0.58) and left carotid intima-media thickness (in µm: 484 ± 119 vs 508 ± 60; p = 0.37). Women with MA had higher heart-rate-averaged augmentation index [median (interquartile range, IQR) of 5 (IQR 0.5 to 18) vs -5 (IQR -16.8 to 8.3), p = 0.005] and heart-rate-adjusted augmentation index [1 (IQR -6 to 12.5) vs -8 (IQR -20.3 to 2.5), p = 0.008] than healthy controls. CONCLUSION: Peripheral endothelial function is not impaired in women with MA, but they have greater arterial stiffness. This may contribute to the increased stroke risk in women with MA.

Three-month stroke outcome: the European Registers of Stroke (EROS) investigators.

BACKGROUND: Contemporaneous data on variations in outcome after first-ever-lifetime stroke between European populations are lacking. We compared differences in case fatality rates, functional outcome, and living conditions 3 months after stroke within the European Registers of Stroke Collaboration. METHODS: Population-based stroke registers were established in France (Dijon), Italy (Sesto Fiorentino), Lithuania (Kaunas), the United Kingdom (London), Spain (Menorca), and Poland (Warsaw). All patients with first-ever-lifetime stroke of all age groups from the source population (1,087,048 inhabitants) were included. Data collection took part between 2004 and 2006. The study investigated population variations in outcome at 3 months (death, institutionalization due to stroke, or Barthel Index below 12 points) using multivariable logistic regression analyses adjusted for age, sex, stroke severity, stroke subtype, and comorbidities. RESULTS: A total of 2,034 patients with first-ever-lifetime stroke were included. Median age was 73 years, 52% were female. The mean weighted cumulative risk of death was 21.8% (95% confidence interval 20.0 to 23.6) with a 3-fold variation across populations. The weighted proportion of poor outcome was 41.3% (95% confidence interval 39.0 to 43.7) with a 2-fold variation across populations. CONCLUSION: More than 40% of patients had a poor outcome, defined as being dead, dependent, or institutionalized 3 months after stroke. Substantial outcome variations were found between populations that were explained by case mix variables in this analysis, yet a trend toward a higher risk of poor outcome was present in Kaunas.

Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project.

BACKGROUND: Randomized trials and meta-analyses indicate positive effects of stroke unit (SU) care on survival and dependency of patients with stroke. However, data on the advantages of SU in 'real-world' settings are limited. We prospectively assessed, in a large University Hospital, the effect of SU versus other conventional wards (OCW) care on all-cause mortality, death or dependency, death or institutionalization. METHODS: In a prospective observational study in the European Registers of Stroke Project, patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, 3-month and 1-year survival, and functional outcome. RESULTS: Overall, 355 patients (54.1% men, mean age 73.4 ± 14.5 years) were registered, 140 (39.4%) admitted to the SU, and 215 (60.6%) to OCW. OCW patients were older, whilst SU patients had more severe strokes according to NIHSS (P for trend = 0.025). SU patients were significantly more often treated by specialists in stroke medicine, stroke nurses, physiotherapists and speech therapists (all P < 0.001), psychologists (P = 0.025), dietitians (P < 0.001), and social workers (P = 0.003). MRI, carotid, and transcranial Doppler were significantly more often performed in SU patients (all P < 0.001). Intravenous fluids (P = 0.003) and intravenous anticoagulation (P < 0.001) were more often prescribed in SU. Controlling for case-mix, SU significantly reduced 1-year mortality (P = 0.020), death or dependency at 3 months (P = 0.006) and 1 year (P = 0.043), and death or institutionalization at 3 months (P = 0.001) and 1 year (P = 0.009). CONCLUSIONS: We confirmed the benefits of SU care in a clinical setting. Further analyses should define the contribution of individual components of care to stroke outcome.

An observational study of acute stroke care in four countries: the European registers of stroke study.

BACKGROUND: The European Registers Of Stroke (EROS) project aimed to assess outcomes of stroke care across Europe, relating these to both case mix information from disease-specific population registers and the quality of stroke care provided at each centre. This included comparing information on quality of care with direct observation of the stroke care process in 4 centres. METHODS: Direct non-participant observational methods were used on a purposive sample of first-stroke patients admitted within the past 14 days to an acute-stroke unit or ward that admits stroke patients in 4 urban hospital sites in London, UK, Dijon, France, Kaunas, Lithuania, and St. Petersburg, Russia. We recorded patient characteristics with levels of contact with multi-disciplinary team (MDT) members and contact with families and mobilization to build a collection of 'snapshots' of stroke care throughout the patients' day. One independent observer undertook all observations over 1 day. RESULTS: We observed differences between centres in the proportion of observations where patients were alone (lowest proportion in London, highest proportion in St. Petersburg) (p > 0.001), where patients had contact with MDT members (p > 0.001) and family, and where patients were out of bed/mobile (p > 0.001) (both with highest proportion in London, lowest proportion in St. Petersburg). CONCLUSIONS: Higher levels of contact with the MDT, family contact and mobilization were observed in the Western European centres than the Eastern European and Russian centres. Differences in case mix may explain some, but not all, of these differences. Direct observation has some limitations; however, it could be developed in future studies to help identify other key aspects of effective stroke care.

