Early Recovery and Functional Outcome are Related with Causal Stroke Subtype: Data from the Tinzaparin in Acute Ischemic Stroke Trial

Cilostazol and isosorbide mononitrate for the prevention of progression of cerebral small vessel disease: baseline data and statistical analysis plan for the Lacunar Intervention Trial-2 (LACI-2) (ISRCTN14911850)

BACKGROUND

Cerebral small vessel disease (SVD) causes lacunar strokes (25% of all ischaemic strokes), physical frailty and cognitive impairment and vascular and mixed dementia. There is no specific treatment to prevent progression of SVD.

METHODS

The LACunar Intervention Trial-2 is an investigator-initiated prospective randomised open-label blinded-endpoint phase II feasibility study assessing cilostazol and isosorbide mononitrate for preventing SVD progression. We aimed to recruit 400 patients with clinically evident lacunar ischaemic stroke and randomised to cilostazol, isosorbide mononitrate, both or neither, in addition to guideline secondary ischaemic stroke prevention, in a partial factorial design. The primary outcome is feasibility of recruitment and adherence to medication; key secondary outcomes include: drug tolerability; recurrent vascular events, cognition and function at 1 year after randomisation; and safety (bleeding, falls, death). Data are number (%) and median (IQR).

RESULTS

The trial commenced on 5 February 2018 and ceased recruitment on 31 May 2021 with 363 patients randomised, with the following baseline characteristics: average age 64 (56.0, 72.0) years, female 112 (30.9%), stroke onset to randomisation 79.0 (27.0, 244.0) days, hypertension 267 (73.6%), median blood pressures 143.0 (130.0, 157.0)/83.0 (75.0, 90.0) mm Hg, current smokers 67 (18.5%), educationally achieved end of school examinations (A-level) or higher 118 (32.5%), modified Rankin scale 1.0 (0.0, 1.0), National Institutes Health stroke scale 1.0 (1.4), Montreal Cognitive Assessment 26.0 (23.0, 28.0) and total SVD score on brain imaging 1.0 (0.0, 2.0). This publication summarises the baseline data and presents the statistical analysis plan.

SUMMARY

The trial is currently in follow-up which will complete on 31 May 2022 with results expected in October 2022.

TRIAL REGISTRATION NUMBER

ISRCTN14911850.

Top Ten Tips Palliative Care Clinicians Should Know About Strokes

Stroke is a common cause of long-term disability and death, which leaves many patients with significant and unique palliative care (PC) needs. Shared decision-making for patients with stroke poses distinct challenges due to the sudden nature of stroke, the uncertainty inherent in prognostication around recovery, and the common necessity of relying on surrogates for decision-making. Patients with stroke suffer from frequently underrecognized symptoms, which PC clinicians should feel comfortable identifying and treating. This article provides 10 tips for palliative clinicians to increase their knowledge and comfort in caring for this important population.

Effect of erroneous body-weight estimation on outcome of thrombolyzed stroke patients

Intravenously administered tissue plasminogen activator (IV-tPA), dose determined by patients' body-weight, remains the only approved drug treatment for acute ischemic stroke (AIS). Since a shorter onset-to-treatment time results in better functional outcome, treatment is often initiated according to the estimated or last-known body-weight of the patient. This approach may result in underdosing or overdosing of tPA. In this multicenter retrospective study, we evaluated the extent of error in tPA dosing in our AIS cohort and its impact on functional outcome and symptomatic intracranial hemorrhage (SICH). Consecutive AIS patients, receiving IV-tPA, dose determined by the estimated body-weight, at three tertiary centers between January and December 2017 were included. Collected data included information about demographics, cardiovascular risk factors, stroke subtype and National Institute of Health Stroke Scale (NIHSS) score. Estimated and measured body-weights were recorded. Modified Rankin scale (mRS) of 2 or more defined unfavorable outcome. The study included 150 patients. Median age was 64 -years (IQR 55-75) with male preponderance (67%) and median NIHSS score of 9 points (IQR 6-17). Mean measured weight of our study population was 58 (SD 13) kg. Median difference between actual and estimated body-weight was 3 kg (IQR 1.5-6). Difference was more than 10% in 35 (23.3%) patients. Good functional outcome (mRS 0-1) was achieved by 74 (49.3%) patients and 10 (6.8%) developed SICH. NIHSS (OR 1.288; 95% CI 1.157-1.435, p < 0.001) and large artery atherosclerosis (OR 5.878; 95% CI 1.929-17.910, p = 0.002) were independent predictors of unfavorable functional outcome. Our finding of the statistically insignificant 2.5-fold increase in poor outcomes among patients where the estimated and actual weight differed by more than 10% should be interpreted with caution due to the limited sample size. Significant difference occurs between estimated and actual body-weight in a considerable proportion of thrombolysed AIS patients. However, this discrepancy does not affect functional outcome or the risk of SICH.

