This project is co-funded by Health and Care Research Wales, who are contributing £134,999.20 (50%).

Why is this research needed?

One in four stroke survivors will have a second stroke within the next five years.

Fortunately, this risk can be reduced with secondary prevention - lifestyle changes and treatments to bring down blood pressure, lower cholesterol and/or prevent blood clots forming.

Unfortunately, many stroke survivors aren't on the recommended treatment. There are lots of reasons why this might happen, ranging from the quality of care you're offered after a stroke to experiencing unpleasant or dangerous side effects from medications.

One reason that doesn't get much attention is frailty - finding it difficult to withstand and recover from illness. As many as three quarters of stroke patients are frail or likely to become frail soon.

For frailer stroke survivors, it's much harder to know how to balance the risks and benefits of treatments to reduce stroke risk, so healthcare professionals may end up not recommending treatment in case it does more harm than good. This happens partly because there's not much evidence about risks and benefits of secondary prevention for frail stroke survivors. However, there are other difficulties in making a decision too: frail stroke survivors are more likely to experience side effects from medication and more likely to have other conditions like diabetes, so healthcare professionals also need to take into account whether a stroke-reducing treatment could interact with a medication that their patient is already taking.

Dr Jonathan Hewitt and the rest of the ERFOS-Cymru team hope to make it easier for frail stroke survivors and their healthcare professionals to make decisions about when and how to offer treatment to reduce the risk of a second stroke. To do this, they're going to analyse information from the SAIL databank, a large store of data about healthcare in Wales.

What are the aims of this research?

First, the ERFOS-Cymru team want to understand how well guidelines for secondary prevention have been followed up till now. They'll look at whether and how treatment varies depending on how frail a patient is, where they live, their age, their gender, their ethnicity, and more.

Then, they will look at the relationship between frailty and stroke. For example, how common is frailty among stroke patients? Are frailer people likely to experience more disability as a result of a stroke?

Finally, they will explore how following or not following secondary prevention guidelines has affected stroke survivors' long term health. Again, they will look at the role of frailty, comparing frail stroke survivors who've received the recommended treatment with those who haven't. It might be that healthcare professionals are correct to be cautious about prescribing secondary prevention medications to frail patients because they do more harm than good, but it's also possible that frail patients actually benefit overall from secondary prevention.

What is the benefit of this research?

Why do some stroke survivors get the secondary prevention treatments recommended by guidelines while others don't? What difference could getting the right treatment make to stroke survivors' long-term health? We simply don't know yet. This project will be the first ever large-scale study to try to answer these questions.

The ERFOS-Cymru team plan for their findings to feed into healthcare strategy. Depending on what they find, that could take many forms, from targeted initiatives promoting the benefits of secondary prevention to healthcare professionals, to guidelines around which types of secondary prevention treatments are offered to frail stroke survivors. Ultimately, this research could help more stroke survivors understand their likely future health and make well-informed choices about treatments and lifestyle changes to promote better health.

What PSP priorities does this research link to?

From 2019 to 2021, we worked with the James Lind Alliance on the Stroke Priority Setting Partnership (PSP). During the PSP process, we collaborated with people with lived experience of stroke and stroke professionals to find out what they thought were the top priorities in stroke research. From this, we identified the top ten priorities in two areas: prevention, diagnosis and short-term care, and rehabilitation and long-term care.

Now, when researchers apply to us for funding, we require that their work addresses at least one of these priorities, or a priority from the Childhood Neurological Disabilities PSP Top 10 as it relates to childhood stroke

ERFOS-Cymru addresses the following priorities from the Stroke PSP:

• Prevention and acute care 5: Recurrent stroke risk (secondary prevention)
• Prevention and acute care 9: Benefits and risks of blood-thinning treatments
• Prevention and acute care 10: Effects of other health conditions and characteristics

Meet the team

ERFOS-Cymru is led by Dr Jonathan Hewitt, Clinical Senior Lecturer in the School of Medicine at Cardiff University and Honorary Consultant Physician at Aneurin Bevan University Health Board. He’s also the Specialty Lead for Stroke in Wales for Health and Care Research Wales. Jonathan is an expert in diseases linked to our blood and lymphatic systems.

Jonathan says, "We are delighted to have received this funding to use the world renowned SAIL Databank to help improve stroke care in Wales and beyond. Many stroke survivors fear having another stroke, but the right treatments and lifestyle changes can significantly reduce the chances of that happening. We hope that in years to come our work will make it easier for stroke survivors and healthcare professionals to understand what ‘the right treatments’ look like for them."

The other members of the team include:

• Julian Halcox, Professor of Clinical Cardiology at Swansea University. Julian is leading on the initial investigation of how well guidelines are being followed and co-leading the investigation on stroke survivors' long-term health.
• Dr Libby Ellins, Senior Vascular Scientist and Research Manager at Swansea University. Libby leads on project management and analysing stroke risk factors.
• Dan King, Research Analyst at Swansea University. Dan works with Daniel and Keeron on collating, linking and analysing the data from the SAIL databank. The team will later be joined by a research assistant who will support Dan with data analysis.
• Dr Keeron Stone, Lecturer in Cardiovascular Physiology at Cardiff Metropolitan University. Keeron supports Dan in interpreting blood pressure data from the SAIL databank and also leads on patient and public involvement for the project.
• Dr Daniel Harris, Clinical Academic Pharmacist and Lead Cardiac Services Pharmacist at Hywel Dda University Health Board. Daniel supports Dan in interpreting medication data from the SAIL databank.
• Ashley Akbari, Professor of Health Data Science and Dr Hywel Turner Evans, Senior Data Scientist at Swansea University. Ashley and Hywel are members of the SAIL databank team and provide guidance on how to use it.
• Michael Gravenor, Professor of Biostatistics and Epidemiology at Swansea University. Michael provides guidance on statistical analysis.
• Barry McDonnell, Professor of Cardiovascular Physiology at Cardiff Metropolitan University. Barry provides expertise on the physiology of the heart and blood vessels.
• Dr Krishnan Manju, Consultant Stroke Physician and Deputy Stroke Lead for Wales at Swansea Bay University Health Board. Krishnan provides expertise on clinical aspects of stroke.
• Dr Nick Evans, Clinical Senior Lecturer at the University of Cambridge. Nick is an expert in frailty in stroke, leads the Stroke Association-funded FIESTO research project and also holds a Stroke Association-funded Senior Clinical Lectureship.