Intensified Secondary Prevention Intending a Reduction of Recurrent Events in TIA and Minor Stroke Patients (INSPiRE-TMS)

Intensified Secondary Prevention Intending a Reduction of Recurrent Events in TIA and Minor Stroke Patients

Intensified Secondary Prevention Intending a Reduction of Recurrent Events in TIA and Minor Stroke Patients (INSPiRE-TMS) A Randomized Trial Comparing a Patient Centered Support Program Versus Conventional Car

Technical University of Munich, University of Erlangen-Nürnberg Medical School, Praxis für Neurologie und Psychiatrie am Prinzregentenplatz, München, Technische Universität Berlin, Aarhus University Hospital, Klinikum Ludwigshafen, Vivantes Auguste-Viktoria-Klinikum, Vivantes Clinic Neukölln

Patients after TIA or Stroke are at high risk of experiencing a new stroke or myocardial infarction. Poor adherence to evidence based secondary prevention regimens is frequently seen. Support programs for patients may not only improve adherence to recommended therapies but also reduce the recurrence rate of stroke and heart attack. The investigators hypothesize that compared to regular care, a structured and patient centered secondary prevention program will lead to a relative risk reduction of at least 28% of recurrent vascular events.

Although effective methods of secondary prevention after stroke or TIA are available, adherence to recommended evidence-based treatments is often poor. Programs for supported secondary prevention after cerebrovascular events with improved health education are promising but have not been evaluated regarding recurrent event reduction so far. A prospective randomized trial has been started to assess the effectiveness of a patient centered structured support program intending a reduction of recurrent vascular events. Usual care consists of structured information given at discharge as well as regular outpatient care by general practitioners. The support program additionally employs a stepwise intensified support program with up to eight appointments over two years in outpatient clinics. Results of risk factor measurements and assessed adherence to medical recommendations are shared with the patients. They are also offered assistance in finding appropriate physical activities or smoking cessation programs. Patients are randomized to regular care or regular care plus support program and will be followed-up until the total number of 317 primary endpoints has been reached. The composite primary endpoint consists of stroke, major coronary event and vascular death.

Consisting of structured information given at hospital discharge regarding stroke etiology and recommended secondary prevention plus regular outpatient care by general practitioners or family doctors.

In addition to regular care: Up to 8 appointments in outpatient clinics. Results of risk factor measurements and assessed adherence to medical recommendations are shared with the patients. In case that a patients fails to meet target values, preventive measures will be modified directly or via recommendation to GPs / family doctors. Patients are also offered assistance in finding appropriate physical activities or smoking cessation programs.

Behavioural: Structured support program Program with up to 8 outpatient appointments focusing on: Measurement of risk factors Assessment of medication intake Monitoring of antithrombotic therapy Joint agreement of an individual target plan Target values for risk factors: Blood pressure < 140/85 mmHg (<130/80 in diabetics), normal circadian profile HbA1c <7.5% Nicotine abstinence LDL < 100mg/dl (< 70mg/dl in high risk patients) Physical activity ≥ 30min >2 x / week Targets for pharmaceutical treatment: Platelet inhibitors for strokes / TIA of arterial etiology Combined platelet inhibition over 3 months in symptomatic intra- or extracranial stenosis Cumarins (INR 2-3) or new oral anticoagulants in AF patients Statin treatment in patients with LDL >100mg/dl Intervention strategies: • According to Motivational Interviewing

Stroke: Acute (focal-) neurological syndrome, caused by brain infarction or intracerebral hemorrhage Major coronary event:Including instable Angina pectoris, STEMI and non-STEMI Vascular death: Caused by stroke (within 30 days of event), or major coronary event (within 7 days of event), or non-cerebral hemorrhage, or by peripheral arterial disease 30 days after vascular event or vascular intervention (intraarterial or surgical), or by pulmonary embolism or sudden death if death occurs within 24 hours in a patients with previously stable and healthy state if no non-vascular cause is documented

Inclusion Criteria: Acute cerebrovascular event (either TIA or minor Stroke within 14 days before study inclusion) according to the following definitions: TIA (clinical restitution within 24 hours and ABCD2-Score ≥3) or visible DWI-lesion in MRI Minor stroke (mRankin ≤2 at time of inclusion) Patients with at least one of the following treatable risk factors: Arterial Hypertension Diabetes mellitus Atrial Fibrillation Smoking Written informed consent prior to study inclusion Realistic perspective in keeping the outpatient appointments Exclusion Criteria: Distance from home to study center not in suitable range for keeping the outpatient appointments cognitive impairment jeopardizing adherence to the support program Modified Rankin Score >2 at time of study inclusion Malignant disease with life expectancy of less than 3 years relevant alcohol or other substance abuse (except for nicotine) Stroke or TIA etiology without options for evidence based secondary prevention (e.g. dissection or vasculitis)

Ihl T, Ahmadi M, Laumeier I, Steinicke M, Ferse C, Klyscz P, Endres M, Hastrup S, Poppert H, Palm F, Kandil FI, Weber JE, von Weitzel-Mudersbach P, Wimmer MLJ, Audebert HJ. Patient-Centered Outcomes in a Randomized Trial Investigating a Multimodal Prevention Program After Transient Ischemic Attack or Minor Stroke: The INSPiRE-TMS Trial. Stroke. 2022 Sep;53(9):2730-2738. doi: 10.1161/STROKEAHA.120.037503. Epub 2022 Jun 15.

Ahmadi M, Laumeier I, Ihl T, Steinicke M, Ferse C, Endres M, Grau A, Hastrup S, Poppert H, Palm F, Schoene M, Seifert CL, Kandil FI, Weber JE, von Weitzel-Mudersbach P, Wimmer MLJ, Algra A, Amarenco P, Greving JP, Busse O, Kohler F, Marx P, Audebert HJ. A support programme for secondary prevention in patients with transient ischaemic attack and minor stroke (INSPiRE-TMS): an open-label, randomised controlled trial. Lancet Neurol. 2020 Jan;19(1):49-60. doi: 10.1016/S1474-4422(19)30369-2. Epub 2019 Nov 7.

Leistner S, Michelson G, Laumeier I, Ahmadi M, Smyth M, Nieweler G, Doehner W, Sobesky J, Fiebach JB, Marx P, Busse O, Kohler F, Poppert H, Wimmer ML, Knoll T, Von Weitzel-Mudersbach P, Audebert HJ. Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial. BMC Neurol. 2013 Jan 24;13:11. doi: 10.1186/1471-2377-13-11.

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