title: Nurse-Led, Telephone-Based, Secondary Preventive Follow-Up after Stroke or Transient Ischemic Attack Improves Blood Pressure and LDL Cholesterol: Results from the First 12 Months of the Randomized, Controlled NAILED Stroke Risk Factor Trial Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial Structured Nursing Intervention Versus Routine Rehabilitation After Stroke Secondary prevention and health promotion after stroke: can it be enhanced? Recurrent stroke and cardiac risks after first ischemic stroke Specific antismoking advice after stroke. Blood pressure 1 year after stroke: the need to optimize secondary prevention. A randomized trial testing the superiority of a postdischarge care management model for stroke survivors. Effectiveness of Goal-Setting Telephone Follow-Up on Health Behaviors of Patients with Ischemic Stroke: A Randomized Controlled Trial. Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II). Utility of a Post-Hospitalization Stroke Prevention Program Managed by Nurses The impact of stroke nurse specialist input on risk factor modification: a randomised controlled trial.
abstract: Background Enhanced secondary preventive follow-up after stroke or transient ischemic attack ( TIA ) is necessary for improved adherence to recommendations regarding blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels . We investigated whether nurse-led , telephone-based follow-up was more efficient than usual care at improving BP and LDL-C levels at 12 months after hospital discharge . Methods We r and omized 537 patients to either nurse-led , telephone-based follow-up ( intervention ) or usual care ( control ) .  BP and LDL-C measurements were performed at 1 month ( baseline ) and 12 months post-discharge . Intervention group patients who did not meet target values at baseline received additional follow-up , including titration of medication and lifestyle counselling , to reach treatment goals ( BP < 140/90 mmHg , LDL-C < 2.5 mmol/L ) . Results At 12 months , mean systolic BP , diastolic BP and LDL-C was 3.3 ( 95 % CI 0.3 to 6.3 ) mmHg , 2.3 mmHg ( 95 % CI 0.5 to 4.2 ) and 0.3 mmol/L ( 95 % CI 0.1 to 0.4 ) lower in the intervention group compared to controls . Among participants with values above the treatment goal at baseline , the difference in systolic BP and LDL-C was more pronounced ( 8.0 mmHg , 95 % CI 4.0 to 12.1 , and 0.6 mmol/L , 95 % CI 0.4 to 0.9 ) . A larger proportion of the intervention group reached the treatment goal for systolic BP ( 68.5 vs. 56.8 % , p = 0.008 ) and LDL-C ( 69.7 % vs. 50.4 % , p < 0.001 ) . Conclusions Nurse-led , telephone-based secondary preventive follow-up , including medication adjustment , was significantly more efficient than usual care at improving BP and LDL-C levels by 12 months post-discharge . Trial Registration IS RCT N Registry IS RCT BACKGROUND AND PURPOSE Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack . The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined . METHODS This was a prospect i ve , multicentre , cluster-r and omized controlled trial with blinded assessment of outcomes and intention-to-treat analysis . Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals . General practice s treating recruited patients were r and omized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care . The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months . RESULTS From January 2010 to November 2013 , 156 general practice s ( 280 patients ) were r and omly assigned to usual care ( control ) and 159 ( 283 patients ) to the intervention . The median age was 70.1 years ; 65 % were male . Overall , > 80 % of participants were prescribed recommended secondary prevention therapies at baseline . The primary efficacy analysis comprised 533 participants , with 30 either dying or lost to follow-up . In adjusted analyses , no significant between-group difference was found in the cardiovascular risk score at 12 months ( 0.04 , 95 % confidence interval -1.7 , 1.8 ) . CONCLUSIONS The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practice Nir Z , Zolotogorsky Z , Sugarman H : Structured nursing intervention versus routine rehabilitation after stroke . Am J Phys Med Rehabil 2004;83:522–529 . Objective : The goal of this study was to examine the effect of a structured , comprehensive nursing intervention on the course of rehabilitation over the first 6 mos after a first-ever stroke . Design : Intervention ( experimental ) study . The participants were 155 elderly stroke survivors who were admitted to a geriatric rehabilitation department . Stratified r and om sampling generated intervention and control groups . The intervention was design ed to work together with the routine rehabilitation program and consisted of 12 consecutive weekly meetings . The control group received only the routine rehabilitation program . Study