Management of stroke: Moving towards a unified system

Medical Tribune June 2008 P14-15

Diagnosis

Stroke is a leading cause of disability and death across many parts of the world and – along with transient ischemic attack (TIA) – is responsible for some 10,000 hospital admissions each year in Singapore alone. Approximately half of these patients present directly to hospital and half present to their general practitioner (GP) first. When faced with an acute stroke, the main aims
of the clinician should be to make a prompt diagnosis, stabilize the patient and dispatch them to hospital as quickly as possible.

Stroke is fairly common, and in the majority of cases the symptoms will be straightforward to recognize. If emergency brain imaging is available it can be used to confirm the diagnosis and establish which type of stroke has occurred. It is also important at this stage to exclude other important differential diagnoses. Blood sugar levels should be measured to rule out hypoglycemia, which can mimic the symptoms of stroke. In the event of any doubt, it is better to be overcautious and refer the patient onwards.

During the clinical evaluation, the GP should also assess the patient’s airway and breathing, circulation and blood pressure, and a drip can be set up if necessary. Any complications, such as swallowing difficulties, should also be noted. An ambulance can be called, and once the patient is stable, transferred to hospital in order to undergo further investigation and treatment. If time permits, the GP should perform a global assessment of the patient – including their social status, income and family situation, and reflect this information in the referral letter to the hospital.

Clinical Practice Guidelines

A range of guidelines have been published jointly by the American Stroke Association and the American Heart Association. The most recent document was released in 2007, focusing on the early management of ischemic stroke in adults. Guidelines for preventing ischemic stroke among patients who have already suffered a stroke or TIA were published in 2006.

Several Asian nations have also issued guidelines. For example, those from the Ministry of Health (MOH) in Singapore recommend that patients be treated in dedicated stroke units, and emphasize the importance of multidisciplinary care at all stages of a patient’s illness. The guidelines also suggest which diagnostic tests could be undertaken during the acute phase,
which treatments are indicated, and how management and rehabilitation could be carried out over the long-term.

Treatment

Prompt treatment for acute stroke patients is vital. Since the majority of treatment during this
phase takes place in hospital, the role of the GP may appear limited, but there are some important measures that can be taken before referral. These include the immediate management of hypoglycemia, hypoxia and hypotension. Alleviation of anxiety and pain is also important in this early stage.

Thrombolytic therapy can be given to carefully-selected ischemic stroke patients who present within 3 hours of onset, but this treatment is not feasible in the GP or clinic setting, as access to brain scanners as well as surgical and intensive care unit back-up is needed. Patients with ischemic stroke should be given antiplatelet therapy – typically aspirin – within 48 hours of onset, as this has been shown to improve outcomesand reduce subsequent recurrence. A brain scan should be performed prior to the administration of antithrombotic therapy. Fever and blood sugar levels should be controlled, and a statin should be given to lower cholesterol rates. Importantly, blood pressure should not be routinely lowered during the acute phase. Much of these interventions will probably be administered in hospital. The major task facing GPs is the long-term follow-up and management of stroke patients once they are discharged from hospital. There
are many factors to consider, and finding the time can be a challenge for the busy doctor – particularly in complicated cases where the patient is bed-bound and requires a lot of attention.

Continuing long-term preventive therapies such as antiplatelets, anticoagulants, lipid-lowering therapies and antihypertensives is one of the key responsibilities for the GP. Many of these medications have generic versions that are low in cost and widely available. Difficulties can arise with patients who require multiple drug regimens, and the combined cost can be a prohibitive factor for the patient. Physicians should also explain the possible side effects of drug therapies to their patients, and encourage them to seek further attention if any adverse symptoms develop.

Anticoagulants (and some antiplatelets) require regular blood monitoring. For GPs who do not have on-site facilities this can mean waiting several days for results, and efficient communication between the practice and the laboratory is crucial for reducing delays. It is also worth noting that different laboratories may use different ranges and parameters, so GPs should find a laboratory that they use consistently. Efficiency can also be improved by arranging for patients to undergo their laboratory tests (ie. blood sugar, lipids, INR) a few days prior to seeing their GP, so that the results are available in time for the consultation.

Stroke is often associated with several risk factors which need careful attention – both for their own sake and for reducing the risk of further stroke. GPs should be aware of all the issues facing a patient, and should handle these carefully on a case-by-case basis.

Common co-morbidities of stroke include high blood pressure, hyperlipidemia, diabetes mellitus and heart disease. Physicians should take the time to discuss these issues with their patients,
and should try to reach a joint agreement as to how often testing will take place and what targets are to be set for blood pressure, blood sugar and cholesterol levels. This approach will help patients to feel a sense of ownership over the decisions, and can encourage them to work towards these targets. Advice on healthy eating and exercise should also be provided, and patients who smoke must be strongly encouraged to stop. Rehabilitation should be continued for as long as the patient derives benefit from it.

Depression, dementia and disability are all common complications of stroke. There are simple
scales that GPs can use to regularly assess these problems, such as the Mini-Mental State Examination for dementia and the Barthel index for disability. Disabled patients may need nasal tubes and catheters to be changed and bedsores to be treated, and special arrangements might be required for follow-up visits. Frail and elderly patients may also have a range of co-morbid
conditions such as arthritis, cataracts and aches and pains. These patients all require more
than just medication, and GPs need to find the time to lend a listening ear despite a busy clinic. Support is needed for the patient, as well as the care-giver who may be stressed by the constant demands of caring for a severely disabled patient.

Disease management tools

The Integrated Services and Interventions for Stroke (ISIS) program was recently launched by the National Healthcare Group Stroke Disease Management Workgroup in Singapore. This project seeks to coordinate care across the different stages of stroke and between the different personnel involved. There is a clearly defined workflow which can be used to guide decision-
making and systems of care. ISIS is currently being piloted in NHG hospitals and polyclinics but could soon be extended to include general practices and care management centers, if proven succesful.

Coordination programs such as ISIS can facilitate the forging of partnerships with stroke nurses,
enabling them to handle aspects of care which might be overlooked by busy doctors who, in turn, can focus on issues such as medication. These programs are also important in helping patients to feel as though they are moving seamlessly through a unified system, and that their care is being coordinated smoothly.

Conclusion

The management of stroke is an ongoing process that begins with a patient’s presentation during the acute phase and continues through to hospitalization, eventual discharge and long-term rehabilitation and follow-up. There are many factors to consider at all stages, and it is important that healthcare providers take a holistic view of all of the issues surrounding each patient. Coordinating care between different groups can help to facilitate the treatment process, ensuring that each patient receives the optimal level of care and achieves better long-term outcomes.