Running head: LITERATURE SEARCH: STROKE PREVENTION

Literature Search: Stroke Prevention Student name Grand Canyon University: NRS-433V-O191 April 28, 2013

STROKE PREVENTION Literature Search: Stroke Prevention A stroke or "brain attack" occurs when a blood clot blocks an artery (a blood vessel that carries blood from the heart to the body), or a blood vessel (a tube through which the blood moves through the body) breaks, interrupting blood flow to an area of the brain. When either of these things happens, brain cells begin to die and brain damage occurs. When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These abilities include speech, movement, and memory. How a stroke patient is affected depends on where the stroke occurs in the brain and how much the brain is damaged. Stroke is the fourth leading cause of death in America and a leading cause of adult disability. Up to 80% of strokes are preventable. There are 2 types of risk factors for stroke: controllable and uncontrollable. Controllable risk factors generally fall into two categories: lifestyle risk factors or medical risk factors. Lifestyle risk factors can often be changed, while medical risk factors can usually be treated. Both types can be managed best by working with a doctor, who can prescribe medications, and advise on how to adopt a healthy lifestyle. Stroke risk can be controlled through early detection and

treatment of many diseases, and modifications of lifestyle that increases the risk of stroke. Some of the treatable diseases that increase the risk of strokes are hypertension, high cholesterol, atrial fibrillation, diabetes, atherosclerosis and the risk factors due to life style are smoking, alcoholism, and obesity. The following articles prove the importance of prevention and treatment of diseases, and the healthy life style to prevent and reduce stroke. Article 1 Fox-Wilson, G., & Cruickshank, S. (2012). Stroke prevention in primary care: optimising management of AF through nurse specialist support. British Journal Of Cardiac Nursing, 7(9), 432-437.

STROKE PREVENTION Atrial fibrillation is the most common heart rhythm disturbance, occurring in 1-2% of

people and prevalence of AF ranged from 0.7% to 1.2% over the years 20072010. Due to silent undetected AF, the prevalence of AF is closer to the 2% of population and the prevalence of AF increases with age. Atrial Fibrillation increases the risk and severity of stroke five times than the people with normal heart rhythm. Warfarin is an effective anticoagulant for the prevention of stroke but is underused. This article describes a pilot which found that providing general practices with expert advice and education from an arrhythmia nurse increased the numbers of patients with atrial fibrillation being prescribed warfarin to reduce their risk of stroke. Results was favorable when compared with a national comparator. Closer links were forged between primary and secondary care and the pilot also demonstrated savings both financially and in terms of strokes prevented. Stroke prevention due to AF is challenging and the pilot showed exiting opportunities to develop new services to optimize management. Article 2 McManus, R., & Mant, J. (2009). Blood pressure-lowering treatment should be offered to all patients regardless of blood pressure. Journal of Clinical Hypertension, 11(12), 698-701. BP measurement has been a routine clinical activity for more than a century and since the late 1960s, the benefits of lowering BP through antihypertensive treatment have been apparent from the results of randomized controlled trials. The first of these trials enrolled only patients with very high BP (e.g., diastolic BP _115 mm Hg), but, since then, thresholds for treatment have become progressively lower and have been tested with a variety of medications on different populations. An analysis by Law and colleagues proposed strategy for offering BP treatment to all over a certain age is attractive in that benefits in terms of risk reduction are similar whatever the BP and accord with epidemiologic evidence. Such a change would fit with developments in

STROKE PREVENTION cholesterol lowering and has the potential to widen access to CV risklowering therapy with subsequent benefits on a whole population basis. However, before such a strategy can be widely applied, key questions remain including cost effectiveness compared with a strategy based on identifying and treating high risk individuals, detection and management of secondary causes of hypertension, how very high risk younger individuals will be detected and treated, and whether patients and professionals will accept such a sea change in practice. If such questions can be answered, then BP management could be revolutionized. Article 3 Foy, R., Eccles, M., Hrisos, S., Hawthorne, G., Steen, N., Gibb, I., & ... Grimshaw, J. (2011). A cluster randomised trial of educational messages to improve the primary care of diabetes. Implementation Science, 6129. A program of cluster randomized controlled trials was set in primary care practices in one primary care trust in England. Participants were the primary care practices constituent healthcare professionals and patients with diabetes. Interventions comprised brief educational messages added to paper and electronic primary care practice laboratory test reports and

