Search

Background Data on resuming oral anticoagulants (OACs) after bleeding are primarily from studies involving patients given warfarin, with few data on direct OACs (DOACs). We aimed to characterize prescribing patterns for OACs after OAC-related bleeding and compare the rates of bleeding, thrombosis and mortality in patients who resumed either type of OAC with those who did not. Methods We conducted a population-based cohort study of adults aged 66 years or older who were admitted to hospital for bleeding while receiving OACs from Apr. 1, 2012, to Mar. 31, 2017, using linked administrative health databases from Ontario. We used competing risk methods to calculate cause-specific adjusted hazard ratios (HRs) for thrombosis, bleeding and mortality with resumption of OACs adjusted as a time-varying covariate. We determined time to OAC resumption using the Kaplan-Meier method. Results We included 6793 patients with gastrointestinal (n = 4297, 63.3%), intracranial (n = 805, 11.9%) or other bleeding (n = 1691, 25.0%). At cohort entry, 3874 patients (57.0%) were prescribed warfarin and 2919 patients (43.0%) were prescribed a DOAC. The most common indication for OAC was atrial fibrillation (n = 5557, 81.8%), followed by venous thromboembolism (n = 1367, 20.1%). Oral anticoagulants were resumed in 4792 patients (70.5%) within 365 days of the index bleed. The median time to resumption was 46 (interquartile range 6-550) days. We found that resuming OAC was associated with reduced rates of thrombosis (adjusted HR 0.60, 95% confidence interval [CI] 0.50-0.72) and mortality (adjusted HR 0.54, 95% CI 0.48-0.60), and an increased rate of rebleeding (adjusted HR 1.88, 95% CI 1.64-2.17). Interpretation We found that resuming OAC is associated with a reduction in thrombosis and mortality but an increase in bleeding. Randomized controlled trials that evaluate the net benefit of strategies for resumption of OAC after a bleeding event are warranted.

