https://acpinternist.org/weekly/archives/2021/07/27/2.htm

Scientific statement addresses primary care's role in poststroke care

Effective communication by primary care clinicians can improve adherence to necessary interventions after stroke, boost patient motivation, and reduce barriers to care, the American Heart Association and American Stroke Association advised.


A scientific statement proposes ways that primary care clinicians could achieve five generally accepted goals for poststroke care: Provide patient-centered care, prevent recurrent brain injury, maximize function, prevent late complications, and optimize quality of life.

The American Heart Association/American Stroke Association scientific statement on primary care of adult patients after stroke noted that one year after stroke, 50% to 70% of patients achieve a blood pressure of less than 140/90 mm Hg, 79% take statins, 84% don't smoke, and 48% exercise. Only 17% are at a healthy weight. Unmet needs for physical rehabilitation, activities of daily living, mobility, pain control, and communication are common, said the statement, which was published by Stroke on July 15.

It lists priorities for the first poststroke visit, including:

  • review hospital records,
  • ask patients if they understand the event and address questions or fears,
  • classify the stroke pathogenesis by confirming the evaluation is complete and treatment is in place,
  • implement time-sensitive management if indicated, including carotid revascularization, antiplatelets, or statin therapy,
  • identify and remediate precursors of the stroke.

Most readmissions within 30 days of a stroke are for medical rather than neurological causes and may be reduced by early primary care interventions, according to the statement authors. The statement said, “Because there are important and complex decisions to make early after a stroke, this is when primary care physicians and neurologists may want to collaborate most closely. The work they do around the time of this visit can improve the transition to long-term primary care management.”

Ongoing care should focus on managing high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia, the statement noted. Poststroke complications to consider include anxiety, bone fracture, cognitive impairment, depression, falling, fatigue, seizure, spasticity, and thromboembolism. Some stroke complications can be prevented, while others can be managed to reduce morbidity, the statement said.

To reduce risk of recurrent stroke, patients should engage in lifestyle modifications, and primary care clinicians can promote physical activity, the statement noted. Linking patients to community exercise programs is particularly effective, it said. Simple tools can help, such as the “Exercise Vital Sign” that includes two questions on the number of days and minutes per week that patients engage in moderate to vigorous activity. The statement also noted that primary care practices can use quality improvement strategies and available resources to deliver evidence-based care and improve outcomes after stroke. For example, using pharmacists in a practice can improve medication adherence and achieve better control of hypertension and diabetes.