Multimodal Secondary Prevention Behavioral Interventions for TIA and Stroke: A Systematic Review and Meta-Analysis

Abstract

BackgroundGuidelines 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.StrategySearches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines.ResultsTwenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (−6.24 to −2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (−3.19 to −0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (−6.69 cm, −11.44 to −1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (−1.20, −1.77 to −0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I2 = 0%, 4,053 participants).ConclusionsThere are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required.Review RegistrationPROSPERO CRD42012002538.

Long-Term Effect of Participation in an Early Exercise and Education Program on Clinical Outcomes and Cost Implications, in Patients with TIA and Minor, Non-Disabling Stroke

“…Encouraging trends were also evident when assessing the frequency of minor stroke and recurrent TIAs (Table 1 & 2); an interesting finding when considering that previous research has demonstrated high rates of TIA following an initial stroke/TIA episode [8,9]. The findings from the present study are in contrast to a recent meta-analysis which demonstrated no difference in the odds of stroke/TIA reoccurrence when patients engaged in a lifestyle management intervention compared to receiving usual care [14].…”

“…The meta-analysis by Lawrence and colleagues [14] has previously shown no significant differences in the odds of death between those partaking in lifestyle management interventions compared to those randomized to a usual care control group. The small number of studies investigated (n = 4), the different lifestyle management interventions employed, and the varying population groups assessed, may be an underpinning reason for this finding.…”

“…Current guidelines for stroke/TIA recommend multifaceted interventions to aid in preventing recurrent events [13][14][15]. In this regard, short-term exercise and education programs, administered within 2 weeks of TIA or minor stroke diagnosis, have shown to be beneficial in improving systolic blood pressure (≤ 13 mmHg), diastolic blood pressure (≤ 7 mmHg), and blood lipid profile (~0.5 mmol/L for total cholesterol) [16][17][18].…”

“…However, there is a paucity of research investigating long-term clinical outcome measures, such as hospital readmission, surgical intervention and recurrent events [14]. A recent study with patients with noncardioembolic mild ischemic stroke demonstrated that individuals who engaged in a 6 month exercise training, salt restriction and nutrition advice program experienced fewer recurrent vascular events than those in a control group, over a median period of 2.9 years [18].…”

Nationwide Impact of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines on Stroke Survivors

“…The finding that less than one third of stroke survivors have normal BP, according to the new guidelines, is expected to trigger earlier pharmacological interventions (for SBP/DBP >130/90 mm Hg) and lifestyle modifications among stroke survivors. Lifestyle modifications to prevent cardiovascular events in stroke survivors have been well summarized in 3 recent meta‐analyses 16, 17, 18. One of the main findings from these meta‐analyses is a 1.34– to 4.21–mm Hg reduction in SBP with lifestyle changes.…”