Background: For patients investigated for suspected acute coronary syndrome, there is uncertainty if a single measurement of high-sensitivity cardiac troponin I (hs-cTnI) at emergency department (ED) presentation can identify patients at both low and high risk for mortality. Methods: We included consecutive adult patients in the ED who had a Clinical Chemistry Score (CCS) taken at presentation (ie, combination of glucose, creatinine for estimated glomerular filtration rate determination, and hs-cTnI assay) in a Canadian city between 2012 and 2013. Outcomes were 3-month, 1-year, and 5-year all-cause mortality using the provincial death registry. Mortality rates and test performance (eg, sensitivity and specificity) with 95% confidence intervals (CIs) were obtained for the CCS or hs-cTnI assay alone using established cutoffs for these tests. Results: Our cohort included 5974 patients with a 1-year mortality rate of 17.2% (95% CI, 16.2-18.3). A CCS ≥ 1 yielded a sensitivity of 99.2% (95% CI, 98.4-99.6) compared with the hs-cTnI ≥ 5 ng/L cutoff sensitivity of 88.4% (95% CI, 86.3-90.3), with the mortality rate being significantly lower for patients with CCS < 1 (2.0%; 95% CI, 0.9-4.0) vs patients with hs-cTnI < 5 ng/L (5.0%; 95% CI, 4.2-6.0) at 1 year (P = 0.01). A CCS of 5 also yielded a higher specificity (88.5%; 95% CI, 87.5-89.3) compared with hs-cTnI > 26 ng/L (83.9%; 95% CI, 82.9-84.9), with no difference in mortality rates (37.4% vs 36.3%; P = 0.66). This trend was consistent at 3-month and 5-year mortality. Conclusion: For patients in the ED with a potential cardiac issue, using the CCS cutoffs can better identify patients at low and high risk for mortality than using published cutoffs for hs-cTnI alone. Résumé: Contexte: Dans le cas des patients chez qui l’on soupçonne un syndrome coronarien aigu, des doutes subsistent à savoir si la mesure de la troponine I cardiaque à haute sensibilité (TnIc-hs) à l’arrivée au service des urgences peut, à elle seule, permettre de repérer les patients présentant un risque de mortalité faible ou élevé. Méthodologie: L’étude portait sur les patients adultes qui se sont présentés consécutivement au service des urgences dans une ville canadienne entre 2012 et 2013 et pour lesquels un score CCS (Clinical Chemistry Score, ou score des paramètres biochimiques cliniques, c’est-à-dire glycémie, créatininémie [aux fins du calcul du débit de filtration glomérulaire estimé] et dosage de la TnIc-hs) a été établi à leur arrivée. Les critères d’évaluation étaient la mortalité toutes causes confondues à 3 mois, à 1 an et à 5 ans, déterminée à partir des actes de décès inscrits au registre provincial. Les taux de mortalité et la fiabilité des tests (sensibilité et spécificité) avec des intervalles de confiance (IC) à 95 % ont été déterminés pour le score CCS et pour le dosage de la TnIc-hs seulement au moyen des valeurs seuils établies pour ces tests. Résultats: La cohorte réunissait 5 974 patients, et le taux de mortalité à 1 an s’établissait à 17,2 % (IC à 95 % : 16,2-18,3). Un score CCS ≥ 1 a été associé à une sensibilité de 99,2 % (IC à 95 % : 98,4-99,6) comparativement à 88,4 % (IC à 95 % : 86,3-90,3) pour une valeur seuil de TnIc-hs ≥ 5 ng/l, le taux de mortalité à 1 an étant significativement plus bas chez les patients ayant un score CCS < 1 (2,0 %; IC à 95 % : 0,9-4,0) que chez ceux ayant un taux de TnIc-hs < 5 ng/l (5,0 %; IC à 95 % : 4,2-6,0) (p = 0,01). Un score CCS de 5 a en outre été associé à une plus grande spécificité (88,5 %; IC à 95 % : 87,5-89,3) qu’un taux de TnIc-hs > 26 ng/l (83,9 %; IC à 95 % : 82,9-84,9); il n’y avait pas de différence entre les taux de mortalité (37,4 % vs 36,3 %; p = 0,66). Les résultats relatifs à la mortalité à 3 mois et à 5 ans concordaient avec cette tendance. Conclusion: Dans le cas des patients admis au service des urgences en raison d’un problème cardiaque potentiel, les valeurs seuils du score CCS peuvent permettre de mieux repérer les patients qui présentent un risque de mortalité faible ou élevé, comparativement aux seules valeurs seuils publiées des taux de TnIc-hs.

Background: The use of intravenous thrombolysis is associated with improved clinical outcomes. Whether thrombolysis is associated with reduced incidence of poststroke dementia remains uncertain. We sought to estimate if the use of thrombolysis following first-ever ischemic stroke was associated with a reduced rate of incident dementia using a pragmatic observational design. Methods: We included first-ever ischemic stroke patients from the Ontario Stroke Registry who had not previously been diagnosed with dementia. The primary outcome was incident dementia ascertained by a validated diagnostic algorithm. We employed inverse probability of treatment-weighted Cox proportional hazard models to estimate the cause-specific hazard ratio for the association of thrombolysis and incident dementia at 1 and 5 years following stroke. Results: From July 2003 to March 2013, 7072 patients with ischemic stroke were included, 3276 (46.3%) were female and mean age was 71.0 (SD, 12.8) years. Overall, 38.2% of the cohort (n=2705) received thrombolysis, 77.2% (n=2087) of which was administered within 3 hours of stroke onset. In the first year following stroke, thrombolysis administration was associated with a 24% relative reduction in the rate of developing dementia (cause-specific hazard ratio, 0.76 [95% CI, 0.58–0.97]). This association remained significant at 5 years (cause-specific hazard ratio, 0.79 [95% CI, 0.66–0.91]) and at the end of follow-up (median 6.3 years; cause-specific hazard ratio, 0.79 [95% CI, 0.68–0.89]). Conclusions: Thrombolysis administration following first-ever ischemic stroke was independently associated with a reduced rate of dementia. Incident dementia should be considered as a relevant outcome when evaluating risk/benefit of thrombolysis in ischemic stroke patients.

