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Study objective Observational studies assessing direct oral anticoagulant (DOACs) dosage in atrial fibrillation (AF) reported that a lower proportion of patients received high-dose DOACs compared to those in randomized controlled trials (RCTs). Effectiveness and safety of high-dose DOACs relative to apixaban in a real-world AF population need to be addressed. The aim is to assess comparative effectiveness and safety of high-dose rivaroxaban relative to apixaban. Design We conducted a cohort study. Setting We built a cohort of patients hospitalized and discharged in community with a primary or secondary AF diagnosis from 2011-2017 using Quebec administrative databases (Med-Echo and RAMQ). Patients Cohort entry was defined as the first OAC claim in new users of high-dose rivaroxaban and apixaban, with no OAC claims in the prior year. Intervention To compare effectiveness and safety of high-dose rivaroxaban to apixaban. Measurement We ascertained patient demographics, comorbidities, CHA2DS2-VASc and HASBLED scores and Charlson score within 3 years prior to cohort entry. Primary effectiveness and safety were a composite of ischemic stroke/systemic thrombosis, death, myocardial infarction, and of intracranial bleeding (ICH), extracranial major bleeding, in the first year following drug initiation. We conducted propensity score matching and estimated hazard ratios (HRs) for outcomes using Cox proportional hazard models. All the analyses were conducted to account for competing risks. Main results The cohort consisted of 4,632 and 6,771 patients received high-dose rivaroxaban and apixaban, respectively. High-dose rivaroxaban users were younger with a mean age of 73.2 years, presented less associated comorbidities and had lower CHA2DS2-VASc scores compared to apixaban. High-dose rivaroxaban at the intention to treat was associated with a higher risk of stroke/SE/death (HR 1.21, 95% CI 1.04-1.40) and worse composite effectiveness (HR 1.21: 1.05-1.40); under treatment exposure, those values were at HR (1.66: 1.21-2.29) and HR (1.58:1.19-2.10), respectively. And, rivaroxaban presented a less favorable safety profile relative to apixaban. Conclusion In this study, composite effectiveness and safety varied between rivaroxaban and apixaban. High-dose apixaban was observed to have a better effectiveness and safety.

Background Low-dose direct oral anticoagulant (DOAC) use is quite prevalent in clinical practice, but evidence of its effectiveness and safety compared with high-dose DOAC in patients with atrial fibrillation (AF) remains limited. We aimed to assess the effectiveness and safety of low-dose and high-dose DOACs in patients with AF with similar baseline characteristics. Methods We used a cohort of hospitalized patients with a primary or secondary diagnosis of AF after discharge to the community, whose data were stored in the Quebec administrative databases, from 2011 to 2017. Older adults with AF newly prescribed with rivaroxaban (15 or 20 mg) or apixaban (2.5 mg or 5 mg) were classified as under treatment (UT) and intent to treat (ITT). We used an inverse probability treatment weighting study of new users of rivaroxaban and apixaban to address confounding by indication. The primary effectiveness outcome was ischemic stroke/systemic embolism (SE), while the primary safety outcome was major bleeding (MB). We used Cox proportional models to estimate the marginal hazard ratios (HRs). Findings A total of 1,722 and 4,639 patients used low-dose and standard-dose rivaroxaban, respectively, while 3,833 and 6,773 patients used low-dose and standard-dose apixaban, respectively. No significant difference was observed in the incidence of comparative stroke/SE and MB between low-dose and standard-dose rivaroxaban, except for the risk of acute myocardial infarction (AMI), which was increased with the low dose in the UT analysis. For apixaban, no difference was found in the bleeding rates, but the risk of stroke/SE (HR: 1.95; 95% confidence interval (CI): 1.38–2.76) and death (HR: 1.99; 95% CI: 1.46–2.70) were greater in the low-dose group than in the standard-dose group in the UT analysis. Similar results were observed for the ITT analysis. Conclusion No significant differences were observed in the effectiveness or safety outcome between low-dose and standard-dose rivaroxaban, except for AMI. However, low-dose apixaban was associated with a greater risk of stroke/SE and death without a reduction in the bleeding rates.

Background and purpose Data on oral anticoagulant (OAC) uptake and pattern of use are limited. Real-life data in patients with atrial fibrillation (AF) are important for understanding patient exposure. A cohort study of new OAC users was built to assess trends of drug use from 2011 to 2017, persistence rate, switching rate, adherence level, and predictors of adherence. Methods We built a cohort using the Regie d'Assurance Maladie du Quebec (RAMQ) and Med-Echo administrative databases of new adult OAC users within 1 year following hospitalization with a diagnosis of AF. New users of OAC were defined as having no OAC claims in the year before cohort entry. We assessed trends of OAC use; persistence rate, defined as a gap between refills of no longer than two times the duration of the previous prescriptions; and adherence level, defined as the proportion of days covered (PDC) over a 1-year period following initiation. Predictors of nonadherence (PDC less than 80%) were analyzed using logistic regression models. Results The cohort consisted of 33,311 incident OAC users. Of total OAC claims, the proportions of warfarin claims decreased from 77.9% in 2011 to 12.7% in 2017, with direct oral anticoagulants (DOACs) accounting for 87.3% of claims, of which apixaban and rivaroxaban accounted for 60.1% and 23.4%, respectively, by the end of 2017. One year after OAC initiation, persistence rates ranged from 53% with warfarin to 77% with a high dose of apixaban. Approximately 75% of incident OAC users were considered "adherent" (PDC 80% or more), with a mean PDC of 95.6-98.1%, compared with "nonadherent," with a mean PDC varying between 43.1% and 50.7%. Older age, female sex, higher CHA2 DS2 -VASc score (to predict thromboembolic risk in AF), prior stroke, and treatment with chronic cardiovascular disease drugs were associated with high adherence levels. Conclusion The clinical uptake of DOACs increased over time, accounting for 87.3% of prescriptions in 2017. In our study, 25% of new OAC users presented a low adherence level. Adherence to OACs remains a significant challenge in patients with AF.

