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113
THE TEES STROKE REGISTER: THE VALUE
SOURCES OF CASE ASCERTAINMENT
OF MULTIPLE
A CANI 1 •2, H RODCERS1'2, R D O B S O N U , J MURPHY 3 , B HERD4,
O JAMES1 and R THOMSON 2
114
CHANGES IN SERUM
OUTCOME IN STROKE
ALBUMIN
CONCENTRATION
AND
JREID
Manor Hospital, Walsall
Departments of 'Medicine (Geriatrics) and 2Epidemiology and
Public Health, University of Newcastle, 3 Darlington Memorial
Hospital; 4 North Tees General Hospital
Introduction
The value of a stroke register as a means of assessing incidence
depends upon the reliability and completeness of case
ascertainment. We report upon the value of a number of
overlapping primary and secondary notification sources used for a
population based stroke register.
Method
We aimed to identify all cases of incident stroke occurring in
residents in Darlington and North Tees districts (population
303,000) 01.01.96-31.12.96. The primary sources were on call
doctors and ward nurses; general practitioners; and community and
nursing home staff. Secondary sources included CT scan lists, GP
registers, hospital discharge data (HDD), district health authority out
of area hospitalisation data and death certificate lists.
Results
The table shows sources of notification.
Source
Doctor
Nurse
GP
Other Doc
CT
GPReg
HDD
DHA
DHA Death
Other
Notifications
(n-2915)
458
335
151
60
619
402
338
77
299
176
Confirmed
stroke
nCW
327(71)
230 (69)
113(75)
53 (88)
371 (60)
266 (66)
277 (82)
22 (29)
222 (74)
133(76)
1st notification
of stroke
n(%)
Only source of
notification
n
311 (30)
135(17)
64(8)
39(5)
36(5)
51 (6)
9(91)
16(92)
42(5)
95(12)
28
15
29
12
29
32
4
16
37
35
Conclusion
Numerous sources of case ascertainment are required for a
population based stroke register. GP computerised records and
registers are an invaluable secondary source for identifying patients
who are not admitted to hospital. Although CT scan yields are low,
they provide an important source of "missed" cases.
Introduction
Stroke is associated with a decline in nutritional state (Smithard et a/
1995, Age Ageing 24 supp.1:6). Serum albumin is a marker of
nutritional status, although it is also affected by illness. This study
tested the hypothesis that poor outcome in stroke would be
associated with a greater fall in albumin in the first two weeks.
Methods
52 inpatients with acute stroke were assessed within 72 hours of
admission from home and again 14 days after the initial assessment.
No patient had been admitted from institutional care and none had
proteinuria, transfusion, or significant bleeding. Blood was taken for
serum albumin and haematocnt. Discharge destination (censored at
90 days) was used as the outcome measure and was categorised as
either adequate (discharge to own home) or poor (death or
institutionalisation).
Results
Mean + s.d.
n
nitial albumin
Fall in albumin
Discharge
home
Poor outcome
Significance
26
26
N .S
42.9 + 4.0
41.5 + 4.2
2.27 ±
5.69 ± 4.36
P _ 0.0032
17 patients were dysphagic at initial assessment. Day 14 albumin
was significantly lower in these patients (35.1 + 3.2 vs 39.7 + 4.8,
p<0.005). Only 4 patients were tube fed.
Conclusions
Decline in serum albumin is strongly associated with poor outcome
in stroke. This may be due to nutritional factors, although causality
cannot be inferred.
115
EXTENDING THE THERAPEUTIC WINDOW OF STROKE?
INSIGHTS FROM MULTt-MODAL MAGNETIC RESONANCE
IMAGING (MRI)
S ALLDER, A MOODY, J GLADMAN and G LENNOX
University Department of Clinical Neurology, Queen's Medical
Centre, Nottingham
Introduction
A drawback to treatment of acute stroke is the short therapeutic time
window. Using the novel technique Multi-modal MRI (a
combination of Diffusion Weighted, Perfusion, MR Angiography)
the assumptions regarding this window can be examined.
54
Stroke
Methods
We present four patients who presented with a Total Anterior
Circulation Syndrome. These patients were followed clinically and
had multi-modal MRI scanning on admission and days 2, 4 and 7.
ANnTHROMBOnC PRESCRIBING FOR ATRIAL
FIBRILLATION IN A PRIMARY CARE SETTING
| | 7
A.HENDRY', P. CRAWFORD1, A.POTTER2, AND A. WILDING1
Department of Geriatric Medicine, Gartnavel General Hospital1 and
Clydcbank Health Centre 2, Glasgow
Results
On admission all patients had similar National Institute of Health
scores (mean — 17>. One had scan appearances of a complete
infarct on admission and made little recovery. The other three had
no
initial
infarct,
but
had
perfusion
deficits.
One
of
these
spontaneously recovered clinically without developing infarction. In
the other two, infarcts developed within the perfusion deficit - in one
INTRODUCTION
Recent ludil of anticoagulation for atria] fibrillation (AF) in primary care has
raised issues of comorbidity, safety and access for monitoring of anticoagulation Following the audit we reassessed antithrombotic prescribing and
identified the potential to optimise this in the current service or with the
provision of an outreach model improving access.
case in a step-wise manner over the seven days, and in the other
case very late between days 4 and 7.