Serial high-sensitivity cardiac troponin (hsTn) testing in the emergency department (ED) and the intensive cardiac care unit may assist physicians in ruling out or ruling in acute myocardial infarction (MI). There are three major algorithms proposed for high-sensitivity cardiac troponin I (hsTnI) using serial measurements while incorporating absolute concentration changes for MI or death following ED presentation. We sought to determine the diagnostic estimates of these three algorithms and if one was superior in two different Canadian ED patient cohorts with serial hsTnI measurements. An undifferentiated ED population (Cohort-1) and an ED population with symptoms suggestive of acute coronary syndrome (ACS, Cohort-2) were clinically managed with non-hsTn testing with the hsTnI testing performed in real-time with physicians blinded to these results (i.e., hsTnI not reported). The three algorithms evaluated were the European Society of Cardiology (ESC), the High-STEACS pathway, and the COMPASS-MI algorithm. The diagnostic estimates were derived for each algorithm for the 30-day MI/death outcome for the rule-out and rule-in arm in each cohort and compared to proposed diagnostic benchmarks (i.e., sensitivity ≥ 99.0% and specificity ≥ 90.0%) with 95% confidence intervals (CI). In Cohort-1 (n = 2966 patients, 15.3% had outcome) and Cohort-2 (n = 935 patients, 15.6% had outcome), the algorithm that obtained the highest sensitivity (97.8%, 95% CI: 96.0–98.9 and 98.6%, 95% CI: 95.1–99.8, respectively) in both cohorts was COMPASS-MI. Only Cohort-2 with both the ESC and COMPASS-MI algorithms exceeded the specificity benchmark (97.0%, 95% CI: 95.5–98.0 and 96.7%, 95% CI: 95.2–97.8, respectively). Patient selection for serial hsTnI testing will affect specificity estimates, with no algorithm achieving a sensitivity ≥ 99% for 30-day MI or death.

Background Guidelines recommend both acetylsalicylic acid and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization. Methods Accessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada, between 2008 and 2018. Using interrupted-time series with descriptive statistics and segmented regression analysis, we evaluated types of P2Y12 inhibitors prescribed at discharge and changes to their utilization in patients managed with percutaneous intervention (PCI), coronary artery bypass grafting (CABG) or medically, following national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society), ticagrelor’s national approval by Health Canada, and ticagrelor’s coverage by a publicly funded medication plan. Results We included 114,142 patients (49.4%-PCI; mean age 75.71±6.94 and 62.3% male and 7.7%-CABG; mean age 74.11±5.63 and 73.5% male). Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (pp=0.03). Among PCI patients, ticagrelor utilization increased within the first month (ppp=0.003) and ticagrelor utilization increased monthly (p=0.05) after 2012 CCS guidelines. Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (p Conclusion National guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.

BACKGROUND: The ability to rule out or in a major adverse cardiac event (MACE) in patients with suspected acute coronary syndrome at emergency department (ED) presentation would be beneficial to patient care and the health care system. The clinical chemistry score (CCS) was evaluated in this context. METHODS: This diagnostic accuracy study evaluated 2 different ED cohorts with suspected acute coronary syndrome. For patients in cohort 1, who presented to the ED of 3 hospitals in Hamilton, Ontario, between May and August 2013, retrospective measurements were taken using the Ortho Clinical Diagnostics high-sensitivity cardiac troponin I (hs-cTnI) assay; for patients in cohort 2, who presented to the ED of the same 3 hospitals in Hamilton between November 2012 and February 2013, an ED cardiac presentation blood test panel was performed with the Abbott Diagnostics hs-cTnI assay. The sensitivity and specificity of the CCS (cut-offs of ≥ 1 and 5) and hs-cTnI alone (published cut-offs) were compared for MACE (composite of death, myocardial infarction, unstable angina, revascularization) at 30 days for both cohorts and at 90 days for cohort 2. RESULTS: The incidence of MACE at 30 days was higher in cohort 1 (n = 1058) (19.4%, 95% confidence interval [CI] 16.8%–22.2%) than in cohort 2 (n = 5974) (14.6%, 95% CI 13.6%–15.6%). In cohort 1, a CCS of 1 or above yielded a sensitivity of 99.5% (95% CI 97.3%–99.9%). The sensitivity with an Ortho hs-cTnI cut-off of 1 ng/L or above was 91.2% (95% CI 86.5%–95.7%). The specificity of a CCS of 5 (97.8%, 95% CI 96.5%–98.7%) was higher than when the overall 99th-percentile cut-off for the Ortho hs-cTnI assay (> 11 ng/L; 90.1%, 95% CI 87.9%–92.0%) was used. A similar pattern was observed in cohort 2 at 30 days and persisted at 90 days with the Abbott hs-cTnI assay. INTERPRETATION: The CCS derived with 2 different hs-cTnI assays and ED populations yielded higher sensitivity and specificity estimates for MACE than hs-cTnI alone. An intervention study is needed to evaluate the impact of the CCS at both the patient and hospital levels. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT01994577

