Association Between Immigration Status and Ambulatory Secondary Stroke Preventive Care in Ontario, Canada

BACKGROUND AND OBJECTIVES

Secondary stroke preventive care includes evaluation and control of vascular risk factors to prevent stroke recurrence. Our objective was to evaluate the quality of ambulatory stroke preventive care and its variation by immigration status in adult stroke survivors in Ontario, Canada.

METHODS

We conducted a population-based administrative database-derived retrospective cohort study in Ontario, Canada. Using immigration records, we defined immigrants as those immigrating after 1985 and long-term residents as those arriving before 1985 or those born in Canada. We included community-dwelling stroke survivors 40 years and older with a first-ever stroke between 2011 and 2017. In the year following their stroke, we evaluated the following metrics of stroke prevention: testing for hyperlipidemia and diabetes; among those with the condition, control of diabetes (hemoglobin A1c ≤7%) and hyperlipidemia (low-density lipoprotein <2 mmol/L); medication use to control hypertension, diabetes, and atrial fibrillation; and visit to a family physician and a specialist (neurologist, cardiologist, or geriatrician). We determined age and sex-adjusted absolute prevalence difference (APD) between immigrants and long-term residents for each metric using generalized linear models with binomial distribution and an identity link function.

RESULTS

We included 34,947 stroke survivors (median age 70 years, 46.9% women) of whom 12.4% were immigrants. The receipt of each metric ranged from 68% to 90%. Compared with long-term residents, after adjusting for age and sex, immigrants were slightly more likely to receive screening for hyperlipidemia (APD 5.58%; 95% CI 4.18-6.96) and diabetes (5.49%; 3.76-7.23), have visits to family physicians (1.19%; 0.49-1.90), receive a prescription for antihypertensive (3.12%; 1.76-4.49) and antihyperglycemic medications (9.51%; 6.46-12.57), and achieve control of hyperlipidemia (3.82%; 1.01-6.63). By contrast, they were less likely to achieve diabetes control (-4.79%; -7.86 to -1.72) or have visits to a specialist (-1.68%; -3.12 to -0.24). There was minimal variation by region of origin or time since immigration in immigrants.

DISCUSSION

Compared with long-term residents, many metrics of secondary stroke preventive care were better in immigrants, albeit with small absolute differences. However, future work is needed to identify and mitigate the factors associated with the suboptimal quality of stroke preventive care for all stroke survivors.

Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis

BACKGROUND

Percutaneous closure of a patent foramen ovale (PFO) or the left atrial appendage (LAA) are controversial procedures to prevent stroke but often used in clinical practice. We assessed the regional variation of these interventions and explored potential determinants of such a variation.

METHODS

We conducted a population-based analysis using patient discharge data from all Swiss hospitals from 2013-2018. We derived hospital service areas (HSAs) using patient flows for PFO and LAA closure. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). SCV values >5.4 indicate a high and >10 a very high variation. Because the evidence on the efficacy of PFO closure may differ in patients aged <60 years and ≥60 years, age-stratified analyses were performed. We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.

RESULTS

Overall, 2574 PFO and 2081 LAA closures from 10 HSAs were analyzed. The fully adjusted PFO and LAA closure rates varied from 3 to 8 and from 1 to 9 procedures per 100,000 persons per year across HSAs, respectively. The regional variation was high with respect to overall PFO closures (EQ 3.0, SCV 8.3) and very high in patients aged ≥60 years (EQ 4.0, SCV 12.3). The variation in LAA closures was very high (EQ 16.2, SCV 32.1). In multivariate analysis, women had a 28% lower PFO and a 59% lower LAA closure rate than men. French/Italian language areas had a 63% lower LAA closure rate than Swiss German speaking regions and areas with a higher proportion of privately insured patients had a 86% higher LAA closure rate. After full adjustment, 44.2% of the variance in PFO closure and 30.3% in LAA closure remained unexplained.

CONCLUSIONS

We found a high to very high regional variation in PFO closure and LAA closure rates within Switzerland. Several factors, including sex, language area, and insurance status, were associated with procedure rates. Overall, 30-45% of the regional procedure variation remained unexplained and most probably represents differing physician practices.

Effectiveness of a Health Education Program for Patients Who Had a Stroke and Their Caregivers by Controlling Modifiable Risk Factors to Reduce Stroke Recurrence in a Tertiary Hospital in Bangladesh: Protocol for a Randomized Controlled Trial

BACKGROUND

Stroke is a significant public health concern that causes severe and long-lasting disability. The recurrence of stroke is increasing due to lack of patients' knowledge and compliance with treatment to control modifiable risk factors and lifestyle changes. Health education can be an effective way to increase knowledge about behavioral changes in patients who had a stroke.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a health education program in Bangladesh for patients who had their first stroke and their family caregivers in order to reduce the recurrence of stroke by controlling modifiable risk factors.

METHODS

This is a parallel, open-label, prospective randomized controlled trial conducted at the National Institute of Neurosciences & Hospital in Dhaka, Bangladesh. We enrolled ≥18-year-old patients of both sexes who had a history of first stroke attack (transient ischemic attack, hemorrhagic stroke, lacunar stroke, atherothrombotic stroke, or cardioembolic stroke). We stratified patients into those aged <65 years and those aged ≥65 years and according to types of strokes for randomization. Our estimated sample size was 432. The intervention group receives face-to-face counseling on lifestyle modifications, blood pressure monitoring, and medication compliance-related health education during enrollment and monthly follow-ups. However, the control group receives only usual care from the hospital. The primary end point of this study is the reduction in the stroke recurrence rates at the end of the 12-month follow-up period. The secondary end points are to (1) assess the occurrence of all adverse events such as other cardiac events and all-cause mortality, (2) evaluate the status of the controlling modifiable risk factors such as blood pressure, glycated hemoglobin, and non-high-density lipoprotein cholesterol, (3) assess the knowledge related to stroke by using the investigator-developed questionnaire, (4) evaluate the lifestyle behavior related to stroke by using the investigator-developed questionnaire, (5) assess medication adherence, and (6) evaluate the quality of life of patients who had a stroke and their family caregivers. The evaluation points will be at baseline, 6 months, and 12 months for both groups.

RESULTS

Patients' enrollment started on October 2022, and follow-up will be completed in March 2024. A total of 432 participants were included in both the intervention (n=216) and control groups (n=216). This study was approved by the institutional review board and the ethics review board of the National Institute of Neurosciences & Hospital (IRB/NINSH/2022/151) on August 30, 2022.

CONCLUSIONS

Our health education program is expected to reduce the recurrence of stroke and improve the quality of life of patients who have had the first stroke. The results of this study will provide insights into the importance of health education for (self)-management and prevention of stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05520034; https://clinicaltrials.gov/ct2/show/NCT05520034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51178.

