Volume – 14, Issue – 1, January – 2023

IJPPR (2023), Vol. 14, Issue 1 Research Article

INTERNATIONAL JOURNAL OF

PHARMA PROFESSIONAL’S

RESEARCH

STUDY ON QUALITY OF LIFE AND MANAGEMENT OF HYPONATREMIA

AND HYPERTENSION IN STROKE PATIENTS IN THE NEUROLOGY
DEPARTMENT OF A TERTIARY CARE TEACHING HOSPITAL IN SOUTH
INDIA
Josin Joseph1, Maria Thomas1, Hanna Rose Thomas1, Naveen Kumar Panicker2*
1 Doctor of Pharmacy, St. Joseph’s College of Pharmacy, Cherthala, Kerala, India.
2 Dept. of Pharmacy Practice, St. Joseph’s College of Pharmacy, Cherthala, Kerala, India.
1,2 Neurology Department, Lourdes Hospital, Ernakulam, India

Keywords: ABSTRACT:
Stroke. Hyponatremia, Background:
Hypertension, Stroke scales, A stroke or cerebrovascular accident is an abrupt onset of a neurologic
NIHSS, Modified Rankin Scale, deficit that lasts for at least 24 hours and is mainly of vascular origin. Stroke
Barthel Index
is one of the leading causes of death and disability in our country and leads
to long-term disability and functional dependency. Hyponatremia is one of
Corresponding Author-
the common electrolyte abnormalities seen in patients with neurological
Naveen Kumar Panicker,
disorders which may be due to SIADH or CSWS. Hypertension is one of
Assistant Professor, Dept. of
the important risk factors and it is proven that anti-hypertensive therapy can
Pharmacy Practice, St. reduce the risk of developing stroke. The various scales that have proved
Joseph’s College of Pharmacy, reliability and valid in stroke trials are the National Institutes of Health
Cherthala, Kerala, India. Stroke Scale (NIHSS), the modified Rankin scale (Mrs), the Barthel index
Email: (BI),
[email protected]
Methods:
A detailed history of the patient was collected using a pre-designed patient
data collection form. In addition, time of onset of symptoms and treatment
received were also recorded. Blood pressure of the patient was recorded
every 24 hours and examined for any spikes. Serum electrolytes such as
sodium and potassium were examined to find out if there were any
variations. The reference range for serum sodium is 135–145 mEq/L. The
time course of recovery of patients with mild, moderate and severe stroke
was assessed. Regular follow up of patients included in the study was taken
after one month, two months and three months after discharge. Before
beginning the study, informed written consent was obtained from the
patient or bystanders. Ethical clearance was obtained from the institutional

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ethical committee. Analysis of reduce the occurrence of stroke. In our study majority of the patients (19)
the data was conducted using showed improved BP with a Z-value 3.635 which is significant with p <
SPSS software version 26. 0.001 which is statistically significant. The medications used were normal
saline for most of the patients (88%), oral salt (23%), 3% hyper-tonic saline
Results:
(23%), and tolvaptan (12%), respectively. Since the significance (p-value)
A total of 35 patients were
is less than 0.001, we can conclude that the average improvement in the
enrolled in the study. In our
sodium levels (2.706), is significant.
study, we found that stroke
affects mainly the elderly people Conclusion:
of age >70 years (31.4%). The The study concludes that proper management of the co-morbidities can
incidence of stroke increases with prevent stroke to a limit, especially in the case of hypertension. Also,
increasing age. The male improvement in sodium levels is highly significant to show the impact of
population is more susceptible to medication on patients. From the scales used for measuring the severity,
stroke (60.0%) than females quality of life, and degree of disability of stroke patients, it is concluded
(40.0%). Most of the patients that remarkable improvement was shown after the 1st, 2nd, and 3rd follow-
reported ischemic stroke (77.1%) ups. The quality of life is hampered by a stroke in the majority of the
rather than haemorrhagic stroke patients.
(22.9%). Left hemisphere stroke
(57.1%) was identified more
often than right hemisphere
stroke (42.9%). In our study,
most of the patients who were
alcoholics and smokers were
male. In our sample population,
40% of patients were smokers,
followed by 22.85% of patients
who were alcoholics, and 11.42%
of patients had the habit of using
both alcohol and cigarettes. Most
of the patients in our study had
hypertension (69%). The drug
that was used the most was
Telmisartan (62%). Proper
management of hypertension can

