Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial Secondary Prevention after Minor Stroke and TIA - Usual Care and Development of a Support Program In-Hospital Initiation of Secondary Stroke Prevention Therapies Yields High Rates of Adherence at Follow-up Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: a randomized trial. Combining Multiple Approaches for the Secondary Prevention of Vascular Events After Stroke: A Quantitative Modeling Study The NAILED stroke risk factor trial (Nurse based Age independent Intervention to Limit Evolution of Disease after stroke): study protocol for a randomized controlled trial Safety and feasibility of post-stroke care and exercise after minor ischemic stroke or transient ischemic attack: MotiveS & MoveIT. Compliance With Secondary Prevention of Ischemic Stroke: A Prospective Evaluation Peer education for secondary stroke prevention in inner-city minorities: design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial. The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788] The effect of a locally adapted, secondary stroke risk factor self-management program on medication adherence among veterans with stroke/TIA Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance. Multifaceted Intervention Including Motivational Interviewing to Support Medication Adherence after Stroke/Transient Ischemic Attack: A Randomized Trial Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II). Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia
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 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 Effective methods of secondary prevention after stroke or TIA are available but adherence to recommended evidence -based treatments is often poor . The study aim ed to determine the quality of secondary prevention in usual care and to develop a stepwise modeled support program . Methods Two consecutive cohorts of patients with acute minor stroke or TIA undergoing usual outpatient care versus a secondary prevention program were compared . Risk factor control and medication adherence were assessed in 6-month follow-ups ( 6M-FU ) . Usual care consisted of detailed information concerning vascular risk factor targets given at discharge and regular outpatient care by primary care physicians . The stepwise modeled support program additionally employed up to four outpatient appointments . A combination of educational and behavioral strategies was employed . Results 168 patients in the observational cohort who stated their openness to participate in a prevention program ( mean age 64.7 y , admission blood pressure ( BP ) : 155/84 mmHg ) and 173 patients participating in the support program ( mean age 67.6 y , BP : 161/84 mmHg ) were assessed at 6 months . Proportions of patients with BP according to guidelines were 50 % in usual-care and 77 % in the support program ( p<0.01 ) . LDL<100 mg/dl was measured in 62 versus 71 % ( p = 0.12 ) . Proportions of patients who stopped smoking were 50 versus 79 % ( p<0.01 ) . 72 versus 89 % of patients with atrial fibrillation were on oral anticoagulation ( p = 0.09 ) . Conclusions Risk factor control remains unsatisfactory in usual care . Targets of secondary prevention were met more often within the supported cohort . Effects on (cerebro-)vascular recurrence rates are going to be assessed in a multicenter r and omized trial Background and Purpose — The Stroke PROTECT ( Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment ) program systematic ally implements , at the time of acute transient ischemic attack ( TIA ) or ischemic stroke admission , 8 medication/behavioral secondary prevention measures known to improve outcome in patients with cerebrovascular disease . The objective of this study was to determine if the high utilization rates previously demonstrated at hospital discharge were maintained at 90 days after discharge . Methods — Data were prospect ively collected on consecutively encountered ischemic stroke and TIA patients admitted to a university hospital stroke service beginning September 1 , 2002 .  PROTECT interventions were initiated before hospital discharge in all PROTECT – target ( underlying stroke mechanism large vessel atherosclerosis or small vessel disease ) and PROTECT – ACS ( At-risk for Coronary Sequelae ) patients . Adherence to program goals was assessed 3 months after discharge . Results — During the period from September 2002 to August 2003 , 144 individuals met criteria for PROTECT intervention . Of the 130 patients ( 90 % ) with available day 90 follow-up data , mean age was 72 ( range , 37 to 95 ) , and 63 % were male .  Adherence rates in patients without specific contraindications were 100 % for antithrombotics , 99 % for statins , 92 % for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers , and 80 % for thiazides . Awareness of the importance of calling 911 in response to stroke was 87 % . Adherence to diet and exercise guidelines were 78 % and 70 % , respectively . Of the 24 smokers , tobacco cessation was maintained in 20 ( 83 % ) . Conclusions — High rates of adherence to PROTECT therapies were maintained at 90 days after hospital discharge BACKGROUND This r and omized controlled trial tested the effectiveness of comprehensive , interdisciplinary postdischarge care management in improving a profile of indicators of health recovery and secondary prevention ( profile of health and prevention ) in stroke and transient ischemic attack ( TIA ) patients . METHODS