variables were measured at entry to study and after 3- and 6-mo intervals . Results : Although there were no significant differences between the two groups at entry to study , at 3 and 6 mos after stroke , the intervention group showed better scores than the control group in functional status ( FIM ™ instrument ) , depression ( Geriatric Depression Scale ) , self-perceived health , self-esteem , and dietary adherence . Conclusion : The nursing intervention had both short- and long-term effects on functional , psychological , and emotional variables . Serious consideration should be given to implementing comprehensive nursing interventions during rehabilitation tailored to meet the specific needs of stroke survivors and their caregivers The aim was to study if health outcome and secondary prevention were satisfactory 1 year after stroke and if nurse-led interventions 3 months after stroke could have impact . Design was a r and omized controlled open trial in a 1-year population . Primary outcome was health status 1 year after stroke . One month after stroke , survivors were r and omized into  intervention group ( IG ) with follow-up by a specialist nurse ( SN ) after 3 months ( n = 232 ) , and control group ( CG ) with st and ard care ( n = 227 ) , all to be followed up 1 year after stroke . At the first follow-up , patients grade d their health , replied to the EuroQol-5 Dimensions ( EQ-5D ) health outcome questions , health problems were assessed , and supportive counseling was provided in the IG . Health problems requiring medical interventions were primarily referred to a general practitioner ( GP ) . One year after stroke , 391 survivors were followed up . Systolic blood pressure ( BP ) had decreased in IG ( n = 194 ) from median 140 to 135 ( P = .05 ) , but about half were above the limit 139 in both groups . A larger proportion ( 22 % ) had systolic BP > 155 in the CG ( n = 197 ) than in the IG ( 14 % ; P = .05 ) . In the IG , 62 % needed referrals compared with the 75 % in the CG ( P = .009 ) . Forty percent in the IG and 52.5 % in the CG ( P = .04 ) reported anxiety/depression . In the IG , 75 % and 67 % in the CG rated their general health as fairly good or very good ( P = .05 ) . Although nurse-led interventions could have some effect , the results were not optimal . A more powerful strategy could be closer collaboration between the SN and a stroke clinician , before referring to primary care Background : Few population -based studies with long-term follow-up have compared risk of recurrent stroke and cardiac events after first ischemic stroke . The relative risk of these two outcomes may inform treatment decisions . Methods : In the population -based Northern Manhattan Study , first ischemic stroke patients age 40 or older were prospect ively followed for recurrent stroke , myocardial infa rct ion ( MI ) , and cause-specific mortality . Fatal cardiac events were defined as death secondary to MI , congestive heart failure , sudden death/arrhythmia , and cardiopulmonary arrest . Risk of events ( with 95 % CIs ) was calculated using Kaplan – Meier survival analysis and adjusted for sex and age using Cox proportional hazard models . Results : Mean age ( n = 655 ; median follow-up 4.0 years ) was 69.7 ± 12.7 years .  The risk of recurrent stroke was more than twice that of cardiac events ( including nonfatal MI ) at 30 days and approximately twice cardiac risk at 5 years . The age- and sex-adjusted 5-year risk of fatal or nonfatal recurrent stroke was 18.3 % ( 14.8 to 21.7 % ) , and the 5-year risk of MI or fatal cardiac event was 8.6 % ( 6.0 to 11.2 % ) . The adjusted 5-year risk of nonfatal stroke ( 14.8 % , 11.6 to 17.9 % ) was approximately twice as high as fatal cardiac events ( 6.4 % , 4.1 to 8.6 % ) and four times higher than risk of fatal stroke ( 3.7 % , 2.1 to 5.4 % ) . Conclusions : Cardiac mortality is nearly twice as high as mortality owing to recurrent stroke , but long-term risk of all stroke , fatal or nonfatal , is approximately twice the risk of all cardiac events . The high risk of nonfatal recurrent stroke reinforces the importance of therapies aim ed at preventing stroke recurrence in addition to preventing cardiac events INTRODUCTION Many stroke survivors would benefit from modification of their lifestyle in order to reduce their risk of recurrent stroke . We investigated if tailored smoking cessation advice would yield a higher smoking cessation rate and a higher rate with sustained abstinence in  ex-smokers in the intervention group than among controls . MATERIAL AND METHODS Patients admitted with an acute stroke or a transient ischaemic attack were included in a r and omised controlled trial focusing on control of lifestyle risk factors and hypertension . Here , we report the intervention focused on  smoking cessation .  