Reducing Recurrent Stroke: Methodology of the Motivational Interviewing in Stroke (MIST) Randomized Clinical Trial Stroke recurrence Long-Term Disability After First-Ever Stroke and Related Prognostic Factors in the Perth Community Stroke Study, 1989–1990 Cause of Stroke Recurrence Is Multifactorial: Patterns, Risk Factors, and Outcomes of Stroke Recurrence in the South London Stroke Register Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial Multidisciplinary transmural rehabilitation for older persons with a stroke: the design of a randomised controlled trial A randomised controlled comparison of alternative strategies in stroke care. Discontinuation of secondary preventive treatment of stroke: An unexplored scenario in India Long-term risk of first recurrent stroke in the Perth Community Stroke Study. Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial Stroke incidence and risk factors for stroke in Copenhagen, Denmark. Prevention of stroke in urban China: a community-based intervention trial. Recurrent stroke and cardiac risks after first ischemic stroke [A prospective study of stroke recurrence and the risk factors]. Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. Stop Stroke: development of an innovative intervention to improve risk factor management after stroke.
Rationale Recurrent stroke is prevalent in both developed and developing countries , contributing significantly to disability and death . Recurrent stroke rates can be reduced by adequate risk factor management . However , adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor , leading to a large number of preventable recurrent strokes . Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke . Aims and /or hypothesis The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke . Design Recruitment of 430 first-ever stroke participants will occur in the Auckl and and Waikato regions . R and omization will be to intervention or usual care groups . Participants r and omized to intervention will receive four motivational interviews and five follow-up assessment s over 12 months . Nonintervention participants will be assessed at the same time points . Study outcomes Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke . Secondary outcomes include self-reported adherence and barriers to prescribed medications , new cardiovascular events ( including stroke ) , changes in quality of life , and mood . Discussion The results of the motivational interviewing in stroke trial will add to our underst and ing of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant We compared stroke severity , risk factors , and prognosis in patients with recurrent versus first-ever stroke . In the Copenhagen Stroke Study , we prospect ively studied 1,138 unselected patients with acute stroke . Stroke was recurrent in 265 ( 23 % ) despite most of these patients being given prophylactic treatment prior to recurrence . Only 12 % of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence . In multivariate analysis , recurrence was more frequently associated with a history of TIA , atrial fibrillation , male gender , and hypertension , but not with age , daily alcohol consumption , smoking , diabetes , ischemic heart disease , serum cholesterol , or hematocrit . Mortality was almost doubled compared with patients with a first-ever stroke . In survivors , however , both neurologic and functional outcomes and the speed of recovery were , in general , similar in the two groups . Despite similar neurologic impairments , patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence , implying that the ability to compensate functionally is decreased in patients with contralateral recurrence . Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension . Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence . Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke , but those who survive recover as well and as fast as patients with a first-ever stroke . However , if recurrence is contralateral to the first stroke , functional recovery is poorer Background and Purpose — Few reliable estimates of the long-term functional outcome after stroke are available . This population -based study aim ed to describe disability , dependency , and related independent prognostic factors at 5 years after a first-ever stroke in patients in Perth , Western Australia . Methods — All individuals with a suspected acute stroke who were resident in a geographically defined region ( population , 138 708 ) of Perth , Western Australia , were registered prospect ively and assessed according to st and ardized diagnostic criteria over a period of 18 months in 1989 to 1990 . Patients were followed up prospect ively at 4 and 12 months and 5 years after the index event . Results — There were 370 cases of first-ever stroke , and 277 patients survived to 30 days . Of these early survivors , 152 ( 55 % ) were alive at 5 years , and among those who were neither institutionalized ( n=146 ) nor disabled ( n=129 ) at