Recurrent strokes can be avoided with optimal prevention and follow-up

Patients who have had a stroke are prescribed medication to prevent new strokes. Nevertheless, fewer than half achieve the optimal treatment targets.

A sample of 431 Norwegian patients who had suffered a stroke were followed up in a study at the Norwegian University of Science and Technology (NTNU) three years after their initial hospitalization.

The majority of the patients reported that they were still taking the medications they had been prescribed.

However, fewer than half had achieved the treatment targets for both blood pressure and cholesterol.

One in ten patients who have had a stroke experiences another stroke within five years, and the second stroke is often worse than the first. Therefore, following up on these patients is crucial."

Erlend Fagerli, a resident doctor and study's lead author

At the same time, research shows that 80 per cent of recurrent strokes can be avoided with optimal prevention and follow-up of patients after the first stroke. Lowering blood pressure and reducing levels of harmful LDL cholesterol are most important.

Struggling with blood pressure

Strokes They affect approximately 9000 people in Norway each year. Almost 5000 people experience a transient ischemic attack (TIA), a temporary disruption of blood flow to the brain that causes stroke-like symptoms but no lasting damage. The risk of having another stroke is roughly the same for individuals who have had either a cerebral infarction or a transient ischemic attack.

Fagerli is particularly struck by the fact that many people do not achieve their blood pressure treatment targets.

Three years after having a stroke, only 42 per cent of patients have managed to lower their blood pressure to an optimal level. This is despite the fact that more than nine out of ten patients continued taking the blood pressure medications they were prescribed after their stay in hospital.

"Blood pressure is the most important factor when it comes to stroke risk. If there is one thing you should do, it is to get your blood pressure under control," explained Fagerli.

The study also shows that most of the patients with high blood pressure were only taking one single type of blood pressure medication.

"When someone has had a stroke, it is very important for them to lower their blood pressure, and combining different blood pressure medications can help achieve that. It can therefore be better to take two different medications at a slightly lower dose rather than a high dose of just one single medication," Fagerli said.

More medicine gives better results

The study shows a similar tendency for treating high cholesterol. Despite 83 per cent of patients still taking their prescribed cholesterol medications, only 47 per cent manage to lower their harmful LDL cholesterol to the desired level.

"We see that patients on higher doses of cholesterol-lowering medication are more likely to reach their treatment target. We also observed that patients with multiple illnesses more often achieved their targets than patients with fewer other illnesses. It often takes two different cholesterol-lowering medications to reach the treatment targets."

The study also showed a difference between men and women in respect of cholesterol. The women had higher levels of harmful LDL cholesterol than the men and were less likely to reach the treatment target.

"This may be connected to the fact that LDL cholesterol levels rise after the menopause. Other studies also show that women often receive lower doses of cholesterol-lowering medications, which might be part of the explanation," explained Fagerli.

Doctor-patient collaboration

The conclusion is that risk factors after a stroke are still not being adequately followed up, despite the fact that many patients take their medications and follow the advice they are given. Fagerli also points out that they lack data on why patients do not achieve their targets.

"That is a limitation of the study. For example, we do not know why the patients were not given higher doses of medication. There are often good reasons for that," said Fagerli.

He emphasizes that the follow-up of stroke patients is complex.

"Each patient is different, and medications, dosages and needs vary. Sometimes it may be due to patients not continuing their follow-up or the doses being too low. Other times, it has to do with the patient's personal preferences. It is complex."

Perhaps the patient does not want to take multiple medications. Fagerli feels it is important that patients understand why their doctor wants them to reach the treatment targets.

"This is to avoid another stroke or other cardiovascular events. We want there to be an alliance between the doctor and the patient, and that they collaborate to achieve the treatment targets.

Check your blood pressure

So what should you do if you have had a stroke and are unsure whether you are being followed up adequately?

"Good follow-up is crucial. Most patients receive a check-up at the hospital within three months, but after that, follow-up is left to the GP and the patient. Blood pressure and cholesterol should be measured regularly," said Fagerli.

If you have had a stroke, you are a high-risk patient.

"If, after a while, you still have slightly high blood pressure or slightly elevated cholesterol levels, it should be followed up."

He also emphasizes that lifestyle changes can be important.

"In this study, we found no clear correlation between physical activity and control of blood pressure or cholesterol. Nevertheless, adapted and regular physical activity can be considered a treatment target in itself and is recommended for everyone who has had a transient ischemic attack or cerebral infarction," said Fagerli, adding:

"Three out of four participants in our study were not physically active enough, based on the Norwegian Directorate of Health's definition."