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. 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 In-Hospital Initiation of Secondary Stroke Prevention Therapies Yields High Rates of Adherence at Follow-up The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788] Compliance With Secondary Prevention of Ischemic Stroke: A Prospective Evaluation Reductions in the risks of recurrent stroke in patients with and without diabetes: The PROGRESS Trial Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial Secondary Prevention after Minor Stroke and TIA - Usual Care and Development of a Support Program The Secondary Prevention of Small Subcortical Strokes (SPS3) Study Implications of small reductions in diastolic blood pressure for primary prevention. Stop Stroke: development of an innovative intervention to improve risk factor management after stroke. Utility of electronic patient records in primary care for stroke secondary prevention trials Effect of Peer Education on Stroke Prevention: The Prevent Recurrence of All Inner-City Strokes Through Education Randomized Controlled Trial Impact of prophylactic beta-blocker therapy to prevent stroke after noncardiac surgery. Beta-adrenergic blockade after stroke. A preliminary closed cohort study. Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial
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 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 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 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 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 : Analyses of the risks of stroke were conducted for subjects with and without diabetes , participating in a r and omized , double‐blind , placebo‐controlled  trial of a perindopril‐based blood pressure lowering regimen in 6105 people with prior stroke or transient ischaemic attack ( TIA ) , followed for a median of 3.9 years . Findings : Seven hundred and sixty‐one patients had diabetes at baseline . Diabetes increased the risk of recurrent stroke by 35 % ( 95 % CI 10–65 % ) principally through an effect on ischaemic stroke ( 1.53 , 95 % CI 1.23–1.90 ) . Active treatment reduced blood pressure by 9.5/4.6 mmHg in patients with diabetes and by 8.9/3.9 mmHg in patients without diabetes . The proportional risk reductions achieved for stroke in patients with diabetes , 38 % ( 95 % CI 8–58 % ) , and patients without diabetes , 28 % ( 95 % CI 16–39 % ) , were not significantly different ( p homogeneity = 0.5 ) . The absolute reduction in the risk of recurrent stroke in the patients with diabetes was equivalent to one stroke avoided among every 16 ( 95 % CI 9–111 ) patients treated for 5 years . Conclusions : Diabetes is an important risk factor for stroke in patients with established cerebrovascular disease . Treatment with the ACE inhibitor perindopril with discretionary use of the diuretic indapamide produced reductions in the risk of recurrent stroke in patients with diabetes that were at least as great as those achieved in patients without diabetes 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 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 Small subcortical strokes , also known as lacunar strokes , comprise more than 25 % of brain infa rcts , and the underlying vasculopathy is the most common cause of vascular cognitive impairment . How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear . The aim of the Secondary Prevention of Small Subcortical Strokes study ( Trial registration : NCT00059306 ) is to define strategies for reducing stroke recurrence , cognitive decline , and major vascular events . Methods Secondary Prevention of Small Subcortical Strokes is a r and omised , multicentre clinical trial ( n=3000 ) being conducted in seven countries , and sponsored by the US NINDS/NIH . Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously r and omised , in a 2 × 2 factorial design , to antiplatelet therapy – 325 mg aspirin daily plus 75 mg clopidogrel daily , vs. 325 mg aspirin daily plus placebo , double-blind – and to one of two levels of systolic blood pressure targets –‘intensive ’ ( < 130 mmHg ) vs. ‘ usual ’ ( 130–149 mmHg ) . Participants are followed for an average of four-years . Time to recurrent stroke ( ischaemic or haemorrhagic ) is the primary outcome and will be analysed separately for each intervention . The secondary outcomes are the rate of cognitive decline and major vascular events . The primary and most secondary outcomes are adjudicated central ly by those unaware of treatment assignment . Conclusions Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infa rcts , which are likely due to small vessel disease . The results will inform the management of millions of patients with this common vascular disorder OBJECTIVES To estimate the impact of small reductions in the population distribution of diastolic blood pressure ( DBP ) , such as those potentially achievable by population -wide lifestyle modification , on incidence of coronary heart disease ( CHD ) and stroke . DESIGN Published data from the Framingham Heart Study , a longitudinal cohort study , and from the National Health and Nutrition Examination Survey II , a national population survey , were used to examine the impact of a population -wide strategy aim ed at reducing DBP by an average of 2 mm Hg in a population including normotensive subjects . SETTING / PARTICIPANTS White men and women aged 35 to 64 years in the United States . MAIN OUTCOME MEASURES Incidence of CHD and stroke , including transient ischemic attacks ( TIAs ) . RESULTS Data from overviews of observational studies and r and omized trials suggest that a 2-mm Hg reduction in DBP would result in a 17 % decrease in the prevalence of hypertension as well as a 6 % reduction in the risk of CHD and a 15 % reduction in risk of stroke and TIAs . From an application of these results to US white men and women aged 35 to 64 years , it is estimated that a successful population intervention alone could reduce CHD incidence more than could medical treatment for all those with a DBP of 95 mm Hg or higher . It could prevent 84 % of the number prevented by medical treatment for all those with a DBP of 90 mm Hg or higher . For stroke ( including TIAs ) , a population -wide 2-mm Hg reduction could prevent 93 % of events prevented by medical treatment for those with a DBP of 95 mm Hg or higher and 69 % of events for treatment for those with a DBP of 90 mm Hg or higher . A combination strategy of both a population reduction in DBP and targeted medical intervention is most effective and could double or triple the impact of medical treatment alone . Adding a population -based intervention to existing levels of hypertension treatment could prevent an estimated additional 67,000 CHD events ( 6 % ) and 34,000 stroke and TIA events ( 13 % ) annually among all those aged 35 to 64 years in the United States . CONCLUSIONS A small reduction of 2 mm Hg in DBP in the mean of the population distribution , in addition to medical treatment , could have a great public health impact on the number of CHD and stroke events prevented . Whether such DBP reductions can be achieved in the population through lifestyle interventions , in particular through sodium reduction , depends on the results of ongoing primary prevention trials as well as the cooperation of the food industry , government agencies , and health education professionals 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 Background This study aim ed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records ( EPRs ) as potential outcome measures . The study also evaluated achievement of recommended st and ards of care ; variation between family practice s ; and changes in risk factor values from before to after stroke . Methods Data from the UK General Practice Research Data base ( GPRD ) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practice s. For each subject , the EPR was evaluated for the 12 months before and after stroke . Measures relevant to stroke secondary prevention were analysed including blood pressure ( BP ) , cholesterol , smoking , alcohol use , body mass index ( BMI ) , atrial fibrillation , utilisation of antihypertensive , antiplatelet and cholesterol lowering drugs . Intraclass correlation coefficients ( ICC ) were estimated by family practice . R and om effects models were fitted to evaluate changes in risk factor values over time . Results In the 12 months following stroke , BP was recorded for 90 % , cholesterol for 70 % and body mass index ( BMI ) for 47 % . ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol . For subjects with records available both before and after stroke , the mean reductions from before to after stroke were : mean systolic BP , 6.02 mm Hg ; diastolic BP , 2.78 mm Hg ; total cholesterol , 0.60 mmol/l ; BMI , 0.34 Kg/m2 . There was an absolute reduction in smokers of 5 % and heavy drinkers of 4 % . The proportion of stroke patients within the recommended guidelines varied from less than a third ( 29 % ) for systolic BP , just over half for BMI ( 54 % ) , and over 90 % ( 92 % ) on alcohol consumption . Conclusions Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention . Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke . Better recording of lifestyle factors in the GPRD has the potential to exp and the scope of the GPRD for health care research and practice Background and Purpose — Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success . We aim ed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors . Methods — Between 2009 and 2012 , we enrolled 600 stroke or transient ischemic attack survivors from diverse , low-income communities in New York City into a 2-arm r and omized clinical trial that compared a 6 week ( 1 session/week ) , peer-led , community-based , stroke prevention self-management group workshop ( N=301 ) to a wait-list control group ( N=299 ) . The primary outcome was the proportion with a composite of controlled blood pressure ( < 140/90 mm Hg ) , low-density lipoprotein cholesterol < 100 