For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012&ndash, February 2013 and April 2013&ndash, September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS &lt, 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS &gt, 2 (n = 3936) (p &lt, 0.001). At 90 days, patients with CCS &lt, 2 (median age = 52y (IQR = 46&ndash, 60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32&ndash, 0.82) for the composite outcome and patients with a CCS &gt, 2 (median age = 74y (IQR = 64&ndash, 82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98&ndash, 3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS &lt, 2, 2, or &gt, 2 respectively, had the composite outcome (p &lt, 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.

ObjectiveTo compare the risk of 1-year ischemic stroke recurrence between atrial fibrillation (AF) diagnosed after stroke (AFDAS) and sinus rhythm (SR) and investigate whether underlying heart disease is as frequent in AFDAS as it is in AF known before stroke (KAF).MethodsIn this retrospective cohort study, we included all ischemic stroke patients admitted to institutions participating in the Ontario Stroke Registry from July 1, 2003, to March 31, 2013. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We modeled the relationship between heart rhythm groups and 1-year ischemic stroke recurrence by using Cox regression adjusted for multiple covariates (e.g., oral anticoagulants). We compared the prevalence of coronary artery disease, myocardial infarction, and heart failure among the 3 groups.ResultsAmong 23,376 ischemic stroke patients, 15,885 had SR, 587 AFDAS, and 6,904 KAF. At 1 year, 39 (6.6%) patients with AFDAS, 661 (9.6%) with KAF, and 1,269 (8.0%) with SR had recurrent ischemic strokes (p = 0.0001). AFDAS-related ischemic stroke recurrence adjusted risk was not different from that of SR (hazard ratio 0.90 [95% confidence interval 0.63, 1.30]; p = 0.57). Prevalence of coronary artery disease (18.2% vs 34.7%; p < 0.0001), myocardial infarction (11.6% vs 20.5%; p < 0.0001), and heart failure (5.5% vs 16.8%; p < 0.0001) were lower in AFDAS relative to KAF.ConclusionsThe lack of difference in 1-year ischemic stroke recurrence between AFDAS and SR and the lower prevalence of heart disease in AFDAS compared to KAF suggest that the underlying pathophysiology of AFDAS may differ from that of KAF.