Prognostic Factors for Long-Term Recovery of Homonymous Visual Field Defects After Posterior Circulation Ischemic Stroke

OBJECTIVES

Ischemic stroke (IS) is the main cause of homonymous visual field defects (HVFDs) in adults. Some reports suggest recovery even in late-phase strokes, but data is sparse. This study examines the frequency of long-term recovery from HVFDs in patients with posterior circulation infarction (POCI) and evaluates whether demographic or clinical characteristics are prognostic factors of perimetric recovery.

MATERIALS AND METHODS

Our study included patients with HVFDS due to POCI who had undergone 2 or more kinetic perimetric evaluations at least 6 months after the index IS. Clinical and imaging data were systematically reviewed and we performed univariate and multivariate logistic regression analyses to determine whether demographic, stroke etiology (TOAST classification), and initial perimetric patterns were prognostic factors of visual recovery occurring 6 months and beyond from POCI.

RESULTS

One hundred one patients with POCI were included. Median subject age was 60 years and 54.4% were female. After a median perimetric follow-up time of 13.5 months, spontaneous visual improvement was observed in 15.8% of patients. Prognostic factors for visual improvement were age < 50 years (OR 4.6; P = 0.093), POCI associated with hypercoagulable states (OR 12.3; P = 0.048), and vertebral artery dissection (OR 12.6; P = 0.048), while the presence of complete homonymous hemianopia was a negative predictor of recovery (OR 0.2; P = 0.048).

CONCLUSION

Partial visual recovery in HVFDs is observed even 6 months and beyond POCI. Age < 50 years and stroke etiology were predictors of recovery.

Relationship between first mobilization following the onset of stroke and clinical outcomes in patients with ischemic stroke in the general ward of a hospital: A cohort study

OBJECTIVE

The purpose of this study was to compare the effects of first mobilization following a stroke with independently performing the activities of daily living at discharge in acute phase ischemic stroke patients in a general ward of a hospital.

METHODS

A total of 158 patients with ischemic strokes were admitted to a general ward from June 1, 2014 to March 31, 2015. Of the 158 patients, 53 met the study's eligibility criteria. First mobilization was defined as the transfer of a patient from the bed to a wheelchair by a rehabilitation therapist. A favorable primary outcome at discharge was defined as a modified Rankin Scale score of < 3. The outcome was analyzed using the proportional hazards analysis and receiver operating characteristic curves.

RESULTS

The age of the participants was 78.2 ± 11.7 years, stroke severity evaluated by the National Institutes of Health Stroke Scale scores on admission was 14.3 ± 10.6 points, and first mobilization of this population was 6.4 ± 5.2 days. Thirteen [25%] patients had a favorable outcome. Hazards analysis showed a favorable outcome due to first mobilization (adjusted hazards ratio 0.80, 95% confidence interval 0.65-0.98; p < 0.05). The cutoff point for first mobilization to produce a favorable outcome was 6.5 days after the stroke onset (area under the curve 0.729; p < 0.05).

CONCLUSION

As seen in stroke units, early first mobilization is associated with improved clinical outcomes in ischemic stroke patients admitted to a general ward.

Role of Hyperintense Acute Reperfusion Marker for Classifying the Stroke Etiology

Purpose

The hyperintense acute reperfusion marker (HARM) is a delayed enhancement of the subarachnoid or subpial space observed on post-contrast fluid-attenuated inversion recovery (FLAIR) images and is associated with permeability changes to the blood–brain barrier in acute stroke. We investigated the relationship between HARM and stroke etiology based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. In addition, we evaluated the relationship between HARM and stroke locations with respect to vascular territories and anatomic compartments.

