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Efficacy and safety of a TIA/stroke electronic support tool (FASTEST) trial: Study protocol Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study Population-Based Study of Disability and Institutionalization After Transient Ischemic Attack and Stroke: 10-Year Results of the Oxford Vascular Study Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial Randomized Controlled Trial of a Multipronged Intervention to Improve Blood Pressure Control among Stroke Survivors in Nigeria VITATOPS, the VITAmins TO Prevent Stroke Trial: Rationale and Design of a Randomised Trial of B-Vitamin Therapy in Patients with Recent Transient Ischaemic Attack or Stroke (NCT00097669) (ISRCTN74743444) Peer education for secondary stroke prevention in inner-city minorities: design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial. 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Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: a randomized trial. Stop Stroke: development of an innovative intervention to improve risk factor management after stroke. Pulse pressure and cardiovascular events in postmenopausal women with coronary heart disease. Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient: design of the European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment randomized trial. Secondary Stroke Prevention With Ximelagatran Versus Warfarin in Patients With Atrial Fibrillation: Pooled Analysis of SPORTIF III and V Clinical Trials Secondary Prevention after Minor Stroke and TIA - Usual Care and Development of a Support Program Lower testosterone levels predict incident stroke and transient ischemic attack in older men. 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Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care Secondary stroke prevention with low-dose aspirin, sustained release dipyridamole alone and in combination. ESPS Investigators. European Stroke Prevention Study. Potential for quality improvement of acute stroke management in a district general hospital Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness Cluster randomized trial in the general practice research database: 2. Secondary prevention after first stroke (eCRT study): study protocol for a randomized controlled trial Randomized, Controlled Trial of an Intervention to Enable Stroke Survivors Throughout the Los Angeles County Safety Net to “Stay With the Guidelines” Early invasive treatment (endarterectomy vs. stenting) of moderate-to-severe carotid stenosis in patients with transient ischaemic attack or minor stroke Effects of Pioglitazone for Secondary Stroke Prevention in Patients with Impaired Glucose Tolerance and Newly Diagnosed Diabetes: The J-SPIRIT Study. Case management reduces global vascular risk after stroke: secondary results from the The preventing recurrent vascular events and neurological worsening through intensive organized case-management randomized controlled trial. Rationale and design of the Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial. Risk of Recurrent Cerebrovascular Events in Patients with Cryptogenic Stroke or Transient Ischemic Attack and Patent Foramen Ovale: The FORI (Foramen Ovale Registro Italiano) Study Patients’ and Providers’ Perspectives of a Polypill Strategy to Improve Cardiovascular Prevention in Australian Primary Health Care: A Qualitative Study Set Within a Pragmatic Randomized, Controlled Trial Tailored Hospital-based Risk Reduction to Impede Vascular Events After Stroke (THRIVES) study: qualitative phase protocol. Stroke Complicating Transcatheter Aortic Valve Implantation: Incidence, Risk Factors and Outcome B vitamins in patients with recent transient ischaemic attack or stroke in the VITAmins TO Prevent Stroke (VITATOPS) trial: a randomised, double-blind, parallel, placebo-controlled trial Exercise intervention to prevent falls and enhance mobility in community dwellers after stroke: a protocol for a randomised controlled trial Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial Clopidogrel added to aspirin adds no benefit but bleeding risk in patients with recent lacunar stroke. 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Risk factors for stroke after acute coronary syndromes in the Orbofiban in Patients with Unstable Coronary Syndromes--Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 study. Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance. Risks of gastrointestinal bleeding during secondary prevention of vascular events with aspirin--analysis of gastrointestinal bleeding during the UK-TIA trial. Second European Stroke Prevention Study: antiplatelet therapy is effective regardless of age L-Arginine-Mediated Vasoreactivity in Patients with a Risk of Stroke Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial Reduction of stroke incidence after myocardial infarction with pravastatin: the Cholesterol and Recurrent Events (CARE) study. The Care Investigators. 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Implementation of a Structured Guideline–Based Program for the Secondary Prevention of Ischemic Stroke in China Mixed methods feasibility study for a trial of blood pressure telemonitoring for people who have had stroke/transient ischaemic attack (TIA) A prospective study of plasma fibrinogen levels and the risk of stroke among participants in the bezafibrate infarction prevention study. 