the time of their stroke , 21 ( 14 % ) were institutionalized in a nursing home , and 47 ( 36 % ) were disabled . The most important predictors of death or disability at 5 years were increasing age , baseline disability defined by a Barthel Index score of < 20/20 ( odds ratio [ OR ] , 6.3 ; 95 % confidence interval [ CI ] , 2.7 to 14 ) , moderate hemiparesis ( OR , 2.7 ; 95 % CI , 1.1 to 6.2 ) , severe hemiparesis ( OR , 4.5 ; 95 % CI , 1.1 to 19 ) , and recurrent stroke ( OR , 9.4 ; 95 % CI , 3.0 to 30 ) . A low level of activity before the stroke was a significant predictor of institutionalization , and subsequent recurrent stroke was a consistent , independent predictor of institutionalization , disability , and death or institutionalization , increasing the odds of each of these 3 adverse outcomes by 5- to 15-fold . Conclusions — Among 30-day survivors of first-ever stroke , about half survive 5 years ; of survivors , one third remain disabled , and 1 in 7 are in permanent institutional care . The major modifiable predictors of poor long-term outcome are a low level of activity before the stroke and subsequent recurrent stroke . Efforts to increase physical activity among the elderly and to prevent recurrent stroke in survivors of a first stroke are likely to reduce the long-term burden of cerebrovascular disease Background and Purpose — This article examines stroke recurrence and whether the subtype of the initial stroke influences the risk and subtypes of further strokes . The proportion of recurrences attributable to conventional risk factors is quantified . Methods — From January 1995 to August 2000 , all first-in-a-lifetime strokes ( n=1626 ) were identified and prospect ively followed up in a defined multiethnic inner city population of 234 533 . Twelve overlapping referral sources and face-to-face follow-up at 3 months and 1 and 3 years were used to attain complete registration of stroke recurrence . Index and recurrent stroke were classified according to the Oxford Community Stroke Project classification . Results — In 2744 person-years of follow-up , 153 recurrences were observed . At 5 years , the cumulative risk of first stroke recurrence was 16.6 % ( 95 % CI , 13.5 to 20.4 ) , and the combined risk of death or stroke recurrence was 65.3 % ( 95 % CI , 61.9 to 68.6 ) . Ethnicity and subtype of index stroke were not associated with stroke recurrence . A change in subtype between index and recurrent stroke occurred in 45.5 % ( 95 % CI , 35.8 to 55.2 ) of cases and was most frequent among index lacunar strokes and primary intracerebral hemorrhages . In multivariable analyses , diabetes mellitus and atrial fibrillation were associated with both stroke recurrence and recurrence-free survival . In the stroke population , 9.1 % ( 95 % CI , −2.0 to 20.2 ) of recurrences were attributable to diabetes and 4.9 % ( 95 % CI , −7.3 to 17.2 ) to atrial fibrillation during the first year after the index stroke . Conclusions — The cause of stroke recurrence is multifactorial , and the subtypes of index and recurrent strokes are often not identical . Most recurrences remain unexplained by conventional risk factors Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 Background Stroke is one of the major causes of loss of independence , decreased quality of life and mortality among elderly people . About half of the elderly stroke patients discharged after rehabilitation in a nursing home still experience serious impairments in daily functioning one year post stroke , which can lead to difficulties in picking up and managing their social life . The aim of this study is to evaluate the effectiveness and feasibility of a new multidisciplinary transmural rehabilitation programme for older stroke patients . Methods A two group multicentre r and omised controlled trial is used to evaluate the effects of the rehabilitation programme . The programme consists of three care modules : 1 ) neurorehabilitation treatment for elderly stroke patients ; 2 ) empowerment training for patient and informal caregiver ; and 3 ) stroke education for patient and informal caregiver . The total programme has a duration of between two and six months , depending on the individual problems of the patient and informal caregiver . The control group receives usual care in the nursing home and after discharge .  