Introduction: high rates of incidence, prevalence, morbidity, and

A stroke or cerebrovascular accident is an abrupt onset mortality, as well as the increased occurrence of stroke
of a neurologic deficit that lasts for at least 24 hours in the younger population, determining the
predisposing risk factors for stroke is critical. Various
and is mainly of vascular origin [1]. It occurs when
risk factors are involved in the causation of stroke. The
there is a loss of blood flow to different parts of the modifiable risk factors for stroke include high blood
brain. This blocks the supply of oxygen and nutrients, pressure and atrial fibrillation, which are more
causing damage to brain tissue [2]. Stroke is one of the significant than others. Other factors include high
leading causes of death and disability worldwide and blood cholesterol levels, cigarette smoking, heavy
can lead to long-term disability and functional alcohol consumption, diabetes mellitus, a lack of
dependency [3, 4]. As a result, the primary goals of physical activity, obesity, an unhealthy diet, etc.
Among non-modifiable risk factors, age and gender
poststroke rehabilitation are to reduce stroke disability
are the most significant. About 95% of stroke cases
and improve stroke survivors' independence [3]. occur in people age 45 and above, and 2/3rd of cases
Stroke is an important health problem faced by both occur in those over the age of 65 [12]. The risk factors
developed and developing countries. Because of the for stroke vary in young and elderly patients [6]. Men

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is more prone to stroke than women, i.e., about 25% water retention. The water permeability of the
[5]. Stroke is a devastating and disabling disease that collecting duct and ascending limb of the loop of
leads to economic loss. Henle is regulated by antidiuretic hormone (ADH) and
allows the kidney to reabsorb water. ADH is produced
According to the World Health Organization, stroke is despite the hypotonicity of body fluid. The negative
the fifth leading cause of death in people aged 15 to 59 feedback mechanism is disturbed, and then it is unable
years old. Recent studies show that one in six people to control the ADH secretion. This can result in
worldwide will have a stroke in their lifetime [7]. The uncontrolled ADH release into the blood stream.
major risk factors observed are hypertension, diabetes CSWS can be explained by excessive sodium
mellitus, smoking, dyslipidaemia, cardiovascular excretion in urine, dehydration, hyponatremia, and
causes, family history, obesity, socioeconomic status, trauma in patients with intracerebral disease, trauma,
dietary habits, TIA, physical activity, etc. and cerebral lesions. In CSWS, there is depletion of
Hypertension was assessed as per JNC-7 criteria. body volume, not volume expansion [11]. In elderly
Diabetes mellitus was diagnosed when subjects had people, their ability to maintain water and electrolyte
random blood sugar levels greater than 200 mg/dl, homeostasis in response to dietary and environmental
fasting blood sugar levels greater than 125 mg/dl, or changes is impaired, and as a result, the incidence of
HbA1c levels greater than 6.5%. Diabetes mellitus hyponatremia is higher in the elderly [12]. Serum
doubles the possibility of stroke when compared to osmolality is affected by two factors, such as water
non-diabetic patients. Dyslipidaemia is defined as intake and circulating arginine vasopressin (AVP);
fasting blood cholesterol > 200 mg/dL, triglycerides > hyponatremia may occur if these defence mechanisms
180 mg/dL, and LDL > 100 mg/dL during a hospital are defective [13]. Sodium is one of the main cations
stay. A smoker is defined as someone who has smoked in the extracellular fluid. Nearly 50% of body sodium
100 or more cigarettes in his or her lifetime. is present in bones, 40% in extracellular fluid, and the
Cardiovascular causes include myocardial infarction, rest in soft tissue. Sodium, along with chloride and
coronary artery bypass grafting, angina, or bicarbonate, helps in regulating the body’s acid-base
percutaneous transluminal angioplasty. It is balance and also in maintaining osmotic pressure and
determined by recording the 12 lead ECG of each fluid balance. This plays an important part in the
patient. The presence of high QRS voltage, i.e., the intestinal absorption of glucose, galactose, and amino
sum of the S wave in the V1 lead and the R wave in acids and is also unavoidable for normal muscle
the V5 or V6 lead of 35 mm or more, indicates left irritability and cell permeability [14].
hypertrophy. A 1 mm depression of the ST segment
indicates possible or definite myocardial ischemia, HYPERTENSION
and the presence of the Q/QS pattern and atrial
fibrillation, if present, indicates myocardial infarction. Many modifiable and non-modifiable risk factors exist
Family history is also considered a risk factor if a for stroke and transient ischemic attack (TIA). Among
patient has a first-degree relative who has had a stroke them, hypertension is one of the important risk factors,
or TIA. A BMI of more than 30 kg/sqm, i.e., obesity, and it is proven that antihypertensive therapy can
is also considered a factor. Recent studies claim that reduce the risk of developing stroke. Both stroke and
TIA increases the risk of stroke 13-fold. In young hypertension have circadian variations. Patients with
adults, chronic heavy drinking and acute intoxication normal blood pressure experienced an increase in
account for cerebral infarction. Some studies also blood pressure within 24 hours of a stroke. This is
showed that light to moderate alcohol intake decreased known as the "acute hypertensive response," which is
the risk of coronary artery disease, increased HDL also highly prevalent and self-limiting and results in
cholesterol, and increased endogenous tissue temporary or permanent damage to the regions of the
plasminogen activator [8]. A stroke can affect patients brain involved in cardiovascular functioning,
in various ways. Based on the side of the brain including BP. A U-shaped relationship was noticed
affected, the symptoms may vary. between blood pressure and mortality in the
international stroke trial. The ischemic penumbra
HYPONATREMIA (area surrounding an ischemic event such as a
thrombotic or embolic stroke) remains viable for some
Hyponatremia is one of the common electrolyte hours in cases of acute ischemic stroke, as blood flow
abnormalities seen in patients with neurological is maintained by the collateral channels to a certain
disorders (stroke, subarachnoid haemorrhage, and extent, whereas on the other hand, it is highly
meningitis), which may be due to the syndrome of susceptible to further ischemic injury with sudden
inappropriate anti-diuretic hormone (SIADH) or blood pressure reduction. So, elevated blood pressure
cerebral salt wasting syndrome (CSWS) [9]. It is may be an advantage for patients with ischemic
defined as having a serum sodium level less than 135 penumbra. The American Stroke Association (ASA)
mEq/L [10]. SIADH causes hyponatremia due to