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BACKGROUND Approximately one third of the 780,000 people in the United States who have a stroke each year have recurrent events . Although efficacious secondary prevention measures are available , levels of adherence to these strategies in patients who have had stroke are largely unknown . Underst and ing medication-taking behavior in this population is an important step to optimizing the appropriate use of proven secondary preventive therapies and reducing the risk of recurrent stroke . METHODS The Adherence eValuation After Ischemic Stroke Longitudinal ( AVAIL ) registry is a prospect i ve study of adherence to stroke prevention medications from hospital discharge to 1 year in patients admitted with stroke or transient ischemic attack . The primary outcomes are medication usage as determined by patient interviews after 3 and 12 months . Potential patient- , provider- , and system-level barriers to persistence of medication use are also collected . Secondary outcomes include the rates of recurrent stroke or transient ischemic attack , vascular events , and rehospitalization and functional status as measured by the modified Rankin score . RESULTS The AVAIL enrolled about 2,900 subjects from 106 hospitals from July 2006 through July 2008 . The 12-month follow-up will be completed in August 2009 . CONCLUSIONS The AVAIL registry will document the current state of adherence and persistence to stroke prevention medications among a nationwide sample of patients . These data will be used to design interventions to improve the quality of care post acute hospitalization and reduce the risks of future stroke and cardiovascular events Background Patients with recent stroke or TIA are at high risk for new vascular events . Several evidence based strategies in secondary prevention of stroke are available but frequently underused . Support programs with multifactorial risk factor modifications after stroke or TIA have not been investigated in large-scale prospect i ve controlled trials so far . INSPiRE-TMS is a prospect i ve , multi-center , r and omized open intervention trial for intensified secondary prevention after minor stroke and TIA . Methods / design Patients with acute TIA or minor stroke admitted to the participating stroke centers are screened and recruited during in-hospital stay . Patients are r and omised in a 1:1 ratio to intervention ( support program ) and control ( usual care ) arms . Inclusion of 2.082 patients is planned . The support program includes cardiovascular risk factor measurement and feedback , monitoring of medication adherence , coaching in lifestyle modifications , and active involvement of relatives . St and ardized motivational interviewing is used to assess and enhance patients ’ motivation . Primary objective is a reduction of new major vascular events defined as nonfatal stroke and myocardial infa rct ion or vascular death . Recruitment time is planned for 3.5 years , follow up time is at least 2 years for every patient result ing in a total study time of 5 years ( first patient in to last patient out ) . Discussion Given the high risk for vascular re-events in acute stroke and the available effective strategies in secondary prevention , the INSPIRE-TMS support program has the potential to lead to a relevant reduction of recurrent events and a prolongation of the event-free survival time . The trial will provide the basis for the decision whether an intensified secondary prevention program after stroke should be implemented into regular care . A cost-effectiveness evaluation will be performed . Trial registration clinical trials.gov : BACKGROUND Despite the beneficial effect of cardiac rehabilitation after myocardial infa rct ion , a rehabilitation program to improve cardiorespiratory fitness and influence secondary prevention has not been implemented for ischemic stroke and transient ischemic attack ( TIA ) . OBJECTIVE To investigate the safety and feasibility of a post-stroke care including an exercise program after minor ischemic stroke or TIA . METHODS In a r and omised controlled trial , 20 patients with a recent minor stroke or TIA without cardiac contraindications were r and omly assigned to one of the two interventions ; post-stroke care without exercise or post-stroke care with exercise . Patients were evaluated at baseline , 6 and 12 months . RESULTS Eighteen patients completed the intervention . In none of the patients cardiopulmonary contraindications for the maximal exercise test and exercise program were found . No cardiovascular events occurred during the maximal exercise tests and exercise program . After one year , significantly more patients in the post-stroke care with exercise group achieved the composite endpoint of optimal medical therapy . CONCLUSIONS Post-stroke care including an exercise program is safe and feasible in the acute phase after minor stroke or TIA and might be a way to increase effectiveness