Cancer is a risk factor for thrombosis, but unlike venous thrombosis, its association with ischemic stroke, and its impact on stroke management and post-stroke outcomes are not well characterized. The primary objective of this study was to measure and compare the risk of ischemic stroke in individuals with a new diagnosis of cancer and those without a history of cancer in two separate matched cohorts based on the absence (Matched Cohort 1) or presence (Matched Cohort 2) of a prior diagnosis of ischemic stroke (Figure 1). Methods: We conducted a population-based matched cohort study of adults ≥18 years using linked clinical and administrative health databases in Ontario, Canada (2010 to 2019). Individuals with a new diagnosis of cancer were matched (1:1) to cancer-free controls by age and sex. Cancer diagnoses were determined using ICD-O-3 diagnostic codes (basal and squamous cell carcinoma and primary central nervous system tumors were excluded). For cancer patients, the index date was the diagnosis date and a corresponding dummy index date was assigned to the matched cancer-free control. The primary outcome was the incidence of ischemic stroke (time to ischemic stroke following index) determined using validated ICD-9 or -10 diagnostic codes from hospitalizations or emergency department visits. Analyses were conducted separately, in parallel, for each cohort. Standardized differences were used to compare the distributions of baseline characteristics. Cumulative incidence function (CIF) curves were generated for ischemic stroke and all-cause mortality. Competing risk methods were used to calculate sub-distribution adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for ischemic stroke, where death was treated as a competing event. Interactions with the timeline at 1.5 years after index were incorporated to assess if the hazard ratio for the main exposure (cancer vs cancer-free) varied before and after the 1.5-year mark. Regression analyses were adjusted using baseline characteristics for which there was imbalance between groups. Results: Matched Cohort 1 included 620,647 individuals with cancer and 620,647 controls. Matched Cohort 2 included 13,924 individuals with cancer and 13,924 controls. Baseline characteristics were generally well balanced (Table 1). Use of antithrombotic medications (prior to index) among individuals ≥66 years was similar between the groups (data not shown). CIF curves for ischemic stroke and mortality are shown in Figure 2. In Matched Cohort 1 (no history of stroke), the risk of ischemic stroke was increased in cancer patients compared to cancer-free controls 1.5 years post-index (aHR 1.40, 95%CI 1.34-1.47). From 1.5 years to 5 years, the risk of ischemic stroke was lower in cancer patients compared to controls (aHR 0.72, 95%CI 0.69-0.74). In Matched Cohort 2 (prior history of ischemic stroke), the risk of ischemic stroke was similar at 1.5 years after the index date in individuals with and without cancer (aHR 1.00, 95%CI 0.88-1.14). From 1.5 to 5 years, the risk of ischemic stroke was reduced (aHR 0.53, 95%CI 0.46-0.62) in cancer patients compared to controls. Conclusions: Compared to cancer-free controls, the risk of ischemic stroke among individuals with a new cancer diagnosis depended on the presence or absence of prior history of ischemic stroke, a novel finding not previously reported. In individuals without a prior history of stroke, those with cancer had a 1.5-fold higher risk of ischemic stroke at 1.5 years compared to controls. In individuals with a prior history of stroke, those with cancer had a similar risk of stroke compared to controls. At 5 years post-index, the risk of ischemic stroke was lower in cancer patients in both cohorts which may reflect high early mortality rates and lower stroke risk among long-term survivors of cancer. The risk of death among cancer patients was highest during the first 1.5 years after the index date in both cohorts. However, the magnitude of the risk increase was higher in individuals without a prior history of stroke (10-fold) compared to those with a prior history of cancer (5-fold). Limitations include unknown causes of death and unavailability of some covariates (e.g. smoking and antithrombotic use in individuals aged Figure 1 Figure 1. Disclosures Siegal: BMS-Pfizer: Honoraria; Leo Pharma: Honoraria; Novartis: Honoraria; Portola: Honoraria; Servier: Honoraria. Carrier: Pfizer: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Servier: Honoraria; Leo Pharma: Honoraria, Research Funding; Bayer: Honoraria; Sanofi: Honoraria. Gross: Valeo: Honoraria; Leo Pharma: Honoraria; Bayer: Honoraria; BMS-Pfizer: Honoraria.

Purpose of review Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research. Recent findings Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated. Summary AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants.

