Medical prevention of stroke and stroke recurrence in patients with TIA and minor stroke

Background: Secondary stroke prevention after transient ischemic stroke (TIA) or minor stroke is of major importance in order to avoid recurrent cerebrovascular events and decrease morbidity and mortality. Objective/methods: Systematically review of recently published, high-quality studies emphasizing the need for emergency assessment and treatment of patients with TIA and minor stroke and to give a comprehensive and distinct overview over medical secondary stroke prevention trials performed in these patients. Results/conclusions: Evaluation and implementation of preventive stroke therapy has to be immediate in patients with TIA and stroke. For patients with non-cardioembolic stroke, antiplatelet agents are the treatment of choice. Aspirin plus extended-release dipyridamole and clopidogrel are more effective than aspirin and should be used in patients with a high risk of recurrent stroke. Oral anticoagulation is highly effective in patients with a cardiac source of embolism. Treatment of risk factors such as arterial hypertension and high cholesterol is even more important in secondary stroke prevention than in primary prevention. Vitamin supplementation and lowering of elevated levels of homocysteine are not effective in stroke prevention.     

Antiplatelet therapy for the prevention of recurrent stroke and other serious vascular events: a review of the clinical trial data and guidelines

ABSTRACT

Background: One strategy of reducing the burden of stroke is the prevention of recurrent stroke, following an initial ischaemic stroke or transient ischaemic attack (TIA) of arterial origin, by means of antiplatelet therapy.

Scope: This review article surveys and discusses the current clinical trial data and guidelines for the use of antiplatelet therapy in the prevention of recurrent stroke/TIA of arterial origin (not stroke due to atrial fibrillation). Based on the latest available evidence, a new antiplatelet treatment algorithm for the long-term treatment of patients following atherothromboembolic ischaemic stroke or TIA is proposed.

Findings: Meta-analyses of randomised clinical trials in patients with TIA and ischaemic stroke of arterial origin indicate that, compared with control, the relative risk reduction (RRR) for recurrent stroke and other serious vascular events is 13% (95% confidence interval [CI] 6% to 19%) with aspirin, 13% (4% to 21%; p = 0.046) with dipyridamole and 34% (24% to 43%) with the combination of aspirin and dipyridamole. Compared with aspirin, the relative risk of recurrent stroke and other serious vascular events is reduced by 7.3% (95% CI –5.7% to 18.7%) with clopidogrel and 18% (9% to 26%; p = 0.0003) with the combination of aspirin and dipyridamole. The combination of aspirin and clopidogrel is not significantly more effective in preventing serious vascular events than clopidogrel alone (RRR 6.4%; –4.6% to 16.3%) in the long-term treatment of patients with previous ischaemic stroke and TIA, mainly because of a cumulative excess of bleeding complications. The relative risks and benefits of long-term treatment with clopidogrel and the combination of aspirin and dipyridamole are being compared in an ongoing large clinical trial (PRoFESS). Current Australian therapeutic guidelines for antiplatelet therapy among patients with TIA and ischaemic stroke of arterial origin have incorporated important new findings from recently published clinical trials and recommend aspirin or the combination of dipyridamole plus aspirin as the preferred long-term antiplatelet therapy.

Conclusion: Whilst awaiting the results of the PRoFESS trial, the combination of dipyridamole plus aspirin is the preferred antiplatelet regimen to reduce the risk of recurrent vascular events among patients with TIA and ischaemic stroke of arterial origin.     

Safety of clopidogrel and aspirin for stroke prevention: implications of the CHARISMA trial.