We used multiple logistic regression analysis to identify patient characteristics associated with smoking cessation . Analyses were by intention to treat excluding those who died or suffered severe disease . RESULTS We included 254 patients with a history of smoking . Two years after inclusion , 15 of 57 ( 26 % ) baseline smokers in the intervention group had stopped smoking versus eight of 56 ( 14 % ) among controls ( p = 0.112 ) . Living with a partner ( p = 0.012 ) , having at least ten years of education ( p = 0.012 ) , and not being exposed to smoking at home ( p = 0.036 ) were independent predictors of smoking cessation . CONCLUSION We did not achieve our aim of higher smoking cessation rates in the intervention group . Future smoking cessation interventions should be more intensive , focus on patients ' social circumstances and , if possible , involve patients ' relatives . FUNDING This study was supported by the Ludvig and Sara Elsass Foundation , the Lundbeck Foundation and The Danish Heart Foundation ( Grant 07 - 4-B703-A1378 - 22384F ) . TRIAL REGISTRATION This protocol is registered with Clinical Trials.gov ( NCT 00253097 ) 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 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 BACKGROUND Adopting healthy behaviors is critical for secondary stroke prevention , but many patients fail to follow national guidelines regarding diet , exercise , and abstinence from risk factors . Compliance often decreases with time after hospital discharge , yet few studies have examined programs promoting long-term adherence to health behaviors . Goal setting and telephone follow-up have been proven to be effective in other areas of medicine , so this study evaluated the effectiveness of a guideline -based , goal - setting telephone follow-up program for patients with ischemic stroke . METHODS This was a multicenter , assessor-blinded , parallel-group , r and omized controlled trial . Ninety-one stroke patients were r and omized to either a control group or an intervention group . Intervention consisted of predischarge education and 3 goal - setting follow-up sessions conducted by phone . Data were collected at baseline and during the third and sixth months after hospital discharge . RESULTS Six months after discharge , patients in the intervention group exhibited significantly higher medication adherence than patients in the control group . There were no statistically significant differences in physical activity , nutrition , low-salt diet adherence , blood pressure monitoring , smoking abstinence , unhealthy use of alcohol , and modified Rankin Scale ( mRS ) scores between the 2 groups . CONCLUSIONS Goal - setting telephone follow-up intervention for ischemic stroke patients is feasible and leads to improved medication adherence . However , the lack of group differences in other health behavior subcategories and in themRS score indicates a need for more effective intervention strategies to help patients reach guideline -recommended targets BACKGROUND Reduction of blood pressure ( BP )  after stroke or TIA decreases stroke recurrence and is a major goal of secondary Stroke Prevention Clinics ( SPCs ) . Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication . METHODS This multicentred , r and omized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits ( e.g. , lack of confidence in the utility of medications , poor memory , mild cognitive impairment ) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program ( monthly telephone calls , motivational interviewingfor lifestyle change , plus home BP monitoring and use ofdosettes for medication administration ) would improve BP measures and adherence to medications . RESULTS Both  intervention ( n=29 ) and usual care  groups ( n=27 ) showed a trend-for'reduced BP at six months ( Median ql-q3 , Systolic BR p=0.46 ; Diastolic BR p=0.37 ) . Diabetic patients , irrespective of the group to which they were r and omized , were less likely to meet Best Practice Guideline targets than those without diabetes ( Chi Square test , p=0.0001 ) . CONCLUSION Stroke and TIA patients with diabetes may require additional re sources and support in order to reach BP target values 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 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: Conclusion : We found that interventions in which nurses had a primary role were effective on improving medical and behavioral risk factors , as well as knowledge of risk factors as part of secondary prevention of stroke
background: Background and purpose : Among members of the health care team , nurses play a large role in actively engaging stroke survivors in secondary stroke prevention programs .
  This systematic review and meta- analysis examines the effectiveness of interventions in which nurses have a primary role on modification of risk factors among stroke survivors .