Among those aged 80 years and older in Ontario, Canada, stroke and dementia incidence declined concomitantly from 2002-03 to 2013-14. This study aimed to report the concurrent temporal trends of stroke and dementia prevalence in Ontario among the same age demographic. The prevalence of both stroke and dementia increased from 2003-04 to 2012-13 in both sexes and the magnitude in which prevalence of dementia increased over time exceeded that of stroke. The substantial increase in the prevalence of dementia may be because of increased recognition and diagnoses of dementia and increased survival of stroke patients who are at higher risk of developing dementia.Des preuves quant à une augmentation simultanée de la prévalence des AVC et de la démence. De 2002-2003 à 2013-2014, on a noté une diminution simultanée de l’incidence des AVC et de la démence parmi les individus âgés de plus de 80 ans vivant en Ontario (Canada). Ce qui nous intéresse dans cette étude, ce sont les tendances temporelles simultanées en ce qui a trait à la prévalence des AVC et de la démence au sein de la même tranche d’âge et dans la même province. On a ainsi noté que tant la prévalence des AVC que celle de la démence ont augmenté entre 2003–2004 et 2012–2013, et ce, tant chez les hommes que chez les femmes. Cela dit, l’ampleur de l’augmentation de la prévalence de la démence a fini par dépasser au fil du temps celle des AVC. Il se pourrait que l’augmentation substantielle de la prévalence des cas de démence puisse être attribuée à un dépistage accru et à l’établissement de plus nombreux diagnostics ainsi qu’à un accroissement de la survie des patients victimes d’AVC, ces derniers étant alors plus susceptibles d’être atteints de démence.

Background: It has been hypothesized that ischemic stroke can cause atrial fibrillation. By elucidating the mechanisms of neurogenically mediated paroxysmal atrial fibrillation, novel therapeutic strategies could be developed to prevent atrial fibrillation occurrence and perpetuation after stroke. This could result in fewer recurrent strokes and deaths, a reduction or delay in dementia onset, and in the lessening of the functional, structural, and metabolic consequences of atrial fibrillation on the heart. Methods: The Pathophysiology and Risk of Atrial Fibrillation Detected after Ischemic Stroke (PARADISE) study is an investigator-driven, translational, integrated, and transdisciplinary initiative. It comprises 3 complementary research streams that focus on atrial fibrillation detected after stroke: experimental, clinical, and epidemiological. The experimental stream will assess pre- and poststroke electrocardiographic, autonomic, anatomic (brain and heart pathology), and inflammatory trajectories in an animal model of selective insular cortex ischemic stroke. The clinical stream will prospectively investigate autonomic, inflammatory, and neurocognitive changes among patients diagnosed with atrial fibrillation detected after stroke by employing comprehensive and validated instruments. The epidemiological stream will focus on the demographics, clinical characteristics, and outcomes of atrial fibrillation detected after stroke at the population level by means of the Ontario Stroke Registry, a prospective clinical database that comprises over 23,000 patients with ischemic stroke. Conclusions: PARADISE is a translational research initiative comprising experimental, clinical, and epidemiological research aimed at characterizing clinical features, the pathophysiology, and outcomes of neurogenic atrial fibrillation detected after stroke. Fil: Paquet, Maryse. Institute for Clinical Evaluative Sciences; Canadá Fil: Cerasuolo, Joshua O.. Institute for Clinical Evaluative Sciences; Canadá Fil: Thorburn, Victoria. Institute for Clinical Evaluative Sciences; Canadá Fil: Fridman, Sebastian. Institute for Clinical Evaluative Sciences; Canadá Fil: Alsubaie, Rasha. Institute for Clinical Evaluative Sciences; Canadá Fil: Lopes, Renato D.. University of Duke; Estados Unidos Fil: Cipriano, Lauren E.. Institute for Clinical Evaluative Sciences; Canadá Fil: Salamone, Paula Celeste. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Instituto de Neurología Cognitiva. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Fundación Favaloro. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt; Argentina Fil: Melling, C. W. James. Institute for Clinical Evaluative Sciences; Canadá Fil: Khan, Ali R.. Institute for Clinical Evaluative Sciences; Canadá Fil: Sedeño, Lucas. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Instituto de Neurología Cognitiva. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Fundación Favaloro. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt; Argentina Fil: Fang, Jiming. Institute for Clinical Evaluative Sciences; Canadá Fil: Drangova, Maria. Western University; Canadá Fil: Montero Odasso, Manuel. Western University; Canadá. Parkwood Institute and Lawson Health Research Institute; Canadá Fil: Mandzia, Jennifer. Western University; Canadá Fil: Khaw, Alexander V.. Western University; Canadá Fil: Racosta, Juan M.. Western University; Canadá Fil: Paturel, Justin. Western University; Canadá Fil: Samoilov, Lucy. Western University; Canadá Fil: Stirling, Devin. Western University; Canadá Fil: Balint, Brittany. Western University; Canadá Fil: Jaremek, Victoria. Western University; Canadá Fil: Koschinsky, Marlys L.. Western University; Canadá Fil: Boffa, Michael B.. Western University; Canadá Fil: Summers, Kelly. Western University; Canadá Fil: Ibáñez Barassi, Agustín Mariano. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Instituto de Neurología Cognitiva. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt | Fundación Favaloro. Instituto de Neurociencia Cognitiva y Traslacional. Fundación Ineco Rosario Sede del Incyt; Argentina. Universidad Adolfo Ibañez; Chile. Universidad Autónoma del Caribe; Colombia. Australian Research Council; Australia Fil: Mrkobrada, Marko. Western University; Canadá Fil: Saposnik, Gustavo. University of Toronto; Canadá Fil: Kimpinski, Kurt. Western University; Canadá Fil: Whitehead, Shawn N.. Western University; Canadá Fil: Sposato, Luciano A.. Western University; Canadá

