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.

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.

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.

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.