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guidelines recommend that it is not crucial to lower ➢ To assess the severity of stroke by using National
blood pressure in acute conditions. According to the Institute Health Stroke Scale.
consensus of the ASA, antihypertensive agents must
be withheld unless the diastolic blood pressure is >120
mmHg or the systolic blood pressure is >220 mmHg. METHODOLOGY
High blood pressure may increase the risk of
intracerebral haemorrhage (ICH) caused by an STUDY SETTINGS
aneurysmal rupture or arteriovenous malformation.
The study has been conducted in the neurology
This suggests that the risk-benefit ratio is nearly equal.
department and at Lourdes Hospital, Kochi, which is a
Therefore, guidelines for the management of acute
tertiary care teaching hospital. It is a 600-bed multi-
ICH given by the American Stroke Association
speciality tertiary care referral teaching hospital with
suggest maintaining systolic blood pressure below 180
a wide range of amenities. The institution is equipped
mmHg and maintaining arterial pressure below 130
with seven super specialty departments and 22 other
mmHg [15]. About 75% or more of patients with acute
departments, with facilities comprising twelve
stroke have elevated BP, which is associated with a
operation theatres, ten intensive care units, and a
poor outcome. High BP can result in cerebral edema
computerised Lourdes Mediware System. Clinical
or haemorrhagic transformation, and low BP can lead
laboratories are governed by ISO standards. It is one
to increased cerebral infarction or perihematomal
of the top hospitals in Kerala.
ischemia. [16]
STUDY DURATION
STROKE SCALES
This is a prospective, observational study done from
A single outcome measure cannot describe or predict
the records of adult patients who have come to the
all dimensions of recovery and disability after an acute
Neurology Department from November 2019 to April
stroke [17]. Changes in neurological deficits are useful
2020.
outcome measures in acute stroke because they can
measure inter-subject changes on the entire spectrum INCLUSION CRITERIA:
of scales starting at baseline [18]. The various scales
that have proved reliability and validity in stroke trials ➢ Patients from Neurology Department.
are the National Institutes of Health Stroke Scale ➢ Stroke patients of both genders above 30 years.
(NIHSS), the modified Rankin scale (MRS), the ➢ Consecutive CT or MRI proven stroke patients
Barthel index (BI), the Glasgow outcome scale (GOS), within 7 days of stroke.
and the stroke impact scale (SIS). The NIHSS is used
for early prognostication and serial assessment, and EXCLUSION CRITERIA:
the BI is used to plan rehabilitative strategies. The
Modified Rankin Scale and GOS provide summary ➢ Patients who are not willing to participate in the
measures of outcome and are more relevant to study.
clinicians and patients considering early interventions. ➢ Pregnant and lactating women.
The SIS was designed to measure patients’ views on ➢ Patients with pre-existing renal or hepatic failure.
the effects of stroke [17].
STUDY DESIGN
A detailed history of the patient was collected using a
AIM pre-designed patient data collection form.
Additionally, the time of onset of symptoms and
To assess the quality of life and the management of treatment received were recorded. Pressure of the
hyponatremia and hypertension in stroke patients. patient was recorded every 24 hours and examined for
OBJECTIVE any spikes. Increased blood pressure was treated with
antihypertensive agents as per stroke protocol. Serum
➢ To assess the quality of life in stroke patients by electrolytes such as sodium and potassium were
using Barthel Index Scale. examined to find out if there were any variations. The
➢ To analyse the management of hyponatremia in reference range for serum sodium is 135–145 mEq/L.
stroke patients. The recovery times of patients with mild, moderate,
➢ To analyse the management of hypertension in and severe strokes were studied. Patients in the study
stroke patients. were followed up with one month, two months, and
➢ To assess the degree of disability by using three months after discharge. Before beginning the
Modified Rankin Scale. study, informed written consent was obtained from the
patient or bystanders. Ethical clearance was obtained