Antiplatelet therapy is universally recommended for the prevention of recurrent events in patients with noncardioembolic ischaemic stroke or transient ischaemic attack (TIA), acute and chronic coronary artery disease, or peripheral arterial disease. However, choosing which antiplatelet agents to use in these situations remains controversial. The use of aspirin, aspirin plus extended-release dipyridamole, or clopidogrel is recommended as initial therapy in patients with noncardioembolic ischaemic stroke or TIA to reduce the risk of recurrent stroke and other cardiovascular events. Based on the results of the MATCH trial, combination therapy with aspirin plus clopidogrel is not recommended for patients with ischaemic stroke or TIA due to the increased risk of haemorrhage.The results of the CHARISMA trial support this recommendation; despite previous data demonstrating a favourable benefit-risk profile of aspirin plus clopidogrel in patients with acute coronary syndrome, this combination should not be used in patients at high risk for atherothrombosis and those with previous stroke or TIA. In these patients, the CHARISMA trial demonstrated a lack of significant clinical efficacy and an increased risk of bleeding with clopidogrel plus aspirin compared with aspirin alone.Further research is needed to assess the benefit-risk ratio of clopidogrel plus aspirin in specific subpopulations of patients at high risk for atherothrombotic events, and to determine the role of clopidogrel plus aspirin in preventing cardioembolic stroke or early recurrent stroke after symptomatic large-vessel atherostenosis. Recent and ongoing studies are seeking to better define the roles of different antiplatelet regimens in preventing recurrent stroke.     

Contemporary management of transient ischemic attack: role of the pharmacist

Transient ischemic attacks (TIAs) have been redefined recently. The new tissue-based definition of TIA abandons the 24-hour restriction on symptom duration previously used to differentiate TIA from acute ischemic stroke and requires neuroimaging studies to identify the cause of the ischemia and to determine the presence and extent of brain injury. This new definition brings to light the need for urgent diagnostic testing and timely initiation of treatment, as well as secondary prevention measures to reduce the increased risk of stroke, cardiovascular complications, and death in the days and weeks after a TIA. Pharmacists play a key role in identifying patients at risk for a first or recurrent TIA or stroke, educating high-risk patients on the signs and symptoms of TIA or stroke and the need for urgent evaluation and treatment, overcoming barriers to timely diagnosis and treatment, and ensuring that appropriate primary or secondary prevention strategies are in place. Furthermore, studies have shown that pharmacist-led interventions can lead to significant improvements in modifiable risk factors, such as blood pressure and cholesterol levels, as well as drug adherence, and may reduce the occurrence of strokes. These interventions may also help maintain patients' health-related quality of life and improve patients' satisfaction with care.     

Drug therapy for the secondary prevention of stroke in hypertensive patients: current issues and options

Hypertension is the major risk factor for ischaemic and haemorrhagic clinical strokes as well as for silent brain infarcts with a continuous association between both systolic and diastolic blood pressures. Epidemiological data highlight the increasing burden to come over the next decades. Without any doubt, antihypertensive treatment is the most important therapy to reduce the risk of stroke by approximately 30-40%. International guidelines recommend antihypertensive treatment for primary prevention with evidence level A.Recurrent strokes or transient ischaemic attack (TIA) are an important practical, clinical and economic problem, and have a major impact on the development of vascular dementia. All stroke patients and patients with TIA have to be regarded as very high-risk patients. Hypertension increases the risk of recurrent strokes. Only limited data directly address the role of blood pressure treatment among individuals with stroke or TIA.There is a general lack of definitive data regarding when to start antihypertensive treatment in the initial phase, and treatment of hypertension in the acute period after stroke is still under debate. Experimental and clinical data suggest that reducing the activity of the renin-angiotensin aldosterone system (RAAS) may have beneficial effects beyond the lowering of blood pressure. There is increasing evidence of cerebroprotective effects for medication influencing the RAAS, such as angiotensin receptor antagonists or ACE inhibitors. The MOSES study showed for the first time superiority of an angiotensin receptor antagonist compared with a calcium channel antagonist in antihypertensive treatment for secondary stroke prevention. Optimal blood pressure range in secondary prevention seems to be 120-140/80-90 mm Hg, but questions about a J- or U-shaped curve are still not answered sufficiently. The effects of additional antihypertensive treatment in the evening for stroke patients with 'non-dipping' blood pressure need to be investigated.Currently, the most important goal in primary and secondary prevention of stroke is a strict normotensive blood pressure control. Antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in individuals who have had an ischaemic stroke or TIA (class I, level of evidence A). Many open questions remain and funding of stroke research needs to be increased in the near future.     

