Cognitive function is an important component of aging and predicts quality of life, functional independence, and risk of institutionalization. Advances in our understanding of the role of ...cardiovascular risks have shown them to be closely associated with cognitive impairment and dementia. Because many cardiovascular risks are modifiable, it may be possible to maintain brain health and to prevent dementia in later life. The purpose of this American Heart Association (AHA)/American Stroke Association presidential advisory is to provide an initial definition of optimal brain health in adults and guidance on how to maintain brain health. We identify metrics to define optimal brain health in adults based on inclusion of factors that could be measured, monitored, and modified. From these practical considerations, we identified 7 metrics to define optimal brain health in adults that originated from AHA’s Life’s Simple 74 ideal health behaviors (nonsmoking, physical activity at goal levels, healthy diet consistent with current guideline levels, and body mass index <25 kg/m) and 3 ideal health factors (untreated blood pressure <120/<80 mm Hg, untreated total cholesterol <200 mg/dL, and fasting blood glucose <100 mg/dL). In addition, in relation to maintenance of cognitive health, we recommend following previously published guidance from the AHA/American Stroke Association, Institute of Medicine, and Alzheimer’s Association that incorporates control of cardiovascular risks and suggest social engagement and other related strategies. We define optimal brain health but recognize that the truly ideal circumstance may be uncommon because there is a continuum of brain health as demonstrated by AHA’s Life’s Simple 7. Therefore, there is opportunity to improve brain health through primordial prevention and other interventions. Furthermore, although cardiovascular risks align well with brain health, we acknowledge that other factors differing from those related to cardiovascular health may drive cognitive health. Defining optimal brain health in adults and its maintenance is consistent with the AHA’s Strategic Impact Goal to improve cardiovascular health of all Americans by 20% and to reduce deaths resulting from cardiovascular disease and stroke by 20% by the year 2020. This work in defining optimal brain health in adults serves to provide the AHA/American Stroke Association with a foundation for a new strategic direction going forward in cardiovascular health promotion and disease prevention.
Abstract only Introduction: The consent process for stroke therapies is limited by the hectic nature of the emergency environment, limited understanding by the patient and family, and ...time-sensitivity of the event. Patients are often unable to consent, placing the burden on surrogates to infer treatment wishes. Given time-based thrombolytic options, understanding true patient preferences is of paramount importance. We have piloted in a single center (UCSD) study the “Coordinating Options for Acute Stroke Therapy” (COAST) Advanced Directive form to assess and document patient treatment preferences prior to the time of acute stroke presentation. Methods: The COAST initiative was piloted at a large comprehensive stroke center (UCSD), with deployment including electronic medical record (EMR) integration and provider training. COAST has since been initiated at a second comprehensive stroke center (Stanford), with ongoing expansion into the NIH StrokeNet under a central IRB. In collaboration with the AHA, educational materials are being created to supplement the COAST form and improve the process for a potential larger national deployment. Results: Patients with a history of stroke, or those at high risk, complete COAST prior to hospital discharge or at clinic visits. The EMR has proven crucial to the deployment and tracking of COAST patients. In a plan to disseminate it “COAST to COAST”, participating StrokeNet centers are deploying the initiative, and collecting data for analysis. A preliminary report on the patients who have completed a COAST form, the optimal location for recruitment, and data on recurrent events, will be provided at the International Stroke Conference. Conclusions: The COAST advanced directive is a much needed innovation which will make stroke care more efficient, optimize patient autonomy, improve healthcare quality, and streamline the ethical management of complex care decisions in acute stroke. The inherent benefit of COAST is in providing patients and their families with more information regarding stroke and its treatment options, allowing them to take a more active role in their care.
OBJECTIVE To develop recommendations for the establishment and operation of primary
stroke centers as an approach to improve the medical care of patients with
stroke. PARTICIPANTS Members of the ...Brain Attack Coalition (BAC), a multidisciplinary group
of representatives from major professional organizations involved with delivering
stroke care. Supplemental input was obtained from other experts involved in
acute stroke care. EVIDENCE A review of literature published from 1966 to March 2000 was performed
using MEDLINE. More than 600 English-language articles that had evidence from
randomized clinical trials, meta-analyses, care guidelines, or other appropriate
methods supporting specific care recommendations for patients with acute stroke
that could be incorporated into a stroke center model were selected. CONSENSUS PROCESS Articles were reviewed initially by 1 author (M.J.A.). Members of the
BAC reviewed each recommendation in the context of current practice parameters,
with special attention to improving the delivery of care to patients with
acute stroke, cost-effectiveness, and logistical issues related to the establishment
of primary stroke centers. Consensus was reached among all BAC participants
before an element was added to the list of recommendations. CONCLUSIONS Randomized clinical trials and observational studies suggest that several
elements of a stroke center would improve patient care and outcomes. Key elements
of primary stroke centers include acute stroke teams, stroke units, written
care protocols, and an integrated emergency response system. Important support
services include availability and interpretation of computed tomography scans
24 hours everyday and rapid laboratory testing. Administrative support, strong
leadership, and continuing education are also important elements for stroke
centers. Adoption of these recommendations may increase the use of appropriate
diagnostic and therapeutic modalities and reduce peristroke complications.