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from the institutional ethical committee. Analysis of (28.6%), and the least was found in the age group 40-
the data was conducted using SPSS software version 50 years (17.1%).
26.
Increased age is a known risk factor for stroke. In our
SAMPLE SIZE study too, the occurrence of stoke increased with age.
The sample size was calculated with the help of a GENDER WISE DISTRIBUTION OF THE
statistician, and a total of 35 patients were included in PATIENTS
the study.
DATA COLLECTION TOOL:
GENDER
➢ Lourdes Mediware system
➢ Specially designed data collection form
➢ Barthel Index Scale Female
➢ Modified Rankin Scale 40%
Male
➢ National Institute Health Stroke Scale 60%
DATA COLLECTION
Patient data were gathered prospectively, which
comprised the demographics of the patient, chief
complaints on admission, past medical and medication
histories, lab parameters, and drug therapy during the Figure 1. Gender wise distribution
hospital stay; the transition of care; and pertinent lab Figure 1 shows that male patients are 60% more likely
parameters, including blood pressure, that were to have a stroke than female patients (40%). When we
extracted from the drug information centre, medical analysed our data, we observed that the majority of
records department, and Mediware software (hospital male patients consumed alcohol and were smokers.
data software). Smoking and excessive alcohol consumption are the
STATISTICAL ANALYSIS main risk factors for stroke.

The collected data were compiled using Microsoft CHARACTERISTICS OF STROKE

Excel and SPSS and presented using tables and graphs. Table 2 Characteristics of stroke
Calculation of mean and SD were done by using
statistical software and SPSS. Type of Stroke Hemisphere of Stroke
RESULT AND DISCUSSION Ischemi Left Right
Hemorrhag
c Hemisphe Hemisphe
DEMOGRAPHIC DETAILS OF THE PATIENTS ic Stroke
Stroke re re
ENROLLED IN THE STUDY n=35
n=35 n=35 n=35
77.1% 22.9% 57.1% 42.9%
AGE DISTRIBUTION OF PATIENTS
A total of 35 patients were included in the study. Their In our study, most of the patients were found to have
age distribution was as follows; ischemic stroke (77.1%) than hemorrhagic stroke
(22.9%). Other than this most of the patients had a
Age Frequency Percentage stroke on their left hemisphere (57.1%) than right
40-50 6 17.1% hemisphere (42.9%).
51-60 8 22.9% SOCIAL HISTORY
61-70 10 28.6%
>70 11 31.4% Table 3. Social history of patients
Total 35 100% Social History Frequency Percentage
Non-smokers/non
15 42.85
Table 1. Age wise distribution alcoholic
Alcoholic 8 22.85
The above table helps us understand the occurrence of Smoking 14 40
stroke in different age groups. In our study, the Alcoholic and
occurrence of stroke was seen highest among the age 4 11.42
smoking
group >70 years (31.4%), followed by 61-70 years

