Table 2 Target levels and interventions for risk factors at the 3-month risk factor assessment
Condition | Target | Intervention to achieve the targets |
|---|---|---|
Hypertension | BP < 140/90 mmHg BP < 130/85 mmHg in patients with diabetes, renal impairment or small-vessel disease | Adjustment of anti-hypertensive medication Information on supportive lifestyle changes Written recommendations to and intensified management by the GP |
Dyslipidaemia | LDL-C < 100 mg/dL LDL-C < 70 mg/dL in very high-risk patients | Adjustment of statin dosage Prescription of ezetimibe additionally to high-dose statins (according to guidelines) Involvement of a lipid-clinic and prescription of PCSK9 inhibitors (according to guidelines) Individualised recommendations by a dietitian |
Diabetes | HbA1c < 7% | Re-evaluation of the therapeutic regime by a diabetes-specialist Additional management by the GP, re-instruction in correct administration of injectable pharmacological agents Individualised recommendations by a dietitian |
Smoking | Nicotine abstinence | Motivational interviewing and counselling Provision of informational material Involvement of a psychiatric specialist for behavioural or pharmacological therapy |
Physical inactivity | Physical activity of moderate to vigorous intensity with an average of 40 min at least 3 times per week | Motivational interviewing Provision of informational material |
Non-adherence to drug prescriptions | Adherence to drug prescription (proportion of days covered ≥90%) | Motivational interviewing with information on indication & therapeutic effect of current medication Simplification of drug-regimes Home support by nurses and/or relatives |
Poor “stroke-knowledge” of patients & family-members or caregivers | Information on stroke pathophysiology & individual stroke mechanism Provision of a book and standardised information material | |
Post-stroke complicationsa & poor functional outcome | Improvement of QoL | Individualised treatment & prevention of post-stroke complications Provision of further outpatient or inpatient rehabilitation Re-assessment on nursing demands, social integration & outpatient care Involvement of a social worker |