Supplemental Digital Content is available in the text, Objective: To estimate national and geography-based variations in blood pressure and burden of hypertension in Cameroon, generally called ‘miniature Africa’. Methods: PubMed, Medline, EMBASE, CINHAL, Web of Science, Popline, Scopus and BDSP were searched through November 2018, for hypertension studies among Cameroonians aged at least 18 years. Hypertension was measured as SBP at least 140 mmHg or DBP at least 90 mmHg. Random-effects meta-analysis was used. Results: Twenty studies involving 46 491 participants met inclusion criteria. Overall hypertension prevalence was 30.9% [95% confidence interval (CI) 27.0–34.8]: 29.6% (24.1–35.1) and 32.1% (27.2–37.1) in 1994–2010 and 2011–2018, respectively. Of hypertensive participants, only 24.4% (18.9–30.0) – 31.6% (21.0–42.3) and 20.8% (14.0–27.7) in 1994–2010 and 2011–2018, respectively – were aware of their status, 15.1% (10.6–19.6) were taking antihypertensive medications and 8.8% (5.7–11.9) – 10.4% (7.5–13.3) and 8.3% (4.4–12.3) in 1994–2010 and 2011–2018, respectively – were controlled. Hypertension prevalence varied by sex: 34.3% (30.0–38.6) for men and 31.3% (26.5–36.1) for women; ethnicity: from 3.3% (0.4–6.2) among Pygmies to 56.6% (49.4–63.8) among Bamileke; urbanity: 25.4% (17.1–33.7) for rural and 31.4% (27.3–35.5) for urban dwellers; agroecological zone: from 35.1% (28.9–41.3) in Tropical highlands to 28% (20.1–35.9) in Guinea-Savannah; and subnational region: from 36.3% (27.8–44.9) in the West to 17.1% (9.9–44.2) in the South. Conclusion: Cameroon's hypertension prevalence is high and increasing whereas awareness, treatment and control are low and declining. Emerging patterns call urgently for effective campaigns to raise hypertension awareness alongside strategies for hypertension prevention and BP control.

In 2010, we published our stroke prevention clinic's performance as compared to Canadian stroke prevention guidelines. We now compare our clinic's adherence with guidelines to our previous results, following the implementation of an electronic documentation form.All new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008-2010) regarding vascular risk management and treatment.Three hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (plt;0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, plt;0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, plt;0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04-2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.Our study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.En 2010, nous avons rendu publics les résultats de notre clinique de prévention des AVC en ce qui regarde les lignes directrices canadiennes de prévention des AVC. Suite à la mise en place d’un formulaire d’information électronique, nous voulons maintenant comparer l’adhésion actuelle de notre clinique à ces lignes directrices à celle mesurée en 2010.Tous les nouveaux patients adressés à notre clinique (Centre universitaire de santé McGill) pour des cas récents d’ischémie cérébrale transitoire (ICT) ou d’AVC ischémique survenus entre 2014 et 2017 ont été inclus dans cette étude. Nous avons ainsi comparé l’adhésion actuelle aux lignes directrices évoquées ci-haut à celle du précédent rapport (N = 408 patients pour la période allant de 2008 à 2010), et ce, en ce qui concerne la prise en charge du risque vasculaire et les traitements nécessaires.Au total, 392 patients ont été inclus; de ce nombre, 36 % d’entre eux avaient été victimes d’ICT tandis que 64 % avaient été victimes d’un AVC ischémique. Leur âge moyen était de 70 ans et 43 % d’entre eux étaient de sexe féminin. Bien que la cohorte la plus récente, à la suite de l’introduction de nouvelles lignes directrices portant sur la surveillance cardiaque prolongée, ait donné à voir une proportion plus élevée d’AVC d’origine cardio-embolique comparativement à la précédente (19,1 % par opposition à 14,7 %), la popularité croissante de l’angiographie par tomodensitométrie ne s’est pas traduite par une proportion plus grande de sous-types d’AVC affectant de grandes artères (26,3 % de 2014 à 2017 par opposition à 26,2 % de 2008 à 2010). Les valeurs cibles fixées en matière de pression artérielle ont été atteintes dans 83 % des cas comparativement à 70 % des cas dans notre rapport précédent (p0,01). L’atteinte de la valeur cible en ce qui concerne le taux de LDL-cholestérol (lipoprotéines de faible intensité) a également été améliorée dans notre plus récent rapport (66 % par opposition à 46 %; p0,01). Ajoutons aussi qu’aucune différence notable n’a été observée quant à une utilisation constante d’anti-thrombotiques (97,7 % par opposition à 99,8 %; p = 0,08). Fait à souligner, un déclin dans l’abandon du tabagisme a été noté (35 % par opposition à 73%; p = 0,02). Dans l’ensemble, les conditions d’une guérison optimale (optimal therapy status) ont été davantage atteintes dans la cohorte la plus récente comparativement à celle de 2008 à 2010 (52 % par opposition à 22 %; p0,01). Le fait d’être de sexe masculin a été associé à de meilleures conditions de guérison optimale (rapport des cotes: 1,61; IC 95 %, 1,04 – 2,51). Enfin, mentionnons que le nombre de consultations de suivi et la durée des suivis n’ont pas été associés à l’atteinte de valeurs cibles en matière de prévention des AVC.Notre étude montre une série d’améliorations dans l’atteinte des objectifs thérapeutiques recommandés par les lignes directrices canadiennes de prévention des AVC. Cela pourrait être en partie attribuable à la mise en place de dossiers médicaux informatisés au sein de notre clinique. Parmi les aspects qui méritent une amélioration, citons l’établissement d’un programme de counseling en ce qui regarde l’abandon du tabagisme et le dépistage du diabète.

Aim Real-world predictors of major bleeding (MB) have been well-studied among warfarin users, but not among all direct oral anticoagulant (DOAC) users diagnosed with atrial fibrillation (AF). Thus, our goal was to build a predictive model of MB for new users of all oral anticoagulants (OAC) with AF. Methods We identified patients hospitalized for any cause and discharged alive in the community from 2011 to 2017 with a primary or secondary diagnosis of AF in Quebec’s RAMQ and Med-Echo administrative databases. Cohort entry occurred at the first OAC claim. Patients were categorized according to OAC type. Outcomes were incident MB, gastrointestinal bleeding (GIB), non-GI extracranial bleeding (NGIB) and intracranial bleeding within 1 year of follow-up. Covariates included age, sex, co-morbidities (within 3 years before cohort entry) and medication use (within 2 weeks before cohort entry). We used logistic-LASSO and adaptive logistic-LASSO regressions to identify MB predictors among OAC users. Discrimination and calibration were assessed for each model and a global model was selected. Subgroup analyses were performed for MB subtypes and OAC types. Results Our cohort consisted of 14,741 warfarin, 3,722 dabigatran, 6,722 rivaroxaban and 11,196 apixaban users aged 70–86 years old. The important MB predictors were age, prior MB and liver disease with ORs ranging from 1.37–1.64. The final model had a c-statistic of 0.63 (95% CI 0.60–0.65) with adequate calibration. The GIB and NGIB models had similar c-statistics of 0.65 (95% CI 0.63–0.66) and 0.67 (95% CI 0.64–0.70), respectively. Conclusions MB and MB subtype predictors were similar among DOAC and warfarin users. The predictors selected by our models and their discriminative potential are concordant with published data. Thus, these models can be useful tools for future pharmacoepidemiologic studies involving older oral anticoagulant users with AF.

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.