Materials and methods

We recruited 264 consecutive patients (109 women; mean age 68.63 years) who were diagnosed with acute ischemic stroke and underwent brain magnetic resonance imaging (MRI) including post-contrast FLAIR and DWI within 7 days of symptom onset from May 2015 to March 2016 for this retrospective study. Post-contrast FLAIR images were obtained 5 min after gadolinium administration. The mean time interval between the onset of stroke symptoms and MRI acquisition in total included patients was 18 h and 7 min (median 12 h and 57 min, range 2–127 h). We analyzed the overall incidence and distribution patterns of HARM in acute ischemic stroke cases and compared the relative incidence and distribution patterns of HARM between the subgroups of stroke etiology based on conventional TOAST classification. We obtained odds ratio (OR) of HARM in different stroke locations based on vascular territories and anatomical compartments. This study was approved by our institutional review board.

Results

Among the 264 patients, 67 (25.38%) patients were HARM positive and 197 (74.62%) patients were HARM negative. There was significant difference in HARM incidence among the stroke subgroups (p < 0.001). Small vessel occlusion (SVO) was associated with the HARM-negative group (p < 0.001), while large artery atherosclerosis (LAA) and cardioembolism (CE) were associated with the HARM-positive group (p = 0.001). Also, regional pattern of HARM on the same vascular territory as the acute infarction was dominantly demonstrated regardless of stroke etiology. The OR for HARM from middle cerebral artery (MCA) infarction was 1.868 [95% confidence interval (CI): 1.025–3.401]. The OR for HARM from cortical infarction was 9.475 (95% CI: 4.754–18.883) compared to other anatomic compartments.

Conclusion

The presence of the HARM was significantly associated with embolic infarctions including LAA and CE. Conversely, SVO was exclusively associated with the absence of the HARM. Second, MCA and cortical infarction showed a more pronounced HARM compared to infarctions at other vascular territories and anatomic compartments. According to the results in the current study, we speculate that the presence of HARM on post-contrast FLAIR images was associated with specific stroke causes especially in embolic causes.

Proof-of-Concept Randomized Trial of the Monoclonal Antibody GSK249320 Versus Placebo in Stroke Patients

Supplemental Digital Content is available in the text.

Background and Purpose—

One class of poststroke restorative therapy focuses on promoting axon outgrowth by blocking myelin-based inhibitory proteins such as myelin-associated glycoprotein. The purpose of the current study was to extend preclinical and clinical findings of GSK249320, a humanized monoclonal antibody to myelin-associated glycoprotein with disabled Fc region, to explore effects on motor outcomes poststroke.

Methods—

In this phase IIb double-blind, randomized, placebo-controlled study, patients at 30 centers with ischemic stroke 24 to 72 hours prior and gait deficits were randomized to 2 IV infusions of GSK249320 or placebo. Primary outcome measure was change in gait velocity from baseline to day 90.

Results—

A total of 134 subjects were randomized between May 2013 and July 2014. The 2 groups were overall well matched at baseline. The study was stopped at the prespecified interim analysis because the treatment difference met the predefined futility criteria cutoff; change in gait velocity to day 90 was 0.55±0.46 (mean±SD) in the GSK249320 group and 0.56±0.50 for placebo. Secondary end points including upper extremity function were concordant. The 2 IV infusions of GSK249320 were well tolerated. No neutralizing antibodies to GSK249320 were detected.

Conclusions—

GSK249320, within 72 hours of stroke, demonstrated no improvement on gait velocity compared with placebo. Possible reasons include challenges translating findings into humans and no direct evidence that the therapy reached the biological target. The antibody was well tolerated and showed low immunogenicity, findings potentially useful to future studies aiming to use a monoclonal antibody to modify activity in specific biological pathways to improve recovery from stroke.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01808261.

Functional Status and Disability in Patients After Acute Stroke: A Longitudinal Study

BACKGROUND

Stroke is a major public health problem.

OBJECTIVE

To use the Barthel Index to evaluate basic activities of daily living in stroke survivors and detect any predictors of functional outcome at 6 months after stroke.

METHODS

In an observational longitudinal study, data were gathered on consecutive patients admitted to the comprehensive stroke unit at Hospital San Pedro de Alcantara, Cáceres, Spain. Sociodemographic and clinical data were obtained prospectively at hospital admission and during follow-up 6 months later. Information on type of stroke, score on the Barthel Index, findings from the neurological evaluation, and other relevant data were collected.

RESULTS

Of 236 patients admitted, 175 participated in the study. Mean age was 69.60 (SD, 12.52) years, 64.6% were men, and mortality was 12.8%. Six months after experiencing a stroke, 84.8% of patients had returned to their own homes, 8.0% were institutionalized, and the others were residing at a family member's home. Scores on the Barthel Index 6 months after stroke correlated with baseline scores on the National Institute of Health Stroke Scale (r = -0.424; P < .001) and with depressive mood 6 months after stroke (r = -0.318; P < .001). Age was negatively associated with Barthel Index scores at the time of hospital discharge and 6 months after stroke.

