May is Stroke Awareness month, and every year in the U.S., nearly 800,000 people have one. Of those who survive, up to two-thirds will have some degree of physical or cognitive disability, and 1 in 4 will have another stroke within five years.
The relationship between high blood pressure and stroke is well-known, and research at Wake Forest University School of Medicine aims to find more effective ways for stroke patients to monitor and lower their blood pressure. Cheryl D. Bushnell, MD, is leading the Telehealth-Enhanced Assessment and Management After Stroke – Blood Pressure (TEAMS-BP) trial that compares effectiveness of in-clinic- and telehealth-based treatment plans.
Considering approximately 47% of American adults have high blood pressure, according to the American Heart Association’s 2024 Statistical Update, the TEAMS-BP findings could have significant impact.
“This is a very complex, very innovative trial with two interventions,” says Bushnell, professor and vice chair of research in the department of neurology at Wake Forest University School of Medicine and co-director of the Neuroscience Clinical Trials and Innovations Center. “Our feasibility phase of the trial was critical, because we needed to know can we enroll, can we retain, can we deliver the interventions and what do the stakeholders think about their experience, including participants or coordinators or providers.”
The intensive clinic management intervention provides patients with a home blood pressure monitor, and they fill out a daily log, which they bring back to the clinic monthly for provider review. This continues until the blood pressure is considered controlled. Patients also receive reminders to take the blood pressure at home, take medications and be physically active.
The intensive tailored telehealth intervention also has patients take their blood pressure at home, but the information is digitally transmitted for remote monitoring. Patients also receive a physical activity monitor and health coaching, and they document their medications. A program creates a graphic showing two weeks of data for blood pressure readings, steps per day and medication adherence.
“Seeing all of that information together is really helpful, because sometimes when a patient is less active, their blood pressure may go up, or if they're more active their blood pressure may come down,” says Bushnell. “So both participants and providers get to see how dynamic blood pressures are and what factors can affect that.”
Bushnell says that the hardest parts of stroke care are post-acute and secondary stroke prevention. Once a person leaves the hospital after a stroke, follow-up care might be left to their primary care provider (if they have one) or a phone call. And some patients face significant barriers, such as distance or transportation logistics with returning for follow-up care.
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“Many participants just didn't realize how important blood pressure was until they were part of the study. Understanding the different things in their life that influence blood pressure was enlightening for a lot of patients, and they didn't realize how measuring their blood pressure every day could really have a major impact on their ability to get it under control and reduce the risk of stroke.” |
The combination of telehealth, remote monitoring and health coaching could foster closer, more frequent contact between patients and providers, even if it’s not in person. And, of course, providers can see the data and have patients come in, if necessary.
In both interventions, patients receive a care plan that shows risk factors for secondary stroke and what patients can do to modify those factors. In the tailored telehealth version, health coaches also get a copy of the care plan and go through various learning modules with the patient to work on risk factors such as diet, exercise, smoking and other lifestyle habits.
Funded by a $29.9 million award from the Patient-Centered Outcomes Research Initiative (PCORI), the multicenter, patient-randomized trial has 2 phases:
- An 18-month feasibility study (complete)
- A 5-year, large-scale trial (started October 2023)
The large-scale trial is being implemented at nine sites throughout the southeast (also known as the Stroke Belt) and two Advocate Health sites in Illinois. Now that Wake Forest University School of Medicine is the academic core of Advocate Health, the third-largest nonprofit integrated health system in the United States, TEAMS-BP is one of the first School of Medicine studies to enroll participants at Advocate Health’s midwestern locations. Participating sites include:
- Advocate Christ Medical Center
- Advocate Lutheran General Hospital
- Atrium Health Wake Forest Baptist Medical Center
- Atrium Health Carolinas Medical Center
- Duke University Medical Center
- Grady Memorial Hospital
- University of South Carolina/Health Sciences South Carolina
- Mayo Clinic Florida
- Medical University of South Carolina
- University of Alabama-Birmingham Hospital
- Vanderbilt University Medical Center
Bushnell says all hospitals should be enrolling by January 2025, and the goal is to have 1,550 participants, with emphasis on Black patients and patients with cognitive and/or physical disability from previous stroke. (About 60% of participants in the feasibility study had some level of dysfunction resulting from stroke.)
Bushnell said the feasibility study was promising, with good adherence to study visits and few were lost-to-follow-up. Participants also loved the health coaching intervention.
“Many participants just didn't realize how important blood pressure was until they were part of the study,” says Bushnell. “Just understanding the different things in their life that influence blood pressure was enlightening for a lot of patients, and they didn't realize how measuring their blood pressure every day could really have a major impact on their ability to get it under control and reduce the risk of stroke.”
After TEAMS-BP wraps up in 2028 – depending on the results – Bushnell says the plan would be to scale the most effective intervention so any health system that wants to implement it can do so. She is also interested in seeing what approaches could broaden the benefit across communities, particularly to underrepresented groups.
Blood pressure is the most modifiable risk factor for stroke, and the interventions in TEAMS-BP empower patients to manage that. Regardless of which intervention proves most effective, for the more than 7 million stroke survivors in the U.S., the study will help advance post-stroke care and help prevent secondary strokes.