of secondary stroke prevention . We are currently conducting a larger trial to vali date these results We targeted stroke/transient ischemic attack ( TIA ) survivors to engage in self-management practice s to manage secondary stroke risk factors . We conducted a r and omized , regional pilot trial of a locally adapted , secondary stroke prevention program . We implemented the program at two Veterans Administration Medical Centers . Program sessions targeted stroke risk factor self-management . Specifically , we evaluated the effect of the program on the reach , implementation , and effectiveness on patient self-efficacy ; stroke-specific , health-related quality of life ; and medication adherence for the prevalent stroke risk factors : ( 1 ) diabetes , ( 2 ) hypertension , and ( 3 ) hyperlipidemia . Medication possession ratios were calculated to evaluate medication adherence using VA pharmacy benefits data pre ( 6 months prior ) and post ( 6 months after ) the stroke/TIA event . Based upon the literature st and ard of 80 % compliance rate , we dichotomized compliance and modeled the data using logistical regression . Final sample included 174 veterans with an acute stroke or TIA who were r and omized to receive either the intervention ( n = 87 ) or attention control program ( n = 87 ) .  Patient self-efficacy and stroke-specific , health-related quality of life at 6 months did not significantly differ between groups . We found improvements in medication adherence within the intervention group . In the intervention group , the odds of compliance with diabetes medications post-stroke were significantly larger than the odds of compliance prior to the stroke ( odds ratio = 3.45 ( 95 % CI = 1.08–10.96 ) . For compliance to hypertension medications , the intervention group showed significantly greater odds of compliance post intervention than pre intervention ( odds ratio = 3 . 68 ( 95 % CI = 1.81–7.48 ) . The control group showed no difference in compliance rates from baseline to follow-up . For adherence to hypercholesterolemia medications , both the intervention ( odds ratio = 5.98 ( 95 % CI = 2.81–12.76 ) and control groups ( odds ratio = 3.83 ( 95 % CI = 1.83–8.01 ) , had significant increases in the odds of compliance to statin medications ; however , the comparison of changes in log odds of compliance between these two groups showed that the increases were not significantly different . We observed within group improvements in medication adherence among those receiving a post-stroke risk factor self-management program suggesting that a self-management format may be feasible to enable adherence to prescribed medications to reduce secondary stroke risk after stroke in concordance with guideline care . Additional research is needed to enhance intervention components to improve effectiveness outcomes BACKGROUND Recurrent vascular events remain a major source of morbidity and mortality after stroke or transient ischemic attack ( TIA ) . The IRIS Trial is evaluating an approach to secondary prevention based on the established association between insulin resistance and increased risk for ischemic vascular events . Specifically , IRIS will test the effectiveness of pioglitazone , an insulin-sensitizing drug of the thiazolidinedione class , for reducing the risk for stroke and myocardial infa rct ion ( MI ) among insulin resistant , nondiabetic patients with a recent ischemic stroke or TIA . DESIGN Eligible patients for IRIS must have had insulin resistance defined by a Homeostasis Model Assessment -Insulin Resistance > 3.0 without meeting criteria for diabetes . Within 6 months of the index stroke or TIA , patients were r and omly assigned to pioglitazone ( titrated from 15 to 45 mg/d ) or matching placebo and followed for up to 5 years . The primary outcome is time to stroke or MI . Secondary outcomes include time to stroke alone , acute coronary syndrome , diabetes , cognitive decline , and all-cause mortality .  Enrollment of 3,876 participants from 179 sites in 7 countries was completed in January 2013 . Participant follow-up will continue until July 2015 . SUMMARY The IRIS Trial will determine whether treatment with pioglitazone improves cardiovascular outcomes of nondiabetic , insulin-resistant patients with stroke or TIA . Results are expected in early 2016 Background and Purpose — Numerous effective strategies for the secondary prevention of cardiovascular events in high-risk patients have now been established . We sought to calculate the cumulative benefit of combining multiple strategies for preventing recurrent events in patients with a history of ischemic stroke or transient ischemic attack . Methods — A comprehensive literature search was undertaken to identify meta-analyses of r and omized controlled trials reporting on the efficacy of secondary prevention strategies . The baseline incidence of vascular events was modeled from the Life Long After Cerebral Ischemia study . Strategies were combined on a multiplicative scale and cumulative risk reductions were computed over a 5-year interval . Results — The combination of 5 proven strategies applied to survivors of an initial stroke or transient ischemic