CONCLUSIONS

Functional status 6 months after stroke was influenced by age, sex, stroke severity, type of stroke, baseline status, mood, and social risk. Comorbid conditions, socioeconomic level, and area of residence did not affect patients' functional status.

Recovery Potential After Acute Stroke

In acute stroke, the major factor for recovery is the early use of thrombolysis aimed at arterial recanalization and reperfusion of ischemic brain tissue. Subsequently, neurorehabilitative training critically improves clinical recovery due to augmention of postlesional plasticity. Neuroimaging and electrophysiology studies have revealed that the location and volume of the stroke lesion, the affection of nerve fiber tracts, as well as functional and structural changes in the perilesional tissue and in large-scale bihemispheric networks are relevant biomarkers of post-stroke recovery. However, associated disorders, such as mood disorders, epilepsy, and neurodegenerative diseases, may induce secondary cerebral changes or aggravate the functional deficits and, thereby, compromise the potential for recovery.

Neural function, injury, and stroke subtype predict treatment gains after stroke

OBJECTIVE

This study was undertaken to better understand the high variability in response seen when treating human subjects with restorative therapies poststroke. Preclinical studies suggest that neural function, neural injury, and clinical status each influence treatment gains; therefore, the current study hypothesized that a multivariate approach incorporating these 3 measures would have the greatest predictive value.

METHODS

Patients 3 to 6 months poststroke underwent a battery of assessments before receiving 3 weeks of standardized upper extremity robotic therapy. Candidate predictors included measures of brain injury (including to gray and white matter), neural function (cortical function and cortical connectivity), and clinical status (demographics/medical history, cognitive/mood, and impairment).

RESULTS

Among all 29 patients, predictors of treatment gains identified measures of brain injury (smaller corticospinal tract [CST] injury), cortical function (greater ipsilesional motor cortex [M1] activation), and cortical connectivity (greater interhemispheric M1-M1 connectivity). Multivariate modeling found that best prediction was achieved using both CST injury and M1-M1 connectivity (r(2) = 0.44, p = 0.002), a result confirmed using Lasso regression. A threshold was defined whereby no subject with >63% CST injury achieved clinically significant gains. Results differed according to stroke subtype; gains in patients with lacunar stroke were best predicted by a measure of intrahemispheric connectivity.

INTERPRETATION

Response to a restorative therapy after stroke is best predicted by a model that includes measures of both neural injury and function. Neuroimaging measures were the best predictors and may have an ascendant role in clinical decision making for poststroke rehabilitation, which remains largely reliant on behavioral assessments. Results differed across stroke subtypes, suggesting the utility of lesion-specific strategies.

Revised iScore to predict outcomes after acute ischemic stroke

The iScore is a validated tool to predict mortality and functional outcome after acute ischemic stroke. It incorporates stroke subtype according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification as one of its factors. However, the TOAST stroke subtype may not be easily determined without extensive investigations. We aimed to test if the stroke subtype can be substituted by the Oxfordshire Community Stroke Project (OCSP) classification. We applied the iScore and the revised iScore, in which the TOAST subtype was replaced by the OCSP classification, to patients admitted to a single hospital for acute ischemic stroke. Outcome measures included poor functional status (modified Rankin scale score, 3-6) at discharge and 3 months. The performance between the iScore and the revised iScore was assessed by determining the discrimination and calibration of the scores. We studied 3196 patients at the acute stage, and among them 2349 patients were available for the 3-month assessment. The discrimination of the revised iScore was comparable with the iScore for poor outcome at discharge (area under the receiver operating characteristic curve, .767 versus .775; P=.06) and at 3-month (.801 versus .810; P=.06). The correlation between the observed and the expected outcomes was high for both the iScore (Pearson correlation coefficient, .993 at discharge and .995 at 3 months; both P<.0001) and the revised iScore (.985 and .993, respectively; both P<.0001). The revised iScore reliably predicts clinical outcomes at discharge and 3 months for patients with acute ischemic stroke.

Racial and ethnic differences in outcomes in older patients with acute ischemic stroke

BACKGROUND

Little is known as to whether long-term outcomes of acute ischemic stroke (AIS) vary by race/ethnicity. Using the American Heart Association Get With The Guidelines-Stroke registry linked with Medicare claims data set, we examined whether 30-day and 1-year outcomes differed by race/ethnicity among older patients with AIS.

