O.O. Faluyi, PhD, J.A. Omodara, MSc, K.H. Tay, M.B.B.S. and K. Muhiddin, PhD, FRCP.
Medical Directorate, Derby NHS Hospital Foundation Trust, Derby, UK
Background: There is some evidence to suggest that the standard of acute medical care provided to patients with cerebrovascular disease is a major determinant of the eventual outcome. Consequently, the Royal College of Physicians (RCP) of London issues periodic guidelines to assist healthcare providers in the management of patients presenting with stroke.
Objective: An audit of the acute management of stroke in two hospitals belonging to the same health care trust in the UK. Method: Retrospective review of 98 randomly selected case-notes of patients managed for cerebrovascular disease in two acute hospitals in the UK between April and June 2004. The pertinent guidelines of RCP (London) are highlighted while audit targets were set at 70%.
Results: 84% of patients presenting with cerebrovascular disease had a stroke rather than a TIA, anterior circulation strokes were commonest. All patients with stroke were admitted while those with TIAs were discharged on the same day but most patients with TIA were not followed up by Stroke specialists. Most CT-imaging of the head was done after 24 hours delaying the commencement of anti-platelets for patients with ischaemic stroke or neurosurgical referral for haemorrhagic stroke. Furthermore, there was a low rate of referral for carotid ultrasound in patients with anterior circulation strokes. Anti-platelets and statins were commenced for most patients with ischaemic stroke while diabetes was well controlled in most of them. However, ACE-inhibitors and diuretics such as indapamide were under-utilized for secondary prevention in such patients. Warfarin anti-coagulation was under- utilized in patients with ischaemic stroke who had underlying chronic atrial fibrillation. While there was significant multi-disciplinary team input, dysphagia and physiotherapy assessments were delayed. Similarly, occupational therapy input and psychological assesment were omitted from the care of most patients.
Conclusion: Hospital service provision for the management of cerebrovascular disease needs to provide appropriate specialist follow up for patients with TIA, prompt radiological imaging and multi-disciplinary team input for patients with stroke. Furthermore, physicians need to utilize appropriate anti- hypertensives and anti-coagulation more frequently in the secondary prevention of stroke.
Keywords: Stroke, anti-platelets, anti-coagulation, carotid stenosis, secondary prevention
Abbreviations: ACE-inhibitors: angiotensin-converting enzyme inhibitors, AF: atrial fibrillation, CT-head: computerized tomography scan of the head, DCGH: Derby City General Hospital, DRI: Derbyshire Royal Infirmary, HMG-CoA: 3-hydroxy-3-methylglutaryl-coenzyme-A, MRI: magnetic resonance imaging, NHS: National Health Service, RCP: Royal College of Physicians, TIA: transient ischemic attack.
Cerebrovascular disease refers to focal neurological deficit of vascular origin. This spectrum of clinical disorders ranges from a transient ischemic attack (TIA) which lasts less than 24 hours to a stroke which lasts longer than 24 hours. Approximately 150 000 cases of stroke are diagnosed annually in the population of England and Wales with 65% of cases occurring in those over the age of 751. Cerebrovascular disease remains a leading cause of morbidity and mortality worldwide particularly among the elderly2. Furthermore, strokes remain one of the most common reasons for the acute admission of elderly patients3. In a large population-based study of approximately 20 000 people in Copenhagen, age, sex, household income, smoking, systolic blood pressure, diabetes mellitus, serum cholesterol, ischaemic heart disease and atrial fibrillation were identified as significant risk factors for stroke4. In multi-racial communities, cerebrovascular disease has a higher incidence in the black population5. The largest longitudinal study reported in the UK suggests that despite a reduction in the age and gender-specific incidence rates of stroke over the past 25 years and disability from stroke, the overall disease burden has been stable due to the increasing elderly population6. This suggests that given the further projected increase in the elderly population over the forthcoming years, more effort needs to be devoted to the effective management of cerebrovascular disease to reduce disability and mortality from this condition.