Pharmacotherapy in stroke rehabilitation

Background: Pharmacotherapy is commonly given to patients recovering from a stroke to prevent further complications (e.g. recurrent stroke, seizures) or enhance recovery. However, some drugs may have a negative impact on neuroplasticity. Objectives: This review examines currently used drugs that are believed to promote recovery from motor and cognitive disturbances associated with stroke. Methods: Literature regarding the properties, efficacy, safety, and dosing of drugs used to promote recovery after stroke was reviewed. Results: The data on pharmacotherapy are insufficient to support a claim of significantly improved rehabilitation outcomes. Moreover, a growing body of evidence indicates that some agents can impair functional reorganization and slow the recovery process. However, a few chemicals are reported to be beneficial for stroke rehabilitation. The most promising are noradrenergic and dopaminergic agents, as well as several growth factors; these should be the future focus of extensive randomized clinical trials. Conclusions: Currently there is no drug with proven efficacy in enhancing poststroke recovery.     

入院血清Lp-PLA2水平预测短暂性脑缺血发作后早期卒中风险

目的:探讨入院血清脂蛋白相关磷脂酶A2（Lp-PLA2）预测短暂性脑缺血发作（TIA）后早期卒中发生风险的价值。方法:回顾性连续收集2015年8月至2019年11月在连云港市第二人民医院神经内科住院的TIA患者179例,其中男100例,女79例,年龄（66.2±7.8）岁。根据TIA发病后90 d随访是否发生卒中分为卒...     

Safety of selective serotonin reuptake inhibitor treatment in recovering stroke patients

Introduction: Selective serotonin reuptake inhibitors (SSRIs) are widely used for psychiatric complications after stroke. Studies have indicated additional effects, and SSRIs could potentially be used as enhancers of stroke recovery. However, beneficial effects should be weighed against potential adverse effects. In particular, the possible association with cerebrovascular events has raised concern.

Areas covered: We review the literature on cerebrovascular events associated with SSRI treatment after stroke. The possible beneficial effects of SSRI treatment for stroke recovery and survival, and potential safety concerns, are discussed.

Expert opinion: Evidence suggests that SSRIs may enhance stroke recovery. Most studies on cerebrovascular risk are from non-stroke populations and little is known about recurrent events and mortality post-stroke. In non-stroke populations treatment has been associated with increased risk of intracerebral and intracranial hemorrhage; however the absolute risk is low. The association between SSRIs and ischemic stroke is less clear. Randomized stroke trials indicate that treatment is safe and well tolerated, and the most common side effects are often benign and transient. The trials are small however and not powered to detect potential differences in cerebrovascular events. We await several ongoing large randomized trials before SSRIs can be recommended as a routine pharmacotherapy in stroke recovery.     

Primary and secondary stroke prevention with antiplatelet drugs

Aspirin is not effective in the primary prevention of stroke. Patients with TIA or ischemic stroke carry a risk of recurrent stroke between 5 and 20% per year. In patients with TIA or ischemic stroke of noncardiac origin antiplatelet drugs are able to decrease the risk of stroke by 11-15% and the risk of stroke, MI and vascular death by 15-22%. Aspirin is the most widely used drug. It is affordable and effective. Low doses of 50-325 mg aspirin are as effective as high doses and cause less gastrointestinal side effects. Severe bleeding complications are dose-dependent. The combination of aspirin with slow release dipyridamole is superior to aspirin alone for stroke prevention. Clopidgrel is superior to aspirin in patients at high risk of recurrence. The combination of aspirin plus clopidogrel is not more effective than clopidogrel alone but carries a higher bleeding risk. None of the antiplatelet agents is able to reduce mortality.     

