Last year saw some significant updates to the National Clinical Guideline for Stroke, both in terms of acute management and post-stroke care. The overarching theme was more! More attention to interventions to help prevent stroke, more patients receiving life-saving treatment and more rehabilitation. While we all strive to improve patient outcomes, achieving more is incredibly difficult without more time and resources. Here we discuss the key updates to the National Stroke Guideline and how we can begin to fulfil these aspirations in an increasingly constrained NHS.
The single factor that has the biggest influence on stroke outcomes is direct admission to a specialist Stroke Unit, necessitating early recognition and pre-hospital triage. Nine ambulance providers currently engage in pre-hospital video triage, helping to identify strokes before they have reached the hospital front door.
Early recognition of stroke will invariably have implications on treatment, with the potential for clot-busting (thrombolysis) and clot retrieving (mechanical thrombectomy) in acute ischaemic stroke if patients fall within the therapeutic window - onset within 4.5 hours for thrombolysis and 6 hours for mechanical thrombectomy. Rates of thrombolysis have remained relatively stagnant between 10-12% from 2019-2023, improvements in system efficiency should help increase the number of patients eligible for this treatment.
Some of the patients that receive thrombolysis to dissolve a clot in the brain do not benefit from the treatment because the clot is too large. For this subset of patients, the evidence suggests that retrieval of the clot, referred to as mechanical thrombectomy is an effective treatment that can reduce brain damage. This is a procedure that requires skilled physicians and the infrastructure to support them (facilities, personnel and equipment). The resource-intensive nature of thrombectomy may explain why only 3% of patients receive this treatment and two thirds of eligible patients miss out. Increasing rates of mechanical thrombectomy was the focus of the Stroke Association’s Saving Brains campaign last year.
Last year stroke survivors averaged just 22.5 minutes of therapy per day
Continuing with the theme of more, the recommendations for therapy have doubled: the minimum intensity of rehabilitation after stroke should be 3 hours per day at least 5 days per week. Even just as an aspiration, this is huge progress. The problem is closing the gap between clinical targets and the service provision: last year, stroke survivors received an average of 22.5 minutes of therapy per day - this is both physiotherapy and occupational therapy combined.
Rewire is committed to solving this problem and while we firmly believe software must be a part of the solution, it is not the only approach. Dr Andy Kerr’s team at The University of Strathclyde are trialing gyms fitted with sophisticated hardware that makes rehabilitation fun and engaging. Click here to find out more.
20,000 strokes every year are recurrent cerebrovascular events. This group of patients represent an opportunity to avoid a potentially fatal event, be that a stroke or a heart attack. Both share the same risk factors, one of which is hypertension. The guideline has been updated with a lower target home blood pressure of 125/75mmHg.
Research demonstrates that home monitoring leads to a better reduction in blood pressure than being led by your GP practice. If you’ve had a stroke, get your hands on a blood pressure monitor, take a week’s worth of readings twice daily (at rest) then get on the phone to your GP to determine whether your treatment is optimised.
The target for bad cholesterol has also been lowered (non-HDL cholesterol should be lower than 2.5mmol/L) with new therapies to achieve this. There is an increased role for ezetimibe as an add-on therapy if bad cholesterol remains high. There are also injectable therapies that can be used to help manage high cholesterol. Medication to lower blood pressure and cholesterol is the easy part, unfortunately there have not been any major breakthroughs when it comes to leading a healthier lifestyle. The same old stuff applies: eat well and exercise. If you wish to make lasting change, find yourself a friend who will make the same commitment. Please reach out to us for help or resources to support lifestyle modification.
If you are a stroke survivor reading this then you should be reassured that the healthcare system is committed to improving care and outcomes. As a clinician reading this, your excitement may be tempered by a healthy dose of scepticism as to how these targets can be achieved. We believe the first step is education and, unsurprisingly, we are convinced that technology has to be part of the solution. We're working on both and we assure you, it won't be more of the same.