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Blood pressure management following acute stroke: informing changes to UK and US stroke guidelines

Summary of the impact

Stroke is the third most common cause of death and single most important cause of adult disability in the UK, affecting over 150,000 individuals per annum and costing the economy approximately £8 billion annually in health, social and indirect care costs.

High blood pressure (BP) is the most common modifiable risk factor to prevent stroke, but the use of BP-lowering therapy in the acute phase of stroke is controversial. Clinical trials co-ordinated at the University of Leicester have confirmed the safety of continuation of pre-existing BP-lowering therapy in acute stroke and the de novo treatment of high blood pressure in acute intracerebral haemorrhage. This has resulted in changes to the most recent US (2013) and UK (2012) guidelines, which will significantly impact on clinical management of this common clinical problem in acute stroke.

Submitting Institution

University of Leicester

Unit of Assessment

Clinical Medicine

Summary Impact Type

Political

Research Subject Area(s)

Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Clinical Sciences, Neurosciences

Redefining hypertension treatment practice to reduce primary and secondary stroke risk

Summary of the impact

Stroke is the leading cause of disability and a major cause of death in the developed world. Hypertension (high blood pressure) is the single most important modifiable risk factor for stroke, contributing to around 50% of all events. University of Glasgow researchers have played lead roles in the design, conduct and analysis of pivotal clinical trials on treatment regimens for hypertension. These research findings have informed European and UK hypertension and stroke guidelines, advancing treatment strategies, and contributed to the observed ~25% reduction in the incidence of primary (first) and secondary (recurrent) stroke.

Submitting Institution

University of Glasgow

Unit of Assessment

Clinical Medicine

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Clinical Sciences, Public Health and Health Services

B: Graduated compression stockings do not reduce the risk of post-stroke deep vein thrombosis

Summary of the impact

Impact: Health and welfare: reducing morbidity; providing evidence to disinvest in an ineffective and damaging treatment; policy change.

Significance: Since 2009, applied clinical trial findings have resulted in approximately 6000 fewer complications (e.g., skin breaks) in the UK. Stocking use has decreased by 95%, which has saved the NHS in excess of £20M per annum.

Beneficiaries: Stroke patients worldwide, the NHS and healthcare delivery organisations, the economy.

Attribution: Trials were designed and led by Professor M Dennis, UoE.

Reach: Changed national guidelines in at least seven countries worldwide (Europe, N America, South Africa, Singapore).

Submitting Institution

University of Edinburgh

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Clinical Sciences, Neurosciences

Re-organisation of ambulance services and increased public awareness of stroke symptoms through the Act FAST campaign have improved outcomes for stroke.

Summary of the impact

Stroke is a major health burden to patients, carers and the NHS, with UK costs estimated at £15.5bn annually. Clot-busting agents (thrombolytics) can substantially improve the consequences of ischaemic stroke, but only if administered rapidly. Newcastle research that recognised the importance of rapid referral to a stroke unit allowed reconfiguration of ambulance services for direct transport of victims to a specialised centre. Newcastle work also validated a test developed for paramedics to recognise the signs of stroke, which was developed as the nationwide Face-Arms-Speech-Time (Act FAST) campaign. Use of thrombolytics has increased eightfold between 2005 and 2012, and there has been a considerable increase in public awareness of FAST.

Submitting Institution

Newcastle University

Unit of Assessment

Public Health, Health Services and Primary Care

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Clinical Sciences, Neurosciences, Public Health and Health Services

A: Reducing the global burden of stroke by using aspirin and avoiding heparin use in the treatment of acute stroke

Summary of the impact

Impact: Health and welfare; saving lives by determining that aspirin is an effective treatment for acute stroke and that heparin anticoagulation is ineffective.

Significance: In the UK, treating all acute stroke patients with aspirin and avoiding heparin means 1800 people avoid death or disability each year; aspirin is also highly cost-effective.

Beneficiaries: Stroke patients, the NHS, the economy.

Attribution: Sandercock, UoE, designed, led and reported the International Stroke Trial, and was on the steering committee of the Chinese Acute Stroke Trial.

Reach: Up to 15M stroke patients annually affected by guideline changes worldwide, encompassing Europe, North America and Australasia; educational events by the World Stroke Academy promote aspirin use.