Objective: To evaluate the association between the presence of integrated systems of stroke care and stroke case-fatality across Canada. Methods: We used the Canadian Institute of Health Information9s Discharge Abstract Database to retrospectively identify a cohort of stroke/TIA patients admitted to all acute care hospitals, excluding the province of Quebec, in 11 fiscal years from 2003/2004 to 2013/2014. We used a modified Poisson regression model to compute the adjusted incidence rate ratio (aIRR) of 30-day in-hospital mortality across time for provinces with stroke systems compared to those without, controlling for age, sex, stroke type, comorbidities, and discharge year. We conducted surveys of stroke care resources in Canadian hospitals in 2009 and 2013, and compared resources in provinces with integrated systems to those without. Results: A total of 319,972 patients were hospitalized for stroke/TIA. The crude 30-day mortality rate decreased from 15.8% in 2003/2004 to 12.7% in 2012/2013 in provinces with stroke systems, while remaining 14.5% in provinces without such systems. Starting with the fiscal year 2009/2010, there was a clear reduction in relative mortality in provinces with stroke systems vs those without, sustained at aIRR of 0.85 (95% confidence interval 0.79–0.92) in the 2011/2012, 2012/2013, and 2013/2014 fiscal years. The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services. Conclusion: In this retrospective study, the implementation of integrated systems of stroke care was associated with a population-wide reduction in mortality after stroke.

Background and Purpose Patients with nonvalvular atrial fibrillation (NVAF) who survive an intracranial hemorrhage (ICH) have an increased risk of ischemic stroke and systemic embolism (IS/ SE). We investigated whether starting oral anticoagulants (OACs) among older NVAF patients after an ICH was associated with a lower risk of IS/SE and mortality but offset by an increase in major bleeding. Methods We assembled a patient cohort from the Quebec Régie de l’Assurance Maladie du Québec (RAMQ) and Med-Echo administrative databases. We identified older adults with NVAF from 1995 to 2015. All patients with incident ICH and discharged in community were included. Patients were categorized according to OAC exposure. Outcomes included IS/SE, all-cause mortality, recurrent ICH and major bleeding after a quarantine period of 6 weeks. Crude event rates were calculated at 1-year of follow-up, and Cox proportional hazard models with a time-dependent binary exposure were used to assess adjusted hazard ratios (AHRs). Results The cohort of 683 NVAF patients with ICH aged 83 years on average. The rates (per 100 person-years) for IS/SE, death, ICH and major bleeding were 3.3, 40.6, 11.4, and 2.7 for the no OAC group; and 2.6, 16.3, 5.2, and 5.2 for OAC group, respectively. The AHR for IS/SE and death was 0.10 (95% confidence interval [CI], 0.05 to 0.21), 0.43 (95% CI, 0.19 to 0.97) for recurrent ICH and 1.73 (95% CI, 0.71 to 4.20) for major extracranial bleeding comparing OAC exposure to non-exposed. Conclusions Initiating OAC after ICH in older individuals with NVAF is associated with a reduction of IS/SE and mortality and a trend in recurrent ICH supporting its use after ICH.

Background— The aim of this study is to examine the relationship between time in the therapeutic range (TTR) and clinical outcomes in heart failure patients in sinus rhythm treated with warfarin. Methods and Results— We used data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial to assess the relationship of TTR with the WARCEF primary outcome (ischemic stroke, intracerebral hemorrhage, or death), with death alone, ischemic stroke alone, major hemorrhage alone, and net clinical benefit (primary outcome and major hemorrhage combined). Multivariable Cox models were used to examine how the event risk changed with TTR and to compare the high TTR, low TTR, and aspirin-treated patients, with TTR being treated as a time-dependent covariate. A total of 2217 patients were included in the analyses; among whom 1067 were randomized to warfarin and 1150 were randomized to aspirin. The median (interquartile range) follow-up duration was 3.6 (2.0–5.0) years. Mean (±SD) age was 61±11.3 years, with 80% being men. The mean (±SD) TTR was 57% (±28.5%). Increasing TTR was significantly associated with reduction in primary outcome (adjusted P P =0.001), and improved net clinical benefit (adjusted P P =0.082 for ischemic stroke and adjusted P =0.109 for major hemorrhage). Conclusions— In patients with heart failure in sinus rhythm, increasing TTR is associated with better outcome and improved net clinical benefit. Patients in whom good quality anticoagulation can be achieved may benefit from the use of anticoagulants. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00041938.

Background: We analyzed a 10-year stroke administrative dataset to examine trends in admissions, mortality, and discharge destination in Canada. Methods: We conducted an analysis of hospital administrative data from April 1 st 2003 to March 31 st 2013 from the Canadian Institute of Health Information's Discharge Abstract Database. Ten-year trends for population-based age- and sex- standardized admission rates were calculated. We reviewed 10-year trends in absolute stroke admissions for differences between provinces and age groups. Stroke 30-day in-hospital mortality rates were calculated and adjusted for sex, age, stroke type and comorbidities. We documented changes in discharge location for ischemic and hemorrhagic stroke patients discharged from acute care. Results: The rate of hospital admissions has declined from 140.2 to 117.5 (per 100,000 people). The number of absolute stroke admissions within provinces increased in Alberta and British Columbia (21.7% and 16.2% respectively). The proportion of stroke patients aged 40-69 years old increased by 4.8% (p

Background and Purpose— Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. Methods— We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. Results— Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142–1973) among those who subsequently had AF detected versus 45 (interquartile range, 14–250) in those without AF ( P P P =0.0017) and 2 years ( P =0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from Conclusions— Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00846924.

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.

Over- and undercoagulation with warfarin are associated with hemorrhagic and thromboembolic events, respectively. Genetic and clinical factors affect warfarin response, and the causes of this variability remain unclear. We present descriptive statistics and test for predictors of poor anticoagulation control. The Quebec Warfarin Cohort (QWC) comprises 1059 new warfarin users, with prospective follow-up using telephone questionnaires every 3 months for 1 year, and using healthcare administrative databases (RAMQ and Med-Echo) for 5 years prior to cohort entry and up to 10 years following active patient participation. Genetic material was collected, and genotyping of CYP2C9 and VKORC1 genes was conducted. Measured outcomes included the percentage of time patients spent within therapeutic range, anticoagulation control, warfarin dose, bleeding, and thromboembolic events. We report baseline characteristics and outcomes after 1 year of follow-up. Poor anticoagulation control was defined as time in therapeutic range