introduced over two phases. Phase one messages, attached to Hemoglobin A1c (HbA1c) reports, targeted glycaemic and cholesterol control. Phase two messages, attached to albumin: creatinine ratio (ACR) reports, targeted blood pressure (BP) control, and foot inspection. Main outcome measures comprised practice mean HbA1c and cholesterol levels, diastolic and systolic BP, and proportions of patients having undergone foot inspections. Initially, 35 out of 37 eligible practices participated. Outcome data were available for a total of 8,690 patients with diabetes from 32 practices. The BP message produced a statistically significant reduction in diastolic BP (-0.62 mmHg; 95% confidence interval -0.82 to -0.42 mmHg) but not systolic BP (-0.06 mmHg,

STROKE PREVENTION -0.42 to 0.30 mmHg) and increased the odds of achieving target BP control (odds ratio 1.05; 1.00, 1.10). The foot inspection message increased the likelihood of a recorded foot inspection (incidence rate ratio 1.26; 1.18 to 1.36). The glycaemic control message had no effect on mean HbA1c (increase 0.01%; -0.03 to 0.04) despite increasing the odds of a change in likelihood of HbA1c tests being ordered (OR 1.06; 1.01, 1.11). The cholesterol message had no effect (decrease 0.01 mmol/l, -0.04 to 0.05). Three out of four interventions improved intermediate outcomes or process of diabetes care. The diastolic BP reduction approximates to relative reductions in mortality of 3% to 5% in stroke and 3% to 4% in ischemic heart disease over 10

years. The lack of effect for other outcomes may, in part, be explained by difficulties in bringing about further improvements beyond certain thresholds of clinical performance. Article 4 Dudl, R., Wang, M., Wong, M., & Bellows, J. (2009). Preventing myocardial infarction and stroke with a simplified bundle of cardioprotective medications. American Journal of Managed Care, 15(10), e88-94. Seminal clinical trials established that statins and angiotensin converting enzyme inhibitors (ACEIs) individually reduce the rate of fatal and nonfatal cardiovascular events among people with diabetes and/or cardiovascular disease. In patients with diabetes, coronary artery disease (CAD), or other occlusive arterial disease, simvastatin 40 mg/day reduces by about onequarter the risk of myocardial infarction (MI), stroke, revascularization procedures, and coronary deaths.1,2 Among individuals with known vascular disease or diabetes and another risk factor, ACEIs reduce the rate of MIs by 18% and the rate of stroke by 23%.A simplified method for bundling fixed doses of a generic statin and an ACEI/ARB was successfully implemented in a

STROKE PREVENTION large, diverse population in an integrated healthcare delivery system, reducing the risk of hospitalization for MI and stroke.

STROKE PREVENTION References Dudl, R., Wang, M., Wong, M., & Bellows, J. (2009). Preventing myocardial infarction and stroke with a simplified bundle of cardioprotective medications. American Journal Of Managed Care, 15(10), e88-94. Retrieved from

http://library.gcu.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true &db=rzh&AN=2010475909&site=eds-live&scope=site Fox-Wilson, G., & Cruickshank, S. (2012). Stroke prevention in primary care: optimising management of AF through nurse specialist support. British Journal Of Cardiac Nursing, 7(9), 432-437. Retrieved from http://www.internurse.com/cgibin/go.pl/library/abstract.html?uid=93854 Foy, R., Eccles, M., Hrisos, S., Hawthorne, G., Steen, N., Gibb, I., & ... Grimshaw, J. (2011). A cluster randomised trial of educational messages to improve the primary care of diabetes. Implementation Science, 6129. doi:10.1186/1748-5908-6-129 McManus, R., & Mant, J. (2009). Blood pressure-lowering treatment should be offered to all patients regardless of blood pressure. Journal Of Clinical Hypertension, 11(12), 698-701. doi:10.1111/j.1751-7176.2009.00183.x