Submitting Institution

University of Edinburgh

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Clinical Sciences, Neurosciences

Transforming stroke rehabilitation research and care

Summary of the impact

Forster, House and Young have played a leading role in establishing the importance of long-term psychological and social distress after stroke, shifting the clinical emphasis (and evidence base) in stroke care from a limited focus on physical recovery to acceptance of the importance of psychological and social factors. Evidence we have generated has informed the stroke care pathway in national and international clinical guidelines that influence stroke service delivery, by providing guidance to clinical teams on psychological treatments after stroke and information provision. In tandem we have developed the methodology of stroke rehabilitation research, involving clinical staff in delivery of multi-site studies and thereby enhancing evidenced-based stroke care.

Submitting Institution

University of Leeds

Unit of Assessment

Public Health, Health Services and Primary Care

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Clinical Sciences, Neurosciences, Public Health and Health Services

UOA04-11: Reduction of Stroke Risk by Risk Stratification and Urgent Intervention after a Transient Ischaemic Attack (TIA) or Minor Stroke

Summary of the impact

Research in Oxford by Rothwell and colleagues since 2000 has radically changed how minor strokes and transient ischaemic attacks (TIAs) are managed. First, the risk of a major stroke in days after a minor stroke/TIA was found to be much higher than thought. In consequence, these `warning' events were rebranded as a medical emergency in clinical guidelines. Second, Rothwell showed that a delay in treating individuals at high risk of major stroke substantially reduced the benefits. Third, the Rothwell group developed a simple risk score (`ABCD system') to triage high-risk individuals, showing that more urgent treatment reduced the 90-day risk of major stroke by 80%. This strategy has been implemented in the National Stroke Strategy and NICE and international guidelines. In the UK it is estimated to prevent 10,000 strokes per year, and to save the NHS £200 million in acute care costs alone.

Submitting Institution

University of Oxford

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Clinical Sciences, Neurosciences, Public Health and Health Services

Specialist stroke services become the national standard of care

Summary of the impact

Worldwide, around 5 million stroke-related deaths occur annually, while another 5 million people are left with chronic disabilities following strokes. University of Glasgow research demonstrated that admission to a specialist stroke unit significantly improves patients' chances of survival and recovery. This discovery transformed the culture of stroke service delivery in the UK. These studies drove the development of new advice in national and international clinical practice guidelines and promoted the implementation of NHS healthcare targets and audit activities to standardise and evaluate the quality of stroke care. In the UK, the early death rate after stroke has fallen from over 45% to under 30% in the past 20 years; at least one-fifth of that decline is attributed to the introduction of stroke units.

Submitting Institution

University of Glasgow

Unit of Assessment

Clinical Medicine

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Neurosciences, Public Health and Health Services

D: The FOOD trials: feeding policies in hospitalised stroke patients influence patient outcomes

Summary of the impact

Impact: Health and wellbeing; improvement in mortality and morbidity; changes in policy and guidelines.

Significance: Clinical trial findings have led to 1160 fewer deaths and 780 fewer severely disabled patients each year in the UK; rationalising feeding policies saves over £12M annually.

Beneficiaries: Stroke patients, the NHS and healthcare delivery organisations, the economy.

Attribution: Trials were designed and led by Professor M Dennis, UoE.

Reach: Worldwide: revised national guidelines in UK, Europe, North America, South Africa, Singapore, Australasia.

Submitting Institution

University of Edinburgh

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Clinical Sciences, Neurosciences, Public Health and Health Services

J: Thrombolysis for acute ischaemic stroke is effective for a wide range of patients, including those over 80 years, and improves long-term function and quality of life

Summary of the impact

Impact: Health and welfare; a large randomised controlled trial (third International Stroke Trial (IST)-3) and meta-analysis determined that the thrombolytic agent recombinant tissue plasminogen activator alteplase is a long-term effective treatment for acute ischaemic stroke in a wide range of patients.

Significance: Thrombolysis would result in 1488 more stroke patients being alive and independent per year in the UK.

Beneficiaries: Stroke patients, the NHS and healthcare delivery organisations, the UK economy.

Attribution: The IST-3 trial was led from UoE (Sandercock), with UoE (Wardlaw, Dennis) and University of Sydney (Lindley) colleagues.

Reach: Worldwide. Applicable to 4 million stroke patients per year; guidelines changed in Europe, N America, Asia, Australia.

Submitting Institution

University of Edinburgh

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Clinical Sciences, Neurosciences

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