Patients aged 65 years and over are eligible for study participation when they are admitted to a geriatric rehabilitation unit in a nursing home due to a recent stroke and are expected to be able to return to their original home environment after discharge . Data are gathered by face-to-face interviews , self-administered question naires , focus groups and registration forms . Primary outcomes for patients are activity level after stroke , functional dependence , perceived quality of life and social participation . Outcomes for informal caregivers are perceived care burden , objective care burden , quality of life and perceived health . Outcome measures of the process evaluation are implementation fidelity , programme deliverance and the opinion of the stroke professionals , patients and informal caregivers about the programme . Outcome measures of the economic evaluation are the healthcare utilisation and associated costs . Data are collected at baseline , and after six and 12 months . The first results of the study will be expected in 2014.Trial registration International St and ard R and omised Controlled Trial Register Number IS RCT N62286281 , The Dutch Trial Register OBJECTIVES To compare outcomes between stroke patients managed on the stroke unit , on general wards with stroke team support or at home by specialist domiciliary team and to derive prognostic variables that will identify patients most suitable for management by each strategy . To describe organisational aspects of individual strategies of stroke care and to evaluate cost-effectiveness of each strategy and its acceptability to patients , carers and professionals . DESIGN Prospect i ve single-blind r and omised controlled trial undertaken in patients recruited from a community-based stroke register . SETTING Suburban district in south-east Engl and . PARTICIPANTS Patients with disabling stroke who could be supported at home . INTERVENTIONS The stroke unit gave 24-hour care provided by specialist multidisciplinary team based on clear guidelines for acute care , prevention of complications , rehabilitation and secondary prevention . The stroke team provided management on general wards with specialist team support . The team undertook stroke assessment s and advised ward-based nursing and therapy staff on acute care , secondary prevention and rehabilitation aspects . Domiciliary care involved management at home under the supervision of a GP and stroke specialist with support from specialist team and community services . Support was provided for a maximum of 3 months . MAIN OUTCOME MEASURES The primary measure was death or institutionalisation at 1 year . Secondary measures were dependence , functional abilities , mood , quality of life , re source use , length of hospital stay , and patient , carer and professional satisfaction . RESULTS Of the 457 patients r and omised , 152 patients were allocated to the stroke unit ; 152 patients to stroke team and 153 patients to domiciliary stroke care ( average age 76 years , 48 % women ) . The groups were well matched for baseline characteristics , stroke type and severity , level of impairment and initial disability . Fifty-one ( 34 % ) patients in the domiciliary group were admitted to hospital after r and omisation . Mortality and institutionalisation at 1 year were lower on stroke unit compared with stroke team or domiciliary care . Significantly fewer patients on the stroke unit died compared with those managed by the stroke team . The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team or domiciliary care . These differences were present at 3 and 6 months after stroke . Stroke survivors managed on the stroke unit showed greater improvement on basic activities of daily living compared with other strategies . Achievement of higher levels of function was not influenced by strategy of care . Quality of life at 3 months was significantly better in stroke unit and domiciliary care patients . There was greater dissatisfaction with care on general wards compared with stroke unit or domiciliary care . Poor outcome with domiciliary care and on general wards was associated with Barthel Index < 5 , incontinence and , on general wards , age over 75 years . The total costs of stroke per patient over the 12-month period were pound 11,450 for stroke unit , pound 9527 for stroke team and pound 6840 for home care . However , the mean costs per day alive for the stroke unit were significantly less than those for the specialist stroke team patients , but no different from domiciliary care patients . Costs for the domiciliary group were significantly less than for those managed by the specialist stroke team on general wards . CONCLUSIONS Stroke units were found to be more effective than a specialist stroke team or specialist domiciliary care in reducing mortality , institutionalisation and dependence after stroke . A role for specialist domiciliary services for acute stroke is not supported by this study . Management of patients with strokes on general medical wards , even with specialist team input , is not supported by this study . The stroke unit intervention was less costly per patient day alive and more effective than the stroke team intervention . The stroke unit was more effective and of equivalent cost when compared to home care . Hence , the stroke unit is a more cost-effective intervention than either stroke team or home care . Further research is needed to underst and processes contributing to the reduction in mortality on stroke units and to determine the generalisability of these results and the factors that will influence the implementation of the findings of this study in clinical practice OBJECTIVE This prospect i ve study will evaluate the socioeconomic factors responsible for the discontinuation of secondary preventive treatment of stroke in India and its outcome . DESIGN S METHODS : A total of 1212 stroke patients ( male=708 , mean age 58 ± 2 years ; female=504 , mean age 56 ± 2 years ; intra-cerebral haemorrhage=496 ; ischaemic=716 ) were enrolled in the stroke clinic for secondary preventive treatment from 1st January 2006 to 1st January 2008 and were followed up at 4 - 6-week intervals . Among them , 512 patients were grouped as being below the poverty line .  