Background: Hypertension holds a unique place in population health and health care because it is the leading cause of cardiovascular disease and the most common noncommunicable condition seen in primary care worldwide. Without effective prevention and control, raised blood pressure significantly increases the risk of stroke, myocardial infarction, chronic kidney disease, heart failure, dementia, renal failure, and blindness. There is an urgent need for stakeholders—including individuals and families—across the health system, researchers, and decision makers to work collaboratively for improving prevention, screening and detection, diagnosis and evaluation, awareness, treatment and medication adherence, management, and control for people with or at high risk for hypertension. Meeting this need will help reduce the burden of hypertension-related disease, prevent complications, and reduce the need for hospitalization, costly interventions, and premature deaths. Objective: This review aims to synthesize evidence on the epidemiological landscape and control of hypertension in Cameroon, and to identify elements that could potentially inform interventions to combat hypertension in this setting and elsewhere in sub-Saharan Africa. Methods: The full search process will involve several steps, including selecting relevant databases, keywords, and Medical Subject Headings (MeSH); searching for relevant studies from the selected databases; searching OpenGrey and the Grey Literature Report for gray literature; hand searching in Google Scholar; and soliciting missed publications (if any) from relevant authors. We will select qualitative, quantitative, or mixed-methods studies with data on the epidemiology and control of hypertension in Cameroon. We will include published literature in French or English from electronic databases up to December 31, 2016, and involving adults aged 18 years or older. Both facility and population-based studies on hypertension will be included. Two reviewers of the team will independently search, screen, extract data, and assess the quality of selected studies using suitable tools. Selected studies will be analyzed by narrative synthesis, meta-analysis, or both, depending on the nature of the data retrieved in line with the review objectives. Results: This review is part of an ongoing research program on disease prevention and control in the context of the dual burden of communicable and noncommunicable diseases in Africa. The first results are expected in 2017. Conclusions: This review will provide a comprehensive assessment of the burden of hypertension and control measures that have been designed and implemented in Cameroon. Findings will form the knowledge base relevant to stakeholders across the health system and researchers who are involved in hypertension prevention and control in the community and clinic settings in Cameroon, as a yardstick for similar African countries. Trial Registration: PROSPERO registration number: CRD42017054950; http://www.crd.york.ac.uk/PROSPERO/ display_record.asp?ID=CRD42017054950 (Archived by WebCite at http://www.webcitation.org/6qYSjt9Jc) [JMIR Res Protoc 2017;6(5):e102]

BackgroundFew studies have assessed the performance of stroke prevention clinics. In particular, limited information exists on patient compliance, achievement of therapeutic targets, and related occurrence of vascular events.MethodsWe compared our clinical practice to recommendations from published guidelines in newly referred patients for transient ischemic attack (TIA) or ischemic stroke between 2008 and 2010. We monitored our cohort for at least 1 year and assessed for adequacy of vascular risk factor management, drug adherence, and occurrence of nonlethal vascular outcomes.ResultsOf 408 patients, 57.8% had a stroke and 42.2% a TIA. The mean age was 68±13 years, and 52% male. Average follow-up was 15.8 months. During follow-up, 253 patients (70.3%) completely achieved their blood pressure target, 151 (45.5%) achieved their low-density lipoprotein (LDL) cholesterol target, and 407 (99.8%) were on antithrombotics. Eighty-nine patients (21.8%) attained optimal therapy status, defined as reaching targets for LDL cholesterol, blood pressure, and antithrombotic use. Adherence to drug therapy was associated with attainment of optimal therapy status (p=0.01). Diabetes was associated with lower probability of attaining optimal therapy status (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.20-0.66) and blood pressure targets (OR, 0.09; 95% CI, 0.05-0.17). During follow-up, 52 (12.7%) patients had a nonlethal vascular event.ConclusionOur study shows good attainment of therapeutic goals associated with adherence to drug therapy. However, optimal therapy status and blood pressure targets were more difficult to attain in patients with diabetes; therefore, more intensive preventive efforts may be required for these individuals.

Objective: To assess whether adding clopidogrel to acetylsalicylic acid (ASA) has a long-term protective vascular effect in patients with lacunar stroke while taking ASA. Methods: Post hoc analysis of 838 patients with ASA failure and recent lacunar stroke from the Secondary Prevention of Small Subcortical Strokes Trial (SPS3) cohort randomly allocated to aspirin (325 mg/day) and clopidogrel (75 mg/day) or placebo. Primary efficacy outcome was stroke recurrence (ischemic and intracranial hemorrhage) and main safety outcome was major extracranial hemorrhage. Patients were followed for a mean period of 3.5 years. Results: The ASA failure group had a significantly higher risk of vascular events including ischemic stroke when compared with the non–ASA failure group (n = 2,151) in SPS3 ( p = 0.03). Mean age was 65.6 years and 65% were men. The risk of recurrent stroke was not reduced in the dual antiplatelet group, 3.1% per year, compared to the aspirin-only group, 3.3% per year (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.61–1.37). There was also no difference between groups for ischemic stroke (HR 0.90; 95% CI 0.59–1.38). The risk of gastrointestinal bleeding was higher in the dual antiplatelet group (HR 2.7; 95% CI 1.1–6.9); however, the risk of intracranial hemorrhage was not different. Conclusions: In patients with a recent lacunar stroke while taking ASA, the addition of clopidogrel did not result in reduction of vascular events vs continuing ASA only. Classification of evidence: This study provides Class I evidence that for patients with recent lacunar stroke while taking ASA, adding clopidogrel as compared to continuing ASA alone does not reduce the risk of recurrent stroke.

BACKGROUND: The benefit of intravenous tissue plasminogen activator (tPA) given within 3 h of acute ischaemic stroke to patients over 80 years of age is uncertain. AIM: To examine the clinical characteristics and complications and the predictors of outcome after intravenous tPA treatment in patients aged > or = 80 years. METHODS: Data (n = 1135) prospectively collected from the Canadian Alteplase for Stroke Effectiveness Study were reviewed and patients aged > or = 80 years (n = 270) treated with intravenous tPA for acute ischaemic stroke were compared with those aged or = 80 years and or = 80 years and in 40% of those or = 80 years than in those aged or = 80 years, stroke severity, baseline Alberta Stroke Program Early CT Score and glucose level were found to be the major independent predictors of outcome. CONCLUSION: In carefully selected elderly patients, the use of intravenous tPA was not found to be associated with an increased risk of symptomatic intracerebral haemorrhage. Age-related differences were seen in the clinical characteristics and outcome in the elderly population.

Background:The thromobolytic drug, tissue plasminogen activator (tPA) has been approved in the United States for the treatment of acute ischemic stroke amid controversy and concern about the balance of risk and benefit. The Canadian Stroke Consortium (CSC), a national network of neurologists who collaborate on joint projects in stroke medicine, including clinical trials and consensus statements, has developed guidelines for the use of tPA in Canada.Methods and Results:The CSC Board of Directors wrote a preliminary report based on existing publications, including randomized drug trials and the report of a special committee struck by the Stroke Council of the American Heart Association. This draft was circulated to the CSC membership-at-large for suggestions or amendments, to produce this final draft.Conclusions:The present guidelines have been devised to represent a Canadian viewpoint of management. The Health Protection Branch of the Ministry of Health of Canada has not yet produced an evaluation. Further modification of these guidelines may be necessary when more data from clinical trials and experience with the drug become available.