Classification of outcome events in the Dutch TIA trial: prognostic value of accepted and rejected events

Objective: In large multicentre clinical trials adjudication of outcome events most often is done centrally. Some of these events would eventually be judged not to meet the criteria and hence would be rejected. If the classification procedures work correctly one would expect a higher risk of future vascular events after an 'accepted' rather than after a 'rejected event. In the present study we aimed at testing the adequacy of a classification procedure in a trial of patients with a transient ischemic attack (TIA) or minor ischemic stroke by comparing the further outcome between patients in whom a possible event was either rejected or accepted for the final analysis in this trial.

Research design and methods: The vascular outcome events were analysed in 3150 patients with TIA or minor stroke who participated in the Dutch TIA trial. We identified the patients with a first 'accepted' or 'rejected' non-fatal stroke or myocardial infarction (MI). In these two groups of patients we determined the occurrence of the subsequent vascular events (vascular death, stroke or MI). The incidence was compared with survival analysis techniques.

Results: Among 308 patients with a first nonfatal 'accepted' event in 81 (26.3%) a new vascular event occurred; among the 51 patients with a 'rejected' event there were 12 (23.5%) such events. The hazard ratio for new vascular events was 1.22 (95% CI 0.67-2.22). After multivariate adjustment for age, type of qualifying event, history of smoking, angina pectoris and myocardial infarction, and Rankin score > 3, the hazard ratio was 1.49 (95% CI 0.78–2.84).

Conclusion: our study suggested that the adjudication process of outcome events in the Dutch TIA trial was done correctly because a trend towards a higher recurrence rate of vascular events among patients with 'accepted' outcome events was found.     

Treatment strategies for childhood stroke

Background: Ischaemic stroke (arterial ischaemic stroke and cerebral sinovenous thrombosis) is increasingly recognised in childhood and has a significant attendant morbidity and mortality. Objective: To review the most recent evidence underpinning treatment of childhood ischaemic stroke. Methods: A literature search was performed through Medline and Cochrane Reviews database using search terms such as management/treatment/therapy of ischaemic stroke in children, anticoagulants, thrombolysis, aspirin for the prevention of stroke in childhood. Articles reviewed were published within the last 20 years. Conclusions: Two separate treatment guidelines for childhood ischaemic stroke have been published and are those of the Royal College of Physicians in the UK and more recently the American Heart Association Stroke Council. In addition, the American College of Chest Physicians provide guidance on the use of anticoagulants and antithrombotic therapy in childhood stroke. Supportive care and neuroprotective strategies are important considerations in children with ischaemic stroke. Antithrombotic strategies are advocated; the choice of agent varies according to the underlying risk factors. Divergence between the published guidelines highlights the lack of a firm evidence base for published recommendations. Thrombolytic treatment is not advocated. Specific pathologies may require targeted management, for example surgical revascularisation for moyamoya. Clinical trials are urgently needed to establish comprehensive evidence-based guidelines for the treatment of childhood ischaemic stroke.     

A systematic review of vinpocetine therapy in acute ischaemic stroke

Objectives: To determine whether vinpocetine decreases short- and long-term case fatality and proportion of dependent survivors if administered within 2 weeks of stroke onset. Methods: All published and unpublished trials were attempted to be identified using the standard search strategy of the Cochrane Collaboration Stroke Review Group, using MEDLINE searches performed with all known manufacturer code names and trade names of vinpocetine and by contacting manufacturers of vinpocetine to give information of all randomised controlled trials on vinpocetine in stroke. Researchers who participated in trials on vinpocetine in Hungary were asked for further information. Only truly randomised, unconfounded clinical trials that compared the effect of vinpocetine to either placebo or another reference treatment for acute stroke where treatment started no later than 14 days after stroke onset were eligible for inclusion. Data synthesis and analysis was performed using the Cochrane Review Manager software (RevMan version 3.0). Results: Among the identified studies on vinpocetine in stroke, only one fulfilled the selection criteria for inclusion in the review. No death occurred in the study groups and no statistically significant difference was found in dependency between the treatment and the placebo groups. No adverse effects were reported. Conclusions: Based on only one small randomised controlled unconfounded study, presently there is not enough evidence to decide whether the administration of vinpocetine does or does not decrease case fatality and dependency in acute stroke. Received: 16 December 1998 / Accepted in revised form: 2 March 1999     