Discontinuation of treatment for more than 2 weeks by a patient placed that patient in a group labelled discontinued . Outcomes of discontinuation of secondary preventive treatment were evaluated with respect to ( 1 ) control of risk factors , ( 2 ) recurrence of stroke , and ( 3 ) mortality rate . Reasons for the discontinuation were comparatively analysed with respect to awareness , education , economy , distance , and daily cost of treatment , types of stroke and disability status . RESULTS AND ANALYSIS During the study period of 2 years , the following was observed : 420 patients ( 34.65 % ) discontinued secondary preventive treatment ; 112 patients ( 9.24 % ) dropped out ; 680 patients ( 56.10 % ) continued . Chi-square and null hypothesis procedures were applied for statistical analysis . Distance , economy , poor awareness on stroke , low educational level , types of stroke , cost of treatment and disability status all were significant factors in the discontinuation of treatment . The discontinued group had poor control of risk factors , higher recurrence of both types of stroke and higher mortality . CONCLUSIONS Discontinuation of secondary preventive treatment due to diverse socioeconomic factors results in greater recurrence and disabilities among stroke survivors , and these findings should be reported to national and international planning authorities to strengthen preventive measures to achieve better outcomes and reductions of the stroke burden globally BACKGROUND AND PURPOSE Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke . This study aim ed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population -based series of people with first-ever stroke in Perth , Western Australia . METHODS Between February 1989 and August 1990 , all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth , Western Australia , with a population of 138 708 people , were registered prospect ively and assessed according to st and ardized diagnostic criteria . Patients were followed up prospect ively at 4 months , 12 months , and 5 years after the index event . RESULTS Three hundred seventy patients with a first-ever stroke were registered , of whom 351 survived > 2 days . Data were available for 98 % of the cohort at 5 years , by which time 199 patients ( 58 % ) had died and 52 ( 15 % ) had experienced a recurrent stroke , 12 ( 23 % ) of which were fatal within 28 days . The 5-year cumulative risk of first recurrent stroke was 22.5 % ( 95 % confidence limits [ CL ] , 16.8 % , 28.1 % ) . The risk of recurrent stroke was greatest in the first 6 months after stroke , at 8.8 % ( 95 % CL , 5.4 % , 12.1 % ) . After adjustment for age and sex , the prognostic factors for recurrent stroke were advanced , but not extreme , age ( 75 to 84 years ) ( hazard ratio [ HR ] , 2.6 ; 95 % CL , 1.1 , 6.2 ) , hemorrhagic index stroke ( HR , 2.1 ; 95 % CL , 0.98 , 4.4 ) , and diabetes mellitus ( HR , 2.1 ; 95 % CL , 0.95 , 4.4 ) . CONCLUSIONS Approximately 1 in 6 survivors ( 15 % ) of a first-ever stroke experience a recurrent stroke over the next 5 years , of which 25 % are fatal within 28 days . The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88 % of cases . The predictors of first recurrent stroke in this study were advanced age , hemorrhagic index stroke , and diabetes mellitus , but numbers of recurrent events were modest . Because the risk of recurrent stroke is highest ( 8.8 % ) in the first 6 months after stroke , strategies for secondary prevention  should be initiated as soon as possible after the index event Background Patients with recent stroke or TIA are at high risk for new vascular events . Several evidence based strategies in secondary prevention of stroke are available but frequently underused . Support programs with multifactorial risk factor modifications after stroke or TIA have not been investigated in large-scale prospect i ve controlled trials so far . INSPiRE-TMS is a prospect i ve , multi-center , r and omized open intervention trial for intensified secondary prevention after minor stroke and TIA . Methods / design Patients with acute TIA or minor stroke admitted to the participating stroke centers are screened and recruited during in-hospital stay . Patients are r and omised in a 1:1 ratio to intervention ( support program ) and control ( usual care ) arms . Inclusion of 2.082 patients is planned . The support