The establishment of primary stroke centers has the potential to improve the
care of patients with stroke.
The American Heart Association's (AHA's) mission is "to build healthier lives, free of cardiovascular diseases and stroke." This first article in a 2-part series will serve to present an overview of ...the work the AHA has undertaken to translate evidence into practice for healthcare professionals. It describes the extensive work of the AHA to support and further the delivery of evidence-based medicine, which includes the following: (1) supporting scientific discovery and the next generation of healthcare professionals and researchers; (2) disseminating scientific information; (3) developing evidence-based guidelines and statements; (4) creating and advocating for the implementation of performance indicators/measures; (5) developing clinical decision support and quality improvement tools; and (6) developing directed-cause campaigns, all of which can lead to improved patient care. This article also discusses the need for novel approaches and some of the AHA's evolving strategies to help address gaps in care. The second article, which will be published shortly after this one, will examine the AHA's efforts to engage and empower healthcare consumers to become more involved with their own health and health care.
The American Stroke Association (ASA) assembled a multidisciplinary group of experts to develop recommendations regarding the potential effectiveness of establishing an identification program for ...stroke centers and systems. "Identification" refers to the full spectrum of models for assessing and recognizing standards of quality care (self-assessment, verification, certification, and accreditation). A primary consideration is whether stroke center identification might improve patient outcomes.
In February 2001, ASA, with the support of the Stroke Council's Executive Committee, decided to embark on an evaluation of the potential impact of stroke center identification. HealthPolicy R&D was selected to prepare a comprehensive report. The investigators reported on models outside the area of stroke, ongoing initiatives within the stroke community (such as Operation Stroke), and state and federal activities designed to improve care for stroke patients. The investigators also conducted interviews with thought leaders in the stroke community, representing a diverse sampling of specialties and affiliations. In October 2001, the Advisory Working Group on Stroke Center Identification developed its consensus recommendations. This group included recognized experts in neurology, emergency medicine, emergency medical services, neurological surgery, neurointensive care, vascular disease, and stroke program planning.
There are a variety of existing identification programs, generally falling within 1 of 4 categories (self-assessment, verification, certification, and accreditation) along a continuum with respect to intensity and scope of review and consumption of resources. Ten programs were evaluated, including Peer Review Organizations, trauma centers, and new efforts by the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations to identify providers and disease management programs. The largest body of literature on clinical outcomes associated with identification programs involves trauma centers. Most studies support that trauma centers and systems lead to improved mortality rates and patient outcomes. The Advisory Working Group felt that comparison to the trauma model was most relevant given the need for urgent evaluation and treatment of stroke. The literature in other areas generally supports the positive impact of identification programs, although patient outcomes data have less often been published. In the leadership interviews, participants generally expressed strong support for pursuing some form of voluntary identification program, although concerns were raised that this effort could meet with some resistance.
Identification of stroke centers and stroke systems competencies is in the best interest of stroke patients in the United States, and ASA should support the development and implementation of such processes. The purpose of a stroke center/systems identification program is to increase the capacity for all hospitals to treat stroke patients according to standards of care, recognizing that levels of involvement will vary according to the resources of hospitals and systems.
Stroke is the third-leading cause of death and a leading cause of disability in adults in the United States. In recent years, leaders in the stroke care community identified a national registry as a ...critical tool to monitor the practice of evidence-based medicine for acute stroke patients and to target areas for continuous quality of care improvements. An expert panel was convened by the Centers for Disease Control and Prevention to recommend a standard list of data elements to be considered during development of prototypes of the Paul Coverdell National Acute Stroke Registry.
A multidisciplinary panel of representatives of the Brain Attack Coalition, professional associations, nonprofit stroke organizations, and federal health agencies convened in February 2001 to recommend key data elements. Agreement was reached among all participants before an element was added to the list.
The recommended elements included patient-level data to track the process of delivering stroke care from symptom onset through transport to the hospital, emergency department diagnostic evaluation, use of thrombolytic therapy when indicated, other aspects of acute care, referral to rehabilitation services, and 90-day follow-up. Hospital-level measures pertaining to stroke center guidelines were also recommended to augment patient-level data.
Routine monitoring of the suggested parameters could promote community awareness campaigns, support quality improvement interventions for stroke care and stroke prevention in each state, and guide professional education in hospital and emergency system settings. Such efforts would reduce disability and death among stroke patients.
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