Current Management of Transient Ischemic Attack

Transient ischemic attack (TIA) is a precursor to ischemic stroke. At least half of patients with TIA have a new, small ischemic lesion demonstrable on magnetic resonance imaging using a diffusion weighted sequence. The risk of subsequent major stroke is 10-20% in the next 3 months with much of that risk front-loaded in the first week. Strategies to identify and treat high-risk patients need to be defined. The optimal treatment approach and the timing of interventions, both medical and surgical, remains unknown. In general, aspirin is the first line of treatment to prevent further stroke. Other antiplatelet agents such as clopidogrel alone or in combination with aspirin and the combination aspirin/extended-release dipyridamole may be administered. Endarterectomy or carotid stenting is of great benefit to patients with TIA secondary to stenosis in the extracranial carotid artery.     

Discovery,development and effectiveness of coagulation-inhibiting drugs for stroke therapy

Introduction: Stroke is the third leading cause of death in the US and the leading cause of major disability. A large variety of drugs and new therapeutic strategies are the basis for modern stroke therapy. There is scientific evidence for the effectiveness of only a few coagulation-inhibiting drugs for stroke prevention and treatment, but a lot of clinical trials have been conducted or are ongoing in order to gain more scientific data on stroke management and therapy.

Areas covered: This paper gives a general overview of modern coagulation-inhibiting drugs discovered and investigated for prevention or acute stroke therapy and offers prospects of future therapy options.

Expert opinion: Without the development of more cost-effective future therapies and implementation of extended prevention programs, stroke will remain the leading cause of disability. There is still a strong need for the discovery of novel drug therapies that effectively avoid blood clotting and stroke without increasing the risk of hemorrhage.     

ROCKs as immunomodulators of stroke

Introduction: Stroke is the third leading cause of death and a major cause of long-term disability in the adult population. Growing evidence suggests that inflammation may play an important role in the evolution of stroke. Because Rho-associated coiled-coil containing kinases (ROCKs) are important mediators of inflammation, they may contribute to stroke and stroke recovery.

Areas covered: The pathophysiological role of ROCKs in mediating inflammation at different phases of stroke, and the therapeutic opportunities for stroke prevention and stroke treatment with ROCK inhibitors will be discussed.

Expert opinion: Inflammation is a double-edged sword during the evolution of stroke. Immunomodulation might provide a novel therapeutic approach for stroke prevention and stroke treatment. ROCK plays an important role in mediating the inflammatory response following vascular injury as well as platelet activation and thrombus formation. ROCK inhibitors have been shown to be beneficial in stroke prevention, acute neuroprotection and chronic stroke recovery by affecting inflammatory-mediated platelet and endothelial function, smooth muscle contraction and neuronal regeneration. Thus, ROCK-mediated inflammation could be a potential therapeutic target for stroke prevention and stroke treatment. However, the mechanism by which ROCKs regulate the inflammatory response is unclear, and the role of the two ROCK isoforms in stroke and stroke recovery remains to be determined.     