program includes cardiovascular risk factor measurement and feedback , monitoring of medication adherence , coaching in lifestyle modifications , and active involvement of relatives . St and ardized motivational interviewing is used to assess and enhance patients ’ motivation . Primary objective is a reduction of new major vascular events defined as nonfatal stroke and myocardial infa rct ion or vascular death . Recruitment time is planned for 3.5 years , follow up time is at least 2 years for every patient result ing in a total study time of 5 years ( first patient in to last patient out ) . Discussion Given the high risk for vascular re-events in acute stroke and the available effective strategies in secondary prevention , the INSPIRE-TMS support program has the potential to lead to a relevant reduction of recurrent events and a prolongation of the event-free survival time . The trial will provide the basis for the decision whether an intensified secondary prevention program after stroke should be implemented into regular care . A cost-effectiveness evaluation will be performed . Trial registration clinical trials.gov : BACKGROUND AND PURPOSE Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack . The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined . METHODS This was a prospect i ve , multicentre , cluster-r and omized controlled trial with blinded assessment of outcomes and intention-to-treat analysis . Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals . General practice s treating recruited patients were r and omized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care . The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months . RESULTS From January 2010 to November 2013 , 156 general practice s ( 280 patients ) were r and omly assigned to usual care ( control ) and 159 ( 283 patients ) to the intervention . The median age was 70.1 years ; 65 % were male . Overall , > 80 % of participants were prescribed recommended secondary prevention therapies at baseline . The primary efficacy analysis comprised 533 participants , with 30 either dying or lost to follow-up . In adjusted analyses , no significant between-group difference was found in the cardiovascular risk score at 12 months ( 0.04 , 95 % confidence interval -1.7 , 1.8 ) . CONCLUSIONS The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practice Stroke incidence in Copenhagen , Denmark was recorded in a r and om population sample of 19,327 persons invited for two health examinations with 5 years ' interval from 1976 to 1983 . Stroke incidence increased exponentially with age . After adjustment to the age and sex distribution of the Danish population in 1980 , the estimated incidence of first stroke was 1.41/1000 women and 2.48/1000 men ; the total incidence was 1.94/1000 population . Risk factor analysis was based on the initial examination of 13,088 persons greater than 35 years old without previous stroke who responded to the first invitation , in whom 295 first strokes were subsequently observed . We used the regression model of Cox . However , our use of this model differs from the somewhat automatic procedures normally used to develop prognostic models . Evaluation of the causative effect of a particular risk factor requires that the direction of mutual influences between the factor in question and other risk factors is established/postulated . Among the 16 potential risk factors for stroke we examined , significant effects were found for age , sex , household income , smoking habits , systolic blood pressure , diabetes , plasma cholesterol concentration , ischemic heart disease , and atrial fibrillation . No significant effect could be demonstrated for a positive family history of stroke , years of school education , marital status , alcohol consumption , daily use of tranquilizers , body mass index , or postmenopausal hormone treatment BACKGROUND AND PURPOSE Stroke has been the second leading cause of death in large cities in China since the 1980s . Meanwhile , the prevalences of hypertension and smoking have steadily increased over the last 2 decades . Therefore , a community-based intervention trial was initiated in 7 Chinese cities in 1987 . The overall goal of the study was to evaluate the effectiveness of an intervention aim ed at reducing multiple risk factors for stroke . The primary study objective was to reduce the incidence of stroke by 25 % over 3.5 years of intervention . METHODS In May 1987 in each of 7 the cities , 2 geographically separated communities with a registered population of about 10 000 each were selected as either intervention or  control  communities . In each community , a cohort containing about 2700 subjects ( > /=35 years old ) free of stroke was sample d , and a survey was administered to obtain baseline data and screen the eligible subjects for intervention . In each city , a program of treatment for hypertension , heart disease , and diabetes was instituted in the intervention cohort ( n approximately 