A Person-Centered Approach to Poststroke Care: The COMprehensive Post-Acute Stroke Services Model.

Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post-Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster-randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow-up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self-reported assessments of functional and social determinants of health are captured during the clinic visit using a web-based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS model's pragmatic design and quality metrics may support measurable best practices for postacute stroke care.

Concentration of Smaller High-Density Lipoprotein Particle (HDL-P) Is Inversely Correlated With Carotid Intima Media Thickening After Confounder Adjustment: The Multi Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Recent studies have failed to establish a causal relationship between high-density lipoprotein cholesterol levels (HDL-C) and cardiovascular disease (CVD), shifting focus to other HDL measures. We previously reported that smaller/denser HDL levels are protective against cerebrovascular disease. This study sought to determine which of small+medium HDL particle concentration (HDL-P) or large HDL-P was more strongly associated with carotid intima-media thickening (cIMT) in an ethnically diverse cohort. METHODS AND RESULTS: In cross-sectional analyses of participants from the Multi Ethnic Study of Atherosclerosis (MESA), we evaluated the associations of nuclear magnetic resonance spectroscopy-measured small+medium versus large HDL-P with cIMT measured in the common and internal carotid arteries, through linear regression. After adjustment for CVD confounders, low-density lipoprotein cholesterol (LDL-C), HDL-C, and small+medium HDL-P remained significantly and inversely associated with common (coefficient=-1.46 µm; P=0.00037; n=6512) and internal cIMT (coefficient=-3.82 µm; P=0.0051; n=6418) after Bonferroni correction for 4 independent tests (threshold for significance=0.0125; α=0.05/4). Large HDL-P was significantly and inversely associated with both cIMT outcomes before HDL-C adjustment; however, after adjustment for HDL-C, the association of large HDL-P with both common (coefficient=1.55 µm; P=0.30; n=6512) and internal cIMT (coefficient=4.84 µm; P=0.33; n=6418) was attenuated. In a separate sample of 126 men, small/medium HDL-P was more strongly correlated with paraoxonase 1 activity (rp=0.32; P=0.00023) as compared to both total HDL-P (rp=0.27; P=0.0024) and large HDL-P (rp=0.02; P=0.41) measures. CONCLUSIONS: Small+medium HDL-P is significantly and inversely correlated with cIMT measurements. Correlation of small+medium HDL-P with cardioprotective paraoxonase 1 activity may reflect a functional aspect of HDL responsible for this finding.

HDL cholesterol and stroke risk: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND AND PURPOSE: Accurate identification of risk factors for stroke is important for public health promotion and disease prevention. HDL cholesterol is a potential risk factor, yet its role in stroke risk is unclear, as is whether HDL cholesterol content or particle number might be a better indicator of stroke risk. Furthermore, the degree to which ethnicity moderates the risk is unknown. As such, the current study examines the associations between incident stroke and both HDL cholesterol concentration and particle number, and assesses the moderating role of race and ethnicity. METHODS: The sample is a racially diverse cohort of US adults between the ages of 45-84 years enrolled in the Multi-Ethnic Study of Atherosclerosis between 2000 and 2002 and followed until December 2011. The associations among cholesterol content and stroke risk, particle number and stroke risk, and the interaction with race were explored. RESULTS: The incidence of stroke was 2.6%. HDL cholesterol concentration (mmol/L) (Hazard Ratio (HR) = .56; 95% Confidence Interval (CI): .312-.988) and number of large HDL particles (µmol/L) (HR = .52, CI: .278-.956) were associated with lower stroke risk. When interactions with race were evaluated, the relationship between both HDL variables and stroke were significant in Blacks, but not other races. CONCLUSIONS: Higher HDL cholesterol and a higher concentration of large particles are associated with lower risk of stroke in Blacks. Further research is needed to elucidate the mechanisms by which HDL subfractions may differentially affect stroke outcome in different races/ethnicities.

Postoperative blood urea nitrogen is associated with stroke in cardiac surgical patients.

