Interventions for improving modifiable risk factor control in the secondary prevention of stroke

  • Review
  • Intervention

Authors


Abstract

Background

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Evidence-based strategies for secondary stroke prevention have been established. However, the implementation of prevention strategies could be improved.

Objectives

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

Search methods

We searched the Cochrane Stroke Group Trials Register (April 2013), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013), CENTRAL (The Cochrane Library 2013, issue 3), MEDLINE (1950 to April 2013), EMBASE (1981 to April 2013) and 10 additional databases. We located further studies by searching reference lists of articles and contacting authors of included studies.

Selection criteria

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

Data collection and analysis

Two review authors selected studies for inclusion and independently extracted data. One review author assessed the risk of bias for the included studies. We sought missing data from trialists.

Main results

This review included 26 studies involving 8021 participants. Overall the studies were of reasonable quality, but one study was considered at high risk of bias. Fifteen studies evaluated predominantly organisational interventions and 11 studies evaluated educational and behavioural interventions for patients. Results were pooled where appropriate, although some clinical and methodological heterogeneity was present. The estimated effects of organisational interventions were compatible with improvements and no differences in the modifiable risk factors mean systolic blood pressure (mean difference (MD) -2.57 mmHg; 95% confidence interval (CI) -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68), blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64) and mean body mass index (MD -0.68 kg/m2; 95% CI -1.46 to 0.11). There were no significant effects of organisational interventions on lipid profile, HbA1c, medication adherence or recurrent cardiovascular events. Educational and behavioural interventions were not generally associated with clear differences in any of the review outcomes, with only two exceptions.

Authors' conclusions

Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes. The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors. We identified a large number of ongoing studies, suggesting that research in this area is increasing. The use of standardised outcome measures would facilitate the synthesis of future research findings.

Plain language summary

Healthcare interventions for reducing the risk of future stroke in people with previous stroke or transient ischaemic attack (TIA)

Question

We wanted to assess the effects of interventions for implementing secondary stroke prevention strategies to reduce the risk of further stroke or other cardiovascular events in people who have already had a stroke or transient ischaemic attack (TIA).

Background

Stroke and TIA are diseases that are caused by interruptions in the blood supply to the brain. People who experience a stroke or TIA are at risk of future stroke and other cardiovascular events. Several medications and lifestyle changes can be used to lower stroke risk by improving the control of modifiable risk factors. In this review, modifiable risk factors for stroke included systolic and diastolic blood pressure, blood lipids, atrial fibrillation, diabetes management, body mass index (BMI) and the use of preventive medications as prescribed. Research evidence suggests that modifiable risk factors are often not managed effectively following a stroke or TIA. Therefore, it is important to identify healthcare interventions that can facilitate stroke prevention by improving modifiable risk factor control and patient adherence to prescribed medications. The categories of interventions considered in this systematic review were educational and behavioural interventions for patients; educational and behavioural interventions for stroke service providers; organisational interventions.

Study characteristics

We identified 26 studies, up to April 2013, for inclusion in the review. These studies included a total of 8021 participants with cerebrovascular disease and were undertaken in the USA, Canada, Europe, Asia and Australia. The mean or median age of participants ranged from 60 to 73 years. Six studies included participants with a diagnosis of ischaemic stroke, whereas three studies included participants with either ischaemic or haemorrhagic stroke, or did not specify stroke subtype. The majority of studies were set in primary care or community settings. Eleven studies involved educational or behavioural interventions for participants and 15 studies involved predominantly organisational interventions. The majority of interventions had a duration of between three and 12 months.

Key results

Analysis of the effects of changes to the organisation of healthcare services was compatible with meaningful improvements in systolic blood pressure, diastolic blood pressure, blood pressure target achievement and BMI; although the imprecision of these estimates meant that absence of improvements could not be ruled out. The effects of these interventions on changes in blood lipids, diabetes management, use of preventive medications as prescribed, or the occurrence of stroke and other cardiovascular events were imprecise and consistent with benefit and harm. Changes to healthcare services that addressed only patient education or behaviour, without any changes to the organisation of patient care, were generally not associated with clear evidence of changes in modifiable risk factors for stroke. We identified a large number of ongoing studies, suggesting that research in this area is increasing.

Quality of the evidence

We judged all but one of the included studies to be of reasonable quality.