Ninety-six stroke/TIA patients were r and omized to usual care or intervention at discharge from our acute stroke unit . The intervention group received an in-home biopsychosocial assessment by an advanced practice nurse at 1 month . A care plan was developed by an interdisciplinary team and implemented in collaboration with the patient 's primary care physician . The profile of health and prevention , measured at 3 months , was comprised of 5 domains : ( 1 ) Neuromotor Function , ( 2 ) Severe Complications , ( 3 ) Quality of Life , ( 4 ) Management of Risk for common poststroke complications and recurrent stroke , and ( 5 ) Stroke Knowledge . A single global hypothesis test across multiple end points was used to compare the 2 groups . RESULTS The intervention significantly improved the profile of health and prevention ( P < .0001 ) . In addition , each domain showed a positive effect of the intervention . Effect sizes ( in st and ard deviation units ) of the intervention on domains were .1 for Neuromotor Function ( 90 % confidence interval [ CI ] = -.3 to .5 ) ; .4 for Severe Complications ( 90 % CI = .1 to .8 ) ; .5 for Quality of Life ( 90 % CI = .1 to .9 ) ; .6 for Management of Risk for common poststroke complications and recurrent stroke ( 90 % CI = .3 to 1 . ) ; and 1.0 for Stroke Knowledge ( 90 % CI = .6 to 1.4 ) . CONCLUSIONS This model of care management result ed in a significantly better profile of health and prevention for stroke/TIA patients 3 months postdischarge Background and Purpose — Numerous effective strategies for the secondary prevention of cardiovascular events in high-risk patients have now been established . We sought to calculate the cumulative benefit of combining multiple strategies for preventing recurrent events in patients with a history of ischemic stroke or transient ischemic attack . Methods — A comprehensive literature search was undertaken to identify meta-analyses of r and omized controlled trials reporting on the efficacy of secondary prevention strategies . The baseline incidence of vascular events was modeled from the Life Long After Cerebral Ischemia study . Strategies were combined on a multiplicative scale and cumulative risk reductions were computed over a 5-year interval . Results — The combination of 5 proven strategies applied to survivors of an initial stroke or transient ischemic attack — dietary modification , exercise , aspirin , a statin , and an antihypertensive agent — could result in a cumulative relative risk reduction of 80 % . Given a 5-year major cardiovascular event rate of 24 % , this translates to a number needed to treat of about 5 . Further gains would result from applying multimodality therapy over longer intervals and enriching the base strategy with dual antiplatelet therapy , high-dose statins , and more intensive blood pressure – lowering . Even more benefit would be present in high-risk subgroups with the addition , where appropriate , of carotid endarterectomy , moderate intensity oral anticoagulants , glycemic control , and smoking cessation . Conclusions — At least four-fifths of recurrent vascular events in patients with cerebrovascular disease might be prevented by application of a comprehensive , multifactorial approach Background Secondary prevention after stroke and transient ischemic attack ( TIA ) is essential in order to reduce morbidity and mortality . Secondary stroke prevention studies have , however , been fairly small , or performed as clinical trials with non-representative patient selection . Long-term follow-up data is also limited . A nurse-led follow-up for risk factor improvement may be effective but the evidence is limited . The aims of this study are to perform an adequately sized , nurse-led , long-term secondary preventive follow-up with a population -based inclusion of stroke and TIA patients . The focus will be on blood pressure and lipid control as well as tobacco use and physical activity . Methods A r and omized , controlled , long-term , population -based trial with two parallel groups . The patients will be included during the initial hospital stay . Important outcome variables are sitting systolic and diastolic blood pressure , LDL cholesterol and total cholesterol . Outcomes will be measured after 12 , 24 and 36 months of follow-up . Trained nurses will manage the intervention group with a focus on reaching set treatment goals as soon as possible . The control group will receive usual care .  At least 200 patients will be included in each group , in order to reliably detect a difference in mean systolic blood pressure of 5 mmHg . This sample size is also adequate for detection of clinical ly meaningful group differences in the other outcomes . Discussion This study will test the hypothesis that a nurse-led , long-term follow-up after stroke with a focus on reaching set treatment goals as soon as possible , is an effective secondary preventive method . If proven effective , this method could be implemented in general practice at a low cost . Trial registration Current Controlled Trials IS RCT BACKGROUND Despite the beneficial effect of cardiac rehabilitation after myocardial infa rct ion , a rehabilitation program to improve cardiorespiratory fitness and influence secondary prevention has not been implemented for ischemic stroke and transient ischemic attack ( TIA ) . OBJECTIVE To investigate the safety and feasibility of a post-stroke care including an exercise program after minor ischemic stroke or TIA . METHODS In a r and