Review of stroke treatment could save lives
Doctors are underutilising crucial medication to prevent deadly strokes in those with a common type of heart condition, new research says, leading to fresh calls for a review of current treatment strategies and more research into stroke prevention.
Stroke is Australia’s second biggest killer after coronary heart disease and is a major cause of disability. A new study of over 26,000 stroke patients, has found those with Atrial Fibrillation (AF) – an irregular heartbeat commonly seen in the elderly – have a mortality rate almost twice that of other stroke patients.
As many as 90 percent of patients with AF-related stroke do not receive appropriate blood-thinning medication at the time of their stroke. Researchers say a number of fatal and disabling strokes could therefore be prevented through the better use of existing anticoagulant medication.
The study, led by researchers from the University of New South Wales and the Ingham Institute, is published this month in the journal Cerebrovascular Diseases.
It found that patients with AF make up one in four of the most common form of stroke (ischaemic stroke). Patients with AF had twice the chance of dying in hospital and had a mortality rate of 40 per cent, one year after their stroke. Such patients also had much longer hospital stays and were more likely to be disabled. “This is the biggest evidence practice gap in cardiovascular health,” lead report author and UNSW conjoint Associate Professor, John Worthington, said.
Assessing the Risk of a First Stroke
It is helpful for healthcare providers and the public to be able to estimate a person’s risk for a first stroke. As detailed in the sections that follow, numerous factors can contribute to a person’s stroke risk, and many individuals have >1 risk factor. Some of these risk factors are relatively less well documented, and specific or proven treatments may be lacking. Although most risk factors have an independent effect, there may be important interactions between individual factors that need to be considered in predicting overall risk or choosing an appropriate risk modification program. Risk-assessment tools have been used in community stroke screening programs and utilized in some guideline statements to select certain treatments for primary stroke prevention. Some of the goals of such risk-assessment tools are (1) to identify persons at elevated risk who might be unaware of their risk; (2) to assess risk in the presence of >1 condition; (3) to measure an individual’s risk that can be tracked and lowered by appropriate modifications; (4) to estimate a quantitative risk for selecting treatments or stratification in clinical trials; and (5) to guide appropriate use of further diagnostic testing.
He said doctors are underutilising anticoagulants because of an excessive concern over bleeding risk, despite “robust guidelines” being in place for treating AF patients who are over 65 years old. Anticoagulants ‘thin’ the blood to help prevent blood clots that cause ischaemic strokes. There is a small risk that patients on anticoagulants will suffer major bleeding, including the risk of a brain haemorrhage.
The paper also highlights the limitations of existing strategies to accurately predict and prevent stroke among younger AF patients, who account for 10 per cent of young strokes in the study as well as 19 per cent of early deaths. For many of these patients, “their first stroke will be their last,” Assoc. Prof. Worthington said.
However, 20-30 per cent of young stroke patients with AF would have been judged as ‘low risk’ by current practices, and not given anticoagulants. The study calls for “urgent research”, with a focus on how to better determine stroke risk in all AF patients and for trials of new and existing anticoagulants in younger AF patients.
Ischemic stroke
Emergency treatment for an ischemic stroke depends on the location and cause of the clot. Measures will be taken to stabilize your vital signs, including giving you medicines.
* If your stroke is diagnosed soon enough after the start of symptoms, you may be given a clot-dissolving medicine called tissue plasminogen activator (t-PA), which can increase your chances of survival and recovery.
* You may also receive aspirin or another antiplatelet medicine.
Hemorrhagic stroke
Treatment for Hemorrhagic stroke includes efforts to control bleeding, reduce pressure in the brain, and stabilize vital signs, especially blood pressure.
* You will be closely monitored for signs of increased pressure on the brain, such as restlessness, confusion, difficulty following commands, and headache. Other measures will be taken to keep you from straining from excessive coughing, vomiting, or lifting, or straining to pass stool or change position.
* If the bleeding is due to a ruptured brain aneurysm, surgery to repair the aneurysm may be done. Repair may include:
o Using a metal clip to clamp off the aneurysm to prevent renewed bleeding.
o Inserting a small coil into the aneurysm to block it off (endovascular coil embolization).
* In some cases, medicines may be given to control blood pressure, brain swelling, blood sugar levels, fever, and seizures.
* If a large amount of bleeding has occurred and the person is rapidly getting worse, surgery may be needed to remove the blood that has built up inside the brain and to lower pressure inside the head.
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Other researchers on the study were Dr Melina Gattellari, Mr Chris Goumas and Mr Robert Aitken. The study was funded by the Federal Department of Health and Ageing and UNSW.
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Associate Professor John Worthington
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61-298-283-646
University of New South Wales