METHODS AND RESULTS

We analyzed 200 900 patients with AIS >65 years of age (170 694 non-Hispanic whites, 85.0%; 20 514 non-Hispanic blacks, 10.2%; 6632 Hispanics, 3.3%; 3060 non-Hispanic Asian Americans, 1.5%) from 926 US centers participating in the Get With The Guidelines-Stroke program from April 2003 through December 2008. Compared with whites, other racial and ethnic groups were on average younger and had a higher median score on the National Institutes of Health Stroke Scale. Whites had higher 30-day unadjusted mortality than other groups (white versus black versus Hispanic versus Asian=15.0% versus 9.9% versus 11.9% versus 11.1%, respectively). Whites also had higher 1-year unadjusted mortality (31.7% versus 28.6% versus 28.1% versus 23.9%, respectively) but lower 1-year unadjusted all-cause rehospitalization (54.7% versus 62.5% versus 60.0% versus 48.6%, respectively). After risk adjustment, Asian American patients with AIS had lower 30-day and 1-year mortality than white, black, and Hispanic patients. Relative to whites, black and Hispanic patients had higher adjusted 1-year all-cause rehospitalization (black: adjusted odds ratio, 1.28 [95% confidence interval, 1.21-1.37]; Hispanic: adjusted odds ratio, 1.22 [95% confidence interval, 1.11-1.35]), whereas Asian patients had lower odds (adjusted odds ratio, 0.83 [95% confidence interval, 0.74-0.94]).

CONCLUSIONS

Among older Medicare beneficiaries with AIS, there were significant differences in long-term outcomes by race/ethnicity, even after adjustment for stroke severity, other prognostic variables, and hospital characteristics.

Rivermead mobility index can be used to predict length of stay for elderly persons, 5 days after stroke onset

BACKGROUND

Recovery after acute stroke is expected to continue for a long time but is most rapid during the first few days after onset. Because the cost of hospital care is rising constantly, there is increasing pressure from various administrative bodies to reduce the duration of hospital stay. To select the optimal level of care for elderly patients with stroke-related disability, it is important to be aware of adequate discharge destinations and to have reliable predictors for the length of institutional stay (LOS) (ie in hospital or nursing home).

PURPOSE

The purpose of the study was to find feasible prognostic indicators for the LOS, to be used 5 days after acute stroke, in persons 65 years and older.

METHODS

One hundred fifteen consecutive persons, 65 years and older, were assessed 5 days poststroke for the following: consciousness (Glasgow Coma Scale), language (aphasia/no aphasia), perceptual (Cancellation Tasks and Block Test), emotional (lability/no lability), energy and drive (Montgomery-Åsberg Depression Scale), mental (Mini-Mental State Examination), somatosensory (normal/impaired), and urinary (continent/incontinent) functions; mobility (Rivermead mobility index [RMI]); activities of daily living (Barthel Index); and side of hemiplegia or hemiparesis. In addition, previous living arrangements (alone vs with another person), stroke characteristics, and demographic information were documented. Length of institutional stay was recorded 5 days to 3 months poststroke onset.

RESULTS

Multiple regression survival analyses showed that the factors with the greatest positive impact on short LOS, 5 days poststroke, were the following: no previous stroke; Glasgow Coma Scale ≥ 13 (mild brain injury); and RMI ≥ 4 points, corresponding to the ability to rise from a chair in less than 15 seconds and stand there for 15 seconds with or without an aid.

CONCLUSIONS

In addition to medical appraisal, the RMI ≥ 4 points, a quickly performed test, can be used to predict short LOS for persons with stroke as early as 5 days after stroke onset.

Cardioembolic but not other stroke subtypes predict mortality independent of stroke severity at presentation