2700 ) and health education was provided to the full intervention community ( n approximately 10 000 ) . A follow-up survey was conducted in 1990 . Comparisons of intervention and control cohorts in each city were pooled to yield a single summary . RESULTS A total of 18 786 subjects were recruited to the intervention cohort and 18 876 to the control cohort from 7 cities . After 3.5 years , 174 new stroke cases had occurred in the intervention cohort and 253 in the control cohort . The 3.5-year cumulative incidence of total stroke was significantly lower in the intervention cohort than the control cohort ( 0.93 % versus 1.34 % ; RR=0.69 ; 95 % CI , 0.57 to 0.84 ) . The incidence rates of nonfatal and fatal stroke , as well as ischemic and hemorrhagic stroke , were significantly lower in the intervention cohort than the control cohort . The prevalence of hypertension increased by 4.3 % in the intervention cohort and by 7.8 % in the control cohort . The average systolic and diastolic blood pressures increased more in the control cohort than in the intervention cohort . Among hypertensive individuals in the intervention cohort , awareness of hypertension increased by 6.7 % and the percentage of hypertensives who regularly took antihypertensive medication increased 13.2 % . All of these indices became worse in the control cohort . The prevalence of heart diseases and diabetes increased significantly in the both cohorts ( P<0.01 ) . The prevalence of consumption of alcohol increased slightly , and that of smoking remained constant in both cohorts . CONCLUSIONS A community-based intervention for stroke reduction is feasible and effective in the cities of China . The reduction , due to the intervention , in the incidence of stroke in the intervention cohort was statistically significant after 3.5 years of intervention . The sharp reduction in the incidence of stroke may be due to the interventions having blunted the expected increase in hypertension that accompanies aging as well as to better and earlier treatment of hypertension , particularly borderline hypertension . Applied health education to all the residents of the community may have prevented some normotensive individuals from developing hypertension and improved overall health awareness and knowledge Background : Few population -based studies with long-term follow-up have compared risk of recurrent stroke and cardiac events after first ischemic stroke . The relative risk of these two outcomes may inform treatment decisions . Methods : In the population -based Northern Manhattan Study , first ischemic stroke patients age 40 or older were prospect ively followed for recurrent stroke , myocardial infa rct ion ( MI ) , and cause-specific mortality . Fatal cardiac events were defined as death secondary to MI , congestive heart failure , sudden death/arrhythmia , and cardiopulmonary arrest . Risk of events ( with 95 % CIs ) was calculated using Kaplan – Meier survival analysis and adjusted for sex and age using Cox proportional hazard models . Results : Mean age ( n = 655 ; median follow-up 4.0 years ) was 69.7 ± 12.7 years .  The risk of recurrent stroke was more than twice that of cardiac events ( including nonfatal MI ) at 30 days and approximately twice cardiac risk at 5 years . The age- and sex-adjusted 5-year risk of fatal or nonfatal recurrent stroke was 18.3 % ( 14.8 to 21.7 % ) , and the 5-year risk of MI or fatal cardiac event was 8.6 % ( 6.0 to 11.2 % ) . The adjusted 5-year risk of nonfatal stroke ( 14.8 % , 11.6 to 17.9 % ) was approximately twice as high as fatal cardiac events ( 6.4 % , 4.1 to 8.6 % ) and four times higher than risk of fatal stroke ( 3.7 % , 2.1 to 5.4 % ) . Conclusions : Cardiac mortality is nearly twice as high as mortality owing to recurrent stroke , but long-term risk of all stroke , fatal or nonfatal , is approximately twice the risk of all cardiac events . The high risk of nonfatal recurrent stroke reinforces the importance of therapies aim ed at preventing stroke recurrence in addition to preventing cardiac events OBJECTIVE To evaluate prognosis of stroke and identify the risk factors for stroke recurrence . METHODS Based on the West China Hospital stroke register data base , we conducted a prospect i ve follow-up study of stroke patients to record the potential risk factors of stroke recurrence and investigate stroke recurrence at 1 year . Analysis of the risk factors was performed using a logistic regression model . RESULTS A total of 1913 stroke consecutive patients admitted to our department were prospect ively registered . Of these patients , 599 ( 31.3 % ) were identified to have intracerebral hemorrhage ( ICH ) , and 1314 ( 68.7 % ) had ischemic stroke . The total recurrence rate at 1 year was 11.2 % , and was 10.5 % in ischemic patients and 12.7 % in ICH patients . Multivariate analysis adjusted for age and gender identified atrial fibrillation , hypertension , hyperlipemia , family history of stroke , and smoking as the risk factors of stroke recurrence at 1 year . CONCLUSION The 1 year recurrent rate is about 11 % , and monitoring the factors of atrial fibrillation , hyperlipemia , hypertension , and smoking may help reduce the recurrence of stroke BACKGROUND AND PURPOSE There have been few community-based studies of long-term prognosis after acute stroke . This study aims to provide precise estimates of the absolute and relative risks of stroke recurrence in an unselected cohort of patients with a first-ever stroke . METHODS Six hundred seventy-five patients were registered in a community-based stroke register ( the Oxfordshire Community Stroke Project ) and prospect ively followed for up to 6.5 years .  