Laički sažetak

Zdravstvene intervencije za smanjenje rizika novih moždanih udara u ljudi s prethodnim moždanim udarom ili tranzitornom ishemijskom atakom (TIA-om)

Istraživačko pitanje

Autori Cochrane sustavnog pregleda procijenili su učinke intervencija za usvajanje strategija za sekundarnu prevenciju moždanog udara kako bi se smanjio rizik novih moždanih udara ili drugih srčano-žilnih (kardiovaskularnih bolesti) u ljudi koji su ranije imali moždani udar ili tranzitornu ishemijsku ataku (TIA-u)

Dosadašnje spoznaje

Moždani udar i TIA su bolesti koje uzrokuje prekid dotoka krvi u mozak. Osobe koje su imale moždani udar ili TIA-u imaju veći rizik za nove moždane udare i druge kardiovaskularne bolesti. Nekolicina lijekova i promjene stila življenja mogu se koristiti u smanjivanju rizika od moždanog udara poboljšanjem kontrole rizičnih čimbenika. U ovom Cochrane sustavnom pregledu, uključeni čimbenici rizika za moždani udar bili su sistolički i dijastolički krvni tlak, masnoće u krvi, fibrilacija atrija, kontrola šećerne bolesti, indeks tjelesne mase (ITM) i upotreba preventivnih lijekova prema uputama liječnika. Dokazi iz istraživanja pokazuju često neučinkovitu kontrolu čimbenika rizika nakon moždanog udara ili TIA-e. Stoga je važno utvrditi koje zdravstvene intervencije mogu olakšati prevenciju moždanog udara poboljšanjem kontrole čimbenika rizika i pridržavanjem uzimanja propisanih lijekova od strane pacijenta. Vrste intervencija koje su uzete u obzir u ovom sustavnom Cochrane pregledu su edukacijske i bihevioralne intervencije za pacijente; edukacijske i bihevioralne intervencije za zdravstvene radnike; organizacijske intervencije.

Značajke istraživanja

Pronađeno je 26 istraživanja objavljenih do travnja 2013. koja su uključena u ovaj sustavni pregled. Ta istraživanja uključila su ukupno 8.021 ispitanika s bolestima krvnih žila u mozgu (cerebrovaskularnim bolestima), a rađena su u SAD-u, Kanadi, Europi, Aziji i Australiji. Prosječna dob sudionika bila je u rasponu od 60 do 73 godine. Šest istraživanja uključili su sudionike s dijagnozom ishemijskog moždanog udara, dok su tri istraživanja uključila sudionike bilo s ishemijskim ili hemoragijskim moždanim udarom, ili nije navedena vrsta moždanog udara. Većina istraživanja su rađena u primarnoj zdravstvenoj zaštiti ili u zajednici. 11 istraživanja imala su edukacijske ili bihevioralne intervencije za sudionike a 15 istraživanja imala su uglavnom organizacijske intervencije. Većina intervencija trajala je od tri do 12 mjeseci.

Ključni rezultati

Analiza učinaka promjena u organizaciji zdravstvenih usluga bila je u skladu sa značajnim poboljšanjima sistoličkog krvnog tlaka, dijastoličkog krvnog tlaka, ciljnog krvnog tlaka i ITM-a; iako se zbog nepreciznosti tih procjena ne može isključiti izostanak poboljšanja. Učinci tih intervencija na promjene u koncentraciji lipida u krvi, kontrolu šećerne bolesti, korištenje preventivnih lijekova kako je propisano, odnosno pojava moždanog udara i drugih kardiovaskularnih bolesti bili su neprecizni i dosljedni kad je u pitanju procjena njihovih korisnih i štetnih učinaka. Promjene zdravstvenih usluga koje su uključile samo edukaciju pacijenata ili njihovo ponašanje, bez ikakvih promjena u organizaciji skrbi za bolesnike, uglavnom nisu bile povezane s jasnim dokazima promjena čimbenika rizika za moždani udar. Pronađen je velik broj istraživanja koja su u tijeku, što ukazuje na povećanje broja istraživanja u ovom području.

Kvaliteta dokaza

Procijenjeno je kako su sva uključena istraživanja osim jednog bila razumne kvalitete.

Bilješke prijevoda

Hrvatski Cochrane
Preveo: Mato Lakić
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Ancillary