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In our study, we found that stroke can occur even in Figure 2: change in NIHSS between Admission
non-smokers and alcoholic patients (42.8%). The and discharge
sample population consists of 40% smokers, followed
by 22.85% alcoholics, and 11.42% of both alcoholics The percentage of patients who showed improvement
and smokers. in their stroke status from admission is 88.57%, and
those without improvement are 11.43%.

NIHSS Scale Patient Improvement Status

TIME PERIOD IN WHICH TREATMENT
RECEIVED AFTER ONSET OF SYMPTOMS
Table 4 Time of receiving treatment 11%

89%
Time of receiving
Frequency Percentage
treatment
Within 48 hrs. 22 62.9
After 48 hrs. 13 37.1 Total number of patients with improvement
Total 35 100
Patients doesn’t show any improvement

In our study, 62.9% of the patients received

treatment within 48 hours, and 37.1% received Figure 3: Status of patient improvement
treatment after 48 hours. The patients who
Table 6: Mean, S.D. and t value to assess the
received treatment as early as possible had good
improvement in NIHSS
improvements in their quality of life.
Signific
Mean
Me S. d ance
Test n Improve T
ASSESSMENT OF NIHSS SCALE an D. f (p-
ment
value)
Admis 12. 7.
The NIHSS scale is used to measure the severity sion 8 12 3 5. 3 p<
1.91
of stroke in patients. NIHSS was assessed during Discha 10. 6. 5 38 4 0.001*
admission and on discharge in our study. rge 89 69

The Mean column in the t test table displays the

admissions (12.8) and discharge (10.89) mean NIHSS
Table 5 Change in NIHSS between admission
and discharge scores. The Standard Deviation column displays the
standard deviation of the NIHSS scores. The mean
Admission Discharge improvement column is the difference between the
NIHSS
Freq. % Freq. % means of follow-up 1 and the last follow-up of the
Minor stroke 3 8.6% 5 14.3% study. Since the significance (p-value) is less than
Moderate stroke 19 54.3% 19 54.3%
0.001, we can conclude that the average improvement
Moderate to severe
10 28.6% 8 22.9% (1.91) in the NIHSS is significant. So, there is a highly
stroke
Severe stroke 3 8.6% 3 8.6% significant impact of medication on the change in
stroke level of the patients between admission and
discharge.
Change in NIHSS between admission and discharge
60.00% 54.30%54.30%
50.00%
40.00% MODIFIED RANKIN SCALE
28.60%
30.00% 22.90%
20.00% 14.30%
8.60% 8.60% 8.60% The modified Rankin scale (MRS) is used to measure
10.00%
0.00% the disability of the patients. We measured the
Minor stroke Moderate Moderate to Severe stroke modified Rankin scale on admission, discharge, and
stroke severe stroke
after one month, two months, and three months.
Admission Discharge

