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Poster and platform presentations 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. 55