Background and purpose Providing participants with evidence-based care for secondary prevention is an ethical and scientific priority for trials in stroke therapy. The optimal strategy, however, is uncertain. We report the performance of a new approach for delivering preventive care to trial participants. Methods Participants were enrolled in the Insulin Resistance Intervention after Stroke trial, which examined the insulin sensitiser, pioglitazone versus placebo for prevention of stroke and myocardial infarction after ischaemic stroke or transient ischaemic attack. Preventive care was the responsibility of the participants’ personal healthcare providers, but investigators monitored care and provided feedback annually. We studied achievement of 8 prevention goals at baseline and 3 annual visits, with a focus on 3 priority goals: blood pressure

Background:Longitudinal, patient-level data on resource use and costs after an ischemic stroke are lacking in Canada. The objectives of this analysis were to calculate costs for the first year post-stroke and determine the impact of disability on costs.Methodology:The Economic Burden of Ischemic Stroke (BURST) Study was a one-year prospective study with a cohort of ischemic stroke patients recruited at 12 Canadian stroke centres. Clinical history, disability, health preference and resource utilization information was collected at discharge, three months, six months and one year. Resources included direct medical costs (2009 CAN$) such as emergency services, hospitalizations, rehabilitation, physician services, diagnostics, medications, allied health professional services, homecare, medical/assistive devices, changes to residence and paid caregivers, as well as indirect costs. Results were stratified by disability measured at discharge using the modified Rankin Score (mRS): non-disabling stroke (mRS 0-2) and disabling stroke (mRS 3-5).Results:We enrolled 232 ischemic stroke patients (age 69.4 ± 15.4 years; 51.3% male) and 113 (48.7%) were disabled at hospital discharge. The average annual cost was $74,353; $107,883 for disabling strokes and $48,339 for non-disabling strokes.Conclusions:An average annual cost for ischemic stroke was calculated in which a disabling stroke was associated with a two-fold increase in costs compared to NDS. Costs during the hospitalization to three months phase were the highest contributor to the annual cost. A “back of the envelope” calculation using 38,000 stroke admissions and the average annual cost yields $2.8 billion as the burden of ischemic stroke.

Objective: To evaluate the relationship between antihypertensive (AH) drug adherence and cardiovascular (CV) outcomes among patients with a recent ischemic stroke and assess the validity of our approach. Methods: A cohort of 14,227 patients diagnosed with an ischemic stroke was assembled from individuals 65 years and older who were treated with AH agents from 1999 to 2007 in Quebec, Canada. A nested case-control design was used to evaluate the occurrence of nonfatal major CV outcomes and mortality. Each case was matched to 15 controls by age and cohort entry time. Medication possession ratio was used for AH agent adherence level. Adjusted conditional logistic regression models were used to estimate the rate ratio of CV events. The validity of the approach was assessed by evaluating the adherence level of CV-protective and non–CV-protective drugs. Results: Mean age was 75 years, 54% were male, 38% had coronary artery disease, 23% had diabetes, 47% dyslipidemia, and 14% atrial fibrillation or flutter. High adherence to AH therapy was mirrored by similar adherence to statins and antiplatelet agents and was associated with a lower risk of nonfatal vascular events compared with lower adherence (rate ratio 0.77 [0.70–0.86]). We observed a paradoxic link between adherence to several drugs and all-cause mortality. Conclusion: Adherence to AH agents is associated with adherence to other secondary preventive therapies and a risk reduction for nonfatal vascular events after an ischemic stroke. Overestimation of all-cause mortality reduction may be related to frailty and comorbidities, which may confound the apparent benefit of different drugs.

With an aging population, patients are increasingly likely to present with stroke and pre-existing dementia, which may lead to greater death and disability. The aim of this work was to assess the risk of all-cause mortality and poor functional outcomes after ischemic stroke in patients with and without pre-existing dementia. We conducted a multicenter cohort study of all patients presenting to 12 tertiary care institutions participating in the Registry of the Canadian Stroke Network (RCSN) with a first ischemic stroke between 2003 and 2008. Individuals with pre-existing dementia were matched using propensity-score methods with patients without dementia during their index hospitalization based on the following characteristics: age (within 3 years), sex, stroke severity, stroke subtype (lacunar vs. non-lacunar), level of consciousness, vascular risk factors, dysphagia, glucose and creatinine on admission, Charlson index, residence prior to hospitalization (home vs. other), pre-admission dependency, hospital arrival via ambulance, admission to stroke unit, thrombolysis, and palliative care. A propensity score for all-cause mortality and clinical outcomes was developed. Registry of the Canadian Stroke Network (RCSN) and Registered Persons Database (RPDB). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included mortality at discharge and at 1 year, disability at discharge (modified Rankin scale ≥ 3), medical complications (pneumonia), and discharge disposition. A subgroup analysis assessing the risk of intracerebral hemorrhage among those receiving thrombolysis was also conducted. We matched 877 patients with an acute ischemic stroke and pre-existing dementia to 877 stroke patients without dementia. Patients were well matched. The mean age was 82 years and 58 % were women. Mortality at discharge, 30 days, and 1 year after stroke was similar in patients with and without dementia [for mortality at discharge RR 0.88 [95 % confidence interval (CI) 0.74-1.05]; mortality at 30-days: RR 0.88 (95 % CI 0.75-1.03) and mortality at 1 year: RR 1.01 (95 % CI 0.92-1.11). Patients with pre-existing dementia had similar disability at discharge and home disposition. In the subgroup of patients who received thrombolysis, there were no differences between those with and without dementia in the risk of intracerebral hemorrhage (RR 1.27; 95 % CI 0.69-2.35) and no differences in mortality or disability at discharge. Pre-existing dementia is not independently associated with mortality, disability, or institutionalization after ischemic stroke. Pre-existing dementia may not necessarily preclude access to thrombolytic therapy and specialized stroke care.

Adolescents living in youth centers often comply with therapeutic treatment against their will. We think that this forced environment ruptures the therapeutic alliance between adolescents and their therapists and, as such, influences the therapeutic results. It has been reported, however, that therapies evoking rupture of the alliance with its later restoration are more effective than therapies without rupture. We review the literature on models of therapeutic alliance rupture resolution. This review is limited to experimentally- tested models. Firstly, we define the concepts of therapeutic alliance and its rupture. Then, we explore experimental models that quantify therapeutic alliance rupture resolution, describing methods of experimental validation, the results of models applied for experimental validation, and analysis of the data thus obtained.

