In our latest Q&A series, and to mark Stroke Awareness Month, we spoke with Pamela Kushner, MD, Clinical Professor University of California at Irvine, about the evolving landscape of stroke prevention and care.
- Over the past decade, how has our understanding of the role of measures to reduce the risk of stroke evolved?
We now recognize that we need to be more aggressive in our cardiovascular prevention strategies. All of my patients are concerned that they may get a stroke, and it is time to recognize that a stroke is an example of a global vascular disease. This means we need to work on modifiable risk factors such as blood pressure, diet, inactivity, smoking, and obesity. Guidelines now push for rapid lowering and maintaining of blood pressure to more effective goals, adding statins, anti-thrombotic drugs and making lifestyle improvements. These measures can help us improve patient outcomes.
- Why is blood pressure control after stroke still an issue?
There are many obstacles that need to be overcome. Blood pressure is among the most modifiable risk factors for post-stroke prevention. Blood pressure control needs to be a key goal of all members of a patient’s care team and we need multidisciplinary care where clinicians of all specialties work together to take responsibility for patients.
Patients also need more frequent monitoring of their blood pressure with a team-based care approach, not measuring just every few months. Patients and their families need to be made aware of how blood pressure control can affect their prognosis.
- What is your approach to long term care and prognosis after stroke?
When I think about long term care and prognosis, I focus on prevention, function and mental health.
The risk of recurrent stroke remains highest in the first year but also remains elevated long-term, so risk factors have to be aggressively managed at the start and maintained.
Function will depend on the type of stroke, age, and access to rehabilitation. Intensive rehabilitation can make a difference over the long term.
Post stroke cognitive disability is common and often under-diagnosed. Good vascular control can help improve cognition. Unfortunately, depression and anxiety can also affect quality of life and patients’ adherence to multiple drug regimens.
- What challenges do stroke survivors face?
Stroke survivors’ lives, and the lives of their loved ones, are hard, with both physical and mental impairment. In addition to physical challenges, there can be slow processing and memory problems. This makes it difficult to manage healthcare, multiple medications and getting access to healthcare resources. Fragmented follow-up and poor continuity make healing even more complicated.
- What gives you optimism in stroke care and what still needs to change?
Improved stroke units may create more meaningful recoveries. Also, secondary stroke prevention is now much clearer than in the past. There are more digital tools and treatments available that can effectively manage blood pressure and glucose.
Clinical trial evidence post-stroke shows us that better implementation of guidelines from the onset, and getting patients to treatment goals, can make a difference. More home-based care and nurse navigation can also make a big difference to getting more efficient management of blood pressure and other risk factors and helping to support patients and their caregivers. Access to team-based post-stroke care can make a big difference along with emphasizing risk factor reduction.