attack — dietary modification , exercise , aspirin , a statin , and an antihypertensive agent — could result in a cumulative relative risk reduction of 80 % . Given a 5-year major cardiovascular event rate of 24 % , this translates to a number needed to treat of about 5 . Further gains would result from applying multimodality therapy over longer intervals and enriching the base strategy with dual antiplatelet therapy , high-dose statins , and more intensive blood pressure – lowering . Even more benefit would be present in high-risk subgroups with the addition , where appropriate , of carotid endarterectomy , moderate intensity oral anticoagulants , glycemic control , and smoking cessation . Conclusions — At least four-fifths of recurrent vascular events in patients with cerebrovascular disease might be prevented by application of a comprehensive , multifactorial approach Background and Purpose : Adherence to medication is often suboptimal after stroke and transient ischemic attack ( TIA ) , which increases the risk of recurrent stroke and death . Complex interventions and motivational interviewing ( MI ) have been proven effective in other areas of medicine . The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention . Methods : In this r and omized controlled trial , TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care . The intervention consisted of a focused medication review , an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months . The primary outcome was a composite medication possession ratio ( MPR ) for antiplatelets , anticoagulants and statins in the year after hospitalization , assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome . Secondary outcomes included composite MPRs at 3 , 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months . Clinical outcomes included a combined end point of cardiovascular death , stroke or acute myocardial infa rct ion . Patient satisfaction with the service was assessed for the intervention patients . Results : The analyses included 102 intervention patients and 101 controls . At 12 months , the median MPRs ( IQR ) were 0.95 ( 0.77 - 1 ) in the intervention group and 0.91 ( 0.83 - 0.99 ) in the control group , and 28 and 21 % of the patients , respectively , were nonadherent ( MPR < 0.80 ; risk difference : 7 % ; 95 % CI : -5 to 19 % ) . In both groups , the median MPR decreased over time . From 3 to 12 months , the MPR fell by 5 % ( p < 0.05 ) in the intervention group and by 9 % ( p < 0.05 ) in the control group , but between the groups , comparisons showed no statistically significant difference . No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome . The intervention patients were satisfied with the service ; about half of them reported increased knowledge about medication , and one third reported increased confidence with medication use . Pharmacists identified drug-related problems in one third of the patients . Conclusions : A multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes . However , due to the high adherence rates , only little room for improvement existed . Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions Background Despite lack of outward signs , most individuals after non-disabling stroke ( NDS ) and transient ischemic attack ( TIA ) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke , hospitalization for other vascular events , or death . Most have multiple modifiable risk factors ( e.g. , hypertension , physical inactivity , hyperlipidaemia , diabetes , tobacco consumption , psychological stress ) . In addition , accelerated rates of depression , cognitive decline , and poor quality of sleep have been reported following TIA , which correlate with poor functional outcomes and reduced quality of life . Thus , NSD and TIA are important warning signs that should not be overlooked . The challenge is not unlike that facing other ' silent ' conditions - to identify a model of care that is effective in changing people 's current behaviors in order to avert further morbidity . Methods / Design A single blind , r and omized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA . 250 adults within 90 days of being diagnosed with NDS/TIA will be r and omly allocated to a 12-week program of exercise and education ( PREVENT ) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated ( USUAL CARE ) . Primary outcome measures will include blood pressure , waist circumference , 12-hour fasting lipid profile , and 12-hour fasting glucose/hemoglobin A1c . Secondary measures will include exercise capacity , walking endurance , physical activity , cognitive function , depression , goal attainment and health-related quality of life . Outcome assessment will be conducted at baseline , post-intervention , and 6- and 12-month follow-ups . Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared . Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards . Discussion Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known . We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention . Trial registration This trial is registered with the Clinical Trials.gov Registry ( NCT00885456 ) Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 Background and Purpose — The Stroke PROTECT ( Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment ) program systematic ally implements , at the time of acute transient ischemic attack ( TIA ) or ischemic stroke admission , 8 medication/behavioral secondary prevention measures known to improve outcome in patients with cerebrovascular disease . The objective of this study was to determine if the high utilization rates previously demonstrated at hospital discharge were maintained at 90 days after discharge . Methods — Data were prospect ively collected on consecutively encountered ischemic stroke and TIA patients admitted to a university hospital stroke service beginning September 1 , 2002 .  PROTECT interventions were initiated before hospital discharge in all PROTECT – target ( underlying stroke mechanism large vessel atherosclerosis or small vessel disease ) and PROTECT – ACS ( At-risk for Coronary Sequelae ) patients . Adherence to program goals was assessed 3 months after discharge . Results — During the period from September 2002 to August 2003 , 144 individuals met criteria for PROTECT intervention . Of the 130 patients ( 90 % ) with available day 90 follow-up data , mean age was 72 ( range , 37 to 95 ) , and 63 % were male .  Adherence rates in patients without specific contraindications were 100 % for antithrombotics , 99 % for statins , 92 % for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers , and 80 % for thiazides . Awareness of the importance of calling 911 in response to stroke was 87 % . Adherence to diet and exercise guidelines were 78 % and 70 % , respectively . Of the 24 smokers , tobacco cessation was maintained in 20 ( 83 % ) . Conclusions — High rates of adherence to PROTECT therapies were maintained at 90 days after hospital discharge BACKGROUND Evidence is available on the effectiveness and costs of treatments to reduce stroke risk in long-term secondary prevention . However , there are few data on the costs and outcomes of urgent assessment and treatment after the onset of transient ischaemic attack ( TIA ) or minor stroke . The Early use of eXisting PREventive Strategies for Stroke ( EXPRESS ) study showed that urgent assessment and treatment reduced the 90-day risk of recurrent stroke by about 80 % . We now report the effect of the EXPRESS intervention on admissions to hospital , costs , and disability . METHODS EXPRESS was a prospect i ve population -based before ( phase 1 : April 1 , 2002 , to Sept 30 , 2004 ) versus after ( phase 2 : Oct 1 , 2004 , to March 31 , 2007 ) study of the effect of early assessment and treatment of TIA or minor stroke on the risk of early recurrent stroke . This report assesses the effect of the introduction of the phase 2 clinic on admissions to hospital within 90 days , hospital bed-days , hospital costs , and 6-month new disability ( progression from no disability before event [ modified Rankin scale score < or = 2 points ] to disability at 6 months [ modified Rankin scale score > 2 points ] ) or death , compared with the phase 1 clinic . To assess the main predictors of these outcomes , multivariate regression analyses were done . FINDINGS The 90-day risk of fatal or disabling stroke was reduced in phase 2 ( 1 of 281 vs 16 of 310 ; p=0.0005 ) . Hospital admissions for recurrent stroke were also lower in phase 2 than in phase 1 ( 5 vs 25 ; p=0.001 ) , which reduced the overall number of hospital bed-days compared with phase 1 ( 672 vs 1957 days ; p=0.017 ) . Hospital bed-days for admissions to hospital due to vascular causes were also lower in phase 2 ( 427 vs 1365 days ; p=0.016 ) , which generated savings of 624 pounds per patient referred to the phase 2 clinic ( p=0.028 ) . Results from the multivariate analyses showed that assessment in phase 2 was an independent predictor of reduced disability , days in hospital , and costs . INTERPRETATION Urgent assessment and treatment of patients with TIA or minor stroke who were referred to a specialist outpatient clinic reduced subsequent hospital bed-days , acute costs , and 6-month disability Rationale PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack . Within one-year of hospital discharge , up to one-third of patients no longer adhere to secondary prevention behaviors . Adherence rates are lower in minority-underserved groups , contributing to health disparities . In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals . In these groups , low literacy , limited healthcare access , and sparse community re sources may reduce adherence . Lay community health workers ( navigators ) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services . Aims and design PROTECT DC is a Phase II , single-blind , r and omized , controlled trial comparing in-hospital education plus stroke navigators to usual care .  Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington , DC hospitals .  