Noreen Kamal, Oscar Benavente, Karl Boyle, Brian Buck, Ken Butcher, Leanne K. Casaubon,RobertCote,AndrewMDemchuk,YanDeschaintre,DarDowlatshahi,GordonJGubitz,GaryHunter,Tom Jeerakathil, Albert Jin, Eddy Lang, Sylvain Lanthier, Patrice Lindsay, Nancy Newcommon,Jennifer Mandzia, Colleen M. Norris, Wes Oczkowski, Celine Odier, Stephen Phillips,Alexandre Y Poppe, Gustavo Saposnik, Daniel Selchen, Ashfaq Shuaib, Frank Silver, Eric E Smith,Grant Stotts, Michael Suddes, Richard H. Swartz, Philip Teal, Tim Watson, Michael D. Hill

Cardiovascular diseases (CVD) represent a heavy economic burden on individuals, health services, and society. Low adherence to antihypertensive (AH) agents is acknowledged as a major contributor to the lack of blood pressure control, and may have a significant impact on clinical outcomes and healthcare costs.To evaluate the impact of low adherence to AH agents on cardiovascular outcomes and hospitalization costs.A cohort of 59,647 patients with essential hypertension was reconstructed from the Régie de l'assurance maladie du Québec and Med-Echo databases. Subjects included were between 45 and 85 years of age, without any evidence for symptomatic CVD, newly treated with AH agents between 1999 and 2002 and followed-up for a 3-year period. Adherence to AH agents was categorized asor=80% or80%. The adjusted odds ratio (OR) for CVD events between the 2 adherence groups was estimated using a polytomous logistic analysis. A 2-part model was applied for hospitalization costs.Patients with low adherence were more likely to have coronary disease (OR, 1.07; 95% confidence interval [CI], 1.00-1.13), cerebrovascular disease (OR, 1.13; 95% CI, 1.03-1.25), and chronic heart failure (OR, 1.42; 95% CI, 1.27-1.58) within the 3-year follow-up period. Among hospitalized patients, low adherence to AH therapy was associated with increased costs by approximately $3574 (95% CI, $2897-$4249) per person within a 3-year period.Low adherence to AH agents is correlated with a higher risk of vascular events, hospitalization, and greater healthcare costs. An increased level of adherence to AH agents should provide a better health status for individuals and a net economic gain.

Background Evidence from meta-analyses shows that statin therapy reduces all-cause mortality and nonhemorrhagic strokes. Nonadherence to statins may reduce this protective effect. The association between statin adherence and incidence of cerebrovascular disease remains unexplored outside the context of clinical trials. Objective To evaluate the impact of statin adherence on the occurrence of cerebrovascular disease in a real clinical setting. Methods A cohort of 112,092 patients was reconstructed using the Regie d'assurance maladie du Quebec and Med-Echo databases. The Regie d'assurance maladie du Quebec database contains information from 3 types of health-related data, such as demographic information, medical data, and the prescription claims file. The Med-Echo database contains data on acute care hospitalizations on all Quebec residents. All patients without cardiovascular disease aged 45-85 years who were newly treated with statins between 1999 and 2004 were eligible. A nested case-control design was used to study the occurrence of cerebrovascular disease. Adherence level was reported as a medication possession ratio. Conditional logistic regression models were used to estimate the rate ratio of cerebrovascular disease, adjusting for different covariables. Results The mean patient age was 63 years; 49% had hypertension, 21% had diabetes, and 41% were males. Nonadherence was prevalent because only 55% of the patients were exposed to ≥80% of the medication during follow-up. We did not observe any major differences, defined as more than 5%, between the groups, except for the sex, diabetes, and hypertension. High level of adherence to statins was associated with a reduction of cerebrovascular events (rate ratio: 0.74; 95% confidence interval, 0.65-0.84). Conclusions Our study suggests a relatively low level of adherence to statins, but more importantly, that adherence is associated with a risk reduction for cerebrovascular disease. Adherence to statin therapy needs to be improved, so that patients can benefit from the full protective effects of statin therapy.

Background and Purpose— The prevalence of stroke in elderly patients has been increasing in recent years. However, limited information is available about the burden of stroke in individuals over 80. We sought to evaluate differences in clinical outcomes in Canadians over 80 years old hospitalized for an acute ischemic stroke. Methods— The authors conducted a multicenter cohort study including all hospital admissions for ischemic stroke identified from the Canadian Hospital Morbidity and Mortality Database from April 2003 to March 2004. The Hospital Morbidity and Mortality Database contains a national database that contains patient-level sociodemographic, diagnostic, procedural, and administrative information from across Canada. Multivariable analysis was performed using logistic regression. The primary outcome was 7-day case fatality and fatality at discharge. Secondary end points included intensive care unit admissions, medical complications, gender differences, length of hospital stay, and discharge disposition. Results— We analyzed 26 676 patients with ischemic stroke admitted to 606 hospitals across Canada. Mean age (SD) was 74±13 years. Overall, 10 171 (38%) were aged 80 years or older. Case fatality at discharge was 5.7% (age P P P P Conclusions— Aging of the population is a growing reality in Western societies and this translates into an increasing demand on healthcare systems. In our study, patients with stroke over 80 had higher risk-adjusted fatality, longer hospitalization, and were less likely to be discharged to their original place of residence. Strategies need to be implemented to facilitate equal access to specialized stroke care for the elderly.

Objective: To assess the efficacy of carotid endarterectomy for stroke prevention in asymptomatic and symptomatic patients with internal carotid artery stenosis. Additional clinical scenarios, such as use of endarterectomy combined with cardiac surgery, are also reviewed. Methods: The authors selected nine important clinical questions. A systematic search was performed for articles from 1990 (the year of the last statement) until 2001. Additional articles from 2002 through 2004 were included using prespecified criteria. Two reviewers also screened for other relevant articles from 2002 to 2004. Case reports, review articles, technical studies, and single surgeon case series were excluded. Results: For several questions, high quality randomized clinical trials had been completed. Carotid endarterectomy reduces the stroke risk compared to medical therapy alone for patients with 70 to 99% symptomatic stenosis (16% absolute risk reduction at 5 years). There is a smaller benefit for patients with 50 to 69% symptomatic stenosis (absolute risk reduction 4.6% at 5 years). There is a small benefit for asymptomatic patients with 60 to 99% stenosis if the perioperative complication rate is low. Aspirin in a dose of 81 to 325 mg per day is preferred vs higher doses (650 to 1,300 mg per day) in patients undergoing endarterectomy. Conclusions: Evidence supports carotid endarterectomy for severe (70 to 99%) symptomatic stenosis (Level A). Endarterectomy is moderately useful for symptomatic patients with 50 to 69% stenosis (Level B) and not indicated for symptomatic patients with

Background: The clinical impact of blood pressure (BP) and of antihypertensive therapy (AHT) in acute ischemic stroke remains uncertain. Methods: We reviewed the charts of patients admitted to the Montreal General Hospital between April 1, 2002 and October 15, 2005. Ischemic stroke was considered severe if the Canadian Neurological Scale at presentation was ≤7. Poor outcome at 10 days after onset was defined as a modified Rankin Scale >3. Acute change in BP was defined as the percent difference between the mean 24-hour mean arterial pressure (MAP) and the baseline MAP. AHT was considered present if administered ≧5 days during the first week after stroke onset. The association between predictors and outcome was assessed using unconditional multivariable logistic regression. Covariates used included age, stroke severity, diabetes mellitus, coronary artery disease, atrial fibrillation, premorbid hypertension and hyperlipidemia. Results: Three hundred and sixty-four patients were included. Compared to patients with intermediate baseline BP, those with a MAP >130 mm Hg [OR = 2.47 (95% CI, 1.04–5.85)] or a MAP Conclusions: Both high and low MAP at presentation are associated with worse short-term outcome after ischemic stroke.