mg/dL , and use of antithrombotic medications at 6 months . Secondary outcomes included control of the individual stroke risk factors . All analyses were by intent-to-treat . Results — There was no difference in the proportion of intervention and control group participants achieving the composite outcome ( 34 % versus 34 % ; P=0.98 ) . The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group ( 76 % versus 67 % ; P=0.02 ) . This corresponded to a greater change in systolic blood pressure in the intervention versus control group ( −3.63 SD , 19.81 mm Hg versus + 0.34 SD , 23.76 mm Hg ; P=0.04 ) . There were no group differences in the control of cholesterol or use of antithrombotics . Conclusions — A low-cost peer education self-management workshop modestly improved blood pressure , but not low-density lipoprotein cholesterol or antithrombotic use , among stroke and transient ischemic attack survivors from vulnerable , predominantly minority urban communities . Clinical Trial Registration — URL : http://www . clinical trials.gov/show/NCT0102727 . Unique identifier : NCT01027273 beta Blockers are widely used to improve the postoperative cardiac outcome in patients with coronary artery disease scheduled for noncardiac surgery . However , recently serious concerns regarding the safety of perioperative beta blockers have emerged . To assess the incidence , risk factors , and beta-blocker use associated with postoperative stroke in the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography ( DECREASE ) trials , we evaluated all 3,884 patients of the DECREASE trials for postoperative stroke .  All cardiac risk factors and medication use were assessed . The incidence of stroke within 30 days after surgery was recorded . The incidence of postoperative stroke in the DECREASE trials was 0.46 % ( 18 of 3,884 ) . For the beta-blocker users , the incidence was 0.5 % . All the strokes had an ischemic origin . A history of stroke was associated with a greater incidence of postoperative stroke ( odds ratio [ OR ] 3.79 , 95 % confidence interval [ CI ] 1.2 to 11.6 ) . Statins and anticoagulants were not associated with postoperative stroke ( OR 0.85 , 95 % CI 0.3 to 2.4 ; and OR 1.27 , 95 % CI 0.4 to 4.6 , respectively ) . No association with  bisoprolol  therapy was found ( OR 1.16 , 95 % CI 0.4 to 3.4 ) . In conclusion , with a low-dose bisoprolol regimen started > or = 30 days before surgery , no association was observed between beta-blocker use and postoperative stroke To collect background data for a prospect i ve clinical trial of beta-blocking agents in the prevention of deaths after stroke , the long-term prognosis in 60 patients discharged from a stroke unit on beta-blocker therapy  was compared with the outcome in 60 matched patients with stroke but without beta-blockers .  Matching included sex , age , type of stroke , and presence or absence of hypertension and cardiac failure . Thirteen patients ( 22 % ) in the beta-blocker group died during a median followup of 41 months . Of the 60 patients not on beta-blockade at discharge , 21 ( 35 % ) died during a median followup of 36 months . By life-table technique and log-rank test , the relative risk for death was 0.60:1.00 ( p = 0.14 ) . During followup , 12 recurrent strokes were observed in patients on beta-blockers and 19 in patients without beta-blockers ( relative risk 0.57:1.00 ; p = 0.12 ) . It appeared that the reduction in mortality could only marginally be ascribed to fewer deaths from myocardial infa rct ion ; other causes of death were also less frequent in beta-blocker-treated patients . The results emphasize that supplementary information on the effect of beta-blocking agents on mortality after stroke is needed before a larger trial of beta-blocker therapy in patients with manifest cerebrovascular disease can be initiated 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
For other outcomes analysed ( major vascular events , death from all causes , death from cardiovascular causes ) , we observed no significant differences between the groups .
There were minor blood pressure reductions in the intervention group .
To date , no available evidence supports the routine use of beta-blockers for secondary prevention after stroke or TIA .
BACKGROUND Stroke affects 15 million people per year worldwide .
Despite recent developments in acute stroke treatment , prevention remains very important .
Stroke has a high rate of recurrence ; therefore secondary prevention is also important .
Many clinical approaches to control risk factors have been proposed .
One of these approaches is the prescription of beta-blockers that have effects beyond the reduction of blood pressure , which can reduce the recurrence of stroke .
OBJECTIVES To evaluate the efficacy of beta-blockers for preventing stroke recurrence and for reducing death and major vascular events in people with a previous stroke or transient ischaemic attack ( TIA ) , and to determine their safety , particularly with regard to the development of diabetes mellitus .