Utility of a post-hospitalization stroke prevention program managed by nurses.

GOAL: Evidence-based guidelines exist for the prevention and treatment of patients with cerebral ischemia. Despite these guidelines, there are gaps in clinical practice. Our study aimed to determine if a physician-directed, nurse-case-management program could reduce individual patient vascular risk factors. METHODS: Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke (hypertension, tobacco use, dyslipidemia, diabetes) were eligible to enroll in our study. Patients were randomized to management by the nurse-prevention program or usual care. Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year. Patients in the usual-care group underwent further follow-up by primary care and/or neurology as recommended during their hospitalization or outpatient visit. Patients assigned to the prevention group received individualized education, motivational interviewing, and were aided in setting up their risk-factor modification goal plan. Additional education was tailored to each patient based on individualized risk factors. Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist. The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year. RESULTS: At 1-year post-hospitalization, patients in the nurse-care-management group were 42% more likely to have met the primary endpoint (n = 18; 61% nurse-managed patients) compared with 33% (n = 18) of patients undergoing usual care (P = 0.09). There was no significant reduction in minor risk factors for either patient group. Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels (-38 vs -4; P = 0.0083), changes in cardiovascular risk score (-5.2 vs 1.3; P = 0.0033), and had a greater reductions in systolic blood pressure (-12.2 vs -0.105; P = 0.07) than their usual-care counterparts (changes shown respectively). Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group (50% vs 7%, respectively; P = 0.0070) and maintain an exercise program (83% vs 33%, respectively; P = 0.0018). SUMMARY: A physician-directed, nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke. A larger trial is needed to verify trends noted in our study.

Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study.

OBJECTIVES: We sought to determine the association between patent foramen ovale (PFO), atrial septal aneurysm (ASA), and stroke prospectively in a unselected population sample. BACKGROUND: The disputed relationship between PFO and stroke reflects methodologic weaknesses in studies using invalid controls, unblinded transesophageal echocardiography examinations, and data that are unadjusted for age or comorbidity. METHODS: The use of transesophageal echocardiography to identify PFO was performed by a single echocardiographer using standardized definitions in 585 randomly sampled, Olmsted County (Minnesota) subjects age 45 years or older participating in the Stroke Prevention: Assessment of Risk in a Community (SPARC) study. RESULTS: A PFO was identified in 140 (24.3%) subjects and ASA in 11 (1.9%) subjects. Of the 140 subjects with PFO, 6 (4.3%) had an ASA; of the 437 subjects without PFO, 5 had an ASA (1.1%, two-sided Fisher exact test, p = 0.028). During a median follow-up of 5.1 years, cerebrovascular events (cerebrovascular disease-related death, ischemic stroke, transient ischemic attack) occurred in 41 subjects. After adjustment for age and comorbidity, PFO was not a significant independent predictor of stroke (hazard ratio 1.46, 95% confidence interval 0.74 to 2.88, p = 0.28). The risk of a cerebrovascular event among subjects with ASA was nearly four times higher than that in those without ASA (hazard ratio 3.72, 95% confidence interval 0.88 to 15.71, p = 0.074). CONCLUSIONS: These prospective population-based data suggest that, after correction for age and comorbidity, PFO is not an independent risk factor for future cerebrovascular events in the general population. A larger study is required to test the putative stroke risk associated with ASA.

Atherosclerosis of the aorta: risk factor, risk marker, or innocent bystander? A prospective population-based transesophageal echocardiography study.

OBJECTIVES: The goal of this study was to investigate whether complex aortic atherosclerosis is associated with increased risk of vascular events in a non-selected population. BACKGROUND: In selected high-risk patients, aortic atherosclerosis is associated with increased risk of vascular events. METHODS: We describe the relationship between simple versus complex (>4-mm thick or mobile debris) aortic atherosclerotic plaques and vascular events during follow-up in a random sample of 585 persons (age > or =45 years) using 1993 to 2000 data from the Stroke Prevention: Assessment of Risk in a Community (SPARC), a prospective population-based longitudinal study. RESULTS: At five-year median follow-up (range, 0.5 to 6.5 years), cardiac events (death, non-fatal myocardial infarction, coronary revascularization, heart failure associated with coronary artery disease) and cerebrovascular events (ischemic fatal and non-fatal strokes, transient ischemic attacks) had occurred in 95 subjects and 41 subjects, respectively. Age, male gender, prior coronary artery disease, higher pulse pressure, and diabetes were significant cardiovascular predictors. Age, prior myocardial infarction, and a history of atrial fibrillation were significant cerebrovascular predictors. Simple aortic plaques (253 persons) were not independently associated with either cardiac or cerebrovascular events. Complex plaques (44 persons) were marginally associated with cardiac events, adjusting for age and gender (hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.11 to 4.68; p = 0.053 for two degrees of freedom [complex and simple plaques vs. no plaques]) but not after adjusting for additional clinical risk factors (HR, 1.22; 95% CI, 0.57 to 2.62; p = 0.64). Complex plaques were associated with cerebrovascular events only univariately. CONCLUSIONS: Aortic atherosclerotic plaques are not associated with future cardiac or cerebrovascular events. Aortic atherosclerosis may not be an independent risk factor for vascular events in the general population.