Objective: To estimate changes in rates of cerebral infarction and intracerebral hemorrhage, comorbidity profile, and case fatality rates in Quebec over 15 years. Methods: A population-based admission-to-discharge cohort study was conducted, selecting first stroke events from hospital discharge data (MedEcho) from 1988 to 2002. Results: In this study (involving 101,831 persons with cerebral infarctions and 11,215 persons with intracerebral hemorrhages), there was a downturn in the rates of cerebral infarction over 15 years, especially during the last 5 years (32.5% decline for men and 25.5% for women). A concomitant increase in rates of intracerebral hemorrhage, 28% increase for men (2%/year) and 22% for women (1.6%/year), was also noted. Although age and comorbidity of the population increased, case fatality decreased over time. Age and type of stroke were strong predictors for early (≤7 days) and later (8 to 30 days) case fatality, whereas comorbidity was important only for later death. In-hospital bed stay declined dramatically over time for all discharge destinations. Conclusions: A significant decrease in rates of cerebral infarction and a rise in rates of intracerebral hemorrhage were noted in Quebec over 15 years. Age and comorbidity of the population increased. Although stroke is increasingly a condition of the elderly, ill population, case fatality and in-hospital bed stay declined over time.

Background and Purpose— Early supported discharge (ESD) for stroke has been shown to yield outcomes similar to or better than those of conventional care, but there is less information on the impact on costs and on the caregiver. The purpose of this study is to estimate the costs associated with an ESD program compared with those of usual care. Methods— We conducted a randomized controlled trial of stroke patients who required rehabilitation services and who had a caregiver at home. Results— Acute-care costs incurred before randomization when patients were medically ready for discharge averaged $3251 per person. The costs for the balance of the acute-care stay, from randomization to discharge, were $1383 for the home group and $2220 for the usual care group. The average cost of providing the 4-week home intervention service was $943 per person. The total cost generated by persons assigned to the home group averaged $7784 per person, significantly lower than the $11 065 per person for those assigned to usual care. A large proportion of the cost differential between the 2 groups arose from readmissions, for which the usual care group generated costs more than quadruple those of the home intervention group. Conclusions— Providing care at home was no more (or less) expensive for those with greater functional limitation than for those with less. Caregivers in the ESD group scored consistently lower on the Burden Index than caregivers with usual care, even caregivers of persons with major functional limitations. For persons recovering from stroke and their families, ESD provides a cost-effective alternative to usual care.

Mayo NE, Wood-Dauphinee S, Cote R, Durcan L, Carlton J. Activity, participation, and quality of life 6 months poststroke. Arch Phys Med Rehabil 2002;83:1035-42. Objectives: To estimate the extent of activity and participation of individuals 6 months poststroke and their influence on health-related quality of life (QOL) and overall QOL, information that would be useful in identifying services that stroke patients would need in the community. Design: Inception cohort study. Setting: Ten acute care hospitals in metropolitan areas of the province of Quebec. Participants: Persons with first-ever stroke, either ischemic or hemorrhagic. In parallel, a population-based sample of community-dwelling individuals without stroke, frequency matched in age and city district, were also recruited. Interventions: Not applicable. Main Outcome Measures: Stroke subjects were interviewed by telephone at 6-month intervals for 2 years of follow-up. The community-dwelling individuals without stroke were also followed. Results: A total of 434 persons were interviewed approximately 6 months poststroke. Their average age ± standard deviation was 68.4±12.5 years; the average age of the 486 controls was 61.7±12.4 years. The stroke group scored on average 90.6/100 on the Barthel Index; 39% reported a limitation in functional activities, 54% reported limitations with higher-level activities of daily living such as housework and shopping, and 65% reported restrictions in reintegration into community activities. By using the Medical Outcomes 36-Item Short-Form Health Survey (SF-36), persons with stroke rated their physical health 7 points lower than healthy peers; also, 7 of the 8 subscales of the SF-36 were affected by stroke. Conclusion: Almost 50% of the community-dwelling stroke population lived with sequelae of stroke such that, unless there was a full-time and able-bodied caregiver at home, they needed some form of home help. A large proportion also reported lack of meaningful activity, indicating a need for organized support groups for people with stroke; otherwise, boredom will lead to depression and worsening of function, affect, health status, and QOL. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

BACKGROUND Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical. However, paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack (TIA). METHODS We randomly assigned 572 patients 55 years of age or older, without known atrial fibrillation, who had had a cryptogenic ischemic stroke or TIA within the previous 6 months (cause undetermined after standard tests, including 24-hour electrocardiography [ECG]), to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder (intervention group) or a conventional 24-hour monitor (control group). The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after randomization. Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days. RESULTS Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients (16.1%) in the intervention group, as compared with 9 of 277 (3.2%) in the control group (absolute difference, 12.9 percentage points; 95% confidence interval [CI], 8.0 to 17.6; P

Objective The frequency of coronary heart disease (CHD) and stroke are increased in systemic lupus erythematosus (SLE), but the extent of the increase is uncertain. We sought to determine to what extent the increase could not be explained by common risk factors. Methods The participants at two SLE registries were assessed retrospectively for the baseline level of the Framingham study risk factors and for the presence of vascular outcomes: nonfatal myocardial infarction (MI), death due to CHD, overall CHD (nonfatal MI, death due to CHD, angina pectoris, and congestive heart failure due to CHD), and stroke. For each patient, the probability of the given outcome was estimated based on the individual's risk profile and the Framingham multiple logistic regression model, corrected for observed followup. Ninety-five percent confidence intervals (95% CIs) were estimated by bootstrap techniques. Results Of 296 SLE patients, 33 with a vascular event prior to baseline were excluded. Of the 263 remaining patients, 34 had CHD events (17 nonfatal MIs, 12 CHD deaths) and 16 had strokes over a mean followup period of 8.6 years. After controlling for common risk factors at baseline, the increase in relative risk for these outcomes was 10.1 for nonfatal MI (95% CI 5.8–15.6), 17.0 for death due to CHD (95% CI 8.1–29.7), 7.5 for overall CHD (95% CI 5.1–10.4), and 7.9 for stroke (95% CI 4.0–13.6). Conclusion There is a substantial and statistically significant increase in CHD and stroke in SLE that cannot be fully explained by traditional Framingham risk factors alone.