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Table 7: Patients follow up status Table 9: Mean, S.D. and t value to assess the
improvement in MRS
During During
Category Admission Discharge Signific
Percentage Percentage Mean
Me S. D ance
Mild Disability 11.4 14.3 Test n better T
an D. f (p-
Moderate ment
68.6 68.6 value)
Disability Admis 3.4 1.
Severe Disability 20.0 17.1 sion 9 09
Total 100 100 3 7. 3 p<
Last 1.08
2.4 1. 5 52 4 0.001*
follow
0 33
up
First Second Third
In the t test table, the Mean column displays the mean
Follow Follow Follow
Patient Up Up MRS scores of follow-up 1 and follow-up 2. The
Up Standard Deviation column displays the standard
Status n=35 n=31 n=26
deviation of the MRS scores. The mean improvement
Percenta Percenta Percenta
ge ge ge column is the difference between the means of follow-
Patients up 1 (3.49), and follow-up 2 (2.40) of the study.
With Since the significance (p-value) is less than 0.001, we
34.29 25.81 19.23
Improveme can conclude that the average improvement (1.08 in
nt the MRS) is significant. So, there is a highly
Patients significant impact of medication on the change in
Without
65.71 74.19 80.77 stroke level of the patients between admission and the
Improveme
nt last follow-up.
Total 100 100 100
BARTHEL INDEX SCALE
Table 8: Patients who showed improvement The Barthel index scale is used to measure the
improvements in activities of daily life. We measured
Patient Status Frequency Percentage
the Barthel index scale during admission, discharge,
Total patients with
24 68.57 and after one month, two months, and three months.
improvement
Total patients
11 31.43
without improvement On
Total 35 100 On
Admission Discharge
Category
n=35 n=35
MRS Patient Improvement Percentage Percentage
Independent in
Status 8.6 11.4
daily activities
Needs minimal
31% 31.4 40.0
69% help with ADL
Partially
22.9 14.3
dependent
Total number of patients with improvement Very dependent 14.3 11.4
Totally
Patients doesn’t show any improvement 22.9 22.9
dependent
Total 100 100
Figure 4: Patients who showed improvement
 STATISTICAL ANALYSIS

Change in Modified Rankin Scale between

admission and last follow up

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follow-up 2. The Standard Deviation column
First Third displays the standard deviation of the Barthel
Second Index scores. The mean improvement column is
Follow Follow Follow
Up Up the difference between the means of follow-up 1
Category Up (65.06) and follow-up 2 (46.43) of the study.
n=35 n=31 n=26
➢ Since the significance (p-value) is less than 0.001,
Percenta Percenta Percenta we can conclude that the average improvement
ge ge ge (18.62) in the Barthel Index is significant. So,
Patients there is a highly significant impact of medication
with on the change in stroke level of the patients
51.43 45.16 61.54
improveme between follow-up 1 and follow-up 2.
nt
Patients
without HYPERTENSION
48.57 54.84 38.46
improveme In our study, the majority of patients (69%) were
nt hypertensive, with only a few (31%) being non-
Total 100 100 100 hypertensive.

Table 10: Patients’ follow-up status Table 12: Patients with or without HTN
Percentage
Barthel Index Scale Patient Improvement Status Patients
n=35
n=35
With HTN 69%
Without HTN 31%
14%
Total 100%
86%

Table 13. Patients taking and not taking treatment

Total number of patients with improvement Patients Frequency Percentage

Patients doesn’t show any improvement
Taking Medication 21 88%
Not Taking
3 12%
Figure 5: Patients who showed improvement Medication
Total 24 100%
 STATISTICAL ANALYSIS
In our study, most of them were undergoing treatment
Change in Barthel Index Scale between follow up1 for HTN (88%), and few were not (12%).
and follow-up 2
Drug Consumption
Table 11: Mean, S.D. and t value to assess the (n=21)
5%
betterment in Barthel Index Scale 14%

Signific
Mean 81%
Me S. d ance
Test n better T
an D. f (p-
ment
value)
Follo ONE DRUG TWO DRUGS THREE DRUGS
65. 25.
w-up
06 5
1 3 7. 3 p<
18.62 Figure 6: Drug consumption
Follo 5 58 4 0.001*
46. 26. In our study, most of the patients were taking a single
w-up
43 4 drug (81%), whereas some were taking two drugs
2
(14%), and a few were taking three drugs (5%).
➢ The Mean column in the t-test table displays the
mean Barthel Index scores of follow-up 1 and  HYPERTENSION MANAGEMENT