omised controlled trial , 20 patients with a recent minor stroke or TIA without cardiac contraindications were r and omly assigned to one of the two interventions ; post-stroke care without exercise or post-stroke care with exercise . Patients were evaluated at baseline , 6 and 12 months . RESULTS Eighteen patients completed the intervention . In none of the patients cardiopulmonary contraindications for the maximal exercise test and exercise program were found . No cardiovascular events occurred during the maximal exercise tests and exercise program . After one year , significantly more patients in the post-stroke care with exercise group achieved the composite endpoint of optimal medical therapy . CONCLUSIONS Post-stroke care including an exercise program is safe and feasible in the acute phase after minor stroke or TIA and might be a way to increase effectiveness of secondary stroke prevention . We are currently conducting a larger trial to vali date these results Background and Purpose — Compliance with pharmacological therapy is essential for the efficiency of secondary prevention of ischemic stroke . Few data exist regarding patient compliance with antithrombotic and risk factor treatment outside of controlled clinical trials . The aim of the present study was to assess the rate of and predictors for compliance with secondary stroke prevention 1 year after cerebral ischemia and to identify reasons for noncompliance . Methods — Patients with a diagnosis of ischemic stroke or TIA and antithrombotic discharge medication were prospect ively recruited . At 1 year , the proportion of patients compliant with antithrombotic treatment and with medication for risk factors ( eg , hypertension , diabetes , hyperlipidemia ) was evaluated through structured telephone interviews . In addition , the reasons for nontreatment with antithrombotic and risk factor medication were determined . Independent predictors for compliance were analyzed by logistic regression analyses . Results — Of 588 consecutive patients admitted to our stroke unit , 470 had a discharge diagnosis of cerebral ischemia ( TIA 26.2 % , cerebral infa rct 73.8 % ) and recommendations for  antithrombotic therapy . At 1 year , 63 patients ( 13.4 % ) had died and 21 ( 4.5 % ) were lost to follow-up , thus , 386 could finally be evaluated . Of the patients , 87.6 % were still on antithrombotic medication , and 70.2 % were treated with the same agent prescribed on discharge . Of the patients with hypertension , diabetes , and hyperlipidemia , 90.8 % , 84.9 % , and 70.2 % were still treated for their respective risk factors . Logistic regression analyses revealed age ( OR 1.03 , 95 % CI 1.00 to 1.06 ) , stroke severity on admission ( OR 1.09 , 95 % CI 1.00 to 1.20 ) , and cardioembolic cause ( OR 4.13 , 95 % CI 1.23 to 13.83 ) as independent predictors of compliance . Conclusions — Compliance with secondary prevention in patients with ischemic stroke is rather good in the setting of our study . Higher age , a more severe neurological deficit on admission , and cardioembolic stroke cause are associated with better long-term compliance . Knowledge of these determinants may help to further improve the quality of stroke prevention BACKGROUND The highest risk for stroke is among survivors of strokes or transient ischemic attacks ( TIA ) . However , use of proven-effective cardiovascular medications to control stroke risk is suboptimal , particularly among the Black and Latino population s disproportionately impacted by stroke . METHODS A partnership of Harlem and Bronx community representatives , stroke survivors , research ers , clinicians , outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education ( PRAISE ) trial . Using data from focus groups with stroke survivors , they tailored a peer-led , community-based chronic disease self-management program to address stroke risk factors . PRAISE will test , in a r and omized controlled trial , whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control , lipid control , and use of antithrombotic medications . RESULTS Of the 582 survivors of stroke and TIA enrolled thus far , 81 % are Black or Latino and 56 % have an annual income less than $ 15,000 . Many ( 33 % ) do not have blood pressures in the target range , and most ( 66 % ) do not have control of all three major stroke risk factors . CONCLUSIONS Rates of stroke recurrence risk factors remain suboptimal in the high risk , urban , predominantly minority communities studied . With a community-partnered approach , PRAISE has recruited a large number of stroke and TIA survivors to date , and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities Background Survivors of transient ischemic attack ( TIA ) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk . However , vascular risk factors , especially hypertension and high cholesterol , are not managed optimally even in those patients seen in specialized clinics . This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes . In this study , we will be testing a pharmacist case manager for delivery of stroke prevention services . We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes . Methods We will conduct a prospect i ve , r and omized , controlled open-label with blinded ascertainment of outcomes ( PROBE ) trial . Treatment allocation will be concealed from the study personnel , and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient 's clinical care or trial participation and who are masked to baseline measurements . Patients will be  r and omized to control or a pharmacist case manager treating vascular risk factors to guideline -recommended target levels . Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton , Alberta after an ischemic stroke or TIA who have uncontrolled hypertension ( defined as systolic blood pressure ( BP ) > 140 mm Hg ) or dyslipidemia ( fasting LDL-cholesterol > 2.00 mmol/L ) and who are not cognitively impaired or institutionalized . The primary outcome will be the proportion of subjects who attain ' optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L ) at six months compared to baseline ; 12-month data will also be collected for analyses of sustainability of any effects . A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected . Conclusions Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year . If our intervention improves the provision of secondary prevention therapies in these patients , the clinical ( and financial ) implication s will be enormous We targeted stroke/transient ischemic attack ( TIA ) survivors to engage in self-management practice s to manage secondary stroke risk factors . We conducted a r and omized , regional pilot trial of a locally adapted , secondary stroke prevention program . We implemented the program at two Veterans Administration Medical Centers . Program sessions targeted stroke risk factor self-management . Specifically , we evaluated the effect of the program on the reach , implementation , and effectiveness on patient self-efficacy ; stroke-specific , health-related quality of life ; and medication adherence for the prevalent stroke risk factors : ( 1 ) diabetes , ( 2 ) hypertension , and ( 3 ) hyperlipidemia . Medication possession ratios were calculated to evaluate medication adherence using VA pharmacy benefits data pre ( 6 months prior ) and post ( 6 months after ) the stroke/TIA event . Based upon the literature st and ard of 80 % compliance rate , we dichotomized compliance and modeled the data using logistical regression . Final sample included 174 veterans with an acute stroke or TIA who were r and omized to receive either the intervention ( n = 87 ) or attention control program ( n = 87 ) .  Patient self-efficacy and stroke-specific , health-related quality of life at 6 months did not significantly differ between groups . We found improvements in medication adherence within the intervention group . In the intervention group , the odds of compliance with diabetes medications post-stroke were significantly larger than the odds of compliance prior to the stroke ( odds ratio = 3.45 ( 95 % CI = 1.08–10.96 ) . For compliance to hypertension medications , the intervention group showed significantly greater odds of compliance post intervention than pre intervention ( odds ratio = 3 . 68 ( 95 % CI = 1.81–7.48 ) . The control group showed no difference in compliance rates from baseline to follow-up . For adherence to hypercholesterolemia medications , both the intervention ( odds ratio = 5.98 ( 95 % CI = 2.81–12.76 ) and control groups ( odds ratio = 3.83 ( 95 % CI = 1.83–8.01 ) , had significant increases in the odds of compliance to statin medications ; however , the comparison of changes in log odds of compliance between these two groups showed that the increases were not significantly different . We observed within group improvements in medication adherence among those receiving a post-stroke risk factor self-management program suggesting that a self-management format may be feasible to enable adherence to prescribed medications to reduce secondary stroke risk after stroke in concordance with guideline care . Additional research is needed to enhance intervention components to improve effectiveness outcomes Background Despite lack of outward signs , most individuals after non-disabling stroke ( NDS ) and transient ischemic attack ( TIA ) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke , hospitalization for other vascular events , or death . Most have multiple modifiable risk factors ( e.g. , hypertension , physical inactivity , hyperlipidaemia , diabetes , tobacco consumption , psychological stress ) . In addition , accelerated rates of depression , cognitive decline , and poor quality of sleep have been reported following TIA , which correlate with poor functional outcomes and reduced quality of life . Thus , NSD and TIA are important warning signs that should not be overlooked . The challenge is not unlike that facing other ' silent ' conditions - to identify a model of care that is effective in changing people 's current behaviors in order to avert further morbidity . Methods / Design A single blind , r and omized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA . 250 adults within 90 days of being diagnosed with NDS/TIA will be r and omly allocated to a 12-week program of exercise and education ( PREVENT ) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated ( USUAL CARE ) . Primary outcome measures will include blood pressure , waist circumference , 12-hour fasting lipid profile , and 12-hour fasting glucose/hemoglobin A1c . Secondary measures will include exercise capacity , walking endurance , physical activity , cognitive function , depression , goal attainment and health-related quality of life . Outcome assessment will be conducted at baseline , post-intervention , and 6- and 12-month follow-ups . Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared . Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards . Discussion Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known . We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention . Trial registration This trial is registered with the Clinical Trials.gov Registry ( NCT00885456 ) AIM To assess the feasibility of recruiting and retaining patients newly diagnosed with a Transient Ischaemic Attack ( TIA ) into an 8-week exercise programme . METHODS The study was a single-centre , r and omised-controlled trial . TIA was confirmed by a specialist stroke physician within 7 days of symptom onset . Following baseline assessment , participants were r and omised to either an 8-week exercise intervention or control group ( usual care ) . Participants completed a further assessment 2 months after baseline . RESULTS Of the 285 individuals diagnosed with TIA , 97 patients were invited to participate in the trial , of which 60 were successfully recruited ( 62 % ) . Of those invited , 89 % were identified within outpatient care . Individuals were typically of European descent ( 87 % ) and lived within 20 km of the study site ( 81 % ) . Distance to travel was considered the primary barrier for non-participation ( 46 % ) . Three participants ( 5 % ) did not attend the follow-up assessment . CONCLUSION Individuals with TIA were successfully recruited and retained into a RCT . A different approach is required to study interventions in Maori , Pacific Isl and ers , Asian and Indian population s. If the exercise intervention improves vascular risk factors and reduces recurrent vascular events , it could be applied to a large number of people who suffer a TIA or non-disabling stroke Background and Purpose : Adherence 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 . Methods : In this r and omized 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 infa rct ion . Patient satisfaction with the service was assessed for the intervention patients . Results : The 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 . Conclusions : A 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 BACKGROUND Reduction of blood pressure ( BP )  after stroke or TIA decreases stroke recurrence and is a major goal of secondary Stroke Prevention Clinics ( SPCs ) . Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication . METHODS This multicentred , r and omized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits ( e.g. , lack of confidence in the utility of medications , poor memory , mild cognitive impairment ) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program ( monthly telephone calls , motivational interviewingfor lifestyle change , plus home BP monitoring and use ofdosettes for medication administration ) would improve BP measures and adherence to medications . RESULTS Both  intervention ( n=29 ) and usual care  groups ( n=27 ) showed a trend-for'reduced BP at six months ( Median ql-q3 , Systolic BR p=0.46 ; Diastolic BR p=0.37 ) . Diabetic patients , irrespective of the group to which they were r and omized , were less likely to meet Best Practice Guideline targets than those without diabetes ( Chi Square test , p=0.0001 ) . CONCLUSION Stroke and TIA patients with diabetes may require additional re sources and support in order to reach BP target values Rationale PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack . Within one-year of hospital discharge , up to one-third of patients no longer adhere to secondary prevention behaviors . Adherence rates are lower in minority-underserved groups , contributing to health disparities . In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals . In these groups , low literacy , limited healthcare access , and sparse community re sources may reduce adherence . Lay community health workers ( navigators ) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services . Aims and design PROTECT DC is a Phase II , single-blind , r and omized , controlled trial comparing in-hospital education plus stroke navigators to usual care .  Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington , DC hospitals .  Navigators meet with participants during the index hospitalization , perform home visits , and meet by phone . They focus on stroke education , medication compliance , and overcoming practical barriers to adherence . The interventions are driven by the theories of reasoned action and planned behavior . Study outcomes The primary dependent measure is a summary score of four objective measures of stroke risk factor control : systolic blood pressure , low-density lipoprotein , hemoglobin Hb A1C , and antiplatelet agent pill counts . Secondary outcomes include stroke knowledge , exercise , dietary modification , and smoking cessation . Conclusion PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted
There were no significant effects of organisational  interventions on lipid profile , HbA1c , medication adherence or recurrent cardiovascular events .
Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes .
The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors .
BACKGROUND People with stroke or transient ischaemic attack ( TIA ) are at increased risk of future stroke and other cardiovascular events .
Evidence -based strategies for secondary stroke prevention have been established .
However , the implementation of prevention strategies could be improved .
OBJECTIVES To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control , including patient adherence to prescribed medications , and the occurrence of secondary cardiovascular events .