Why is this research needed?

Frailty is a reduced ability to withstand and recover from illness, and is very common among stroke patients. Frail people are less likely to survive having a stroke, and may respond less well to treatments like thrombolysis (clot-busting drugs) and thrombectomy (mechanical clot removal).

Unfortunately, improving matters for frail stroke patients is tricky.

FIESTO lead researcher Dr Nick Evans says, “Our research will look at how we can improve treatments for older and frailer individuals presenting with stroke. Frail people frequently come into hospital with strokes, but they’re often excluded from research on stroke treatments. As a result, we do not always know the best treatment for them. Our research will address that and make sure that we are giving the right treatment to the right people at the right time.”

What are the aims of this research?

The FIESTO team will be asking anyone who has thrombectomy or thrombolysis in stroke centres across the UK whether they’re willing to take part in the study. Stroke patients who say yes will be asked to do some tests so that the team can understand their level of frailty, and to share some information about themselves and their stroke, like their age, ethnicity, and how much disability they’re experiencing after their stroke. The team will analyse this information to understand whether and how frailty affects stroke patients’ response to the treatment they’ve received.

Next, the team want to understand how best to measure frailty in stroke patients. This could be done in one of two ways: looking at someone’s overall frailty, or looking specifically at how frail their brain is.  Both could be important in determining someone’s response to thrombectomy and thrombolysis, so the team will use machine learning to understand the links between what someone’s brain looks like on a scan, what their frailty score says, and their response to thrombectomy/thrombolysis.

While this information about frailty could be enormously helpful for making better decisions about how to treat frail patients, stroke healthcare professionals already have their own opinions about how these decisions should be made. This could lead to some challenges in getting any changes adopted into clinical practice. Nick and the team want to understand how stroke healthcare professionals currently make decisions about frail patients so that they can understand what the challenges to changing clinical practice could be.

What is the benefit of this research?

FIESTO will make it possible for healthcare professionals to make more evidence-based decisions about how to treat frail stroke patients, helping ensure they’re getting the treatments that are most helpful for recovery and making it more likely that frail stroke survivors have the best possible quality of life. This could have both national and international implications – for example, FIESTO could trigger updates to clinical guidelines in the UK which are then adopted by other countries.

Nick says, “I hope that this research will help us ensure we are treating the right patients in the right way. I also hope it will combat preconceptions about age and strengthen the case that we should be looking at an individual’s overall health and physical reserves when making treatment decisions, not simply how many times they have gone round the sun.“

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.

FIESTO addresses the following priority from the Stroke PSP:

  • Prevention 10: Effects of other health conditions and characteristics on stroke

Meet the team

FIESTO is led by Dr Nick Evans, Consultant Stroke Physician at Addenbrooke's Hospital (Cambridge University Hospitals NHS Trust). He also holds a Stroke Association Senior Clinical Lectureship for Medical Professionals at the University of Cambridge and is a member of the Stroke Association-funded ERFOS-Cymru research project team.

Nick says, “I have seen first-hand, both personally and professionally, the impact that stroke can have on the person and their family. Stroke is a cruel disease – a person’s life, and the lives of those around them, can change in an instant – but is also one where advances in research and clinical care are having a real impact in helping peoples’ recovery. I hope that this research will give us a better idea of what treatments work or don’t work for this under-served population. I also hope that it will help our understanding of who can benefit from thrombolysis and thrombectomy, and make it easier to identify those for whom the risks outweigh benefits. There will be important implications for our practice whatever the result.”

The other members of the FIESTO team include:

  • Robert Ward, a stroke survivor who uses his lived experience to advocate for people affected by stroke in research. His input is vital in shaping how FIESTO is carried out.
  • Dr Jonathan Hewitt, Clinical Senior Lecturer in the School of Medicine at Cardiff University and Honorary Consultant Physician at Aneurin Bevan University Health Board. Jonathan is an expert in epidemiology, as well as the lead researcher on ERFOS-Cymru.
  • Dr Lina Massou, Research Associate at the University of Cambridge. Lina is an expert in statistical analysis.
  • Terry Quinn, Professor of Cardiovascular Ageing at the University of Glasgow. Terry is an expert in frailty in stroke and in clinical trials.
  • Dr Michael Roberts, Principal Research Associate at the University of Cambridge. Michael is an expert in machine learning.
  • James Rudd, Professor of Cardiovascular Medicine at the University of Cambridge. James oversees the collaboration with the Cambridge Mathematics of Information in Healthcare (CMIH) hub for the machine learning aspects of the project.
  • Professor Martin Graham, Director of Research at The Healthcare Improvement Studies Institute (THIS) at the University of Cambridge. Martin supports Nick with researching healthcare professionals’ decision-making about frailty.
  • Elizabeth Warburton, Professor of Stroke Medicine at the University of Cambridge. Elizabeth is an expert in running clinical trials and in implementing research findings in clinical guidelines and acts as mentor to Nick.
  • Hugh Markus, Professor of Stroke Medicine at the University of Cambridge. Hugh is an expert in running multicentre research projects like FIESTO and acts as mentor to Nick.