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In our study, the most commonly used drug for Comparison of blood pressure on day 1 and day of
HTN was Telmisartan (62%), followed by Nifedipine discharge using
(14%), Cilnidipine (14%), Amlodipine (10%), Wilcoxon Signed Rank
Figure 7: Comparison of admission and discharge
Clonidine (10%), Losartan (5%), and Cilnidipine +
Telmisartan (5%). Table 16: Blood pressure changes
Table 14 Drugs used for the management of HTN
+ve -ve No Z- p-
N chang chang chang valu valu
Drug Frequency Percentage e e e e e
3.63 p<
Telmisartan 13 62% 35 19 2 14
5 0.01
Nifedipine 3 14%
Positive changes are the number of patients with
Cilnidipine 3 14% positive changes, i.e., the number of patients who have
Amlodipine 2 10% relief in BP. Since the majority of patients have
positive changes (19), the Z-value is 3.635, which is
Clonidine 2 10% significant with a p-value of 0.001. There is a
significant reduction in blood pressure on the day of
Losartan 1 5% discharge.
Cilnidipine+ 1 5%
Telmisartan HYPONATREMIA
Patients with hyponatremia (49%) and those without
 STATISTICAL ANALYSIS hyponatremia (51%), in our study, were found to be
Table 15: Blood Pressure Status roughly equal.

Table 17 Patients with or without

Blood Day 1 Day of discharge hyponatremia
Pressur Frequenc Percentag Frequenc Percentag
e y e y e Patients Frequency Percentage
<140/80 13 37.1% 24 68.6% With Hyponatremia 17 49%
141/81- Without
11 31.4% 11 31.4% 18 51%
160/100 Hyponatremia
161/101
Total 35 100%
- 5 14.3% 0 0.0%
180/120
181/121 Most of the patients were on single-drug therapy
- 5 14.3% 0 0.0% (65%), some were on two-drug therapy (23%), and
200/120 few were on triple-drug therapy (12%).
>201/12
1 2.9% 0 0.0%
1 Drug Consumption
Total 35 100 % 35 100 % (n=21)

Comparison of BP at Day 1 and at time of discharge 12%

<140/80 141/81-160/100 161/101-180/120 181/121-200/120 >201/121

23%
65%
80%
68.60%
70%
Percentage of patients

60%
50%
37.10%
40% 31.40% 31.40%
30% ONE DRUG TWO DRUGS THREE DRUGS
20% 14.30%14.30%
10% 2.90% 0.00% 0.00%0.00%
0%
Figure 8: Drug consumption
Day 1 Day of discharge
BP

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In our study, normal saline was given to most of the a pattern that, as age increases, the incidence of stroke
patients (88%), then oral salt (23%), 3% hypertonic also increases. The reason for increasing co-
saline (23%), and tolvaptan (12%), respectively. morbidities can be due to increasing age. Likewise,
males are more susceptible to stroke than females. The
reason might be that men consume larger amounts of
Table 18 Treatment of hyponatremia alcohol and smoke than women in our country. Most
of the patients reported ischemic strokes rather than
Treatment Frequency Percentage haemorrhagic strokes. A left-hemisphere stroke is
Normal Saline 15 88% more common than a right-hemisphere stroke. In our
sample population, most of the patients were smokers,
Oral Salt 4 23% and smoking as a risk factor for stroke was found to be
3% Hypertonic statistically significant. Similarly, alcohol as a risk
4 23% factor in stroke cases was also found to be highly
Saline
Tolvaptan 2 12% significant statistically. A statistically significant
association was found for both smoking and alcohol as
risk factors in the causation of stroke.
 STATISTICAL ANALYSIS
There are many modifiable and non-modifiable risk
factors for stroke. In our study, hypertension was
Changes in sodium level in follow-up 1 and identified in most of the patients. We can conclude that
follow-up 2 proper hypertension management can limit the
occurrence of strokes to a certain extent. In our study,
Table 19: Mean, S.D. and t value to assess the most of the patients showed improved BP on their
improvement in sodium levels follow-ups with its proper management. Most of the
patients were treated with telmisartan 40 mg.
Signifi Electrolyte imbalances are seen in most stroke
Mean
Me S. d cance patients. Hyponatremia was the most common among
Test N better t
an D. f (p- them. Most of the patients suffered from mild
ment
value) hyponatremia, and only a few suffered from severe
5. hyponatremia. Most of the patients were managed
Follow 135
5 with normal saline, and as the severity increased, oral
-up 1 .2
3 1.4 1 p< salt, 3% hypertonic saline, and tolvaptan were added,
17 2.706
2. 8 6 0.001* respectively. As a result, medication has a significant
Follow 132
9 impact on the change in sodium levels of the patients.
-up 2 .5
5
In our study, most of the patients showed improvement
in each follow-up confirmed by the scales NIHSS,
The Mean column in the t-test table displays the Barthel index and modified Rankin scale. The proper
mean sodium levels of follow-up 1 and follow-up management of stroke and other related co-morbidities
2. The Standard Deviation column displays the has an important role in the recovery of patients. From
standard deviation of the sodium levels. The mean the measurement of scales, we can conclude that the
improvement column is the difference between proper and systematic management of stroke has a
the means of follow-up 1 (135.2) and follow-up 2 great impact on recovery from stroke. Our study
(132.5) of the study. proves that recovery from a stroke is a time-
consuming process, highlighting the importance of
Since the significance (p-value) is less than creating awareness among patients about the
0.001, we can conclude that the average importance of proper management of stroke and
improvement (2.706) in sodium levels is related co-morbidities.
significant. So, there is a highly significant impact
of medication on the change in sodium levels of
the patients between follow-up 1 and follow-up 2. LIMITATION OF STUDY
➢ The long-term improvement in stroke patients
could not be assessed due to the study's short
CONCLUSION duration and small sample size.
In our study, we could conclude that elderly people
(>70 years) are more affected by stroke. We could see

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IJPPR (2023), Vol. 14, Issue 1 Research Article

➢ More studies need to be carried out to determine Gandhinagar, Gujarat. Int J Res Med Sci
the role of other risk factors such as diabetes 2014;2:1446-52
mellitus, physical activity, etc. in stroke.
➢ For the study, only one hospital was used. 7) Patne SV, Chintale KN. Study of clinical profile
of stroke patients in the rural tertiary health care
centre. Int J Adv Med 2016;3:666-70.
ACKNOWLEDGEMENT
8) Kumar A, Reza TA, Agrawal PK, Sonal S,
We express our sincere thanks to the most respected Chauhan S, Alam W, Kumar A, Dubey YK, Saif
guide, Naveen Kumar Paniker, assistant professor, SB, Kumar V, Rahman MB, Bhargav K, Kaifee
department of pharmacy practice, St. Joseph’s College M, Alam MT. An Observation of Risk Factors
of Pharmacy, Cherthala, and our consultant guide, Dr. Associated with Patients with Ischemic Stroke.
Vinod Varghese. M.B.B.S., M.D., D.N.B. [General Ann. Int. Med. Den. Res. 2016; 2(6): ME08-
Medicine] D.M., D.N.B. [Neurology], M.N.A.M.S. ME12.
[Neurology], F.R.C.P., F.E.B.N., and SCE
[Neurology] at Lourdes Hospital, Ernakulam, for the 9) Saleem S, Yousuf I, Gul A, Gupta S, Verma S.
inspiring guidance, valuable suggestions, effective Hyponatremia in stroke. Ann Indian AcadNeurol
criticisms, and constant support. We express our 2014;17:55-7
sincere gratitude to all who supported and helped in 10) Mittal M, Deepshikha, Khurana H. Profile of
the completion of the research. We believe that all hyponatremia in a tertiary care centre in North
those who have directly or indirectly contributed to India. Int J Adv Med 2016;3:1011-5.
this study, whom we have not mentioned personally, 11) Karunanandham S, Rajappa T, Selvaraju K.
are aware of our deep appreciation. Hyponatremia in Patients Admitted with Stroke.
Journal of Clinical & Diagnostic Research. 2018
Aug 1;12(8).
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IJPPR (2023), Vol. 14, Issue 1 Research Article

Josin Joseph

Image Author Affiliation: Pharm D Intern

Author -1 Author Address/Institute Address: St.

Joseph’s College of Pharmacy, Cherthala,
Kerala-688524, India.

Maria Thomas

Image Author Affiliation: Pharm D Intern

Author -1 Author Address/Institute Address: St.

Joseph’s College of Pharmacy, Cherthala,
Kerala-688524, India.

Hanna Rose Thomas

Image Author Affiliation: Pharm D Intern

Author -1 Author Address/Institute Address: St.

Joseph’s College of Pharmacy, Cherthala,
Kerala-688524, India.

Naveen Kumar Panicker – Corresponding

Author

Image Author Affiliation: Assistant Professor,

Department of Pharmacy Practice
Author -2
Author Address/Institute Address: St.
Joseph’s College of Pharmacy, Cherthala,
Kerala-688524, India.

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