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Background: Recent evidence suggests clinical equipoise for managing transient ischaemic attack and minor stroke (TIAMS) either via discharge from the emergency department (ED) with rapid outpatient follow-up or inpatient admission. Understanding patient preferences may guide decision-making around disposition after TIAMS that can lead to higher patient satisfaction and adherence. Psychological distress, particularly a sense of vulnerability (eg, 'threat perception') is associated with adverse psychological outcomes following TIAMS and may influence patient disposition preference. We hypothesised patients with higher threat perceptions in the ED would prefer inpatient admission versus early discharge with rapid outpatient follow-up., Methods: This was a planned secondary analysis of a prospective observational cohort study of ED patients with suspected TIAMS (defined as National Institutes of Health Stroke Scale (NIHSS) score of ≤5). Patients reported disposition preferences and completed a validated scale of threat perception while in the ED (score range: 1-4)., Results: 147 TIAMS patients were evaluated (mean age: 59.7±15.4, 45.6% female, 39.5% Hispanic, median NIHSS=1, IQR: 0, 3). A majority of patients (98, 66.7%) preferred inpatient admission compared with discharge from the ED. Overall threat scores were median 1.0 (IQR: 0.43, 1.68). Those preferring admission had similar threat scores compared with those who preferred early disposition (median: 1.00, IQR: 0.43, 1.57) versus 1.00, (IQR: 0.49, 1.68); p=0.40). In a model adjusted for demographic characteristics, threat perceptions remained unassociated with disposition preference., Conclusion: Overall, two-thirds of TIAMS patients preferred inpatient admission over discharge. Disposition preference was not associated with higher threat perception in the ED. Further research examining potential drivers of patient disposition preferences may inform patient discussions and optimise patient satisfaction., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the independent association between physical activity and subclinical cerebrovascular disease as measured by silent brain infarcts (SBI) and white matter hyperintensity volume (WMHV)., Methods: The Northern Manhattan Study (NOMAS) is a population-based prospective cohort examining risk factors for incident vascular disease, and a subsample underwent brain MRI. Our primary outcomes were SBI and WMHV. Baseline measures of leisure-time physical activity were collected in person. Physical activity was categorized by quartiles of the metabolic equivalent (MET) score. We used logistic regression models to examine the associations between physical activity and SBI, and linear regression to examine the association with WMHV., Results: There were 1,238 clinically stroke-free participants (mean age 70 ± 9 years) of whom 60% were women, 65% were Hispanic, and 43% reported no physical activity. A total of 197 (16%) participants had SBI. In fully adjusted models, compared to those who did not engage in physical activity, those in the upper quartile of MET scores were almost half as likely to have SBI (adjusted odds ratio 0.6, 95% confidence interval 0.4-0.9). Physical activity was not associated with WMHV., Conclusions: Increased levels of physical activity were associated with a lower risk of SBI but not WMHV. Engaging in moderate to heavy physical activities may be an important component of prevention strategies aimed at reducing subclinical brain infarcts.

Background: It is controversial whether physical activity is protective against first stroke among older persons. We sought to examine whether physical activity, as measured by intensity of exercise and energy expended, is protective against ischemic stroke., Methods: The Northern Manhattan Study is a prospective cohort study in older, urban-dwelling, multiethnic, stroke-free individuals. Baseline measures of leisure-time physical activity were collected via in-person questionnaires. Cox proportional hazards models were constructed to examine whether energy expended and intensity of physical activity were associated with the risk of incident ischemic stroke., Results: Physical inactivity was present in 40.5% of the cohort. Over a median follow-up of 9.1 years, there were 238 incident ischemic strokes. Moderate- to heavy-intensity physical activity was associated with a lower risk of ischemic stroke (adjusted hazard ratio [HR] 0.65, 95% confidence interval [0.44-0.98]). Engaging in any physical activity vs none (adjusted HR 1.16, 95% CI 0.88-1.51) and energy expended in kcal/wk (adjusted HR per 500-unit increase 1.01, 95% CI 0.99-1.03) were not associated with ischemic stroke risk. There was an interaction of sex with intensity of physical activity (p = 0.04), such that moderate to heavy activity was protective against ischemic stroke in men (adjusted HR 0.37, 95% CI 0.18-0.78), but not in women (adjusted HR 0.92, 95% CI 0.57-1.50)., Conclusions: Moderate- to heavy-intensity physical activity, but not energy expended, is protective against risk of ischemic stroke independent of other stroke risk factors in men in our cohort. Engaging in moderate to heavy physical activities may be an important component of primary prevention strategies aimed at reducing stroke risk.