Progress in reducing the burden of stroke

1. The burden of stroke worldwide is growing rapidly, driven by an ageing population and by the rapid rate of urbanization and industrialization in the developing world. There are approximately 5 million fatal and 15 million non-fatal strokes each year and over 50 million survivors of stroke alive, worldwide, today. 2. The most important determinant of stroke risk is blood pressure, with a strong, continuous relationship between the level of the systolic and diastolic pressures and the risk of initial and recurrent stroke, in both Western and Asian populations. 3. Randomized clinical trials have clearly demonstrated that blood pressure lowering reduces the risk of initial stroke by 35-40% in hypertensive patients; but, until recently, there was no conclusive evidence that blood pressure lowering was effective in the secondary prevention of stroke. 4. The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) has provided definitive evidence that blood pressure lowering in patients with previous stroke or transient ischaemic attack (TIA) reduces the incidence of secondary stroke by 28%, of major vascular events by 26% and of major coronary events by 26%. These reductions were all magnified by approximately 50% in a subgroup of patients in whom the angiotensin-converting enzyme inhibitor perindopril was routinely combined with the diuretic indapamide. 5. Successful global implementation of a treatment with perindopril and indapamide in patients with a history of stroke or TIA would markedly reduce the burden of stroke and could avert between 0.5 and one million strokes each year, worldwide.     

A benefit-risk assessment of agents used in the secondary prevention of stroke.

Stroke is a major cause of morbidity and mortality. Full assessment of stroke or transient ischaemic attack (TIA) patients is required to identify all risk factors and apply appropriate secondary preventative strategies. Antiplatelet therapies are effective in the secondary prevention of ischaemic stroke and can be justified despite adverse effects such as gastrointestinal haemorrhage. Aspirin (acetylsalicylic acid), aspirin plus dipyridamole, ticlopidine and clopidogrel are all of value but their adverse effect profiles vary significantly. Combinations of antiplatelet agents may offer additional benefit but not all combinations have been studied in stroke patients. Anticoagulation with agents such as warfarin is effective with coexisting atrial fibrillation and other conditions predisposing to cardioembolic stroke. Antihypertensive agents have been extensively studied in the primary prevention of stroke; however, relatively few trials of antihypertensive agents in the secondary prevention of stroke are available. The incidence of adverse effects of antihypertensive agents is relatively low and the benefit-risk profile would tend to favour their use in the secondary prevention of stroke. Recent studies of ACE inhibitors have identified an important role for these agents in the secondary prevention of stroke even in those who are normotensive and in those who have had a haemorrhagic stroke. The incidence of serious adverse effects with ACE inhibitors appears relatively low. Lipid-lowering agents may have a role to play in certain groups of patients with stroke. The incidence of adverse effects is relatively low with HMG-CoA reductase inhibitors. Cigarette smoking is an important risk factor for stroke and evidence is available that smoking cessation does reduce the individual's risk of stroke. Pharmacological agents are available to help smoking cessation. In patients with diabetes mellitus, intensive regimens with insulin and oral hypoglycaemic agents have so far not definitively been shown to reduce the incidence of macrovascular complications such as stroke. Tight glycaemic control has been shown to improve microvascular complications such as retinopathy, nephropathy and neuropathy and hence this is reason enough to advocate the use of these agents. Future developments in the treatment of diabetes may help. Secondary prevention of stroke has improved greatly over the past decade and hopefully will continue to improve. The use of pharmacological agents available currently and in the future will be clarified and refined as further clinical trials report.     

Pharmaceutical care for patients with ischemic stroke: improving the patients quality of life

