Secondary risk factor management 5-years post ischaemic stroke - The ASPIRE-S2 study

Numerous guidelines have been published outlining evidence-based best

practice in secondary stroke prevention, including optimal target control of risk

factors. Despite these guidelines failure to achieve these recommendations in

clinical practice is common. This study, ASPIRE-S2 is a 5-year follow-up study

of the ASPIRE-S Study (Action on Secondary Prevention Interventions and

Rehabilitation in Stroke). The primary aim of this study was to prospectively

assess secondary prevention profiles of Irish ischaemic stroke patients at 5-

years and compare them to that measured at 6-months. Secondary outcomes

at 5-years (cognitive impairment, recurrent stroke events and mortality) and

their association with secondary risk factors measured at 6-months post-stroke

are also reported. The secondary aims of this thesis were to review blood

pressure profiles at 6-months post-stroke among the original ASPIRE-S cohort.

This included examining the prevalence of inter-arm blood pressure difference

and to investigate its associated risk factors. Ambulatory blood pressure profiles

and their association with cognitive impairment 6-months post-stroke was also

reviewed.

Numerous secondary risks were measured at 5-year review including blood

pressure (both clinic and ABPM), fasting risks (lipids and glucose and HBA1C in

diabetics), anticoagulation control in patients on warfarin therapy, and physical

measurements (weight, waist circumference, height). Lifestyle risk factors

(alcohol and smoking) were documented. These were compared to those

measured in the same patient group at 6-months. Secondary end-points at 5-

years post-stroke that were reviewed included death, cognitive impairment,

vulnerability and psychological wellbeing. Association of secondary risk factors

measured at 6-months with mortality at 5-years was analysed. Blood pressure

analysis including inter-arm blood pressure analysis in a post-stroke population

and ambulatory blood pressure patterns associated with cognitive impairment

post-stroke included those patients from the original ASPIRE-S study with

measurements taken at 6-months post-stroke.

Results of this follow-up study revealed that secondary risk factor management

remains suboptimal among stroke survivors at 5-years post-ischaemic stroke

with a substantial proportion of patients not reaching recommended target

control for secondary risks, especially in relation to blood pressure control.

Comparative analysis of risk factors between the two time-points (6-months and

5-years post-stroke) showed an increase in the prevalence of cardiovascular

risk factors (ex: hypertension, hypercholesterolaemia, atrial fibrillation) at 5-year

review. There was no statistically significant improvement in secondary risk

factor control (blood pressure, lipid, diabetic management) at 5-years poststroke

when compared to that measured at 6-months. Analysis of secondary

risk factors measured at 6-months showed that atrial fibrillation, high TC/HDL

ratio, cognitive impairment and vulnerability were associated with mortality at 5-

years.

Results from our blood pressure analysis at 6-months post-stroke showed that

there was a high prevalence of inter-arm blood pressure difference among this

patient population. 40.3% had an intra-arm systolic blood pressure difference

(IASBP) of >10mmHg and 20.6% had a difference of >15mmHg. A history of

alcohol excess was associated with an increased IASBP >15mmHg.

Review of nocturnal blood pressure profiles at 6-months and their association

with cognitive impairment was performed. A reduction in normal systolic dipping

at night-time predicted the presence of cognitive decline (MOCA <26) at 6-

months post-stroke (OR 1.06 CI 1.01-1.11 p=0.02).