Patients who arrive in the emergency department (ED) following a cerebrovascular event—stroke or transient ischemic attack—present a number of challenges to the hospitalist. In addition to the varied clinical presentations characteristic of stroke itself, many patients with stroke exhibit a number of cardiovascular risk factors, as well as one or more comorbidities (such as diabetes mellitus). In addition, these patients may be receiving multiple medications.
The risk factors for ischemic stroke are broadly consistent with those for other forms of atherothrombotic cardiovascular disease. Strong evidence from recent observational and interventional studies indicates, however, that patients who experience a stroke or an acute myocardial infarction are likely to experience a recurrent event of the same type.1,2 Therefore, it is appropriate for the clinician to select preventive therapy specifically directed at stroke prevention.
The prevention of secondary stroke is an element of acute care, but it straddles the boundaries among acute care, rehabilitation, and primary care. It is, therefore, an arena that fully engages the skills of the hospitalist. Goals of the hospital physician include the following:
- Minimize the risks of medical complications;
- Ensure an effective continuum of care, with smooth transitions among ED treatment, inpatient care, and long-term management in the community setting; and
- Maintain/improve the quality and consistency of care vis-à-vis adherence to established guidelines for secondary stroke prevention.
Assessment and Risk Evaluation
Initial assessment of patients with suspected stroke or transient ischemic attack seeks to eliminate other possible causes of current or recent neurologic deficit and to confirm the basic nature of the event (ischemic or hemorrhagic). Evidence-based guidelines from the American Stroke Association should be followed in the diagnosis and assessment of these patients in the ED.3
The sophistication of risk evaluation for primary and secondary stroke generally lags behind the evaluation used for cardiac events—a disparity noted by a number of stroke researchers who have called for more extensive epidemiologic studies in support of an adequate risk assessment structure.4-7 The use of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification structure for ischemic stroke has provided a better footing for such studies; a similar framework is used to guide treatment pathways for secondary prevention8 (See Table 1, p. 33.)
Recent studies generally support hypertension, cigarette smoking, and atrial fibrillation as strong risk factors for first ischemic stroke; however, few studies have been devoted specifically to analysis of secondary stroke risk factors.5,9 One recent study demonstrated that levels of C-reactive protein are strongly predictive of second events after stroke, with the risk in the highest quintile of C-reactive protein (>1.41 mg/mL) more than eight-fold greater than that in the lowest quintile (£0.12 mg/mL).10
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Manage Risk Factors
Several of the risk factors for primary and secondary stroke, including advancing age, male gender, and black and Hispanic racial/ethnic background, are important prognostic determinants. Other important risk factors that are modifiable, at least in theory, include hypertension, smoking, dyslipidemia, obesity, excessive alcohol use, physical inactivity, and impaired glucose tolerance.11
In addition to assessing and managing physical parameters, the clinician should review the patient’s history with regard to contact with the healthcare system. Consider the quality of the patient’s relationship with a primary care provider in light of post-stroke outpatient management. If no such provider exists—or if other concerns are expressed—it may be necessary to help the patient and/or the family in this regard. If evidence reveals that the patient has had problems with medication compliance or regular follow-up, it may be necessary to provide counseling and other support to the patient and family.