Introduction
Results from two separate studies offer relatively simple approaches for better prevention and treatment of patients with ischemic stroke, the first encompassing a simple method of pro-active stroke screening and the second concerning criteria leading to the enhancement of the rate of thrombolysis as the initial therapeutic modality in these patients.

Screening for the Three Immediate Causes of Stroke
Three simple, inexpensive medical tests that can be carried out in less than five minutes have the potential to significantly reduce the annual number of strokes and save billions of dollars in healthcare costs every year, stated George S. Lavenson, M.D., a general surgeon at Kaweah Delta District Hospital, Visalia, California, and a spokesperson for the National Stroke Prevention Screening study.

"A quick carotid scan, an electrocardiogram (EKG) rhythm strip, and a blood pressure determination offer a fast, accurate, cost-effective method for mass screening of the three major stroke risk factors in the elderly: carotid artery disease, atrial fibrillation, and hypertension," Dr. Lavenson said. "Pro-active screening for these immediate causes of stroke to allow management of these conditions before a stroke can occur has the possibility of changing stroke from a major healthcare problem to a minor one."

While these three risk factors are silent in 80% of stroke patients, they are manageable, Dr. Lavenson continued. Screening seniors would lead to the management of these conditions and potentially prevent the majority of strokes. Since stroke is a leading cause of disability and a major factor in healthcare costs, this could lead to significant savings.

As part of a National Stroke Prevention Screening study, Dr. Lavenson explained, a new stroke prevention screening protocol was developed and implemented in Central California, at Madigan Army Hospital, New York University, and by the American Vascular Association. A quick carotid scan was developed to rapidly identify carotid arteries with possible stroke potential lesions. The carotid scan had a sensitivity of 93% at Visalia and 97% at New York University. This test in conjunction with an EKG rhythm strip and blood pressure measurement were the basis for the screening protocol.

A total of 6,046 seniors over the age of 60 were screened in this study, Dr. Lavenson pointed out. Of these, screenings were carried out in 2,532 seniors in Central California. Blockage with a greater than 50% stenosis of the carotid artery was found in 189 persons (7.5%) of those screened. In addition, 128 individuals (5.0%) in the group had atrial fibrillation, and 746 seniors (29.5%) had hypertension. An additional 3,514 seniors were screened at Madigan Army Hospital, by New York University investigators and in American Vascular Association screenings, with similar findings.

It is estimated that these carotid screenings may have prevented 30 strokes and saved $1,944,210 in stroke care costs, Dr. Lavenson said. The strokes were prevented by removing the carotid blockages either with carotid endarterectomy or by medical treatment, depending on the severity of the blockage. Appropriate medical measures also were taken to alleviate atrial fibrillation and control hypertension. Furthermore, it is believed that if all 40 million Medicare recipients were to receive similar stroke prevention screening, more than 200,000 strokes and 30,000 deaths could be prevented annually, for a savings of $12 billion each year.

"Stroke prevention screening should be part of every senior's annual exam and should be made available to seniors on a daily basis as are other screening tests," Dr. Lavenson concluded. "Every effort should be made to have Congress mandate Medicare to provide reimbursement for stroke prevention screenings as for other screening tests. The rationale of stroke prevention screening is valid, the means are available, and there is an imperative to prevent strokes that can be prevented and which we are not now preventing."

Enhancing Rates of Thrombolysis
Using seven elements based on the recommended criteria of the Brain Attack Coalition (BAC) for the establishment of primary stroke centers, including written care protocols for treating stroke and a trained, responsive emergency department staff, may increase the chance that patients with ischemic stroke would receive thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) (Activase®, Genentech), declared S. Clairborne Johnston, M.D., Director of Stroke Services, University of California, San Francisco Medical Center, San Francisco, California.

"We wanted to see how well the Brain Attack Coalition recommendations actually predicted patient outcomes and better quality of care in stroke centers," Dr. Johnston said. "We found that seven of the eleven recommended criteria increased the use for rt-PA. The more a center followed the seven criteria, the greater the use of the drug."

Since the BAC criteria were empirically derived, it was decided to evaluate the relationship between institutional rt-PA usage rates and the total number of stroke center characteristics present at individual medical centers, Dr. Johnston noted. From 1999 to 2001, all 16,853 patients admitted with ischemic stroke through the emergency departments of 334 academic centers were identified from the Health System Consortium database. A questionnaire was sent to stroke specialists at each hospital listing the 11 major stroke center elements proposed by the BAC. The impact of each element on thrombolytic administration was evaluated using generalized estimating equations adjusting for age, gender, ethnicity, admission status, and treatment volume. The effect of the BAC criteria on rates of thrombolysis was then assessed using statistical analyses, comparing the number of people with ischemic stroke treated with rt-PA at each facility with the 11 recommended criteria.

Having written procedures for treating stroke was the strongest predictor for rt-PA use, Dr. Johnston stated. In addition, integrating emergency medical services into the treatment effort, an emergency room staff well trained in recognizing stroke, and continuing medical education in stroke for all members of the stroke team significantly influenced the use of rt-PA.

Three other criteria showed a positive trend toward increased thrombolysis with rt-PA, Dr. Johnston added. These included a stroke team on call around the clock, seven days a week; a formal stroke unit that provided specialized monitoring and care; and the rapid availability of CT scans for neuroimaging to assess whether the stroke was caused by a thrombus or a hemorrhaging blood vessel. While these three criteria did not have a statistically significant impact individually, they were important contributors to the overall picture.

There was a clear trend toward increased rates of thrombolysis at institutions with more of the seven elements individually predictive of rt-PA use, Dr. Johnston pointed out. At institutions that met all seven criteria, patients with ischemic stroke had a 4.7 times greater chance of getting rt-PA. This compared with centers having two or fewer elements, where the rate was only 1.4 times greater.

"Our findings suggest that these key elements may be the most important for primary stroke center designation, at least in terms of identifying centers that can deliver acute treatments rapidly," Dr. Johnston said.

Caution should be taken, however, about dismissing the value of the four non-predictive criteria, Dr. Johnston concluded. This study only looked at a small number of academic medical centers, and a much larger study is needed in medical facilities, including community hospitals. Based on logic and on other observational and clinical studies, the four factors that were not significant predictors of rt-PA use in this study actually could be important in improving the quality of care.


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Source: by Lawrence M. Prescott, Ph.D. (sprescott@aol.com)

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