Conclusion
These surprising findings, which are clinically undetectable, yet
eloquently
demonstrated
using this technique,
reveal
that
the
therapeutic time window may be several days in some patients.
Methods
The study was conducted in an urban health centre general practice of 9935
palicnu. G.P. and hospital case records were reviewed for 92 patients with
confirmed AF. 83% paticnls had an Echocardiognm. Cardioemboltc risk was
defined as HIGH (clinical rifk factors) +/- echo risk factors), HIGH - age
alone (>75 years and no clinical or echo factors) or LOW (<75 yean + no
clinical or echo factors) Patients at higher risk without contraindication! to
anticoagulation and not already on Warfarin were invited for assessment.
Results
ATRIAL FIBRILLATION AND STROKE RISK : ASSESSMENT
IN PRIMARY CARE
| | 6
P. CRAWFORD', A.HENDRY'- A.POTTER 2 , AND A. WILDING 2
Department of Geriatric Medicine, Gartnavel General Hospital' and
Clydcbank Health Centre 2 , Glasgow
Introduction
Recent studies have stratified cardioembolic risk for patients with atrial
fibrillation (AF). Anticoagulation should be directed at those with high
cardioembolic risk (age over 75 years and/or clinical risk factors (hypertension, diabetes, TIA/strokc, arterial embolism, heart failure) and/or Echo
factors (enlarged left atrium and/or left ventricular dysfunction)]. We
considered whether risk assessment is feasible in primary care.
Methods
The study was conducted in an urban health centre general practice with
9935 patients. Using G.P. and hospital case records patients with
documented AF were profiled in terms of clinical and echocardiograptuc
risk factors
Results
AF was confirmed in 92 (47 male) patients mean age 73 (46-90) years
(prevalence 0.9%). Prevalence increased with age to 6.6% in those over 75
years. 76(83%) patients had echocardiography. Clinical risk (actors were
common:- hypertension 38(41%); heart failure 38(41%); TLA/stroke
17(18.5%); diabetes 7(8%); arterial embolism 3(3%). Comorbidity
increased with age. 14 patients (15%) had rheumatic heart disease. Of the
78 patients with non-rheumatic AF 18 had no clinical risk factors. 8 of
these patients were aged over 75 and therefore already at increased
cardioembolic risk. The remaining 10 patients (11%) were apparently low
risk but echo further defined their risk assessment: 6 had a normal echo
confirming their low risk but 4 had abnormalities conferring a high risk.
Risk assessment using clinical factors and age alone identified 82/86(95%)
patients at high cardioembolic risk. Combining age, clinical risk factors and
echo 86/92(93%) patients were identified as high risk and 6/92(7%) as low
risk.
Conclusion
Information from echo further defined the risk assessment in only 11% of
patients Simple risk assessment using age and clinical comorbidity
identified the majority of patients at high cardioembolic risk and is feasible
in a primary care setting.
Risk status was LOW 6 paUcnts (6%); HIGH - age alone 7(8%); HIGH 79
(86%). Contraindications to Warfarin were present in 32/92 (35%) patients
mainly due to dcmcntia/alcohol/compliancc (10); access (9); GI symptoms (6).
bleeding on Warfarin (3), vision (2); falls (I) and pericardia! effusion (1)
Three LOW risk patients had been prescribed Aspirin (2) or Warfarin (I)
Aspirin was appropriate for all six patients. Of 7 patients with HIGH - age
alone risk , 5 received Aspirin (4) or Warfarin (I) The six patient! not
prescribed Warfarin had a contraindication to anticoagulation but potential for
Aspirin. The 79 HIGH risk patient* were prescribed Warfarin (44), Aspinn
(25), Aspirin/Dipyridamole (1), Aspirin/ Warfarin (I) or no antithrombouc
(8). Of the 34 HIGH risk patients not prescribed Warfarin, 16 had • definite
contraindication to anlicoagulalion, 9 were clearly appropriate for Warfarin
and a further 9 could be anticoagulated within a more accessible service
Conclusion
20% of patients with AF and HIGH cardioembolic risk had no absolute contraindication (o Warfarin but were not anticoagulated. Half of these patients
could be anticoagulated in the current system and the othen could be
anticoagulated if a more accessible service was available
118
PATIENT KNOWLEDGE ABOUT THE USE A N D SIDE-EFFECTS OF
WARFARIN FOR STROKE PREVENTION IN ATRIAL FIBRILATION
D L LEUNG, K M A H M O U D and R LODWICK
Department of Elderly Care, The Royal Wolverhampton Hospitals
NHS Trust, West Midlands
Introduction
The use of warfarin for prophylaxis against stroke in elderly patients
with atrial fibrillation (AF) is becoming more common. Decisions
regarding lifelong anticoagulation must be balanced against the
potential side effects of over anticoagulation. We have examined the
basic knowledge about warfarin therapy in such a group of patients.
Methodology
48 patients taking warfarin for atrial fibrillation and attending our
anticoagulation clinic, volunteered to take part in our questionnaire.
All questions were asked verbally by the same doctor.
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