BACKGROUND: This case-control study identified perioperative risk factors associated with postoperative stroke risk after all cardiac surgical procedures. METHODS: Among 5498 adults 18 to 90 years old who underwent cardiac surgical procedures from 2005 to 2010, we identified 180 patients who suffered a stroke within 10 days postoperatively. Controls were randomly selected and frequency matched for sex and age-band to cases. Univariate and multivariate logistic regression analyses were performed to ascertain risk factors for postoperative stroke. RESULTS: Emergency surgical procedures (odds ratio [OR], 3.04; 95% confidence interval [CI], 1.80 to 5.10), current smoking (OR, 1.97; 95% CI, 1.29 to 3.00), peripheral vascular disease (OR, 2.80; 95% CI, 1.41 to 5.53), and previous stroke with residual paralysis (OR, 4.27; 95% CI ,1.18 to 15.38) were associated with increased stroke risk. Preoperative blood pressures were higher in patients with cases than in controls (p < 0.0001). Log of immediate postoperative blood urea nitrogen (BUN) was higher in patients with cases than in controls (p < 0.0001). In adjusted multivariable logistic regression, postoperative BUN was associated with increased odds of stroke (OR, 2.37 per 25% increase in BUN, p < 0.0001). Postoperative stroke risk was also predicted by emergency surgical procedures (OR, 2.70, p = 0.014), current smoking (OR, 2.82, p = 0.002), and preoperative diastolic blood pressure (DBP) (OR, 1.77 for every 10-point increase in DBP, p < 0.0001). Receiver operator characteristic curves indicated that postoperative BUN (area under the curve, 0.855) largely explained the increased postoperative stroke risk. CONCLUSIONS: In these analyses, we identified BUN as a marker of heightened postoperative stroke risk after cardiac surgical procedures. Postoperative risk markers may improve assessment of delayed postoperative strokes.

Predictors of 30-day hospital readmission following ischemic and hemorrhagic stroke.

Stroke patients have a high rate of 30-day readmission. Understanding the characteristics of patients at high risk of readmission is critical. A retrospective case-control study was designed to determine factors associated with 30-day readmission after stroke. A total of 79 cases with acute ischemic or hemorrhagic strokes readmitted to the same hospital within 30 days were compared with 86 frequency-matched controls. Readmitted patients were more likely to have had ≥2 hospitalizations in the year prior to stroke (21.5% vs 2.3% in controls, P < .001), and in the multivariate model, admission National Institutes of Health Stroke Score (NIHSS; odds ratio [OR] = 1.072; 95% confidence interval [CI] = 1.021-1.126 per 1 point increase; P = .005), prior hospitalizations (OR = 2.205; 95% CI = 1.426-3.412 per admission; P < .001), and absence of hyperlipidemia (OR = 0.444; 95% CI = 0.221-0.894; P = .023) were independently associated with readmission. The research team concludes that admission NIHSS and frequent prior hospitalizations are associated with 30-day readmission after stroke. If validated, these characteristics identify high-risk patients and focus efforts to reduce readmission.

Coronary artery calcium and incident cerebrovascular events in an asymptomatic cohort. The MESA Study.

OBJECTIVES: This study assessed the predictive value of coronary artery calcium (CAC) score for cerebrovascular events (CVE) in an asymptomatic multiethnic cohort. BACKGROUND: The CAC score, a measure of atherosclerotic burden, has been shown to improve prediction of coronary heart disease events. However, the predictive value of CAC for CVE is unclear. METHODS: CAC was measured at baseline examination of participants (N = 6,779) of MESA (Multi-Ethnic Study of Atherosclerosis) and then followed for an average of 9.5 ± 2.4 years for the diagnosis of incident CVE, defined as all strokes or transient ischemic attacks. RESULTS: During the follow-up, 234 (3.5%) adjudicated CVE occurred. In Kaplan-Meier analysis, the presence of CAC was associated with a lower CVE event-free survival versus the absence of CAC (log-rank chi-square: 59.8, p < 0.0001). Log-transformed CAC was associated with increased risk for CVE after adjusting for age, sex, race/ethnicity, body mass index, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, cigarette smoking status, blood pressure medication use, statin use, and interim atrial fibrillation (hazard ratio [HR]: 1.13 [95% confidence interval (CI): 1.07 to 1.20], p < 0.0001). The American College of Cardiology/American Heart Association-recommended CAC cutoff was also an independent predictor of CVE and strokes (HR: 1.70 [95% CI: 1.24 to 2.35], p = 0.001, and HR: 1.59 [95% CI: 1.11 to 2.27], p = 0.01, respectively). CAC was an independent predictor of CVE when analysis was stratified by sex or race/ethnicity and improved discrimination for CVE when added to the full model (c-statistic: 0.744 vs. 0.755). CAC also improved the discriminative ability of the Framingham stroke risk score for CVE. CONCLUSIONS: CAC is an independent predictor of CVE and improves the discrimination afforded by current stroke risk factors or the Framingham stroke risk score for incident CVE in an initially asymptomatic multiethnic adult cohort.

A new model for secondary prevention of stroke: transition coaching for stroke.