Complications after acute stroke.

BACKGROUND AND PURPOSE: We sought to observe the type, timing, and frequency of complications occurring in hospitalized patients after an acute stroke. METHODS: In a single hospital, we prospectively identified a consecutive cohort of patients who were either admitted after an acute stroke or who suffered a stroke while already an inpatient (n=613). We retrieved the case notes for 607 (99%) of these strokes, and a single observer, using predefined diagnostic criteria, reviewed the notes and recorded the type, timing, and frequency of complications that occurred during the inpatient period. We also measured the reliability of complication identification from case note review by comparing two observers on a sample of records. RESULTS: Complications were recorded after 360 strokes (59%); the most common individual complications were falls (complicating 22% of all strokes), skin breaks (18%), and urinary tract (16%) or chest (12%) infections. Miscellaneous "other" complications complicated 32% of strokes. Seizures and chest infections occurred early, whereas depression and painful shoulder were later problems. Complications were more common in older patients, who were more disabled before their stroke and had suffered more severe strokes. We demonstrated moderate to good agreement between the two observers for most complications. CONCLUSIONS: Complications after acute stroke are common, confirming that stroke rehabilitation requires active and knowledgeable medical input. Knowing the nature and timing of complications, together with the identification of high-risk patients, may be useful to those planning stroke services. The differences in our results and those previously reported, most notably for skin breaks, are probably due to the different methods used, in particular patient selection and diagnostic criteria for complications. Although complications may be useful as a measure of outcome in comparative studies (eg, therapeutic trials and audit), the methodological difficulties in accurately and reliably measuring them must be addressed.

Patients' and carers' satisfaction with acute stroke management.

We set out to discover how satisfied patients and carers were with existing stroke services. We prospectively identified 164 consecutive patients admitted to a department of general medicine with acute stroke and collected data using a satisfaction questionnaire in a semi-structured interview. of the 110 (67%) survivors, 65 (59%) patients and 80 (73%) carers completed an interview. We also interviewed 34 bereaved carers. Most patients (97%), carers (92%) and bereaved carers (94%) were satisfied with care overall. However, 30 (46%) of our patients, 53 (66%) carers and 18 (53%) bereaved carers who were satisfied with care overall expressed dissatisfaction with at least one component. Carers of patients were significantly more dissatisfied than the patients themselves with the amount of information given and with social work intervention. Carers of patients who were unable to respond to the questionnaire themselves, usually because of cognitive difficulties, were the most dissatisfied group even when compared with bereaved carers. Measuring satisfaction can alert one to deficiencies within a service, aiding service development, but interpreting patients' and carers' overall satisfaction. Efforts to improve communication, discharge planning and follow-up, aimed at carers as well as the patients themselves, are likely to be rewarded with improved satisfaction with stroke services.

A comparison of the Barthel Index and the OPCS disability instrument used to measure outcome after acute stroke.

The Barthel Index has been widely adopted as a measure of disability. The Office of Population Censuses and Surveys (OPCS) disability instrument was developed to provide a comprehensive measure of disability for use in the 1985 survey of disability among adults. Both measures were used on 150 patients surviving 1 year from a consecutive cohort of 246 admissions to hospital with acute stroke. The Barthel Index when summed across categories (as is commonly done), correlated reasonably well with the OPCS disability instrument [-0.73 (p < 0.001) 95% CI 0.64 to 0.80] despite its reliance on arbitrary weights and the omission of categories for communication, vision, hearing and intellectual disability. The broader scope of the OPCS instrument explained most of the floor and ceiling effects seen with the Barthel Index. The Barthel Index continues to have a useful role in stroke rehabilitation when used as a checklist for rehabilitation goals set by clinicians, as a predictor of long-term outcome and as an overall measure of disability or activities of daily living in descriptive studies, randomized controlled trials and audit. However, its floor and ceiling effects may lead to an underestimation of patients' and carers' problems in up to a third of patients. The OPCS instrument may prove to be a more useful outcome measure in randomized controlled trials and audits by virtue of its comprehensive nature.

Perceptions and knowledge of stroke among surviving patients with stroke and their carers.

As part of a survey to collect data which would be useful in planning a district stroke service we set out to discover what the service users' (patients' and carers') perceptions and knowledge of their illness were. We prospectively identified 164 consecutive patients with acute stroke admitted to hospital. Of the 110 (67%) survivors 65 (59%) patients and 80 (73%) carers completed a semi-structured interview. Most (46, 71%) patients and (68, 85%) carers thought they understood what a stroke was but 14 (22%) patients and 12 (15%) carers did not differentiate between a 'stroke' and a 'heart attack'. Carers were significantly more likely than patients to want know all the details about the patients' condition and treatment, to discuss the risk of recurrence, to receive written information and to join information groups. They were more likely than patients to feel that they had to ask for information, yet they were better able to identify general risk factors for stroke. Many patients and carers want more information and discussion about their illness and treatment during their hospital stay, however, some do not. Therefore information giving must be considered on an individual basis. Information could be delivered by: increasing available literature, voluntary group meetings, Stroke Family Care Officers and audio-visual information packages. The most efficient way of achieving an increased understanding amongst patients and carers needs to be found.