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Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses.

ABSTRACT: Non-adherence to secondary preventative medications after stroke is relatively common and associated with poorer outcomes. Non-adherence can be due to a number of patient, disease, medication or institutional factors. The aim of this review was to identify factors associated with non-adherence after stroke.We performed a systematic review and meta-analysis of studies reporting factors associated with medication adherence after stroke. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Knowledge. We followed PRISMA guidance. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance and the Newcastle-Ottawa scales. Where data allowed, we evaluated summary prevalence of non-adherence and association of factors commonly reported with medication adherence in included studies using random-effects model meta-analysis.From 12,237 titles, we included 29 studies in our review. These included 69,137 patients. The majority of included studies (27/29) were considered to be at high risk of bias mainly due to performance bias. Non-adherence rate to secondary preventative medication reported by included studies was 30.9% (95% CI 26.8%-35.3%). Although many factors were reported as related to adherence in individual studies, on meta-analysis, absent history of atrial fibrillation (OR 1.02, 95% CI 0.72-1.5), disability (OR 1.27, 95% CI 0.93-1.72), polypharmacy (OR 1.29, 95% CI 0.9-1.9) and age (OR 1.04, 95% CI 0.96-1.14) were not associated with adherence.This review identified many factors related to adherence to preventative medications after stroke of which many are modifiable. Commonly reported factors included concerns about treatment, lack of support with medication intake, polypharmacy, increased disability and having more severe stroke.Understanding factors associated with medication taking could inform strategies to improve adherence. Further research should assess whether interventions to promote adherence also improve outcomes.

SUBMITTER: Al AlShaikh S

PROVIDER: S-EPMC5992740 | biostudies-literature | 2016 Jun

REPOSITORIES: biostudies-literature

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Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses.

Al AlShaikh Sukainah S Quinn Terry T Dunn William W Walters Matthew M Dawson Jesse J

European stroke journal 20160505 2

<h4>Purpose</h4>Non-adherence to secondary preventative medications after stroke is relatively common and associated with poorer outcomes. Non-adherence can be due to a number of patient, disease, medication or institutional factors. The aim of this review was to identify factors associated with non-adherence after stroke.<h4>Method</h4>We performed a systematic review and meta-analysis of studies reporting factors associated with medication adherence after stroke. We searched MEDLINE, EMBASE, C ...[more]

PMID: 29900404

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Project description:Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.

Project description:ObjectivePredicting the prognosis of transient ischaemic attack (TIA) is difficult for many frontline clinicians. The purpose of this study was to determine whether subsequent stroke in TIA patients can be predicted via red blood cell distribution width (RDW).Material and methodsA total of 360 consecutive patients with new-onset TIA in our stroke centre, were enrolled over the period studied. The patients were divided into three groups: 103 TIA patients, 206 ischaemic stroke (IS) patients and 51 patients with haemorrhagic stroke (HS) within 7 days after TIA. Complete blood count, biochemical parameters and brain imaging were performed on all patients.ResultsThe mean RDW values of patients with IS and HS after TIA were significantly higher than patients with TIA (13.35 ± 1.59 vs 12.84 ± 1.19, 13.32 ± 1.08 vs 12.84 ± 1.19, respectively, all p ≤ .001). In a multivariate model, RDW was independently associated with stroke after TIA (IS: odds ratio (OR) = 2.52, 95% confidence interval (CI) = 1.46-3.35, p = .002; HS: OR = 1.511, 95% CI = 1.101-2.074, p = .011). Compared to ABCD2 scores, the diagnostic power of RDW in the differentiation of patients with IS after TIA was better (area under curve (AUC): 0.731 vs 0.613, p = .015). When an RDW cut-off value of 13.95% was accepted for differentiating patients with IS from TIA, the sensitivity and specificity were 73.7% and 74.3%, respectively. However, the AUC for the ability of the RDW to predict HS was 0.653 (95% CI = 0.589-0.716; p < .001).ConclusionsThe early determination of RDW is a promising, rapid, easy and inexpensive biomarker to predict the subsequent stroke in TIA patients, especially for IS. KEY MESSAGESThe most important result of our study is to show that (1) the higher RDW, the earlier the stroke onset and (2) RDW ≥13.95% has a 2.52-fold risk of ischaemic stroke in TIA patients, and RDW ≥12.85% has a 1.51-fold risk of haemorrhagic stroke.As an economic and accessible hematological marker, baseline RDW may serve as a useful biomarker for risk stratification in TIA patients.