Navigators meet with participants during the index hospitalization , perform home visits , and meet by phone . They focus on stroke education , medication compliance , and overcoming practical barriers to adherence . The interventions are driven by the theories of reasoned action and planned behavior . Study outcomes The primary dependent measure is a summary score of four objective measures of stroke risk factor control : systolic blood pressure , low-density lipoprotein , hemoglobin Hb A1C , and antiplatelet agent pill counts . Secondary outcomes include stroke knowledge , exercise , dietary modification , and smoking cessation . Conclusion PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted Background Aspirin , dipyridamole and clopidogrel are effective in secondary vascular prevention . Combination therapy with three antiplatelet agents might maximise the benefit of antiplatelet treatment  in the secondary prevention of ischaemic stroke . Methodology /Principal Findings A r and omised , parallel group , observer-blinded phase II trial compared the combination of aspirin , clopidogrel and dipyridamole with aspirin alone .  Adult patients with ischaemic stroke or transient ischaemic attack ( TIA ) within 5 years were included . The primary outcome was tolerability to treatment assessed as the number of patients completing r and omised treatment . Recruitment was halted prematurely after publication of the ESPRIT trial ( which confirmed that combined aspirin and dipyridamole is more effective than aspirin alone ) . 17 patients were enrolled : male 12 ( 71 % ) , mean age 62 ( SD 13 ) years , lacunar stroke syndrome 12 ( 71 % ) , median stroke/TIA onset to r and omisation 8 months . Treatment was discontinued in 4 of 9 ( 44 % ) patients receiving triple therapy vs. none of 8 taking aspirin ( p = 0.08 ) . One recurrent stroke occurred in a patient in the triple group who was noncompliant of all antiplatelet medications . The number of patients with adverse events and bleeding complications , and their severity , were significantly greater in the triple therapy group ( p<0.01 ) . Conclusions / Significance Long term triple antiplatelet therapy was asociated with a significant increase in adverse events and bleeding rates , and their severity , and a trend to increased discontinuations . However , the patients had a low risk of recurrence and future trials should focus on short term therapy in high risk patients characterised by a very recent event or failure of dual antiplatelet therapy . Trial Registration Controlled-Trials.com IS RCT The American Heart Association/American Stroke Association ( AHA/ASA ) Writing Committee for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack ( TIA ) has review ed the results of recent trials that were published after our previous recommendations were issued.1 Our intention in the present statement is to provide a brief review of the new data , to up date specific recommendations , and to provide the reasons for any modifications . The 2 areas in which major new clinical trials have been published are ( 1 ) the use of specific antiplatelet agents for stroke prevention in patients with a history of noncardioembolic ischemic stroke or TIA and ( 2 ) the use of statins in the prevention of recurrent stroke . Recently published trials have added to the evidence of the benefit of the use of specific antiplatelet agents for stroke prevention in patients with a history of noncardioembolic ischemic stroke or TIA . The secondary prevention guidelines 1 have been up date d to reflect this new evidence . # # # Addition of Clopidogrel to Aspirin for Prevention of Vascular Events The Clopidogrel and Aspirin Versus Aspirin Alone for the Prevention of Atherothrombotic Events ( CHARISMA ) trial2 was a double-blinded study that r and omized 15 603 subjects with cardiovascular disease or multiple risk factors for cardiovascular disease to either clopidogrel 75 mg plus low-dose aspirin ( 75 to 162 mg ) or placebo plus aspirin ( 75 to 162 mg ) . Roughly 35 % of subjects ( n=4320 ) qualified on the basis of the presence of cerebrovascular disease within 5 years of enrollment ; approximately a third experienced TIA . The median follow-up was 28 months . No significant differences were seen in the rates of nonfatal ischemic stroke between the 2 groups ( 1.7 % versus 2.1 % , P = 0.07 ) . The placebo plus aspirin group showed a higher rate of nonfatal stroke than did the clopidogrel group ( 1.9 % versus 2.4 % , P = 0.03 ) . The 2 groups experienced no differences in the rate of intracerebral hemorrhage Background Strokes are a common cause of adult disability and mortality worldwide . Transient ischaemic attacks ( TIA ) are associated with a high risk of subsequent stroke , and rapid intervention has the potential to reduce stroke burden . This study will assess a novel electronic decision support ( EDS ) tool to allow general practitioners ( GPs ) to implement evidence -based care rapidly without full reliance on specialists . Methods / design This is a cluster r and omized controlled trial comparing  TIA/stroke management of GPs with access to the EDS tool versus usual care .  