Introduction. Etiology of acute ischemic stroke (AIS) is known to significantly influence management, prognosis, and risk of recurrence. Objective. To determine if ischemic stroke subtype based on TOAST criteria influences mortality. Methods. We conducted an observational study of a consecutive cohort of patients presenting with AIS to a single tertiary academic center. Results. The study population consisted of 500 patients who resided in the local county or the surrounding nine-county area. No patients were lost to followup. Two hundred and sixty one (52.2%) were male, and the mean age at presentation was 73.7 years (standard deviation, SD = 14.3). Subtypes were as follows: large artery atherosclerosis 97 (19.4%), cardioembolic 144 (28.8%), small vessel disease 75 (15%), other causes 19 (3.8%), and unknown 165 (33%). One hundred and sixty patients died: 69 within the first 30 days, 27 within 31–90 days, 29 within 91–365 days, and 35 after 1 year. Low 90-, 180-, and 360-day survival was seen in cardioembolic strokes (67.1%, 65.5%, and 58.2%, resp.), followed for cryptogenic strokes (78.0%, 75.3%, and 71.1%). Interestingly, when looking into the cryptogenic category, those with insufficient information to assign a stroke subtype had the lowest survival estimate (57.7% at 90 days, 56.1% at 180 days, and 51.2% at 1 year). Conclusion. Cardioembolic ischemic stroke subtype determined by TOAST criteria predicts long-term mortality, even after adjusting for age and stroke severity.

Quantitative EEG in ischemic stroke: correlation with infarct volume and functional status in posterior circulation and lacunar syndromes

OBJECTIVE

The significant impact of stroke on health care results in an unmet need for efficient stroke care in resources limited environments. Practical, inexpensive and easy to obtain predictive EEG parameters have been suggested in anterior circulation syndromes. We investigated whether EEG parameters are of additional predictive value with regard to lesion volume and short-term functional outcome in lacunar (LACS) and posterior circulation (POCS) syndromes of presumed ischemic origin.

METHODS

Sixty (60) patients presenting with LACS or POCS were incrementally included. EEG parameters were correlated with volume of ischemia and functional status. Predictive values for definite stroke and unfavourable outcome were calculated using receiver operating characteristic (ROC) curves and logistic regression modelling.

RESULTS

The pairwise derived brain symmetry index (pdBSI) emerged as independent predictor for definite stroke in patients presenting with LACS and POCS (odds ratio (OR) 2.69, 95% confidence interval (CI) 1.24-5.82, p=0.012) and in patients with a National Institutes of Health Stroke Scale (NIHSS) score of 0 at EEG recording (OR 7.67, 95% CI 1.24-47.32, p=0.026). In ROC analysis, the (delta+theta)/(alpha+beta) ratio (DTABR) predicted unfavourable outcome at day 7 with an accuracy of 83% in LACS but not in POCS. In logistic regression, unfavourable outcome in LACS was predicted by nominal NIHSS with marginal significance (OR 1.84, 95% CI 1.00-3.37, p=0.05), while in categorical modelling, DTABR>2.4 displayed a statistically significant ominous odd ratio of 13.00 (95% CI 1.11-152.35, p=0.041) with identical predicted and observed values.

CONCLUSIONS

EEG may be of additional value by confirming or excluding definite stroke after resolution of symptoms in lacunar and posterior circulation syndromes of presumed ischemic origin and prognosticating short-term functional status in lacunar syndrome.

SIGNIFICANCE

These findings may have an impact on stroke care.

Race/Ethnicity, Quality of Care, and Outcomes in Ischemic Stroke

Background— Prior studies suggest differences in stroke care associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program.

Methods and Results— We analyzed in-hospital mortality and 7 stroke performance measures among 397 257 patients admitted with ischemic stroke to 1181 hospitals participating in the Get With The Guidelines-Stroke program 2003 through 2008. Relative to white patients, black and Hispanic patients were younger and more often had diabetes mellitus and hypertension. After adjustment for both patient- and hospital-level variables, black patients had lower odds relative to white patients of receiving intravenous thrombolysis (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77 to 0.91), deep vein thrombosis prophylaxis (OR, 0.88; 95% CI, 0.83 to 0.92), smoking cessation (OR, 0.85; 95% CI, 0.79 to 0.91), discharge antithrombotics (OR, 0.88; 95% CI, 0.84 to 0.92), anticoagulants for atrial fibrillation (OR, 0.84; 95% CI, 0.75 to 0.94), and lipid therapy (OR, 0.91; 95% CI, 0.88 to 0.96), and of dying in-hospital (OR, 0.90; 95% CI, 0.85 to 0.95). Hispanic patients received similar care as their white counterparts on all 7 measures and had similar in-hospital mortality. Black (OR, 1.31; 95% CI, 1.28 to 1.35) and Hispanic (OR, 1.16; 95% CI, 1.11 to 1.20) patients had higher odds of exceeding the median length of hospital stay relative to whites. During the study, quality of care improved in all 3 race/ethnicity groups.

Conclusions— Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients. These differences could lead to increased risk of recurrent stroke. Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.