Their relative risk of recurrent stroke was calculated using age- and sex-specific incidence rates for first stroke in Oxfordshire . RESULTS One hundred eighty recurrent episodes of stroke were identified , of which 135 were first recurrences . Given survival , the actuarial risk of suffering a recurrence was 30 % ( 95 % confidence interval , 20 % to 39 % ) by 5 years , about nine times the risk of stroke in the general population . The risk was highest early after the first stroke : 13 % ( 95 % confidence interval , 10 % to 16 % ) by 1 year , 15 times the risk in the general population . After the first year the average annual risk was about 4 % . The risk of stroke recurrence did not appear to be related to age or pathological type of stroke . CONCLUSIONS The absolute and relative risks of recurrent stroke are highest early after the first stroke but remain elevated for several years thereafter . Efforts at secondary prevention should be initiated as soon as possible and continued for several years to gain greatest benefit OBJECTIVE Stroke survivors are at high risk of stroke recurrence yet current strategies to reduce recurrence risk are sub-optimal . The UK Medical Research Council ( MRC ) have proposed a framework for developing and evaluating complex interventions , such as community management of stroke secondary prevention . The Framework outlines a five-phased approach from theory through to implementation of effective interventions . This paper reports Phases I-III of the development of a novel intervention to improve risk factor management after stroke . METHODS The pre- clinical /theoretical phase entailed review ing the literature and undertaking quantitative and qualitative studies to identify current practice s and barriers to secondary prevention . In Phase I ( modelling ) , findings were used to design an intervention with the potential to overcome barriers to effective stroke secondary prevention management . The feasibility of delivering the intervention and its acceptability were tested in the Phase II exploratory trial involving 25 stroke survivors and their general practitioners . RESULTS This led to the development of the definitive risk factor management  intervention . This comprises multiple components and involves using an on-going population stroke register to target patients , carers and health care professionals with tailored secondary prevention advice . Clinical , socio-demographic and service use data collected by the stroke register are transformed to provide an individualised secondary prevention package for patients , carers and health care professionals at three time points : within 10 weeks , 3 and 6 months post-stroke . CONCLUSION The intervention is currently being evaluated in a r and omised controlled trial . Further research is needed to test generalisability to other aspects of stroke management and for other chronic diseases . PRACTICE IMPLICATION S The MRC Framework for complex interventions provides a structured approach to guide the development of novel interventions in public health . Implication s for practice in stroke secondary prevention will emerge when the results of our r and omised controlled trial are published
Conclusions Stroke secondary prevention lifestyle interventions are effective in terms of affecting positive change in relation to lifestyle behaviours , physiological and secondary outcomes .
However , there was insufficient evidence to determine the effect of intervention on incidence of stroke recurrence .
EXECUTIVE SUMMARY Background Each year , approximately 15 million people worldwide have a stroke ; of these , five million die and another five million are chronically disabled .
Stroke recurs in approximately 25 % of patients during the first five years post-stroke ; recurrence may result in death , increased disability or institutionalisation .
Modifiable risk factors for recurrent stroke have been identified , and may be addressed by means of behavioural health promotion interventions .
Objectives This systematic review sought to establish the effectiveness of secondary prevention behavioural interventions , which address one or more modifiable lifestyle risk factors for recurrent stroke i.e. tobacco use , unhealthy diet , physical inactivity and excessive alcohol consumption .