title: Implementation of a Structured Guideline–Based Program for the Secondary Prevention of Ischemic Stroke in China Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model Predictors of Adherence to Secondary Preventive Medication in Stroke Patients Randomised controlled trial of an education and support package for stroke patients and their carers Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance. 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. Does telephone follow-up improve blood pressure after minor stroke or TIA? Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial The cardiac model of rehabilitation for reducing cardiovascular risk factors post transient ischaemic attack and stroke: a randomized controlled trial Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial Blood pressure 1 year after stroke: the need to optimize secondary prevention. Secondary Prevention of New Vascular Events with Lifestyle Intervention in Patients with Noncardioembolic Mild Ischemic Stroke: A Single-Center Randomized Controlled Trial Risk factor management and depression post-stroke: The value of an integrated model of care Knowledge and understanding of disease process, risk factors and treatment modalities in patients with a recent TIA or minor ischemic stroke. A randomized trial testing the superiority of a postdischarge care management model for stroke survivors. Effects of early exercise engagement on vascular risk in patients with transient ischemic attack and nondisabling stroke. Utility of a Post-Hospitalization Stroke Prevention Program Managed by Nurses Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial The impact of stroke nurse specialist input on risk factor modification: a randomised controlled trial.
abstract: Background and Purpose — High rates of ischemic stroke and poor adherence to secondary prevention measures are observed in the Chinese population . Methods — We used a national , multicenter , cluster-r and omized controlled trial in which 47 hospitals were r and omized to either a  structured care program group ( n=23 ) or a usual care group ( n=24 ) . The structured care program consisted of a specialist-administered , guideline -recommended pharmaceutical treatment and a lifestyle modification algorithm associated with written and Internet-accessed educational material for patients for the secondary prevention of ischemic stroke . The primary efficacy outcome was the proportion of patients who adhered to the recommended measures at 12-month postdischarge . This trial is registered with Clinical Trial.gov ( NCT00664846 ) . Results — At 12 months , 1287 ( 72.1 % ) patients in the St and ard Medical Management in Secondary Prevention of Ischemic Stroke in China ( SMART ) group and 1430 ( 72 % ) patients in the usual care group had completed the 12-month follow-up ( P=0.342 ) . Compared with the usual care group , those in the SMART group showed higher adherence to statins ( 56 % versus 33 % ; P=0.006 ) but no difference in adherence to antiplatelet ( 81 % versus 75 % ; P=0.088 ) , antihypertensive ( 67 % versus 69 % ; P=0.661 ) , or diabetes mellitus drugs ( 73 % versus 67 % ; P=0.297 ) . No significant difference in the composite end point ( new-onset ischemic stroke , hemorrhagic stroke , acute coronary syndrome , and all-cause death ) was observed ( 3.56 % versus 3.59 % ; P=0.921 ) . Conclusions — The implementation of a program to improve adherence to secondary ischemic stroke prevention efforts in China is feasible , but these programs had only a limited impact on adherence and no impact on 1-year outcomes . Further development of a structured program to reduce vascular events after stroke is needed . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00664846 Objective : Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease , there are very few structured care programmes for stroke survivors . The aim was to implement and evaluate an integrated care programme in stroke . Methods : 186 patients with stroke were r and omised to either the treatment ( integrated care ) or control ( usual care ) group and were followed up over 12 months . The Integrated Care for the Reduction of Secondary Stroke ( ICARUSS ) model of integrated care involved collaboration between a specialist stroke service , a hospital coordinator and a patient ’s general practitioner . The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education . Results : In the 12 months poststroke , systolic blood pressure ( sBP ) decreased in the treatment group but increased in controls . The group difference was significant , and remained so when age , sex , disability and sBP at discharge were accounted for ( p = 0.04 ) . Treatment patients also exhibited better modification of body mass index ( p = 0.007 ) and number of walks taken ( p<0.001 ) than controls . Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke ( p = 0.003 ) . Conclusions : Through an integrated system of education , advice and support to both patient and GP , the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event Objective The purpose of this study is to identify factors which predict adherence in stroke survivors . Design This is a longitudinal study where 180 stroke survivors were assessed 1 year after their first ischaemic stroke . The relationship between adherence and illness and medication beliefs was tested at baseline ( time 1 ) and again 5–6 weeks later ( time 2).Main Outcome Measures The main outcome measures used in this study are Medication Adherence Report Scale and urinary salicylate levels . Results Four variables predicted time 1 poor adherence : ( 1 ) younger age , ( 2 ) increased specific concerns about medications , ( 3 ) reduced cognitive functioning and ( 4 ) low perceived benefit of medication . Three out of these four variables were again predictive of time 2 adherence and accounted for 24 % of the variance : ( 1 ) younger age , ( 2 ) increased specific concerns about medications and ( 3 ) low perceived benefit of medication . The urinary salicylate assay failed to differentiate between patients taking and not taking aspirin . Conclusion Interventions to improve adherence should target patients ’ beliefs about their medication Objective Tailoring stroke information and providing reinforcement opportunities are two strategies proposed to enhance the effectiveness of education . This study aim ed to evaluate the effects of an education package which utilised both strategies on the knowledge , health and psychosocial outcomes of stroke patients and carers . Design Multisite , r and omised trial comparing usual care with an education and support package . Setting Two acute stroke units . Participants Patients and their carers ( N=138 ) were r and omised ( control n=67 , intervention n=71 ) of which data for 119 participants ( control n=59 , intervention n=60 ) were analysed . Intervention The package consisted of a computer-generated , tailored written information booklet and verbal reinforcement provided prior to , and for 3 months following , discharge . Outcome measures Outcome measures were administered prior to hospital discharge and at 3-month follow-up by blinded assessors . The primary outcome was stroke knowledge ( score range : 0–25 ) . Secondary outcomes were : self-efficacy ( 1–10 ) , anxiety and depression ( 0–21 ) , ratings of importance of information ( 1–10 ) , feelings of being informed ( 1–10 ) , satisfaction with information ( 1–10 ) , caregiver burden ( carers ) ( 0–13 ) and quality of life ( patients ) ( 1–5 ) . Results Intervention group participants reported better : self-efficacy for accessing stroke information ( adjusted mean difference ( MD ) of 1.0 , 95 % CI 0.3 to 1.7 , p=0.004 ) ; feeling informed ( MD 0.9 , 95 % CI 0.2 to 1.6 , p=0.008 ) ; and satisfaction with medical ( MD 2.0 , 95 % CI 1.1 to 2.8 , p<0.001 ) ; practical ( MD 1.1 , 95 % CI 0.3 to 1.9 , p=0.008 ) , services and benefits ( MD 0.9 , 95 % CI 0.1 to 1.8 , p=0.036 ) and secondary prevention information ( MD 1.7 , 95 % CI 0.9 to 2.5 , p<0.001 ) . There was no significant effect on other outcomes . Conclusions Intervention group participants had improved self-efficacy for accessing stroke information and satisfaction with information , but other outcomes were not significantly affected . Evaluation of a more intensive intervention in a trial with a larger sample size is required to establish the value of an educational intervention that uses tailoring and reinforcement strategies . 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 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 hypertension is a common risk factor for stroke/transient ischaemic attack ( TIA ) and there is good evidence that blood pressure ( BP ) control prevents recurrent stroke . We investigated whether telephone follow-up ( TFU ) improved risk factor management in hypertensive patients after stroke/TIA . METHODS we conducted a r and omised controlled trial and assigned hypertensive patients within 1 month of stroke or TIA to receive usual care ( n = 27 ) or usual care plus regular TFU ( n = 29 ) . Primary outcome was the difference in 12 h ambulatory systolic BP change from baseline to 6 months ( DeltaSBP ) in both groups . TFU at 7 days , 1 , 2 and 4 months included patient-focussed education and goal setting . RESULTS mean baseline BP was 145/83 mm Hg ( st and ard deviation ( SD ) 21/14 ) . There was no significant difference in DeltaSBP over 6 months with TFU . Median DeltaSBP was 0 mm Hg ( interquartile range 19.5 ) in the TFU group and 3.0 mm Hg ( 20 ) fall in the usual care group ( P = 0.29 ) . Post hoc analysis showed that statin use increased from baseline to 6 months ( P = 0.02 ) and cholesterol was significantly lower at 6 months in all patients ( mean reduction 0.95 mmol/l ; P < 0.001 ) . CONCLUSION our study found TFU that promoted patient-led management of risk factors did not improve BP control over 6-month follow-up in primary care after stroke/TIA Objective : Little is known about the long-term effectiveness after stroke of interventions for behaviour modification and ensuring concordance with therapies . We describe a follow-up study of a previous r and omized controlled trial of a brief period of behaviour modification . The aim of this study was to determine outcomes three years after the initial intervention . Design : Survivors of the original cohort were contacted and asked to attend for follow-up interview , within a geriatric day hospital . This study was carried out in the Geriatric Day Hospital at Stobhill Hospital , Balornock Road , Glasgow . Interventions : Details of risk factor control , including blood pressure , cholesterol levels and diabetic control , were assessed . Question naires used in the initial study were repeated including the Geriatric Depression Scale score , Euroqol Perceived Health Status and Stroke Services Satisfaction Question naire . Main measures : Primary outcome was collective risk factor control . Clinical outcomes including recurrent cerebrovascular events , medication persistence and perceived health status were also recorded . Results : Mean length of follow-up was 3.6 years ( SD 0.43 ) . Of the 205 patients enrolled in the initial study , 102 patients attended for repeat interview ( 49 intervention/53 control ) . There were no significant differences in the percentage of controlled risk factors between groups ( intervention 51.7 % versus control 55.9 % , P = 0.53 ) . Similarities were observed in the number of recurrent clinical events and medication persistence between groups . No overall difference was observed in perceived health status , satisfaction with care or depression scores . Conclusions : Brief intervention with respect to behaviour modification and risk factor control does not appear to have any long-term benefit . These results must be cautiously interpreted in light of the small study number and further research is required Objective : To evaluate the feasibility and effectiveness of a st and ard National Health Service cardiac rehabilitation programme on risk factor reduction for patients after a minor stroke and transient ischaemic attack . Design : Single-blind r and omized controlled trial . Setting : Cardiac rehabilitation classes . Subjects : Twenty-four patients . Intervention : All participants received st and ard care . In addition , the intervention group undertook an eight-week cardiac rehabilitation programme consisting of weekly exercise and education classes . Outcome measures : Cardiovascular disease risk score ; lipid profiles ; resting blood pressure ; C-reactive protein ( measured with a high sensitive assay ) and fibrinogen levels ; blood glucose ; obesity ; physical activity levels ; subjective health status ( SF-36 ) ; Hospital Anxiety and Depression Scale . Results : Group comparison with independent t-tests showed a significantly greater improvement in the cardiovascular disease risk score for participants in the intervention group compared to st and ard care ( intervention 25.7 ± 22.8 to 23.15 ± 18.3 , control 25.03 ± 15.4 to 27.12 ± 16.1 , t = −1.81 , P < 0.05 ) . There were also significant improvements for the intervention group in activity levels ( intervention 9.41 ± 7.7 to 8.08 ± 5.7 , control 14.50 ± 5.5 to 9.83 ± 6.6 , t = −2.00 , P < 0.05 ) and the SF-36 domains of physical functioning ( intervention 70 ± 24.6 to 75.4 ± 11.1 , control 90.00 ± 12.4 to 83.16 ± 17.3 , t = −2.72 , P < 0.05 ) and mental health ( intervention 84 ± 40 to 92 ± 40 , control 88.00 ± 60 to 84 ± 44 , z = −2.06 , P < 0.05 ) . Conclusion : The results suggest that st and ard cardiac rehabilitation programmes are a feasible and effective means of reducing the risk of future cardiovascular events for patients after minor stroke and transient ischaemic attack Objective : To evaluate whether enhanced secondary prevention more significantly influences readiness to change health behaviour after minor stroke/transient ischaemic attack , compared with conventional stroke secondary prevention . Design : Single-blind r and omized control trial . Setting : Rural district general hospital outpatient clinic . Subjects : Fifteen women and 37 men with a mean age of 68.3 years with first minor stroke or transient ischaemic attack . Interventions : The intervention group received ‘ enhanced secondary prevention ’ ( additional advice , motivational interviewing