Non-adherence to stroke prevention medications is a risk factor for first-ever and recurrent stroke. As of yet, there are no guidelines for processes to recognize and address medication non-adherence in stroke patients. We developed a new model of post-discharge prevention care that measures and addresses medication-taking (transition coaching for stroke or TRACS). TRACS includes personalized education about risk factors and medications prior to discharge, follow-up telephone calls, and appointments with a stroke nurse practitioner (NP). The stroke NP asks about medication use (persistence) and whether doses are missed (adherence), and helps to solve problems with access to medications or side effects. In an analysis of 142 patients enrolled in TRACS from October 2012 to February 2014, medication persistence (use of medications from discharge to the time of measurement) was about 80%. Medication persistence at NP visit was higher in those patients with a first-ever stroke (78.9%) vs. those with recurrent stroke (60.7%; p = 0.045). Concerted efforts with 2-day RN follow-up calls and earlier NP appointments to improve medication-taking behaviors are underway.

Secondary prevention of stroke in the elderly: focus on drug therapy.

Secondary stroke prevention in the elderly in many cases requires the use of drug therapy to maximize risk factor control. However, the elderly (≥65 years) are most likely to receive care that is not evidence-based, because of concerns for adverse events. In this review, we provide evidence to the practitioner in support of the value of blood pressure control with drug therapy to decrease recurrent stroke risk. This review also highlights evidence for the importance of statin therapy in stroke prevention among the elderly. Finally, the appropriate use of antiplatelet therapy and oral anticoagulation is addressed.

Incident stroke is associated with common carotid artery diameter and not common carotid artery intima-media thickness.

BACKGROUND AND PURPOSE: The common carotid artery interadventitial diameter is measured on ultrasound images as the distance between the media-adventitia interfaces of the near and far walls. It is associated with common carotid intima-media thickness (IMT) and left ventricular mass and might therefore also have an association with incident stroke. METHODS: We studied 6255 individuals free of coronary heart disease and stroke at baseline with mean age of 62.2 years (47.3% men), members of a multiethnic community-based cohort of whites, blacks, Hispanics, and Chinese. Ischemic stroke events were centrally adjudicated. Common carotid artery interadventitial diameter and IMT were measured. Cases with incident atrial fibrillation (n=385) were excluded. Multivariable Cox proportional hazards models were generated with time to ischemic event as outcome, adjusting for risk factors. RESULTS: There were 115 first-time ischemic strokes at 7.8 years of follow-up. Common carotid artery interadventitial diameter was a significant predictor of ischemic stroke (hazard ratio, 1.86; 95% confidence interval, 1.59-2.17 per millimeter) and remained so after adjustment for risk factors and common carotid IMT with a hazard ratio of 1.52/mm (95% confidence interval, 1.22-1.88). Common carotid IMT was not an independent predictor after adjustment (hazard ratio, 0.14; 95% confidence interval, 0.14-1.19). CONCLUSIONS: Although common carotid IMT is not associated with stroke, interadventitial diameter of the common carotid artery is independently associated with first-time incident ischemic stroke even after adjusting for IMT. Our hypothesis that this is in part attributable to the effects of exposure to blood pressure needs confirmation by other studies. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00063440.

Imaging characteristics of symptomatic vertebral artery dissection: a systematic review.

BACKGROUND: Vertebral artery dissection (VAD) is an important cause of stroke in the young. VAD can present with a range of imaging findings. We sought to summarize the diagnostic value of various imaging findings in patients with symptomatic VAD. METHODS: We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality and imaging data were abstracted. Pooled proportions were calculated. RESULTS: Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. Most studies utilized conventional angiography or magnetic resonance angiography (MRA) to diagnose VAD; computed tomographic angiography (CTA) and Doppler ultrasonography were described less frequently. Imaging findings reported were vertebral artery stenosis (51%), string and pearls (48%), arterial dilation (37%), arterial occlusion (36%), and pseudoaneurysm, double lumen, and intimal flap (22% each). In cases where conventional angiography was the reference standard, CTA was more sensitive (100%) than either MRA (77%) or Doppler ultrasonography (71%) (P=0.001). CONCLUSIONS: Imaging findings vary widely in patients with VAD, with no single radiographic sign present in the majority of VAD patients. Nonspecific radiographic signs predominate. CTA probably has greater sensitivity for dissection than MRA or ultrasound relative to conventional angiography. Higher quality studies on imaging techniques and radiographic criteria in subjects with VAD are needed. Future studies should compare imaging techniques in well-defined, undifferentiated populations of clinical VAD suspects.

Clinical characteristics of symptomatic vertebral artery dissection: a systematic review.

BACKGROUND: Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD. METHODS: We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated. RESULTS: Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients. CONCLUSIONS: VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.