Atrial fibrillation affects 33.5 million people worldwide and its prevalence is expected to double by 2050 because of the aging population. Atrial fibrillation confers a 5-fold higher risk of ischemic stroke compared to sinus rhythm. We present our view of the role of shared medical decision-making to combat global underutilization of oral anticoagulation for stroke prevention in atrial fibrillation patients. Oral anticoagulation underuse is widespread as it is present within atrial fibrillation patients of all risk strata and in countries across all income levels. Reasons for oral anticoagulation underuse include but are probably not limited to poor risk stratification, over-interpretation of contraindications, and discordance between physician prescription preferences and actual administration. By comparing a catastrophic event to the consequences of atrial fibrillation related strokes, it may help physicians and patients understand the negative outcomes associated with oral anticoagulation under-utilization and the magnitude to which oral anticoagulations neutralize atrial fibrillation burden. Fil: Cerasuolo, Joshua O.. Western University; Canadá Fil: Montero Odasso, Manuel. Western University; Canadá Fil: Ibáñez Barassi, Agustín Mariano. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Neurociencia Cognitiva. Fundación Favaloro. Instituto de Neurociencia Cognitiva; Argentina. Australian Research Council; Australia. Universidad Adolfo Ibañez; Chile. Universidad Autónoma del Caribe; Colombia Fil: Doocy, Shannon. Johns Hopkins Bloomberg School Of Public Health; Estados Unidos. University Johns Hopkins; Estados Unidos Fil: Lip, Gregory YH. University of Birmingham. Institute of Cardiovascular Sciences; Reino Unido Fil: Sposato, Luciano A. Dementia & Heart Disease Laboratory; Canadá

Introduction We discovered a concomitant decline in stroke and dementia incidence rates at a whole population level in Ontario, Canada. This study explores these trends within demographic subgroups. Methods We analyzed administrative data sources using validated algorithms to calculate stroke and dementia incidence rates from 2002 to 2013. Results For more than 12 years, stroke incidence remained unchanged among those aged 20 to 49 years and decreased for those aged 50 to 64, 65 to 79, and 80+ years by 22.7%, 36.9%, and 37.9%, respectively. Dementia incidence increased by 17.3% and 23.5% in those aged 20 to 49 and 50 to 64 years, respectively, remained unchanged in those aged 65 to 79 years, and decreased by 15.4% in those aged 80+ years. Discussion The concomitant decline in stroke and dementia incidence rates may depict how successful stroke prevention has targeted shared risk factors of both conditions, especially at advanced ages where such risk factors are highly prevalent. We lend support for the development of an integrated system of stroke and dementia prevention.