and telephone support ) to change health behaviour . Both groups received ‘ conventional care ’ which included advice given during routine care . Main measures : The primary outcome was ‘ readiness to change behaviour ’ measured using a vali date d stroke specific score based on the transtheoretical model . Secondary outcomes were the Hospital Anxiety and Depression Scale , and self-reported alcohol consumption , smoking behaviour , exercise frequency , and fruit and vegetable consumption . Results : Analysis of the data for the 52 participants showed no statistical difference in the groups for the primary outcome of readiness to change behaviour . Statistically significant improvements for change in self-reported exercise were demonstrated ( P = 0.007 ) ; to 2—3 times per week in the intervention group compared to 0—1 times per week in the control group , and in fruit and vegetable consumption ( P = 0.033 ) ; to 10 portions of fruit and vegetables consumed per week in the intervention group compared to 1 or 2 portions a week for the control group . No evidence of a difference between groups was seen for alcohol consumption or Hospital Anxiety and Depression Scale . Conclusions : While no difference was demonstrated between the groups for readiness to change behaviour , a clinical ly significant effect in reported exercise behaviour and diet were demonstrated in the intervention group . This interesting finding indicates a dissonance between the behaviour scale and actual behaviour change , potentially indicating a lack of sensitivity of the scale to detect a change in this patient group Lowering blood pressure ( BP ) in stroke survivors reduces the risk of recurrent stroke . We tested the hypothesis that a nurse-led nonpharmacologic intervention would lower the BP of participants in an intervention group compared with a control group . A total of 349 patients who had sustained acute stroke or transient ischemic attack were r and omly assigned to either usual care or to 4 home visits by a nurse . During the visits , the nurse measured and recorded BP and provided individually tailored counseling on a healthy lifestyle . A total of 303 patients completed the 1-year follow up . No change in systolic BP was noted in either the intervention group or the control group . Because of an increase in diastolic BP in the control group ( P = .03 ) , a difference in mean diastolic BP between the 2 groups was found at follow-up ( P = .007 ) . Mean BP at follow-up was 139/82 mm Hg in the intervention group and 142/86 mm Hg in the control group . Linear regression analysis demonstrated that BP at the point of discharge was the strongest predictor of BP 1 year later ( P < .0001 ) . The proportion of patients on antihypertensive medication increased in the intervention group ( P = .002 ) . Patients were compliant with antihypertensive therapy , and 92 % of the hypertensive patients in the intervention group followed the advice to see a general practitioner ( GP ) for BP checkups . At follow-up , 187 patients ( 62 % ) were hypertensive , with no difference in the rate of hypertension seen between the groups . Our data indicate that home visits by nurses did not result in a lowering of BP . Patients complied with antihypertensive therapy and GP visits in the case of hypertension . Nonetheless , the majority of patients were hypertensive at the 1-year follow up Background : Lifestyle modification is associated with a substantially decreased risk of cardiovascular events . However , the role of lifestyle intervention for secondary prevention in patients with noncardioembolic ischemic stroke is inadequately defined . We assessed the hypothesis that lifestyle intervention can reduce the onset of new vascular events in patients with noncardioembolic mild ischemic stroke . Methods : We conducted an observer-blind r and omized controlled trial that enrolled 70 patients ( 48 men , mean age 63.5 years ) with acute noncardioembolic mild ischemic stroke . The patients were allocated in equal numbers to a lifestyle intervention group or a control group . We performed lifestyle interventions , which comprised exercise training , salt restriction and nutrition advice for 24 weeks . Then all patients were prospect ively followed up for occurrence of the primary endpoints , including hospitalization due to stroke recurrence and the onset of other vascular events . We also evaluated systolic blood pressure ( SBP ) at the clinic and at home , low-density lipoprotein cholesterol ( LDL-C ) , high-density lipoprotein cholesterol ( HDL-C ) , hemoglobin A1c ( HbA1c ) and high-sensitivity C-reactive protein ( hs-CRP ) to compare the efficacy of the lifestyle interventions . Results : This trial was terminated earlier than expected because of the prespecified early stopping