Effect of Virtual Reality Therapy on Quality of Life and Self-Sufficiency in Post-Stroke Patients

Background and Objectives: The consequences of stroke have a significant impact on self-sufficiency and health-related quality of life (HRQoL). Virtual reality (VR)-based rehabilitation has the potential to impact these modalities, but information on timing, volume, and intensity is not yet available. The aim of this randomized controlled trial (1:1) was to evaluate the impact of conventional rehabilitation combined with VR on self-care and domains of HRQoL in patients ≤6 months post-stroke. Materials and Methods: The intervention group completed a total of 270 min of conventional VR + rehabilitation sessions. The control group underwent conventional rehabilitation only. Primary assessments with the WHO disability assessment schedule 2.0 (WHODAS 2) questionnaire were conducted before rehabilitation (T0), after completion of the intervention (T1), and at the 4-week follow-up (T2); secondary outcomes included self-sufficiency and balance assessments. Results: Fifty patients completed the study (mean age 61.2 ± 9.0 years, time since stroke 114.3 ± 39.4 days). There were no statistically significant differences between the groups in WHODAS 2, self-sufficiency, and balance scores (p > 0.05). Conclusions: In the experimental group, there was a statistically significant difference in WHODAS 2, assessment of self-sufficiency, and balance scores before and after therapy (p < 0.05). VR appears to be a suitable tool to supplement and modify rehabilitation in patients after stroke.

Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention

BACKGROUND AND OBJECTIVES

Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA.

METHODS

In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model.

RESULTS

We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; p = 0.65) nor slope change (parameter estimate 0.30; p = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention.

DISCUSSION

The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

BACKGROUND

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

AIMS

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

SUMMARY OF REVIEW

Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

CONCLUSION

The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Medication non-adherence and associated factors among older adult stroke survivors in China

Aim: Medication non-adherence has remained a common and costly global health issue of growing importance among older adults. This study aims to determine the prevalence and associated factors related to medication non-adherence among older adult stroke survivors in China. Methods and results: In this cross-sectional study, a total of 402 older adult stroke survivors were recruited from three tertiary hospitals in China. The results of the survey showed that 61.4% exhibited medication non-adherence. The chances of medication non-adherence among older adult stroke survivors who had primary school or less educational levels were higher than those who had senior secondary and junior college educational levels [OR (95% CI) = 0.440(0.249, 0.778)] as well as those who had a bachelor's degree or above educational levels [OR (95%CI) = 0.367(0.202, 0.667)]. Moreover, the probability of medication non-adherence with 4-5 and ≥6 types of total prescription medications per day increased by 1.993 times [OR (95% CI) = 1.993(1.190, 3.339))] and 2.233 times [OR (95%CI) = 2.233(1.159, 4.300)], respectively, as compared to when there were ≤3 types. Furthermore, medication non-adherence decreased with the increase in health literacy scores (β = -0.641 (95% CI; (0.913, 0.965)) and BMQ specific-necessity scores (β = -0.131 (95% CI; 0.806, 0.995)). On the other hand, when the BMQ specific-concerns score increased by one unit, medication non-adherence increased by 11.1% [OR (95% CI) = 1.111(1.044, 1.182)]. Conclusion: The present study found that patient medication adherence among older adult stroke survivors in China is problematic and associated with educational levels, total prescribed drugs per day, beliefs about medication, and health literacy scores. This indicates that measures should be taken to enhance medication adherence among such higher-risk populations.

Antithrombotics prescription and adherence among stroke survivors: A systematic review and meta-analysis

OBJECTIVES

We aimed to investigate the prescription of antithrombotic drugs (including anticoagulants and antiplatelets) and medication adherence after stroke.

METHODS

We performed a systematic literature search across MEDLINE and Embase, from January 1, 2015, to February 17, 2022, to identify studies reporting antithrombotic medications (anticoagulants and antiplatelets) post stroke. Two people independently identified reports to include, extracted data, and assessed the quality of included studies according to the Newcastle-Ottawa scale. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

We included 453,625 stroke patients from 46 studies. The pooled proportion of prescribed antiplatelets and anticoagulants among patients with atrial fibrillation (AF) was 62% (95% CI: 57%-68%), and 68% (95% CI: 58%-79%), respectively. The pooled proportion of patients who were treated according to the recommendation of guidelines of antithrombotic medications from four studies was 67% (95% CI: 41%-93%). It was reported that 11% (95% CI: 2%-19%) of patients did not receive antithrombotic medications. Good adherence to antiplatelet, anticoagulant, and antithrombotic medications was 78% (95% CI: 67%-89%), 71% (95% CI: 57%-84%), and 73% (95% CI: 59%-86%), respectively.

CONCLUSION

In conclusion, we found that less than 70% of patients were prescribed and treated according to the recommended guidelines of antithrombotic medications, and good adherence to antithrombotic medications is only 73%. Prescription rate and good adherence to antithrombotic medications still need to be improved among stroke survivors.

Embolic stroke of undetermined source: beyond atrial fibrillation

INTRODUCTION

Embolic stroke of undetermined source (ESUS) accounts for 25% of all cerebral infarcts; only 30% are associated with paroxysmal atrial fibrillation (AF). Various biochemical, electrocardiographic, and echocardiographic findings may suggest left atrial damage and increased risk of embolism in the absence of clinically documented AF or atrial flutter. In this review, we analyse the available evidence on atrial cardiopathy or atrial disease, its involvement in ESUS, and its identification through electrocardiographic, echocardiographic, and serum markers and its possible therapeutic implications.

DEVELOPMENT

A systematic search was conducted on MEDLINE (PubMed) using the following MeSH terms: MeSH [ESUS]+[atrial cardiopathy]+[atrial fibrillation]+[interatrial block]+[treatment]. We selected what we considered to be the most useful original prospective or retrospective studies and systematic reviews. We then read the full texts of the articles and checked the references cited in each article. We analyse epidemiological and demographic variables of patients with ESUS, as well as recent evidence related to presentation and prognosis and factors associated with recurrence and mortality. We review the contribution of atrial cardiopathy diagnosis prior to the detection of AF and the clinical, electrocardiographic, and echocardiographic variables and the biochemical markers associated with its development and its potential contribution to cerebral embolism.

CONCLUSIONS

The systematic search of biochemical and electrocardiographic, and echocardiographic alterations can be useful to identify ESUS patients at higher risk of recurrence.

Embolic stroke of undetermined source: Beyond atrial fibrillation

INTRODUCTION

Embolic stroke of undetermined source (ESUS) accounts for 25% of all cerebral infarcts; only 30% are associated with paroxysmal atrial fibrillation (AF). Various biochemical, electrocardiographic, and echocardiographic findings may suggest left atrial damage and increased risk of embolism in the absence of clinically documented AF or atrial flutter. In this review, we analyse the available evidence on atrial cardiopathy or atrial disease, its involvement in ESUS, and its identification through electrocardiographic, echocardiographic, and serum markers and its possible therapeutic implications.

DEVELOPMENT

A systematic search was conducted on MEDLINE (PubMed) using the following MeSH terms: MeSH [ESUS]+[atrial cardiopathy]+[atrial fibrillation]+[interatrial block]+[treatment]. We selected what we considered to be the most useful original prospective or retrospective studies and systematic reviews. We then read the full texts of the articles and checked the references cited in each article. We analyse epidemiological and demographic variables of patients with ESUS, as well as recent evidence related to presentation and prognosis and factors associated with recurrence and mortality. We review the contribution of atrial cardiopathy diagnosis prior to the detection of AF and the clinical, electrocardiographic, and echocardiographic variables and the biochemical markers associated with its development and its potential contribution to cerebral embolism.

CONCLUSIONS

The systematic search of biochemical and electrocardiographic, and echocardiographic alterations can be useful to identify ESUS patients at higher risk of recurrence.

Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Water-based therapeutic exercise in stroke: a scoping review

PURPOSE

To (1) describe the state of the literature on water-based therapeutic exercise (WBTE) for people living with stroke, (2) describe the content and structure of interventions, (3) summarize the effects of interventions described in the literature, and (4) identify gaps in the literature limiting application and implementation.

MATERIALS AND METHODS

Scoping review methodology described by Arksey and O'Malley (2005) and Levac et al. (2010). Electronic databases were searched for articles with eligibility criteria including: (1) adult stroke survivors (18 years or older) of any type (ischemic/hemorrhagic) or stage (acute/chronic) in any setting, and (2) the study intervention involved WBTE to address a post-stroke deficit.

RESULTS

40 articles were included in this review. Five trials had a treatment control, 20 had an active comparison. Calculated intervention effect sizes demonstrated a strong effect of WBTE on balance and gait related outcomes in 80% of controlled and comparison trials.

CONCLUSIONS

This scoping review highlights common parameters of WBTE interventions and provides an inventory of the differences in the treatment approaches utilized in this population. Opportunities for future work include the development of a standardized treatment protocol, qualitative or mixed methodology research, and greater inclusion of more individuals with more severe stroke-related impairments. IMPLICATIONS FOR REHABILITATIONWater-based therapeutic exercise is an approach that may allow stroke survivors to carry out challenging activities in a safe and accessible environment.Water-based interventions for stroke survivors appear to have a beneficial impact on walking and balance.Given that an aquatic environment offers an opportunity for individuals with more significant physical impairments to carry out early practice of walking and balance related tasks, clinicians should explore the feasibility and effectiveness for this subset of stroke survivors.

Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option?

Purpose of Review

Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients.

Recent Findings

Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients.

Summary

IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.

Patent Foramen Ovale Closure Decreases the Incidence but Not the Size of New Brain Infarction on Magnetic Resonance Imaging: An Analysis of the REDUCE Trial

Background and Purpose

Randomized patent foramen ovale closure trials have used open-label end point ascertainment which increases the risk of bias and undermines confidence in the conclusions. The Gore REDUCE trial prospectively performed baseline and follow-up magnetic resonance imaging (MRIs) for all subjects providing an objective measure of the effectiveness of closure.

Methods

We performed blinded evaluations of the presence, location, and volume of new infarct on diffusion-weighted imaging of recurrent clinical stroke or new infarct (>3 mm) on T2/fluid attenuated inversion recovery from baseline to follow-up MRI at 2 years, comparing closure to medical therapy alone. We also examined the effect of shunt size and the development of atrial fibrillation on infarct burden at follow-up.

Results

At follow-up, new clinical stroke or silent MRI infarct occurred in 18/383 (4.7%) patients who underwent closure and 19/177 (10.7%) medication-only patients (relative risk, 0.44 [95% CI, 0.24–0.81], P=0.02). Clinical strokes were less common in closure patients compared with medically treated patients, 5 (1.3%) versus 12 (6.8%), P=0.001, while silent MRI infarcts were similar, 13 (3.4%) versus 7 (4.0%), P=0.81. There were no differences in number, volumes, and distribution of new infarct comparing closure patients to those treated with medication alone. There were also no differences of number, volumes, and distribution comparing silent infarcts to clinical strokes. Infarct burden was also similar for patients who developed atrial fibrillation and for those with large shunts.

Conclusions

The REDUCE trial demonstrates that patent foramen ovale closure prevents recurrent brain infarction based on the objective outcome of new infarcts on MRI. Only clinical strokes were reduced by closure while silent infarctions were similar between study arms, and there were no differences in infarct volume or location comparing silent infarcts to clinical strokes.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00738894.

Overview of Acute Ischemic Stroke Evaluation and Management

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Association Between Physical Activity and Mortality Among Community-Dwelling Stroke Survivors

BACKGROUND AND OBJECTIVE

To determine the relationship between physical activity (PA) and mortality in community-dwelling stroke survivors.

METHODS

The Canadian Community Health Survey was used to obtain self-reported PA across 4 survey years and was linked to administrative databases to obtain prior diagnosis of stroke and subsequent all-cause mortality. PA was measured as metabolic equivalents (METs) per week and meeting minimal PA guidelines was defined as 10 MET-h/wk. Cox proportional hazard regression models and restricted cubic splines were used to determine the relationship between PA and all-cause mortality in respondents with prior stroke and controls, adjusting for sociodemographic factors, comorbidities, and functional health status.

RESULTS

The cohort included 895 respondents with prior stroke and 97,805 controls. Adhering to PA guidelines was associated with lower hazard of death for those with prior stroke (adjusted hazard ratio [aHR] 0.46, 95% confidence interval [CI] 0.29-0.73) and controls (aHR 0.69, 95% CI 0.62-0.76). There was a strong dose-response relationship in both groups, with a steep early slope and the vast majority of associated risk reduction occurring between 0 and 20 MET-h/wk. In the group of stroke respondents, PA was associated with greater risk reduction in those <75 years of age (aHR 0.21, 95% CI 0.10-0.43) compared to those ≥75 years of age (aHR 0.68, 95% CI 0.42-1.12).

DISCUSSION

PA was associated with lower all-cause mortality in an apparent dose-dependent manner among those with prior stroke, particularly in younger stroke survivors. Our findings support efforts towards reducing barriers to PA and implementation of PA programs for stroke survivors in the community.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in community-dwelling survivors of stroke, adhering to physical activity guidelines was associated with lower hazard of death.

Impairment in Health-Related Quality of Life among Community-Dwelling Stroke Survivors

INTRODUCTION

Health utility instruments are increasingly being used to measure impairment in health-related quality of life (HRQoL) after stroke. Population-based studies of HRQoL after stroke and assessment of differences by age and functional domain are needed.

METHODS

We used the Canadian Community Health Survey linked with administrative databases to determine HRQoL using the Health Utilities Index Mark 3 (HUI3) among those with prior hospitalization or emergency department visit for stroke and compared to controls without stroke. We used multivariable linear regression to determine the difference in HUI3 between those with stroke and controls for the global index and individual attributes, with assessment for modification by age (<60, 60-74, and 75+ years) and sex, and we combined estimates across survey years using random effects meta-analysis.

RESULTS

Our cohort contained 1240 stroke survivors and 123,765 controls and was weighted to be representative of the Canadian household population. Mean health utility was 0.63 (95% confidence interval [CI] 0.58, 0.68) for those with stroke and 0.83 (95% CI 0.82, 0.84) for controls. There was significant modification by age, but not sex, with the greatest adjusted reduction in HUI3 among stroke respondents aged 60-74 years. Individual HUI3 attributes with the largest reductions in utility among stroke survivors compared to controls were mobility, cognition, emotion, and pain.

CONCLUSIONS

In this population-based study, the reduction in HUI3 among stroke survivors compared to controls was greatest among respondents aged 60-74, and in attributes of mobility, cognition, emotion, and pain. These results highlight the persistent impairment of HRQoL in the chronic phase of stroke and potential targets for community support.

Cilostazol Versus Aspirin for Secondary Stroke Prevention: Systematic Review and Meta-Analysis

OBJECTIVES

Cilostazol has promise as an alternative to aspirin for secondary stroke prevention given its vasodilatory and anti-inflammatory properties in addition to platelet aggregation inhibition. We aimed to conduct a systematic review and meta-analysis to estimate the efficacy and safety of cilostazol compared to aspirin for stroke prevention in patients with previous stroke or transient ischemic attack (TIA).