Background —Increased levels of markers of hemostasis may assist in the determination of the extent of carotid occlusive disease and the identification of neurologically intact individuals at increased risk of ischemic events. Methods —We conducted a prospective study of 304 subjects, including 82 with a recent (≤7 days) transient ischemic attack (TIA), 157 asymptomatic individuals with a cervical bruit, and 65 control subjects. Baseline evaluation included a neurological assessment, ECG, cervical ultrasonography, and cerebral CT and/or MRI. Levels of markers of coagulation and fibrinolytic activity were also determined. Results were analyzed in relation to the degree of carotid disease and the subsequent occurrence of cerebral and cardiac ischemic events. Results —Over a mean follow-up period of 2.8 years (SD, 1.3 years), 114 ischemic events occurred. Survival analyses showed that prothrombin fragment 1.2 (F 1.2 ) was a predictor of time to cerebral and cardiac ischemic events in the combined TIA and asymptomatic bruit group (relative risk [RR], 1.46; 95% CI, 1.18 to 1.81) as well as in the asymptomatic bruit group separately (RR, 1.70; 95% CI, 1.14 to 2.53). In the TIA group, both F 1.2 (RR, 2.36; 95% CI, 1.19 to 4.68) and severe (≥80%) carotid stenosis (RR, 3.53; 95% CI, 1.19 to 10.51) were predictive of time to ischemic stroke, myocardial infarction, or vascular death. Conclusions —In patients with TIAs and in asymptomatic individuals with cervical bruits, F 1.2 levels were found to be independent predictors of subsequent cerebral and cardiac ischemic events. Our results are consistent with an active role of the coagulation system through upregulation of thrombin in carotid disease progression and in the pathogenesis of ischemic events in patients at risk.

Background and Purpose —Because stroke management is aimed at facilitating community reintegration, it would be logical that the sooner the patient can be discharged home, the sooner reintegration can commence. The purpose of this study was to determine the effectiveness of prompt discharge combined with home rehabilitation on function, community reintegration, and health-related quality of life during the first 3 months after stroke. Methods —A randomized trial was carried out involving patients who required rehabilitation services and who had a caregiver at home. When medically ready for discharge, persons with stroke were randomized to either the home intervention group (n=58) or the usual care group (n=56). The home group received a 4-week, tailor-made home program of rehabilitation and nursing services; persons randomized to the usual care group received services provided through a variety of mechanisms, depending on institutional, care provider, and personal preference. The main outcome measure was the Physical Health component of the Measuring Outcomes Study Short-Form-36 (SF-36). Associated outcomes measures included the Timed Up & Go (TUG), Barthel Index (BI), the Older Americans Resource Scale for instrumental activities of daily living (OARS-IADL), Reintegration to Normal Living (RNL), and the SF-36 Mental Health component. Results —The total length of stay for the home group was, on average, 10 days, 6 days shorter than that for the usual care group. There were no differences between the 2 groups on the BI or on the TUG at either 1 or 3 months after stroke; however, there was a significantly beneficial impact of the home intervention on IADL and reintegration (RNL). By 3 months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group. Conclusions —Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health.

Objective: We compared the accuracy of clinicians and a risk score (iScore) to predict observed outcomes following an acute ischemic stroke. Methods: The JURaSSiC (Clinician JUdgment vs Risk Score to predict Stroke outComes) study assigned 111 clinicians with expertise in acute stroke care to predict the probability of outcomes of 5 ischemic stroke case scenarios. Cases (n = 1,415) were selected as being representative of the 10 most common clinical presentations from a pool of more than 12,000 stroke patients admitted to 12 stroke centers. The primary outcome was prediction of death or disability (modified Rankin Scale [mRS] ≥3) at discharge within the 95% confidence interval (CI) of observed outcomes. Secondary outcomes included 30-day mortality and death or institutionalization at discharge. Results: Clinicians made 1,661 predictions with overall accuracy of 16.9% for death or disability at discharge, 46.9% for 30-day mortality, and 33.1% for death or institutionalization at discharge. In contrast, 90% of the iScore-based estimates were within the 95% CI of observed outcomes. Nearly half (n = 53 of 111; 48%) of participants were unable to accurately predict the probability of the primary outcome in any of the 5 rated cases. Less than 1% (n = 1) provided accurate predictions in 4 of the 5 cases and none accurately predicted all 5 case outcomes. In multivariable analyses, the presence of patient characteristics associated with poor outcomes (mRS ≥3 or death) in previous studies (older age, high NIH Stroke Scale score, and nonlacunar subtype) were associated with more accurate clinician predictions of death at 30 days (odds ratio [OR] 2.40, 95% CI 1.57–3.67) and with a trend for more accurate predictions of death or disability at discharge (OR 1.85, 95% CI 0.99–3.46). Conclusions: Clinicians with expertise in stroke performed poorly compared to a validated tool in predicting the outcomes of patients with an acute ischemic stroke. Use of the risk stroke outcome tool may be superior for decision-making following an acute ischemic stroke.

Background: The Canadian Stroke Best Practice recommends admission of patients to a specialised stroke unit within three hours. We aimed at assessing delays in our emergency department (ED) and correlating these with medical complications and clinical outcomes. Methods: Predictors and outcomes This is a retrospective review of patients (n=353) admitted with ischemic strokes (January 2011-March 2014). We assessed the length of stay in ED, medical complications in ED and in the stroke unit, functional status (modified Rankin Scale) at discharge and survival. Results: The median delay in ED was 13.8 hours. The rate of medical complications in the ED was 14% (most common being delirium), compared to the stroke unit with 46.7% (most common being pneumonia). Worse functional outcome was correlated with diagnosis of pneumonia (standardised β coefficient=0.2, p=0.001) and presence of brain oedema in the stroke unit (standardised β coefficient=0.2, pConclusions: We found a significant delay in the admission of our patients from the ED to the stroke unit, which is not in keeping with the present guidelines. Medical complications were correlated with worse outcomes. Future analyses will correlate ED delays with clinical outcomes.

Background and Purpose— Evidence-based stroke care has been shown to improve patient outcomes and may reduce health system costs. Cost savings, however, are poorly quantified. This study assesses 4 aspects of stroke management (rapid assessment and treatment services, thrombolytic therapy, organized stroke units, and early home-supported discharge) and estimates the potential for cost avoidance in Canada if these services were provided in a comprehensive fashion. Methods— Several independent data sources, including the Canadian Institute of Health Information Discharge Abstract Database, the 2008–2009 National Stroke Audit, and the Acute Cerebrovascular Syndrome Registry in the province of British Columbia, were used to assess the current status of stroke care in Canada. Evidence from the literature was used to estimate the effect of providing optimal stroke care on rates of acute care hospitalization, length of stay in hospital, discharge disposition (including death), changes in quality of life, and costs avoided. Results— Comprehensive and optimal stroke care in Canada would decrease the number of annual hospital episodes by 1062 (3.3%), the number of acute care days by 166 000 (25.9%), and the number of residential care days by 573 000 (12.8%). The number of deaths in the hospital would be reduced by 1061 (14.9%). Total avoidance of costs was estimated at $682 million annually ($307.4 million in direct costs, $374.3 million in indirect costs). Conclusions— The costs of stroke care in Canada can be substantially reduced, at the same time as improving patient outcomes, with the greater use of known effective treatment modalities.