rule for efficacy . After the 24-week intervention period , the intervention group showed a significant increase in daily physical activity and a significant decrease in salt intake ( physical activity , p = 0.012 ; salt intake , p < 0.001 ) , with a significant difference between the r and omized groups ( physical activity , p < 0.001 ; salt intake , p = 0.018 ) . Similarly , blood pressure was decreased and the HDL-C levels were increased in the intervention group ( SBP , p < 0.001 ; HDL-C , p = 0.018 ) , with significant differences between the r and omized groups ( SBP , p < 0.001 ; HDL-C , p = 0.022 ) . In contrast , LDL-C , HbA1c and hs-CRP tended to decrease in the intervention group , but this decrease did not achieve significance . After a median follow-up period of 2.9 years , 12 patients allocated to the control group and 1 patient in the lifestyle intervention group experienced at least 1 vascular event . A sequential plans analysis indicated the superiority of the lifestyle intervention in interim analysis . Kaplan-Meier survival curves after the log-rank test showed a significant prognostic difference between the r and omized groups ( p = 0.005 ) . Conclusions : Lifestyle intervention with appropriate medication is beneficial for reducing the incidence of new vascular events and improving vascular risk factors in patients with noncardioembolic mild ischemic stroke BACKGROUND AND PURPOSE Shared care initiatives , albeit commonly utilised in managing other chronic conditions have not been implemented in the area of stroke in Australia . The aims of this project were to adopt a shared care approach for stroke survivors comparing an experimental " shared-care " group with a " treatment-as-usual " control group in reference to the normalization or reversal of vascular risk factors and the detection and management of post-stroke depression . METHODS A r and omised controlled experimental research design was implemented with participants r and omized to an intervention or control group and followed over a 12-month period . The treatment group consisted of a r and omly selected group of patients  , discharged from an acute stroke unit and transferred into the shared care model . Risk factors for stroke and depression were compared between the two groups . RESULTS Of 97 patients originally included in the study , 17 dropped out . At 12 months , 80 patients remained for analysis ( 35 in the intervention group and 45 in the control group ) . The findings demonstrated positive trends for patients within the intervention group that were not found within the control group . The percentage of intervention patients reaching target systolic blood pressure ( sBP ) of 140 mmHg after 12 months tended to be greater than in the control group ( p=0.11 , NS ) . In the intervention group , at 12 months , the total cholesterol greater than 5.18 mmol/L was 12.5 % compared to 58.8 % at discharge . In contrast this trend was not so distinct in the control group ( 57.7 % to 42.9 % ) . The percentage of patients reaching target ( recommended ) total cholesterol of 5.18 mmol/L was significantly greater in the shared care patients intervention group relative to the control group ( p=0.02 ) . The average number of walks per week was also significantly greater in intervention group compared to the control group ( p=0.048 ) . Moreover , 45 % of the control group screened as depressed compared with 20 % of the intervention group at 12 months ( p=0.06 ) . CONCLUSIONS This study demonstrates that major risk factors for recurrent stroke and vascular disease in general are better managed with the shared care model than with usual post-discharge care . The significantly reduced depression as found on the screening PHQ9 at 12 months indicated that the intervention was beneficial not only in the detection of depression but also treatment BACKGROUND Patients with acute stroke often have a striking lack of knowledge of causes , warning signs , and risk factors . Lack of knowledge may lead to inappropriate secondary prevention behavior . We investigated the knowledge of patients with a TIA or minor stroke about specific aspects of their disease 3 months after the event . METHODS Patients with a TIA or minor stroke who participated in a r and omized controlled trial of the effect of health education by an individualized multimedia computer program ( IMCP ) were included . All patients received information about their disease from their treating neurologist and half of the patients received extra information through the IMCP . The patients ' knowledge was tested after 3 months by means of a question naire that contained items on pathogenesis , warning signs , vascular diseases , risk factors , lifestyle and treatment . The highest possible score was 71 points . RESULTS