MATERIALS AND METHODS

We searched PubMed and the Cochrane Central Register of Controlled Trials from 1996 to 2019. Randomized clinical trials that compared cilostazol to aspirin and reported the endpoints of ischemic stroke, intracranial hemorrhage and any bleeding were included. A random-effects estimate was computed based on the Mantel-Haenszel method. The pooled risk estimates with 95% confidence intervals were compared between cilostazol and aspirin.

RESULTS

The search identified 5 randomized clinical trials comparing cilostazol vs. aspirin for secondary stroke prevention that collectively enrolled 7240 patients, all from Asian countries (3615 received cilostazol and 3625 received aspirin). Pooled results from the random-effects model showed that cilostazol was associated with significantly lower risk of recurrent ischemic stroke (RR 0.68; 95% CI, 0.54 to 0.87), intracranial hemorrhage (RR 0.42; 95% CI, 0.27 to 0.65) and any bleeding (RR 0.71; 95% CI, 0.55 to 0.91).

CONCLUSIONS

This meta-analysis suggests that cilostazol is more effective than aspirin in preventing recurrent ischemic stroke with lower risk of intracranial hemorrhage and other bleeding. Since all trials to date are from Asian countries, confirmatory trials of cilostazol for secondary stroke prevention in other populations are needed.

Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis

BACKGROUND

Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria.

METHODS

A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations.

RESULTS

The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses.

CONCLUSION

Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.

A pilot randomized controlled trial comparing online versus face-to-face delivery of an aphasia communication partner training program for student healthcare professionals

BACKGROUND

Training conversation partners of people with aphasia who use facilitative communication strategies is one method that can improve access to healthcare for people with aphasia. However, the efficacy of communication partner training (CPT) has been investigated almost exclusively in the context of face-to-face (F2F) delivery. Online training may offer more cost-effective and accessible options to a wider range of conversation partners, including student healthcare professionals.

AIMS

To conduct a pilot randomized controlled trial with student healthcare professionals comparing (1) an online aphasia CPT program, (2) a F2F CPT program and (3) no program (control group) on outcomes relating to attitudes and knowledge of aphasia.

METHODS & PROCEDURES

A 45-min introductory aphasia CPT program was developed using the theories and techniques of Supported Conversations for Adults with Aphasia (SCA)™. A total of 30 first-year undergraduates studying occupational therapy at The University of Sydney were randomly allocated to one of three conditions: online CPT delivery, F2F delivery or delayed training control (no program). Outcomes measures included pre-post-testing with the Aphasia Attitudes, Strategies and Knowledge (AASK) survey.

OUTCOMES & RESULTS

A significant difference existed for the AASK survey pre-post-change scores between the online, F2F and control groups (χ² (2) = 20.038, p = 0.000). Post-hoc analysis revealed that, compared with the control (Ctrl) group, participants in both the online and F2F groups had significantly higher knowledge of aphasia (Online versus Ctrl: p = 0.000; F2F versus control: p = 0.002), knowledge of facilitative strategies (Online versus Ctrl: p = 0.000; F2F versus Ctrl: p = 0.002), and positive attitudes towards aphasia (Online versus Ctrl: p = 0.031; F2F versus Ctrl: p = 0.032). No significant difference was observed between the online and F2F groups for the Total or any subtotals (p = 1.000).

CONCLUSIONS AND IMPLICATIONS

The results from this pilot randomized controlled trial indicate that online delivery of the 45-min introductory CPT is equally as efficacious as F2F delivery, and thus may be a viable mode of delivery for future aphasia CPT programs. These pilot results pave the way for a larger study that will comprehensively evaluate the efficacy of an online aphasia CPT program for improving attitudes, knowledge and skills in a broad range of student healthcare professionals. What this paper adds What is already known on this subject The efficacy of F2F CPT for aphasia is well established. Online delivery of CPT programs may offer more cost-effective and accessible services when compared with F2F approaches; however, there is a need to explore the efficacy of online programs. What this paper adds to existing knowledge The 45-min online aphasia CPT program was found to be efficacious for improving student healthcare professionals' knowledge and attitudes towards aphasia and communication, and produced equally successful outcomes when compared with F2F delivery. This is the first study to report the efficacy of an online CPT program that is aligned with SCA for use with student healthcare professionals that also uses a self-report outcome measure with validated psychometric properties. What are the potential or actual clinical implications of this work? Online CPT programs may be useful in both clinical and education contexts to support improved efficiency of services and to enhance communication environments for people with aphasia in healthcare contexts.

White matter tract microstructure and cognitive performance after transient ischemic attack

BACKGROUND AND PURPOSE

Patients with transient ischemic attack (TIA) show evidence of cognitive impairment but the reason is not clear. Measurement of microstructural changes in white matter (WM) using diffusion tensor imaging (DTI) may be a useful outcome measure. We report WM changes using DTI and the relationship with neuropsychological performance in a cohort of transient ischemic attack (TIA) and non-TIA subjects.

METHODS

Ninety-five TIA subjects and 51 non-TIA subjects were assessed using DTI and neuropsychological batteries. Fractional anisotropy (FA) and mean diffusivity (MD) maps were generated and measurements were collected from WM tracts. Adjusted mixed effects regression modelled the relationship between groups and DTI metrics.

RESULTS

Transient ischemic attack subjects had a mean age of 67.9 ± 9.4 years, and non-TIA subjects had a mean age 64.9 ± 9.9 years. The TIA group exhibited higher MD values in the fornix (0.36 units, P < 0.001) and lower FA in the superior longitudinal fasciculus (SLF) (-0.29 units, P = 0.001), genu (-0.22 units, P = 0.016), and uncinate fasciculus (UF) (-0.26 units, P = 0.004). Compared to non-TIA subjects, subjects with TIA scored lower on the Addenbrooke's Cognitive Assessment-Revised (median score 95 vs 91, P = 0.01) but showed no differences in scores on the Montreal Cognitive Assessment (median 27 vs 26) or the Mini-Mental State Examination (median 30). TIA subjects had lower scores in memory (median 44 vs 52, P < 0.01) and processing speed (median 45 vs 62, P < 0.01) but not executive function, when compared to non-TIA subjects. Lower FA and higher MD in the fornix, SLF, and UF were associated with poorer performance on tests of visual memory and executive function but not verbal memory. Lower FA in the UF and fornix were related to higher timed scores on the TMT-B (P < 0.01), and higher SLF MD was related to higher scores on TMT-B (P < 0.01), confirming worse executive performance in the TIA group.

CONCLUSIONS

DTI scans may be useful for detecting microstructural disease in TIA subjects before cognitive symptoms develop. DTI parameters, white matter hyperintensities, and vascular risk factors underly some of the altered neuropsychological measures in TIA subjects.

Nurse Led Smartphone Electrographic Monitoring for Atrial Fibrillation after Ischemic Stroke: SPOT-AF

BACKGROUND AND PURPOSE

Paroxysmal atrial fibrillation (PAF) underlying acute stroke frequently evades detection by standard practice, considered to be a combination of routine electrocardiogram (ECG) monitoring, and 24-hour Holter recordings. We hypothesized that nurse-led in-hospital intermittent monitoring approach would increase PAF detection rate.