Project description:To examine the comparative efficacy and safety of different antiplatelet regimens in patients with prior non-cardioembolic ischaemic stroke or transient ischaemic attack.Systematic review and network meta-analysis.As on 31 March 2015, all randomised controlled trials that investigated the effects of antiplatelet agents in the long-term (≥ 3 months) secondary prevention of non-cardioembolic transient ischaemic attack or ischaemic stroke were searched and identified.The primary outcome measure of efficacy was serious vascular events (non-fatal stroke, non-fatal myocardial infarction and vascular death). The outcome measure of safety was any bleeding.A total of 36 randomised controlled trials (82,144 patients) were included. Network meta-analysis showed that cilostazol was significantly more effective than clopidogrel (OR 0.77, 95% credible interval 0.60-0.98) and low-dose (75-162 mg daily) aspirin (0.69, 0.55-0.86) in the prevention of serious vascular events. Aspirin (50 mg daily) plus dipyridamole (400 mg daily) and clopidogrel reduced the risk of serious vascular events compared with low-dose aspirin; however, the difference was not statistically significant. Furthermore, low-dose aspirin was as effective as higher daily doses. Cilostazol was associated with a significantly lower bleeding risk than most of the other regimens. Moreover, aspirin plus clopidogrel was associated with significantly more haemorrhagic events than other regimens. Direct comparisons showed similar results as the network meta-analysis.Cilostazol was significantly more effective than aspirin and clopidogrel alone in the long-term prevention of serious vascular events in patients with prior non-cardioembolic ischaemic stroke or transient ischaemic attack. Cilostazol was associated with a significantly lower bleeding risk than low-dose aspirin (75-162 mg daily) and aspirin (50 mg daily) plus dipyridamole (400 mg daily). Low-dose aspirin was as effective as higher daily doses. However, further large, randomised, controlled, head-to-head trials are needed, especially in non-Asian ethnic groups.

Project description:BackgroundAn increasing body of evidence suggests that inflammation plays a key role in stroke, in particular stroke of atherosclerotic origin. Anti-inflammatory medications are a widely heterogeneous group of drugs that are used to suppress the innate inflammatory pathway and thus prevent persistent or recurrent inflammation. Anti-inflammatory agents have the potential to stabilise atherosclerotic plaques by impeding the inflammatory pathway. By targeting specific cytokines, the inflammatory pathway may be interrupted at various stages.ObjectivesTo assess the benefits and harms of anti-inflammatory medications plus standard care versus standard care with or without placebo for prevention of vascular events (stroke, myocardial infarction (MI), non-fatal cardiac arrest, unstable angina requiring revascularisation, vascular death) and all-cause mortality in people with a prior history of ischaemic stroke or transient ischaemic attack (TIA).Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL; last searched 29 May 2019); MEDLINE (1948 to 29 May 2019); Embase (1980 to 29 May 2019); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 29 May 2019); and Scopus (1995 to 29 May 2019). In an effort to identify additional published, unpublished, and ongoing trials, we searched several grey literature sources (last searched 30 May 2019). We incorporated all identified studies into the results section. We applied no restrictions with respect to language, date of publication, or study setting.Selection criteriaWe considered randomised controlled trials (RCTs) and cluster-randomised controlled trials that evaluated anti-inflammatory medications for prevention of major cardiovascular events following ischaemic stroke or TIA.Data collection and analysisTwo review authors independently assessed for inclusion titles and abstracts of studies identified by the search. Two review authors independently reviewed full-text articles for inclusion in this review. We planned to assess risk of bias and to apply the GRADE method.Main resultsWe identified no studies that met the inclusion criteria.Authors' conclusionsThere is currently a paucity of evidence on the use of anti-inflammatory medications for prevention of major cardiovascular events following ischaemic stroke or TIA. RCTs are needed to assess whether use of anti-inflammatory medications in this setting is beneficial.

Project description:The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

Project description:Background and purposeAdherence to medication is often suboptimal after stroke and transient ischemic attack (TIA), which increases the risk of recurrent stroke and death. Complex interventions and motivational interviewing (MI) have been proven effective in other areas of medicine. The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention.MethodsIn this randomized controlled trial, TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care. The intervention consisted of a focused medication review, an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months. The primary outcome was a composite medication possession ratio (MPR) for antiplatelets, anticoagulants and statins in the year after hospitalization, assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome. Secondary outcomes included composite MPRs at 3, 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months. Clinical outcomes included a combined end point of cardiovascular death, stroke or acute myocardial infarction. Patient satisfaction with the service was assessed for the intervention patients.ResultsThe analyses included 102 intervention patients and 101 controls. At 12 months, the median MPRs (IQR) were 0.95 (0.77-1) in the intervention group and 0.91 (0.83-0.99) in the control group, and 28 and 21% of the patients, respectively, were nonadherent (MPR <0.80; risk difference: 7%; 95% CI: -5 to 19%). In both groups, the median MPR decreased over time. From 3 to 12 months, the MPR fell by 5% (p < 0.05) in the intervention group and by 9% (p < 0.05) in the control group, but between the groups, comparisons showed no statistically significant difference. No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome. The intervention patients were satisfied with the service; about half of them reported increased knowledge about medication, and one third reported increased confidence with medication use. Pharmacists identified drug-related problems in one third of the patients.ConclusionsA multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes. However, due to the high adherence rates, only little room for improvement existed. Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions.

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Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses.

Publications

Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses.

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