Objectives To improve patients health-related quality of life (HQL) after transient ischemic attack (TIA) or ischemic stroke; to guarantee an effective secondary prevention; to increase the patient’s satisfaction with recommendations regarding their medication by pharmacists. Setting Stroke Unit, neurological ward at the Klinikum Fulda, rehabilitation hospitals and community-based pharmacies in the region of Fulda, Germany. Method Patients with TIA or ischemic stroke were included. The patients were assigned to an intervention group (IG) or a control group (CG). The individual assignment of patients to IG or CG was based on the type of the local pharmacy to which patients belong. Community-based pharmacies either delivered standard care (CG) or provided additional intensified pharmaceutical care (PC; IG). Pharmacies delivering PC belong to a pre-existing “Quality Assurance Working Group” (QAWG). To evaluate the patient’s HQL, the Short Form-36 (SF-36) was used at study entry in hospital and at 12 months. The secondary prevention was documented at study entry in hospital and at 12 months. The patients’ satisfaction was measured by a questionnaire at the end of the study. Main outcome measures Patients’ HQL; secondary prevention; patients’ satisfaction with recommendations of the pharmacists with regards to their medication. Results Out of 1316 patients screened for participation in this study, 255 were recruited with 90/255 patients assigned to the IG and 165/255 patients assigned to the CG. During the study, the HQL of the patients in the IG did not change significantly. A significant decrease in the HQL was observed for the CG in 7/8 subscales and in both summary measures of the SF-36. After 12 months, 85.3% of the patients in the IG and 86.3% of the patients in the CG were treated with antiplatelet drugs or oral anticoagulants in accordance to treatment guidelines. Patients in the IG were significantly more satisfied with the individualized recommendations of the pharmacists than patients in the CG. Conclusion Our findings indicate that an intensified PC of patients after ischemic stroke by dedicated pharmacists may have a positive impact on HQL and patients’ satisfaction. PC in this study had no impact on adherence to secondary prevention medication.     

脑卒中患者早期康复的预后研究

目的 :探讨急性脑卒中患者早期康复治疗的重要性、安全性及其对预后的影响。方法 :120例发病1周内的急性脑卒中患者 ,随机分为早期康复组和对照组 ,每组60例。两组一般治疗相同 ,早期康复组由经过专业训练的治疗师给予系统的康复训练。采用临床功能缺损评分表、简式Fugl -Meyer运动评分 (FMA)和修订的巴氏指数 (MBI)定期对两组患者进行康复评价。结果 :临床神经功能缺损评分、FMA评分、MBI评价结果显示 ,治疗前两组评分差异无显著性 (P>0 05) ;治疗后 ,早期康复组评分明优于对照组(P<0 05)。结论 :早期康复可以防止和减轻废用综合征的产生 ,促进功能恢复 ,对患者预后有良好的影响。监测病情、康复方案个体化及康复训练循序渐进 ,可使脑卒中早期康复训练安全进行。     

Economic evaluation of prolonged and enhanced ECG Holter monitoring in acute ischemic stroke patients

Objective: Atrial fibrillation (AF) is a major cause for recurrent stroke, has severe impact on a patient’s health and imposes a high economic burden for society. Current guidelines recommend 24?h ECG monitoring (standard-of-care, SoC) to detect AF after stroke to reduce the risk of future events. However, paroxysmal AF (PAF) is difficult to detect within this period as it occurs infrequently and unpredictably. In a randomized controlled trial (Find-AF_RANDOMISED), prolonged and enhanced Holter ECG monitoring (EPM) revealed a significantly higher detection rate of AF compared to SoC, although its cost-effectiveness has not yet been investigated.

Methods: Based on the data of FIND-AF_RANDOMISED, an economic evaluation was conducted. One group received EPM for 10?days after the event, and at 3 and 6?months; the other group received SoC. Healthcare resource use and quality of life (QoL) data were measured at baseline, and after 6 and 12?months. Incremental costs and quality-adjusted life years (QALYs) between both groups were compared. Non-parametric bootstrapping and one-way-sensitivity analyses were performed.

Results: A total of 281 patients with healthcare resource use and QoL data for all measurement points were considered in the economic evaluation (complete case analysis, CCA). The CCA yielded nonsignificant 315€ lower mean costs and 0.0013 less QALYs for patients receiving EPM with no statistically significant differences in any cost categories. Sensitivity analyses revealed robust results. Bootstrapping the results indicated moderate probability of cost-effectiveness.

Conclusions: EPM yielded reduced not significantly different costs without affecting QoL and may be a useful strategy to detect PAF in acute ischemic stroke patients in time.