METHODS

We recruited patients hospitalised for stroke/transient ischemic attack, without history of atrial fibrillation (AF), in a prospective multi-centre observational study. Patients were monitored using a smartphone-enabled handheld ECG (iECG) during routine nursing observations, and underwent 24-hour Holter monitoring according to local practice. The primary outcome was comparison of AF detection by nurse-led iECG versus Holter monitoring in patients who received both tests: secondary outcome was oral anticoagulant commencement at 3-month following PAF detection.

RESULTS

One thousand and seventy-nine patients underwent iECG monitoring: 294 had iECG and Holter monitoring. AF was detected in 25/294 (8.5%) by iECG, and 8/294 (2.8%) by 24-hour Holter recordings (P<0.001). Median duration from stroke onset to AF detection for iECG was 3 days (interquartile range [IQR], 2 to 6) compared with 7 days (IQR, 6 to 10) for Holter recordings (P=0.02). Of 25 patients with AF detected by iECG, 11 were commenced on oral anticoagulant, compared to 5/8 for Holter. AF was detected in 8.8% (69/785 patients) who underwent iECG recordings only (P=0.8 vs. those who had both iECG and 24-hour Holter).

CONCLUSIONS

Nurse-led in-hospital iECG surveillance after stroke is feasible and effective and detects more PAF earlier and more frequently than routine 24-hour Holter recordings. Screening with iECG could be incorporated into routine post-stroke nursing observations to increase diagnosis of PAF, and facilitate institution of guideline-recommended anticoagulation.

Regional Variation in Transient Ischemic Attack and Minor Stroke in Alberta Emergency Departments

Background and Purpose—

Multiple studies have shown the 90-day risk of stroke following an emergency department (ED) diagnosis of transient ischemic attack (TIA) or minor stroke is significant, with the greatest risk of recurrence being within the first 24 to 48 hours following initial symptom onset. This study explored regional differences in ED disposition, neuroimaging, and subsequent 90-day stroke risk of patients diagnosed with TIA or minor stroke in Alberta.

Methods—

We used administrative databases to identify ED visits, neuroimaging, and 90-day return visits for TIA or minor stroke in Alberta from April 2011 to March 2016 among adults ≥20 years of age and stratified them based on regions of presentation (Edmonton, Calgary, or nonmajor urban).

Results—

During the 5-year study period, 22 421 patients had index ED visits for TIA or minor stroke. All 3 regions had a similar number of ED visits for TIA/minor stroke; however, on index ED visit, Calgary had a higher proportion of computed tomographic angiography imaging (48.8%; P <0.0001) compared with Edmonton (6.7%) and nonmajor urban region (5.7%) and higher proportion of discharged patients (83%; P <0.0001) compared with Edmonton (77.7%) and nonmajor urban region (73.5%). The risk of admission for stroke within 90 days of discharge after index ED visit for TIA/minor stroke in Calgary (3.4%) was lower than Edmonton (4.5%) and the nonmajor urban region (4.6%; P =0.002).

Conclusions—

This study demonstrates regional variation in computed tomographic angiography for neurovascular imaging of patients presenting to the ED for TIA/minor stroke and a possible association with frequency of index visit admission and 90-day readmission for the same problem.

Value of routine echocardiography in the management of stroke

BACKGROUND

Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention.

METHODS

We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression.

RESULTS

Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram.

INTERPRETATION

Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke.

Secondary Stroke Prevention: A Population-Based Cohort Study on Anticoagulation and Antiplatelet Treatments, and the Risk of Death or Recurrence

Using claims databases of a public healthcare program (Quebec) for the years 2010-2013, we conducted a cohort study of patients with acute ischemic stroke (AIS) to describe secondary prevention treatments and determine how they stood against practice guidelines. We compared the risk of death or AIS recurrence over 1 year in patients treated with anticoagulants, antiplatelets, and/or other cardiovascular drugs. In the month after discharge, 44.3% of the patients did not receive the recommended treatment and > 20% did not have any treatment. Untreated patients were younger, had less comorbidities, and a more severe AIS. Anticoagulants and antiplatelets were associated with a reduced risk of death or recurrence (hazard ratio (HR) 0.27; 95% confidence interval (CI) 0.20-0.36 and HR 0.25; 95% CI 0.16-0.38, respectively) compared with the untreated group. Effect size was similar for the other treatments. Findings confirm treatment benefits shown in clinical trials and emphasize the importance of AIS secondary prevention.

Endovascular treatment for ischemic stroke beyond the time window: A meta-analysis

Currently, endovascular treatment has been proven to be effective when conducted within 6 hours of symptom onset. However, when patients have symptoms for more than 6 hours, have a daytime-unwitnessed stroke (DUS) or wake up with a stroke (wake-up stroke, WUS), the safety and efficacy of endovascular treatment need to be further elucidated. Therefore, we performed a systematic review and meta-analysis to compare the clinical outcomes of endovascular treatment in patients with ischemic stroke beyond the time window with that ≤6 hours. PubMed, EMBASE, and Ovid MEDLINE were searched from inception to November 2018. The following outcomes were evaluated by a random-effects model: efficacy outcomes, that is, functional independence and successful recanalization, and safety outcomes, that is, symptomatic intracranial hemorrhage and mortality. Subgroup analyses were also performed to examine whether patient or study characteristics were associated with the outcomes. Nine observational studies, including 5192 patients (1414 patients with extended time windows [ETWs]; 3778 patients ≤6 hours), were eligible for analysis. The overall analysis demonstrated that the functional independence was worse in patients with ETWs vs those ≤6 hours (OR, 0.78; 95% CI, 0.68-0.90, P = .0006). However, subgroup analysis showed that there was no significant difference in functional independence between the two groups when patients were selected for a perfusion mismatch by imaging (OR, 1.00; 95% CI, 0.70-1.43, P = 1.000). Therefore, compared with a window ≤6 hours, endovascular treatment with ETWs for ischemic stroke may not result in poor outcomes when patients are typically selected by perfusion techniques.

Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study

BACKGROUND

First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario.

METHODS

Using linked administrative databases, we identified annual cohorts of people aged 20-105 years in Ontario with prevalent diabetes between Apr. 1, 1995, and Mar. 31, 2015. We identified Status First Nations people in Ontario from the Indian Register. We compared age- and sex-standardized rates of hospital admission for stroke or TIA, processes of care and case fatality among First Nations versus other people in Ontario with diabetes.

RESULTS

Overall, 28 874 people with diabetes (of whom 536 were First Nations people) were admitted to hospital with a stroke or TIA between Apr. 1, 2011, and Mar. 31, 2016. Admission rates for stroke or TIA declined over the study period but were higher among First Nations people than other Ontarians in most years after 2005/06. First Nations people admitted with stroke or TIA were as likely as other Ontarians to undergo neuroimaging within 24 hours (94.6% v. 96.0%), be discharged to inpatient rehabilitation (31.8% v. 34.8%) and receive carotid revascularization (1.4% v. 2.7%), but were less likely to receive thrombolysis (6.3% v. 11.0%). Age- and sex-standardized stroke case fatality was similar in First Nations people and other Ontarians at 7 days (12.0% v. 8.5%), 30 days (19.2% v. 16.0%) and 1 year (33.8% v. 28.1%).

INTERPRETATION

Rates of hospital admission for stroke or TIA were higher among First Nations people than other people with diabetes in Ontario. Future work should focus on determining Indigenous-specific determinants of health related to this disparity and implementing appropriate interventions to mitigate the risks and sequelae of stroke in First Nations people.

Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation

Patients with atrial fibrillation (AF) who suffer an acute ischemic stroke are at risk for both hemorrhagic transformation and recurrent ischemic stroke in the acute post-stroke period. Oral anticoagulants are recommended for secondary stroke prevention in patients with AF. The optimal time to initiate anticoagulant therapy after acute ischemic stroke in patients with AF is uncertain. There is concern that early initiation increases the risk of hemorrhagic transformation, whereas delayed initiation leaves the patient at risk for recurrent ischemic stroke. In this article, we provide a review of the risk of hemorrhagic transformation of acute ischemic stroke as well as review the literature and major guidelines addressing the timing of anticoagulation initiation after an acute ischemic stroke in patients with AF. Relevant articles published from 1990 to the present were identified using the PubMed and Embase databases. The majority of available literature is observational data. Large ischemic lesions, cerebral microbleeds, thrombolytic therapy, and other clinical factors may increase the risk of hemorrhagic transformation of an acute ischemic stroke. Parenteral anticoagulation within 48 hours is associated with an increased risk of hemorrhagic transformation and is not recommended. Insufficient data exist to support the safety of routine oral anticoagulant (direct oral anticoagulants or warfarin) initiation within 48 hours of an acute ischemic stroke. Direct oral anticoagulant initiation within 2 days of an acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation. Infarct size and presence of hemorrhage are important factors in identifying the optimal time to initiation and should guide decisions when available. A recommended framework for patient decision making is provided. Randomized controlled trials in this area are needed to identify the optimal timing of anticoagulation initiation, and such trials are under way.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Adherence to recommendations and clinical outcomes of patients hospitalized for stroke: the role of the admission ward-a real-life investigation from Italy

OBJECTIVE

To determine whether out-of-hospital healthcare and adverse outcomes are better in stroke patients admitted to a neurology ward compared with those admitted to general wards.

METHODS

Beneficiaries of the National Health Service from the Italian Lombardy Region who were discharged alive after hospital admission during the year 2009 for ischemic stroke (9776 patients) or intracerebral or subarachnoid hemorrhage (1102 patients) entered into the cohort and were followed until 2012. Exposure of interest was the ward type where inpatients were admitted (neuro vs. general wards). Outcomes were out-of-hospital healthcare (i.e., drug prescriptions, diagnostic procedures, and laboratory clinical evaluations) and adverse clinical outcomes (i.e., all-cause death and hospital readmission). Exposure-outcome associations were investigated. High-dimensional propensity score methodology was used for taking into account confounders. Mediation analysis was used to verify whether the association between ward type and clinical outcomes is mediated by out-of-hospital adherence to healthcare.

RESULTS

Better adherence to out-of-hospital healthcare received from patients discharged from neuro, rather than general, wards was observed being the proportions of adherent patients 42.4% and 39.5%, respectively. Compared with general wards, discharge from neuro was associated with reduced 3-year emergency admissions (from 50.1 to 47.5% among ischemic stroke patients) and reduced 3-year mortality (from 37.5 to 27.0% among hemorrhagic stroke patients). From 10 to 15% of outcome risk, reductions were mediated by better adherence to out-of-hospital healthcare.

CONCLUSIONS

For patients with acute ischemic and hemorrhagic stroke, admission to neuro vs. general wards is associated with better out-of-hospital healthcare and long-term adverse outcomes.

Longitudinal Brain Atrophy Rates in Transient Ischemic Attack and Minor Ischemic Stroke Patients and Cognitive Profiles

Introduction: Patients with transient ischemic attack (TIA) and minor stroke demonstrate cognitive impairment, and a four-fold risk of late-life dementia. Aim: To study the extent to which the rates of brain volume loss in TIA patients differ from healthy controls and how they are correlated with cognitive impairment. Methods: TIA or minor stroke patients were tested with a neuropsychological battery and underwent T1 weighted volumetric magnetic resonance imaging scans at fixed intervals over a 3 years period. Linear mixed effects regression models were used to compare brain atrophy rates between groups, and to determine the relationship between atrophy rates and cognitive function in TIA and minor stroke patients. Results: Whole brain atrophy rates were calculated for the TIA and minor stroke patients; n = 38 between 24 h and 18 months, and n = 68 participants between 18 and 36 months, and were compared to healthy controls. TIA and minor stroke patients demonstrated a significantly higher whole brain atrophy rate than healthy controls over a 3 years interval (p = 0.043). Diabetes (p = 0.012) independently predicted higher atrophy rate across groups. There was a relationship between higher rates of brain atrophy and processing speed (composite P = 0.047 and digit symbol coding P = 0.02), but there was no relationship with brain atrophy rates and memory or executive composite scores or individual cognitive tests for language (Boston naming, memory recall, verbal fluency or Trails A or B score). Conclusion: TIA and minor stroke patients experience a significantly higher rate of whole brain atrophy. In this cohort of TIA and minor stroke patients changes in brain volume over time precede cognitive decline.

Retrospective evaluation of a clinical decision support tool for effective computed tomography angiography utilization in urgent brain imaging of suspected TIA/minor stroke in the emergency department

OBJECTIVES

The Canadian Stroke Best Practice Recommendations suggests that patients suspected of transient ischemic attack (TIA)/minor stroke receive urgent brain imaging, preferably computed tomography angiography (CTA). Yet, high requisition rates for non-cerebrovascular patients overburden limited radiological resources, putting patients at risk. We hypothesize that our clinical decision support tool (CDST) developed for risk stratification of TIA in the emergency department (ED), and which incorporates Canadian guidelines, could improve CTA utilization.

METHODS

Retrospective study design with clinical information gathered from ED patient referrals to an outpatient TIA unit in Victoria, BC, from 2015-2016. Actual CTA orders by ED and TIA unit staff were compared to hypothetical CTA ordering if our CDST had been used in the ED upon patient arrival.

RESULTS

For 1,679 referrals, clinicians ordered 954 CTAs. Our CDST would have ordered a total of 977 CTAs for these patients. Overall, this would have increased the number of imaged-TIA patients by 89 (10.1%) while imaging 98 (16.1%) fewer non-cerebrovascular patients over the 2-year period. Our CDST would have ordered CTA for 18 (78.3%) of the recurrent stroke patients in the sample.

CONCLUSIONS

Our CDST could enhance CTA utilization in the ED for suspected TIA patients, and facilitate guideline-based stroke care. Use of our CDST would increase the number of TIA patients receiving CTA before ED discharge (rather than later at TIA units) and reduce the burden of imaging stroke mimics in radiological departments.

Systematic review and meta-analysis of perioperative and long-term outcomes in patients receiving statin therapy before carotid endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is associated with perioperative stroke and mortality in a minority of cases. The aim of this systematic review and meta-analysis was to investigate the effect of pre-operative statins on perioperative outcomes in patients undergoing CEA for internal carotid artery (ICA) stenosis.

METHODS

A systematic review of PubMed, Medline, and the Cochrane Database of Systematic Reviews was performed. Studies were included which reported perioperative stroke and/or survival outcomes following CEA for ICA stenosis and compared patients who were and were not taking pre-operative statins. Relevant data were extracted and pooled using meta-analysis.

RESULTS

Seven studies met the inclusion criteria, comprising 21,387 patients. A total of 68.9% (14,976) were administered statins and 31.1% (6657) were statin-free. Pre-operative statin use was higher in patients with a history of cardiac disease (12.2 vs. 23.6% in the statin-free group), diabetes (31.6 vs. 25.1% in the statin-free group), and hypertension (83.5 vs. 72.2% in the statin-free group), while a greater proportion of statin-free patients had symptomatic disease (44.9 vs. 55.5% in the statin-free group). Statins were associated with reduced perioperative stroke in all patients (OR 0.57; 95% CI 0.34-0.95; p = 0.03) and in symptomatic patients (OR 0.57; 95% CI 0.35-0.93; p = 0.03). A trend towards lower perioperative mortality (OR 0.54; 95% CI 0.29, 1.03; p = 0.06) and significantly improved overall survival was observed in the statin group (HR 0.69; 95% CI 0.59-0.81; p < 0.001) at a mean follow-up of 62 months (range 27-76 months).

CONCLUSIONS

Administration of statins before CEA is associated with lower rates of perioperative stroke and improved overall survival. Compliance with optimal medical treatment associated with the use of pre-operative statins may limit the clinical significance of these findings. Future investigation to characterize the potential benefit of statin therapy in patients undergoing CEA for ICA stenosis is warranted.

Validation of a proteomic biomarker panel to diagnose minor-stroke and transient ischaemic attack: phase 2 of SpecTRA, a large scale translational study

OBJECTIVE

To validate our previously developed 16 plasma-protein biomarker panel to differentiate between transient ischaemic attack (TIA) and non-cerebrovascular emergency department (ED) patients.

METHOD

Two consecutive cohorts of ED patients prospectively enrolled at two urban medical centers into the second phase of SpecTRA study (training, cohort 2A, n = 575; test, cohort 2B, n = 528). Plasma samples were analyzed using liquid chromatography/multiple reaction monitoring-mass spectrometry. Logistic regression models which fit cohort 2A were validated on cohort 2B.

RESULTS

Three of the panel proteins failed quality control and were removed from the panel. During validation, panel models did not outperform a simple motor/speech (M/S) deficit variable. Post-hoc analyses suggested the measured behaviour of L-selectin and coagulation factor V contributed to poor model performance. Removal of these proteins increased the external performance of a model containing the panel and the M/S variable.

CONCLUSIONS

Univariate analyses suggest insulin-like growth factor-binding protein 3 and serum paraoxonase/lactonase 3 are reliable and reproducible biomarkers for TIA status. Logistic regression models indicated L-selectin, apolipoprotein B-100, coagulation factor IX, and thrombospondin-1 to be significant multivariate predictors of TIA. We discuss multivariate feature subset analyses as an exploratory technique to better understand a panel's full predictive potential.

Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy

The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.

A longitudinal magnetic resonance imaging study of neurodegenerative and small vessel disease, and clinical cognitive trajectories in non demented patients with transient ischemic attack: the PREVENT study

BACKGROUND

Late-life cognitive decline, caused by progressive neuronal loss leading to brain atrophy years before symptoms are detected, is expected to double in Canada over the next two decades. Cognitive impairment in late life is attributed to vascular and lifestyle related risk factors in mid-life in a substantial proportion of cases (50%), thereby providing an opportunity for effective prevention of cognitive decline if incipient disease is detected earlier. Patients presenting with transient ischemic attack (TIA) commonly display some degree of cognitive impairment and are at a 4-fold increased risk of dementia. In the Predementia Neuroimaging of Transient Ischemic Attack (PREVENT) study, we will address what disease processes (i.e., Alzheimer's vs. vascular disease) lead to neurodegeneration, brain atrophy, and cognitive decline, and whether imaging measurements of brain iron accumulation using quantitative susceptibility mapping predicts subsequent brain atrophy and cognitive decline.

METHODS

A total of 440 subjects will be recruited for this study with 220 healthy subjects and 220 TIA patients. Early Alzheimer's pathology will be determined by cerebrospinal fluid samples (including tau, a marker of neuronal injury, and amyloid β1-42) and by MR measurements of iron accumulation, a marker for Alzheimer's-related neurodegeneration. Small vessel disease will be identified by changes in white matter lesion volume. Predictors of advanced rates of cerebral and hippocampal atrophy at 1 and 3 years will include in vivo Alzheimer's disease pathology markers, and MRI measurements of brain iron accumulation and small vessel disease. Clinical and cognitive function will be assessed annually post-baseline for a period of 5-years using a clinical questionnaire and a battery of neuropsychological tests, respectively.

DISCUSSION

The PREVENT study expects to demonstrate that TIA patients have increased early progressive rates of cerebral brain atrophy after TIA, before cognitive decline can be clinically detected. By developing and optimizing high-level machine learning models based on clinical data, image-based (quantitative susceptibility mapping, regional brain, and white matter lesion volumes) features, and cerebrospinal fluid biomarkers, PREVENT will provide a timely opportunity to identify individuals at greatest risk of late-life cognitive decline early in the course of disease, supporting future therapeutic strategies for the promotion of healthy aging.

Factors associated with delay in carotid endarterectomy for patients with symptomatic severe internal carotid artery stenosis: a case-control study

BACKGROUND

The Canadian Best Practice Recommendations for Stroke Care (2008 update) recommend that patients with neurologic symptoms secondary to severe internal carotid artery stenosis undergo carotid endarterectomy within 14 days of symptom onset to prevent stroke. The purpose of this study was to identify patient and system factors associated with meeting, or failing to meet, the guideline.

METHODS

In this case-control study, potential study participants were identified through an electronic search of the Discharge Abstract Database. We reviewed the charts of patients who presented to our centre with neurologic symptoms ipsilateral to internal carotid artery stenosis of 70%-99% and underwent carotid endarterectomy in our centre between Jan. 1, 2009, and Dec. 31, 2014. We performed logistic regression analysis to identify factors associated with meeting, or failing to meet, the guideline.

RESULTS

Of the 412 patients who underwent carotid endarterectomy during the study period, 219 met the inclusion criteria. Sixty-seven patients (30.6%) met the 14-day guideline. Thirty (14.2%) of the 212 patients who could be classified as case or control subjects did not access the health care system within 14 days. Once in the health care system, failure to meet the guideline was associated with a presentation of amaurosis fugax (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05-0.96 compared to completed minor stroke) and presentation to a nonemergency outpatient setting (OR 9.08, 95% CI 2.51-32.80 compared to emergency department).

INTERPRETATION

Improvements in meeting the goal of carotid endarterectomy within 14 days of symptom onset for severe internal carotid artery stenosis should be directed at patient and system factors. A system for rapid diagnosis and referral of symptomatic patients to an appropriate surgeon should be established.

An Intersectional Exploration: Experiences of Stroke Prevention in Middle-Aged and Older Arab Muslim Immigrant Women in Canada

Background Arab immigrants have increasing rates of stroke and uncontrolled stroke risk factors coupled with minimal resources for stroke prevention. Purpose This article describes the results of an interpretive descriptive study about Arab immigrant women's experiences of practicing stroke prevention. We use an intersectionality approach to discuss some of the factors that influenced women's ability to manage their health. Methods Sixteen middle-aged and older Arab Muslim immigrant women were recruited between 2015 and 2016 from two religious centers in an urban Canadian center. Women were between the ages of 45 and 75 years, were living in the community, and had a combination of stroke risk factors. Semi-structured interviews lasting 2-3 h were conducted in Arabic by the primary bilingual researcher. Data analysis was completed in Arabic, with final themes and exemplars translated to English with the support of a certified translator. Results Study themes include relating life stressors to physical health, pursuing knowledge in the dark, negotiating medication and treatment options, making an effort to eat healthy and be active, and identifying triple ingredients for empowerment. Conclusion Economic status, access to transportation, language fluency, life stressors, and personal coping strategies influenced Arab women's ability to manage personal health.

Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study

Background

To evaluate the performance of a novel triage system for Transient Ischemic Attack (TIA) units built upon an existent clinical prediction rule (CPR) to reduce time to unit arrival, relative to the time of symptom onset, for true TIA and minor stroke patients. Differentiating between true and false TIA/minor stroke cases (mimics) is necessary for effective triage as medical intervention for true TIA/minor stroke is time-sensitive and TIA unit spots are a finite resource.

Methods

Prospective cohort study design utilizing patient referral data and TIA unit arrival times from a regional fast-track TIA unit on Vancouver Island, Canada, accepting referrals from emergency departments (ED) and general practice (GP). Historical referral cohort (N = 2942) from May 2013–Oct 2014 was triaged using the ABCD2 score; prospective referral cohort (N = 2929) from Nov 2014–Apr 2016 was triaged using the novel system. A retrospective survival curve analysis, censored at 28 days to unit arrival, was used to compare days to unit arrival from event date between cohort patients matched by low (0–3), moderate (4–5) and high (6–7) ABCD2 scores.

Results

Survival curve analysis indicated that using the novel triage system, prospectively referred TIA/minor stroke patients with low and moderate ABCD2 scores arrived at the unit 2 and 1 day earlier than matched historical patients, respectively.

Conclusions

The novel triage process is associated with a reduction in time to unit arrival from symptom onset for referred true TIA/minor stroke patients with low and moderate ABCD2 scores.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2952-x) contains supplementary material, which is available to authorized users.

Secondary stroke prevention services in Canada: a cross-sectional survey and geospatial analysis of resources, capacity and geographic access

BACKGROUND

Rapid assessment and management of transient ischemic attacks and nondisabling strokes by specialized stroke prevention services reduces the risk of recurrent stroke and improves outcomes. In Canada, with its vast geography and with 16.8% of the population living in rural areas, access to these services is challenging, and considerable variation in access to care exists. The purpose of this multiphase study was to identify sites across Canada providing stroke prevention services, evaluate resource capacity and determine geographic access for Canadians.

METHODS

We developed a Stroke Prevention Services Resource Inventory that contained 22 questions on the organization and delivery of stroke prevention services and quality monitoring. The inventory ran from November 2015 to January 2016 and was administered online. We conducted a geospatial analysis to estimate access by drive times. Considerations were made for hours of operation and access within and across provincial borders.

RESULTS

A total of 123 stroke prevention sites were identified, of which 119 (96.7%) completed the inventory. Most (95) are designated stroke prevention or rapid assessment clinics. Of the 119 sites, 68 operate full time, and 39 operate less than 2.5 days per week. A total of 87.3% of the Canadian population has access to a stroke prevention service within a 1-hour drive; however, only 69.2% has access to a service that operates 5-7 days a week. Allowing provincial border crossing improves access (< 6-h drive) for those who are beyond a 6-hour drive within their home province (3.4%).

INTERPRETATION

Most Canadians have reasonable geographic access to stroke prevention services. Allowing patients to cross borders improves the existing access for many, particularly some remote communities along the Ontario-Quebec and British Columbia-Alberta borders.

Verification of a proteomic biomarker panel to diagnose minor stroke and transient ischaemic attack: phase 1 of SpecTRA, a large scale translational study

OBJECTIVE

To derive a plasma biomarker protein panel from a list of 141 candidate proteins which can differentiate transient ischaemic attack (TIA)/minor stroke from non-cerebrovascular (mimic) conditions in emergency department (ED) settings.

DESIGN

Prospective clinical study (#NCT03050099) with up to three timed blood draws no more than 36 h following symptom onset. Plasma samples analysed by multiple reaction monitoring-mass spectrometry (MRM-MS).

PARTICIPANTS

Totally 545 participants suspected of TIA enrolled in the EDs of two urban medical centres.

OUTCOMES

90-day, neurologist-adjudicated diagnosis of TIA informed by clinical and radiological investigations.

RESULTS

The final protein panel consists of 16 proteins whose patterns show differential abundance between TIA and mimic patients. Nine of the proteins were significant univariate predictors of TIA [odds ratio (95% confidence interval)]: L-selectin [0.726 (0.596-0.883)]; Insulin-like growth factor-binding protein 3 [0.727 (0.594-0.889)]; Coagulation factor X [0.740 (0.603-0.908)]; Serum paraoxonase/lactonase 3 [0.763 (0.630-0.924)]; Thrombospondin-1 [1.313 (1.081-1.595)]; Hyaluronan-binding protein 2 [0.776 (0.637-0.945)]; Heparin cofactor 2 [0.775 (0.634-0.947)]; Apolipoprotein B-100 [1.249 (1.037-1.503)]; and von Willebrand factor [1.256 (1.034-1.527)]. The scientific plausibility of the panel proteins is discussed.

CONCLUSIONS

Our panel has the potential to assist ED physicians in distinguishing TIA from mimic patients.

Rural versus urban academic hospital mortality following stroke in Canada

Introduction

Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada.

Objectives

To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals.

Materials and methods

We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate.

Results

A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities.

Conclusion

Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada’s universal health care system.

Ticagrelor - toward more efficient platelet inhibition and beyond

Novel antiplatelet drugs, including ticagrelor, are being successively introduced into the therapy of atherothrombotic conditions due to their superiority over a standard combination of clopidogrel with acetylsalicylic acid in patients with acute coronary syndromes (ACS). A P2Y12 receptor antagonist, ticagrelor, is unique among antiplatelet drugs, because ticagrelor inhibits the platelet P2Y12 receptor in a reversible manner, and because it demonstrates a wide palette of advantageous pleiotropic effects associated with the increased concentration of adenosine. The pleiotropic effects of ticagrelor comprise cardioprotection, restoration of the myocardium after an ischemic event, promotion of the release of anticoagulative factors and, eventually, anti-inflammatory effects. Beyond the advantageous effects, the increased concentration of adenosine is responsible for some of ticagrelor's adverse effects, including dyspnea and bradycardia. Large-scale clinical trials demonstrated that both standard 12-month therapy and long-term use of ticagrelor reduce the risk of cardiovascular events in patients with ACS, but at the expense of a higher risk of major bleeding. Further trials focused on the use of ticagrelor in conditions other than ACS, including ischemic stroke, peripheral artery disease and status after coronary artery bypass grafting. The results of these trials suggest comparable efficacy and safety of ticagrelor and clopidogrel in extra-coronary indications, but firm conclusions are anticipated from currently ongoing studies. Here, we summarize current evidence on the superiority of ticagrelor over other P2Y12 antagonists in ACS, discuss the mechanism underlying the drug-drug interactions and pleiotropic effects of ticagrelor, and present future perspectives of non-coronary indications for ticagrelor.