Stroke Prevention Programme

Aim: to provide an evidence base to inform optimal stroke prevention in primary care with regard to both blood pressure and cholesterol lowering and to develop tools to support implementation by both users and health care professionals.Objectives: to address the following:1. Is it more cost-effective to titrate treatments to target levels of cholesterol and blood pressure, or to use fixed doses of statins and blood pressure lowering agents (polypill strategy)2. Will tele-monitoring and self management improve blood pressure control in people on treatment for hypertension and in people with a history of stroke or TIA?3. Will setting intensive blood pressure lowering targets for people with a history of stroke and TIA in primary care lead to reduced risk of major vascular events?Background: There have been important advances in stroke prevention, with the demonstration of the value of cholesterol and blood pressure lowering. However many patients are not being treated as intensively as guidelines recommend. Most stroke prevention is carried out in primary care, but the evidence base, particularly for secondary prevention, is derived from populations unrepresentative of primary care. Therefore there is a need both to develop mechanisms to enhance guideline implementation, and for research to clarify whether specific strategies for achieving lower BP and cholesterol are effective and cost-effective.Research Plans: Research question 1.A series of studies (all with important outputs) will lead to the development of an RCT. Firstly, a prevalence survey of a representative sample of practices in MidReC/PCRN using electronic practice data will identify the proportions of the primary care population that fall into different categories of cardiovascular risk. This will be followed by a screening study in which people of indeterminate risk in the first study will be invited to attend the practice to have their cardiovascular risk determined. The third study will use a qualitative design to elicit patient and practitioner attitudes towards treatment with a polypill as compared to treatment to target. The fourth will construct a mathematical model explore the potential impact of using a polypill strategy in different categories of cardiovascular risk as compared to a) current practice; b) full implementation of current guidelines. Results will inform the design of a pilot randomised controlled trial to test the a polypill strategy against treatment to target for cholesterol and blood pressure levels. We will then proceed to a clinical trial powered on the intermediate outcomes of change in blood pressure and change in low density lipoprotein (LDL) cholesterol.Research question 2.Comprises two RCTs, both with qualitative and health economic components. The first compares usual hypertension care with self management of hypertension and telemonitoring (already funded by DH policy Research Programme). The second will develop and test the self management intervention in people who have had a stroke or TIA. Pilot work will be undertaken to find the most appropriate method of telemonitoring in this population (modem or mobile phone solution). Then, we will carry out a RCT in patients with a history of stroke or TIA recruited from general practice. Primary outcome will be change in mean systolic blood pressure between baseline and twelve months.Research question 3.A two phase RCT. The first question to be answered is can intensive targets be achieved in people with a history of stroke or TIA in primary care? Secondly, what is the effect of intensive targets on morbidity and mortality? Shortlisted by HTA Trials Programme, no funding requested from NIHR.Service development work: Tools to support optimal implementation of guidelines for primary and secondary prevention of stroke in primary care, including decision support tools, training programmes, a 'before and after' study of uptake of secondary prevention, methods to optimally involved patients