Secondary Stroke Prevention

Toward a new model of stroke care

Stroke is the leading cause of disability in the United States and the third leading cause of death. It is therefore an important factor in both health care budgets and the emotional economy of families. Although much is known about modifying risk factors to prevent first stroke (primary prevention) or recurrent stroke (secondary prevention), too often a consistent, systematic assessment of stroke risk factors is lacking in clinical practice.

Underutilization of stroke risk assessment strategies creates a gap between existing evidence and actual practice. "This gap is especially concerning for patients after they have already had a stroke, because of the risk of recurrent stroke and the increased likelihood of certain medical disorders," explains Kelly D. Flemming, M.D., a Mayo Clinic neurologist who is investigating the use of new clinical models for stroke prevention.

Among the serious consequences of stroke:

• Subsequent stroke — an estimated 30 percent of survivors of an initial ischemic stroke will have a subsequent stroke within 5 years, 18 percent of which will be fatal
• Cardiac involvement — stroke carries with it a serious risk of cardiac involvement:
  • Of cerebral infarction (CI) patients, 5 percent have myocardial infarction (MI) within the first year after CI
  • More than 3 percent of patients have MI annually for the first 10 years after CI
• Depression — often depression is unrecognized by both caregivers and family members, yet data suggest that nearly 40 percent of stroke patients will experience depression sometime during the first year after the stroke

Secondary stroke prevention is well suited to a new model of care aimed at preventing long-term morbidity and mortality for two main reasons:

1. Risk modification strategies can lessen the likelihood of recurrent stroke or other adverse outcomes.
2. Those patients with initial stroke can be readily identified. One promising new model is the stroke prevention clinic modeled after cardiac rehabilitation clinics.

The Stroke Prevention Clinic Concept

To help close the evidence-practice gap in stroke prevention — and to prepare for the changing demographics of stroke as the population ages and more people are at risk of stroke — Mayo Clinic in Rochester, Minn., is evaluating a physician-led, nurse-assisted stroke management program.

The program is currently being assessed for its long-term effectiveness to manage cerebrovascular disease. It aims to achieve with stroke the success that cardiac rehabilitation clinics have obtained with secondary prevention of coronary heart disease. Through this approach, neurologists play a leading role in meeting the emerging demand for preventive stroke services:

• Obtaining training in management of atherosclerotic risk factors
• Making stroke risk factor modification a part of the neurologic evaluation
• Providing long-term follow-up and appropriate care in the setting of a physician-led, nurse-assisted stroke prevention clinic

The neurologic team can closely collaborate with the patient's primary care provider to optimize management.

Data for similar nurse-assisted, physician-led clinics such as the Stanford Coronary Risk Intervention Project have shown that this approach can improve patient outcomes while reducing use of medical resources.

In the Mayo Clinic secondary stroke prevention initiative, nurses guided by physicians provide intensive multiple risk factor reduction counseling and support in the outpatient setting. This outpatient clinic is the next step in the continuum of care of the stroke patient, after acute treatment and evaluation have been provided in the Saint Marys Hospital inpatient stroke center and, if needed, a stay in the stroke rehabilitation unit.

The goals of this ongoing outpatient care are to support lifestyle changes known to reduce the risk factors of stroke, to prescribe appropriate medications to assist in reducing these risk factors, and to enhance use of appropriate antithrombotic agents.