The 57 patients had a mean total score of 41.2 points ( SD 10.4 ) of the maximum 71 . Only 15 ( 26 % ) correctly identified the brain as the affected organ in stroke and TIA , and only 21 ( 37 % ) could give a correct description of a TIA or stroke . In contrast , 80 - 90 % of the patients identified hypertension and /or obesity as vascular risk factors . Knowledge of various treatment modalities of hypertension , hypercholesterolemia and obesity was moderate to high ( 40 - 91 % adequate responses ) . CONCLUSION The vast majority of patients with TIA or stroke lack specific knowledge about their disease , but they do have a reasonable knowledge of general vascular risk factors and treatment . This suggests that counseling by neurologists of patients with a TIA or stroke can be improved OBJECTIVE We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being . METHODS This was a r and omized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department . An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans . The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months . The intervention and usual care groups were compared using a global and closed hypothesis testing strategy . Outcomes fell into 5 domains : ( 1 ) neuromotor function , ( 2 ) institution time or death , ( 3 ) quality of life , ( 4 ) management of risk , and ( 5 ) stroke knowledge and lifestyle . RESULTS Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain , which showed a significant effect of the intervention ( P = .0003 ) . CONCLUSIONS Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population . The intervention did , however , fill a postdischarge knowledge gap The objective of this study was to conduct a r and omized , parallel-group clinical trial assessed the efficacy of a health-enhancing physical activity program ( exercise and education ) on vascular risk factors and aerobic fitness in patients who have experienced a transient ischemic attack ( TIA ) or nondisabling stroke . Sixty patients ( 69±11 years ) completed a baseline ( BL ) vascular risk stratification and aerobic fitness examination ( cycle test ) within 2 weeks of symptom onset . Subjects were then r and omized to either an 8-week , twice weekly exercise program or to a usual-care control ( CON ) group . Postintervention ( PI ) assessment s were completed immediately after the intervention and at 3-month follow-up . A series of primary ( systolic blood pressure [ SBP ] ) and secondary ( vascular risk factors like total cholesterol [ TC ] , high-density lipoproteins , etc . ; Framingham risk score ; peak oxygen uptake ) outcome measures were assessed . Significantly greater reductions in SBP ( mean change±SD ; -10.4±9.2 mm Hg ) and TC ( -.53±.90 mmol/L ) were observed between BL and PI assessment s for the exercise group compared with the CON group ( -1.9±15.4 mm Hg and -.08±.59 mmol/L , respectively ) ( P<.05 ) . These improvements were maintained between the PI and the 3-month follow-up assessment ( P>.05 ) . Significant improvements in aerobic fitness were also observed and maintained at the 3-month follow-up assessment after regular exercise participation ( P<.05 ) . The early engagement in exercise result ed in significant improvements in vascular risk factors and fitness in those diagnosed with TIA . As these beneficial effects were maintained up to 3 months after completing the exercise program , exercise should be considered a useful additive treatment strategy for newly diagnosed TIA patients . Future research should examine the long-term efficacy of such programs Abstract Goal : Evidence -based guidelines exist for the prevention and treatment of patients with cerebral ischemia . Despite these guidelines , there are gaps in clinical practice . Our study aim ed to determine if a physician-directed , nurse-case-management program could reduce individual patient vascular risk factors . Methods : Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke ( hypertension , tobacco use , dyslipidemia , diabetes ) were eligible to enroll in our study . Patients were r and omized to management by the nurse-prevention program or usual care .  Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year . Patients in the usual-care group underwent further follow-up by primary care and /or neurology as recommended during their hospitalization or outpatient visit . Patients assigned to the prevention group received individualized education , motivational interviewing , and were aided in setting up their risk-factor modification goal plan . Additional education was tailored to each patient based on individualized risk factors . Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist . The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year . Results : At 1-year post-hospitalization , patients in the nurse-care-management group were 42 % more likely to have met the primary endpoint ( n = 18 ; 61 % nurse-managed patients ) compared with 33 % ( n = 18 ) of patients undergoing usual care ( P = 0.09 ) . There was no significant reduction in minor risk factors for either patient group . Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels ( −38 vs −4 ; P = 0.0083 ) , changes in cardiovascular risk score ( −5.2 vs 1.3 ; P = 0.0033 ) , and had a greater reductions in systolic blood pressure ( −12.2 vs −0.105 ; P = 0.07 ) than their usual-care counterparts ( changes shown respectively ) . Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group ( 50 % ) vs 7 % , respectively ; P = 0.0070 ) and maintain an exercise program ( 83 % vs 33 % , respectively ; P = 0.0018 ) . Summary : A physician-directed , nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke . A larger trial is needed to verify trends noted in our study BACKGROUND Our aim was to investigate whether a nurse-coordinated multidisciplinary , family-based preventive cardiology programme could improve st and ards of preventive care in routine clinical practice . METHODS In a matched , cluster-r and omised , controlled trial in eight European countries , six pairs of hospitals and six pairs of general practice s were assigned to an intervention programme ( INT ) or usual care ( UC ) for patients with coronary heart disease or those at high risk of developing cardiovascular disease . The primary endpoints-measured at 1 year-were family-based lifestyle change ; management of blood pressure , lipids , and blood glucose to target concentrations ; and prescription of cardioprotective drugs . Analysis was by intention to treat . The trial is registered as IS RCT N 71715857 . FINDINGS 1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC , respectively . In patients with coronary heart disease who smoked in the month before the event , 136 ( 58 % ) in the INT and 154 ( 47 % ) in the UC groups did not smoke 1 year afterwards ( difference in change 10.4 % , 95 % CI -0.3 to 21.2 , p=0.06 ) . Reduced consumption of saturated fat ( 196 [ 55 % ] vs 168 [ 40 % ] ; 17.3 % , 6.4 to 28.2 , p=0.009 ) , and increased consumption of fruit and vegetables  ( 680 [ 72 % ] vs 349 [ 35 % ] ; 37.3 % , 18.1 to 56.5 , p=0.004 ) , and  oily fish  ( 156 [ 17 % ] vs 81 [ 8 % ] ; 8.9 % , 0.3 to 17.5 , p=0.04 ) at 1 year were greatest in the INT group . High-risk individuals and partners showed changes only for fruit and vegetables ( p=0.005 ) . Blood-pressure target of less than 140/90 mm Hg was attained by both coronary ( 615 [ 65 % ] vs 547 [ 55 % ] ; 10.4 % , 0.6 to 20.2 , p=0.04 ) and high-risk ( 586 [ 58 % ] vs 407 [ 41 % ] ; 16.9 % , 2.0 to 31.8 , p=0.03 ) patients in the INT groups . Achievement of total cholesterol of less than 5 mmol/L did not differ between groups , but in high-risk patients the difference in change from baseline to 1 year was 12.7 % ( 2.4 to 23.0 , p=0.02 ) in favour of INT . In the hospital group , prescriptions for statins  were higher in the INT group ( 810 [ 86 % ] vs 794 [ 80 % ] ; 6.0 % , -0.5 to 11.5 , p=0.04 ) . In general practice s in the intervention groups ,  angiotensin-converting enzyme inhibitors  ( 297 [ 29 % ] INT vs 196 [ 20 % ] UC ; 8.5 % , 1.8 to 15.2 , p=0.02 ) and  statins  ( 381 [ 37 % ] INT vs 232 [ 22 % ] UC ; 14.6 % , 2.5 to 26.7 , p=0.03 ) were more frequently prescribed . INTERPRETATION To achieve the potential for cardiovascular prevention , we need local preventive cardiology programmes adapted to individual countries , which are accessible by all hospitals and general practice s caring for coronary and high-risk patients SIR— Interventions with an educational or counselling component have been reported to be effective in a variety of patient groups to encourage smoking cessation [ 1 ] , lower blood pressure ( BP ) [ 2 , 3 ] , achieve modest reductions in cholesterol [ 4 ] , and promote weight loss [ 5 ] . Evaluation of the impact of education on physical outcomes is lacking in stroke disease , despite evidence that inadequate provision of information may adversely affect compliance with secondary prevention and psychosocial outcomes [ 6 ] . We describe a single-blind r and omised controlled trial of health education and counselling for patients with stroke or transient ischaemic attack ( TIA ) , and its effects on risk factors , satisfaction , mood and perceived health status
target: There was no significant difference in smoking continuance , or improved fruit and vegetable consumption .
  CONCLUSIONS There are benefits to be derived from multimodal secondary prevention interventions .
background: BACKGROUND Guidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke .
  We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions .