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Background and Purpose- Intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator) is associated with improved early functional outcome after stroke, but its long-term effects are less understood. We aimed to determine the association between r-tPA and 1-year outcomes after stroke. Methods- We used the Ontario Stroke Registry to identify patients diagnosed with ischemic stroke between 2002 and 2013 in Ontario, Canada, their baseline characteristics, and whether they received r-tPA. We used propensity score methods to match patients treated with r-tPA to nontreated patients. The primary outcome was 1-year home-time, defined as the number of days spent outside of any healthcare institutions in the first 365 days after the index date of admission. Secondary outcomes were admission to a nursing home and all-cause mortality in the first year. Outcomes were determined using linked administrative data. We used paired t tests to compare mean home-time days and Cox proportional hazards models for mortality and nursing home admission to estimate hazard ratios and 95% CI. Results- All 4449 patients treated with r-tPA in the registry were matched to nontreated patients. Compared with nontreated patients, those treated with r-tPA experienced more time at home in the first year (mean±SD was 248.9 days±137.2 treated versus 239.4 days±139.0 nontreated, P =0.005) and were less likely to be admitted to nursing homes (9.4% treated versus 12.2% nontreated; hazard ratio, 0.84; 95% CI, 0.78-0.91). One-year all-cause mortality was similar between the 2 groups (13.2% treated versus 12.4% nontreated; hazard ratio, 1.07; 95% CI, 0.96-1.20). Conclusions- Despite similar mortality, patients who received r-tPA spent more time at home and were less likely to require nursing home admission in the first year after stroke compared with nontreated patients, suggesting long-term benefits and safety of this treatment.

Aim: We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. Methods and results: In a population‐based retrospective study (2007–2019), we examined the association of material deprivation with 1‐year all‐cause mortality, cause‐specific hospitalization, and 90‐day processes of care. Using cause‐specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66–84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all‐cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10–1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19–1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08–1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09–1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter‐defibrillator/cardiac resynchronization therapy‐pacemaker implantation (p = 0.023), compared to the least deprived. Conclusion: Patients with newly‐diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived. [ABSTRACT FROM AUTHOR]

Background: While individuals living in long‐term care (LTC) homes have experienced adverse outcomes of SARS‐CoV‐2 infection, few studies have examined a broad range of predictors of 30‐day mortality in this population. Methods: We studied residents living in LTC homes in Ontario, Canada, who underwent PCR testing for SARS‐CoV‐2 infection from January 1 to August 31, 2020, and examined predictors of all‐cause death within 30 days after a positive test for SARS‐CoV‐2. We examined a broad range of risk factor categories including demographics, comorbidities, functional status, laboratory tests, and characteristics of the LTC facility and surrounding community were examined. In total, 304 potential predictors were evaluated for their association with mortality using machine learning (Random Forest). Results: A total of 64,733 residents of LTC, median age 86 (78, 91) years (31.8% men), underwent SARS‐CoV‐2 testing, of whom 5029 (7.8%) tested positive. Thirty‐day mortality rates were 28.7% (1442 deaths) after a positive test. Of 59,702 residents who tested negative, 2652 (4.4%) died within 30 days of testing. Predictors of mortality after SARS‐CoV‐2 infection included age, functional status (e.g., activity of daily living score and pressure ulcer risk), male sex, undernutrition, dehydration risk, prior hospital contacts for respiratory illness, and duration of comorbidities (e.g., heart failure, COPD). Lower GFR, hemoglobin concentration, lymphocyte count, and serum albumin were associated with higher mortality. After combining all covariates to generate a risk index, mortality rate in the highest risk quartile was 48.3% compared with 7% in the first quartile (odds ratio 12.42, 95%CI: 6.67, 22.80, p < 0.001). Deaths continued to increase rapidly for 15 days after the positive test. Conclusions: LTC residents, particularly those with reduced functional status, comorbidities, and abnormalities on routine laboratory tests, are at high risk for mortality after SARS‐CoV‐2 infection. Recognizing high‐risk residents in LTC may enhance institution of appropriate preventative measures. [ABSTRACT FROM AUTHOR]

This longitudinal study was designed to evaluate the association between acute pre‐stroke stress and the severity stroke and its outcomes including mortality, recurrence, disability and functional dependency. Patients with first‐ever stroke (FES) were recruited from the Mashhad Stroke Incidence Study. Patients were asked about any acute severe pre‐stroke stress in the 2 weeks prior to index stroke. Disability and functional disability were defined using modified the Rankin Scale and Barthel Index, respectively. We used logistic and ordinal regression tests to assess the association between acute pre‐stroke stress and study outcomes. Among 624 patients with FES, 169 reported acute pre‐stroke stress. Patients with acute pre‐stroke stress were younger than those without stress (60.7 ± 14.4 vs. 66.2 ± 14.7; p < 0.001). The frequency of traditional vascular risk factors was not different in patients with and without acute pre‐stroke stress. We did not find any association between acute pre‐stroke stress and stroke outcomes. Although acute stress was common in our cohort, our results did not support an association between acute pre‐stroke stress and the severity of stroke at admission and long‐term stroke outcomes. [ABSTRACT FROM AUTHOR]

To examine whether the association of co-morbidity with mortality after acute stroke is influenced by stroke type, age, sex, or time since stroke. We conducted a province-wide population-based study using linked administrative databases to identify all admissions for acute stroke between 2007-2018 in Alberta, Canada. We used Cox proportional hazard models to determine the association of severe co-morbidity based on the Charlson Co-morbidity Index with 1-year mortality after stroke, assessing for effect modification by stroke type, age, and sex, and with adjustment for estimated stroke severity, comprehensive stroke centre care, hypertension, atrial fibrillation, and year of study. We used a piecewise model to analyze the impact of co-morbidity across four time periods. We had 28,672 patients in our final cohort (87.8% ischemic stroke). The hazard of mortality with severe co-morbidity was higher for individuals with ischemic stroke (adjusted hazard ratio [aHR] 2.20, 95% CI 2.07-2.32) compared to those with intracerebral hemorrhage (aHR 1.70, 95% CI 1.51-1.92; p int <0.001), and higher in individuals under age 75 (aHR 3.20, 95% CI 2.90-3.53) compared to age ≥75 (aHR 1.93, 95% CI 1.82-2.05, p int <0.001). There was no interaction by sex. The hazard ratio increased in a graded fashion at younger ages and was higher after the first 30 days of acute stroke. There was a stronger association between co-morbidity and mortality at younger age and in the subacute phase of stroke. Further research is needed to determine the reason for these findings and identify ways to improve outcomes among those with stroke and co-morbid conditions at young age. [ABSTRACT FROM AUTHOR]

Background and Purpose: Despite recent declines in stroke mortality in high-income countries, the incidence and mortality of stroke have increased in many low- and middle-income countries. Population-based information on stroke in such countries is a research priority to address this rising trend. This study was designed to evaluate 5-year stroke mortality and its associated factors.Methods: During a 12-month period beginning from November 2006, 624 patients with first-ever stroke (FES) living in Mashhad, Iran, were recruited and followed longitudinally. Kaplan-Meier analyses were used to determine the cumulative risk of death. Prognostic variables associated with death were assessed using a Cox proportional hazard, backward logistic regression model.Results: The 5-year cumulative risk of death was 53.8% for women and 60.5% for men (log rank = .1). The most frequent causes of death were stroke (41.2%), myocardial infarction/vascular diseases (16.4%), and pneumonia (14.2%). In multivariable Cox proportional hazard analysis, male gender (hazard ratio [HR]: 1.29, 95% confidence interval [CI]: 1.01-1.64), age (HR: 1.04, 95% CI: 1.03-1.05, per 1-year increase), National Institute of Health Stroke Scale score at admission (HR: 1.11, 95% CI: 1.09-1.12, per 1-point increase), atrial fibrillation (HR: 1.78, CI: 1.24-2.54), and education < 12 years (HR: 1.61, 95% CI: 1.08-2.4) were associated with greater 5-year case fatality.Conclusions: Long-term case fatality following stroke in Iran is greater than that observed in many high-income countries. Targeting strategies to reduce the poor outcome following stroke, such as treating AF, is likely to reduce this disparate outcome. [ABSTRACT FROM AUTHOR]

Background: Population-based data regarding stroke among women are scarce in developing countries. This study was designed to determine whether sex differences exist in stroke incidence, mortality, and recurrence.Methods: The Mashhad Stroke Incidence Study is a population-based cohort study in Iran. For a period of 1 year, all patients with stroke in 3 geographical regions in Mashhad were recruited and then followed up for 5 years. Age- and sex-specific crude incidence rates were standardized to the World Health Organization New World Population. Male-to-female incidence rate ratios were assessed for all age groups and all subtypes of first-ever stroke (FES).Results: The annual crude incidence rate of FES (per 100,000 population) was similar in men (144; 95% confidence interval [CI]: 129-160) and women (133; 95% CI: 119-149). Standardized FES annual incidence rates were 239 (95% CI: 213-267) for men and 225 (95% CI 200-253) for women, both greater than in most western countries. There were no significant differences in stroke recurrence or case-fatality between women and men during early and long-term follow-up.Conclusion: The similar incidence of stroke between men and women highlights the importance of equally prioritizing adequate preventive strategies for both sexes. The greater relative incidence of stroke in women in Mashhad compared with other countries warrants improvement of primary and secondary stroke prevention. [ABSTRACT FROM AUTHOR]

Background: Advances in acute management and secondary prevention have reduced mortality and early recurrent risk after stroke and transient ischemic attack (TIA). However, whether improved outcomes are sustained long term among those without early adverse complications is not clear. We describe trends in long-term mortality and morbidity in patients with ischemic stroke or TIA who are clinically stable at 90 days.Methods: This is a longitudinal cohort registry study (2003-2013) of patients presenting to stroke centers in Ontario, Canada, with a stroke or TIA, with no hospitalization, stroke, myocardial infarction (MI), institutionalization, or death within 90 days (N = 26,698). Primary outcomes were 1-, 3-, and 5-year age-adjusted composite rates of death, stroke or MI, and institutionalization, and secondary analyses evaluated outcomes individually. Trend tests were used to evaluate change over time.Results: One-year adjusted composite rates decreased from 9.3% in 2003 to 7.4% in 2012 (trend test P = .02). Significant decreases in 3-year (P < .001) and 5-year (P = .002) composite rates were also observed. Rates of recurrent stroke decreased at 1 and 3 years (P < .01), but not 5 years (P = .21), whereas death rates declined across follow-up times. Conversely, rates of institutionalization increased at 3 and 5 years (P < .01).Conclusions: Long-term mortality and morbidity post stroke and TIA have declined, confirming trends for improved long-term outcomes for patients clinically stable during the initial high-risk period. However, increased long-term rates of institutionalization also suggest that stroke and TIA patients are at risk of long-term functional decline, despite improved clinical outcomes. Further studies evaluating challenges for sustaining functional gains after stroke and TIA are required. [ABSTRACT FROM AUTHOR]

Background In developing countries, there are few comprehensive studies of mortality following stroke. Aims and/or hypothesis We aimed to determine the one-year case fatality rate following stroke and to identify factors associated with death in a population-based stroke incidence study in Iran. Methods Six hundred eighty-four patients who had suffered a stroke between November 21, 2006, and November 20, 2007, and were recruited to the Mashhad Stroke Incidence Study were followed up at one-year. Most patients were seen in an outpatient visit. When patients had died, a verbal autopsy was conducted by telephone with the next of kin. Results A total of 226 (34·3%) patients died during the first year following stroke. The cumulative one-year case fatality rate was 30·6% following ischemic stroke and 53·0% following hemorrhagic stroke (55·8% after intracerebral hemorrhage and 35·7% after subarachnoid hemorrhage). The majority of these deaths occurred in the first 28 days after stroke (17·7% with ischemic and 43·0% with hemorrhagic stroke). Factors associated with greater mortality at one-year (excluding those who died during the first week) were hemorrhagic stroke [hazard ratio ( HR) 3·99; 95% confidence interval 1·90-8·37], age ( HR 1·05; 95% confidence interval 1·03-1·08), previous transient ischemic attack ( HR 2·45; 95% confidence interval 1·00-5·99), and National Institutes of Health Stroke Scale on admission ( HR 1·14; 95% confidence interval 1·10-1·17). Conclusion Despite the younger age of stroke occurrence in Iran, the one-year case fatality rate following stroke is similar to that reported in developed countries. [ABSTRACT FROM AUTHOR]

The article intends to develop a clinical prediction rule for severe disability and death from acute ischemic stroke during hospital admission. It offers information on the methods used in the study including population, data collection and definition of variables, and statistical analysis. It concludes that the PLAN clinical prediction rule need further studies in various settings and population groups.

Stroke unit care improves outcomes following ischemic stroke. However, it is not known whether all ischemic stroke subtypes benefit equally from stroke unit admission. To determine whether the benefit of stroke unit admission is similar among all ischemic stroke subtypes. Prospective cohort study including patients admitted with an acute ischemic stroke between July 2003 and September 2007 to stroke centers participating institutions in the Registry of the Canadian Stroke Network. Ischemic stroke subtype information was determined according to the modified Trial of Org 10 172 in Acute Stroke Treatment criteria and categorized as small vessel disease (lacunar), large artery atherosclerotic disease, cardioembolic, or other (including both other determined and undetermined causes). The primary outcome measure was all-cause mortality at 30 days after stroke. Secondary outcomes were seven-day mortality and death or institutionalization at discharge. Among 6223 eligible patients with ischemic stroke admitted to regional stroke centers in Ontario, the mean age was 72 years and 52·4% were male. Overall 30-day mortality was 12·2%. The 30-day risk-adjusted mortality was lower for stroke unit care across all stroke subtypes (for lacunar stroke 3·0% vs. 5·3%; for large artery disease 7·5% vs. 14·5%; for cardioembolic 15·3% vs. 23·3%; and for other causes 8·9% vs. 15·9%). In multivariable analysis, after controlling for age, gender, medical comorbidities, and stroke severity, there was a significant reduction in stroke mortality associated with stroke unit admission in all stroke subtypes (odds ratio (95% confidence interval) for lacunar stroke 0·48 (0·27-0·88), for large artery atherosclerotic disease 0·39 (0·27-0·56), for cardioembolic 0·46 (0·36-0·59), and for other causes 0·45 (0·29-0·70)). The results remained similar after a sensitivity analysis excluding patients receiving palliative care, and a secondary analysis including 3215 patients with missing Trial of Org 10 172 in Acute Stroke Treatment classification. This study provides 'real-world' evidence that all ischemic stroke subtypes do benefit from a stroke unit admission regardless of the etiology. There is no justification for withholding access to stroke unit care based on stroke subtype. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- To compare recent trends in cardiovascular disease (CVD) outcomes among men and women with diabetes with those in the nondiabetic population. RESEARCH DESIGN AND METHODS -- We conducted a retrospective cohort study using provincial health claims data to identify adults with (n = 670,602) and without (n = 9,190,721) diabetes living in Ontario, Canada, between 1 April 1992 and 31 March 2000. We compared changes in the annual age-/sex-adjusted rates and numbers of subjects admitted for acute myocardial infarction (AMI) and stroke and of deaths from AMI, stroke, and all causes between those with and without diabetes. RESULTS -- Over the 8-year period, the rate of patients admitted for AMI and stroke fell to a greater extent in the diabetic than the nondiabetic population (AMI: -15.1 vs. -9.1%, P < 0.0001; stroke: -24.2 vs. 19.4%, P < 0.0001). Diabetic patients experienced similar reductions in case-fatality rates related to AMI and stroke than those without diabetes (-44.1 vs. -33.2%, P = 0.1; - 17.1 vs. -16.6%, P = 0.9, respectively). Declines in all-cause mortality were also comparable in the two populations. Over the same period, the number of diabetes cases increased from 405,471 to 670,602. Thus, while CVD rates fell, the number of events occurring in this population rose substantially (AMI: +44.6%, stroke: +26.1%, AMI deaths: +17.2%, and stroke deaths: +13.2%). CONCLUSIONS -- Our findings demonstrate a significant reduction in the rate of people affected by CVD within the diabetic population. However, as the number of people with diabetes rises, so may the absolute burden of CVD in our society. [ABSTRACT FROM AUTHOR]

Background Rural residence is associated with stroke incidence and mortality, but little is known about potential rural/urban differences in ambulatory stroke care. Methods and Results We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Canada, and divided into primary (N=6 207 032) and secondary (N=75 823) prevention cohorts based on the absence or presence of prior stroke. We defined rural communities as those with a population size of ≤10 000 and within each of the primary and secondary prevention cohorts, compared cardiovascular risk factors and care between rural and urban areas. We then calculated sex-/age-standardized rates of stroke incidence and mortality per 1000 person-years between January 1, 2008 and December 31, 2012 and used cause-specific hazard models to compare outcomes in rural versus urban areas adjusting for age, sex, income, ethnicity, smoking, physical activity and comorbid conditions, and accounting for the competing risk of death in the model for the occurrence of stroke incidence. In the primary prevention cohort, rural residents were less likely than urban ones to be screened for diabetes mellitus (70.9% versus 81.3%) and hyperlipidemia (66.2% versus 78.4%) and less likely to achieve diabetes mellitus control (hemoglobin A1c ≤7% in 51.3% versus 54.3%; P<0.001 for all comparisons). In the secondary prevention cohort, the prevalence and treatment of risk factors were similar in rural and urban residents. After adjustment for sociodemographic and comorbid conditions, rural residence was associated with higher rates of stroke and all-cause mortality in both the primary prevention (adjusted hazard ratio [aHR] for stroke, 1.06; 95% CI, 1.04-1.09; aHR for mortality, 1.09; 95% CI, 1.08-1.10) and the secondary prevention cohort (aHR for stroke, 1.11; 95% CI, 1.02-1.19; aHR for mortality, 1.07; 95% CI, 1.03-1.11). Conclusions In this population-based study of over 6 million people with universal access to physician and hospital services, risk factors were more prevalent but less likely to be controlled in rural than in urban residents without prior stroke, whereas in those with prior stroke, risk factor prevalence and treatment were similar. Rural residence was associated with the rate of stroke and death even after adjustment for risk factors. Future efforts should focus not only on control of known vascular risk factors but also on addressing other determinants of health in rural communities. [ABSTRACT FROM AUTHOR]