Primary care providers (PCPs) should never underestimate the amount of influence they can have in encouraging patients to take steps to reduce their stroke risk. For the best results, in addition to talking to patients about lifestyle changes to decrease their stroke risk, it is important to refer patients to resources that can help them lose weight, quit smoking and exercise, said Margaret Tremwel, MD, a neurologist with the Sparks Regional Medical Center Vascular Neurology and Memory Disorders Clinic in Fort Smith.
“Absolutely healthcare providers can get through to patients,” Tremwel said. “As part of routine office visits, we certainly need to help patients look at ways to address their barriers about diet and exercise.”
One example of a barrier for stopping smoking might be other members of their household who smoke. In cases like that, Tremwel advises the patient that it can’t be just one person who quits; it needs to be the entire family that quits.
Tremwel also often tries to get through to patients by telling them that they should know a stroke doesn’t usually kill them, but leaves them in a nursing home unable to do basic functions like going to the bathroom alone.
“That is why you do what you can to reduce stroke risk,” she said. “Regarding diet, instead of telling people to adhere to a particular diet, I tell them to look at their demons. Don’t try to do everything at once. If you have several bad things you are eating, first cut out the donuts, and then the fried foods. Then, the first thing you know, you are eating a healthy diet.”
She also advises people that making lifestyle improvements like exercise can be easier with a group. Refer patients to local fitness programs at a YMCA or gym.
Tremwel highly recommends a new program in Fort Smith called the Healthy Congregation Ministry. This program provides nurses in many different denominations with educational materials, a blood pressure cuff and glucose monitoring sticks. The program also includes fun group exercise programs and classes on topics like heart healthy cooking.
The program has been modeled after similar faith-based health promotion programs in Memphis, Tenn., and in Mississippi.
“Some people respond more to a faith-based approach,” she said. “These wellness programs can be included as part of Bible studies, retreats and educational events.”
Tremwel said it is also important to get across the message to patients that the incidence of stroke is increasing in the U.S. and Arkansas in people under 65.
The Arkansas Department of Health (ADH) is also a good resource for patient tools to prevent heart attack and strokes. Appathurai Balamurugan, MD, MPH,
medical director, ADH Chronic Disease Prevention and Control Branch, said that PCPs need to be aware that Arkansas consistently ranks first or second in the country in stroke deaths, with stroke being the fourth leading cause of death in Arkansas.
“Every year about 1,800 people die due to stroke in Arkansas,” Balamurugan said. “The number one risk factor is hypertension. It is one of the biggest challenges for the state both from a medical perspective and a public health perspective. About 35 percent of Arkansans have been diagnosed with hypertension, and a significant portion of adults who have it have not been diagnosed. Even of those diagnosed, only 50 percent have their blood pressure under control. So this is a big problem for Arkansas. If we want to really bring down stroke deaths in Arkansas, prevention with blood pressure control is critical.”
There are some excellent and inexpensive medications for hypertension control including $4 generics. Balamurugan, a family physician who also works at the UAMS Family Medical Center one day a week, said clinicians need to make sure they work with patients ensuring that they take the medication, and that they have a prescription for a 60- to 90-day supply so the medication doesn’t run out. One of the common reasons for non-compliance is patients running out of medications and not being able to get through to the physician’s office for a refill or not making an effort to get prescriptions refilled.
Medication reminders like pill dispensers have been shown to increase medication compliance. And these days when most people have a cell phone, patients might consider a smart phone app medication reminder.
Balamurugan recommends that PCPs advise their patients to purchase a blood pressure monitor and monitor their blood pressure at least once per day. Studies have shown that checking blood pressure regularly increases medication compliance.
Patients often think they need to make big lifestyle changes to achieve a significant decrease in blood pressure. But even as little as a five millimeter decrease in blood pressure reduces stroke deaths 10 to 15 percent. Losing weight and increasing physical activity, cumulatively, can result in a five to ten point drop in blood pressure.
“Empower them with that,” Balamurugan said. “Also, I tell my patients to avoid canned foods, which are loaded with salt, and use frozen foods instead. Avoid salty foods like chips and sodas. Patients are surprised to learn sodas have salt in them, but indeed they do. Reducing salt intake can decrease blood pressure five to ten millimeters. The average American consumes 3.5 grams of salt per day, which is nearly double the recommended two grams per day. There are numerous studies showing reducing salt intake reduces blood pressure and reduces stroke deaths.”
Another major risk factor is smoking. It is hard to bring the blood pressure of smokers into a normal range. Smokers can be referred to the Arkansas Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669) for free counseling and smoking cessation aids.
The American Heart Association and American Academy of Family Physicians have good patient educational materials available that Balamurugan recommends.
“Additionally, many of the clinics have now started providing high-risk case management for individuals who are non compliant and don’t show up for regular office visits,” he said. “Clinics usually use a case manager or nurse call to make sure they keep appointments, and are keeping up with taking medications. With the emergence of patient centered medical homes, many are using the case management model for hypertension control, as well.”
Balamurugan also recommends the Million Heart Initiative, promoting the ABCS program (aspirin therapy, blood pressure control, cholesterol management and smoking cessation).
“Definitely aspirin plays a big role in stroke prevention,” he said.
Another way the ADH is involved is through the Arkansas Stroke Registry which is housed at ADH, and working with hospitals in improving care and ensuring that quality care is provided to patients from the time they enter the hospital to discharge and is based on the standards of care.