The intervention period is 12 months with a 3-month follow-up period for individual patients . Primary outcomes consist of stroke within 90 days of presenting event and adherence to the New Zeal and national TIA guideline . Discussion A positive study will provide strong evidence for widespread implementation of this tool in practice and has the potential to improve key outcomes for patients and reduce the burden of stroke . Trial registration Australia New Zeal and Clinical Trials Registry BACKGROUND Determinants of survival and of risk of vascular events after transient ischaemic attack ( TIA ) or minor ischaemic stroke are not well defined in the long term . We aim ed to re study these risks in a prospect i ve cohort of patients after TIA or minor ischaemic stroke ( Rankin grade < or = 3 ) , after 10 years or more . METHODS We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial ( recruitment in 1986 - 89 ; arterial cause of cerebral ischaemia ) . We included 24 hospitals in the Netherl and s that recruited at least 50 patients . Primary outcomes were all-cause mortality and the composite event of death from all vascular causes , non-fatal stroke , and non-fatal myocardial infa rct ion . We assessed cumulative risks by Kaplan-Meier analysis and prognostic factors with Cox univariate and multivariate analysis . FINDINGS Follow-up was complete in 2447 ( 99 % ) patients . After a mean follow-up of 10.1 years , 1489 ( 60 % ) patients had died and 1336 ( 54 % ) had had at least one vascular event . 10-year risk of death was 42.7 % ( 95 % CI 40.8 - 44.7 ) . Age and sex-adjusted hazard ratios were 3.33 ( 2.97 - 3.73 ) for age over 65 years , 2.10 ( 1.79 - 2.48 ) for diabetes , 1.77 ( 1.45 - 2.15 ) for claudication , 1.94 ( 1.42 - 2.65 ) for previous peripheral vascular surgery , and 1.50 ( 1.31 - 1.71 ) for pathological Q waves on baseline electrocardiogram . 10-year risk of a vascular event was 44.1 % ( 42.0 - 46.1 ) . After falling in the first 3 years , yearly risk of a vascular event increased over time . Predictive factors for risk of vascular events were similar to those for risk of death . INTERPRETATION Long-term secondary prevention in patients with cerebral ischaemia still has room for further improvement Background and Purpose — Long-term outcome information after transient ischemic attack ( TIA ) and stroke is required to help plan and allocate care services . We evaluated the impact of TIA and stroke on disability and institutionalization over 5 years using data from a population -based study . Methods — Patients from a UK population -based cohort study ( Oxford Vascular Study ) were recruited from 2002 to 2007 and followed up to 2012 . Patients were followed up at 1 , 6 , 12 , 24 , and 60 months postevent and assessed using the modified Rankin scale . A multivariate regression analysis was performed to assess the predictors of disability postevent . Results — A total of 748 index stroke and 440 TIA cases were studied . For patients with TIA , disability levels increased from 14 % ( 63 of 440 ) premorbidly to 23 % ( 60 of 256 ) at 5 years ( P=0.002 ) , with occurrence of subsequent stroke being a major predictor of disability . For stroke survivors , the proportion disabled ( modified Rankin scale > 2 ) increased from 21 % ( 154 of 748 ) premorbidly to 43 % ( 273 of 634 ) at 1 month ( P<0.001 ) , with 39 % ( 132 of 339 ) of survivors disabled 5 years after stroke . Five years postevent , 70 % ( 483 of 690 ) of patients with stroke and 48 % ( 179 of 375 ) of patients with TIA were either dead or disabled . The 5-year risk of care home institutionalization was 11 % after TIA and 19 % after stroke . The average 5-year cost per institutionalized patient was $ 99 831 ( SD , 67 020 ) for TIA and $ 125 359 ( SD , 91 121 ) for stroke . Conclusions — Our results show that 70 % of patients with stroke are either dead or disabled 5 years after the event . Thus , there remains considerable scope for improvements in acute treatment and secondary prevention to reduce postevent disability and institutionalization BACKGROUND AND PURPOSE Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack . The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined . METHODS This was a prospect i ve , multicentre , cluster-r and omized controlled trial with blinded assessment of outcomes and intention-to-treat analysis . Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals . General practice s treating recruited patients were r and omized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care . The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months . RESULTS From January 2010 to November 2013 , 156 general practice s ( 280 patients ) were r and omly assigned to usual care ( control ) and 159 ( 283 patients ) to the intervention . The median age was 70.1 years ; 65 % were male . Overall , > 80 % of participants were prescribed recommended secondary prevention therapies at baseline . The primary efficacy analysis comprised 533 participants , with 30 either dying or lost to follow-up . In adjusted analyses , no significant between-group difference was found in the cardiovascular risk score at 12 months ( 0.04 , 95 % confidence interval -1.7 , 1.8 ) . CONCLUSIONS The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practice Rationale Stroke is the second-leading cause of death in low- and middle-income countries , but use of evidence -based therapies for stroke prevention in such countries , especially those in Africa , is extremely poor . This study is design ed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge . Aim /Hypothesis The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke ( THRIVES ) significantly improves blood pressure control after stroke . Design This prospect i ve triple-blind r and omized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria . The culturally sensitive , system-appropriate intervention comprises patient report cards , phone text messaging , an educational video , and coordination of posthospitalization care . Study Outcomes The primary outcome is improvement of blood pressure control . Secondary endpoints include control of other stroke risk factors , medication adherence , functional status , and quality of life . We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers . Discussion We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region Background Epidemiological studies suggest that raised plasma concentrations of total homocysteine ( tHcy ) may be a common , causal and treatable risk factor for atherothromboembolic ischaemic stroke , dementia and depression . Although tHcy can be lowered effectively with small doses of folic acid , vitamin B12 and vitamin B6 , it is not known whether lowering tHcy , by means of B vitamin therapy , can prevent stroke and other major atherothromboembolic vascular events . Aim To determine whether the addition of B-vitamin supplements ( folic acid 2 mg , B6 25 mg , B12 500 μg ) to best medical and surgical management will reduce the combined incidence of stroke , myocardial infa rct ion ( MI ) and vascular death in patients with recent stroke or transient ischaemic attack ( TIA ) of the brain or eye . Design A prospect i ve , international , multicentre , r and omised , double blind , placebo-controlled clinical trial . Setting One hundred and four medical centres in 20 countries on five continents . Subjects Eight thous and ( 6600 recruited as of 5 January , 2006 ) patients with recent ( 7 months ) stroke ( ischaemic or haemorrhagic ) or TIA ( brain or eye ) . R and omisation R and omisation and data collection are performed by means of a central telephone service or secure internet site . Intervention One tablet daily of either placebo or B vitamins ( folic acid 2 mg , B6 25 mg , B12 500 μg ) . Primary outcome The composite of stroke , MI or death from any vascular cause , whichever occurs first . Outcome and serious adverse events are adjudicated blinded to treatment allocation . Secondary outcomes TIA , unstable angina , revascularisation procedures , dementia , depression . Statistical power With 8000 patients followed up for a median of 2 years and an annual incidence of the primary outcome of 8 % among patients assigned placebo , the study will have at least 80 % power to detect a relative reduction of 15 % in the incidence of the primary outcome among patients assigned B vitamins ( to 6·8%/year ) , applying a two-tailed level of significance of 5 % . Conclusion VITATOPS aims to recruit and follow-up 8000 patients between 1998 and 2008 , and provide a reliable estimate of the safety and effectiveness of folic acid , vitamin B12 , and vitamin B6 supplementation in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke throughout the world BACKGROUND The highest risk for stroke is among survivors of strokes or transient ischemic attacks ( TIA ) . However , use of proven-effective cardiovascular medications to control stroke risk is suboptimal , particularly among the Black and Latino population s disproportionately impacted by stroke . METHODS A partnership of Harlem and Bronx community representatives , stroke survivors , research ers , clinicians , outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education ( PRAISE ) trial . Using data from focus groups with stroke survivors , they tailored a peer-led , community-based chronic disease self-management program to address stroke risk factors . PRAISE will test , in a r and omized controlled trial , whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control , lipid control , and use of antithrombotic medications . RESULTS Of the 582 survivors of stroke and TIA enrolled thus far , 81 % are Black or Latino and 56 % have an annual income less than $ 15,000 . Many ( 33 % ) do not have blood pressures in the target range , and most ( 66 % ) do not have control of all three major stroke risk factors . CONCLUSIONS Rates of stroke recurrence risk factors remain suboptimal in the high risk , urban , predominantly minority communities studied . With a community-partnered approach , PRAISE has recruited a large number of stroke and TIA survivors to date , and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities In 1988 , we undertook a r and omized , placebo-controlled , double-blind trial to investigate the safety and efficacy of low-dose acetylsalicylic acid ( ASA ) , modified-release dipyridamole , and the two agents in combination for secondary prevention of ischemic stroke . Patients with prior stroke or transient ischemic attack ( TIA ) were r and omized to treatment with ASA alone ( 50 mg daily ) , modified-release dipyridamole alone ( 400 mg daily ) , the two agents in a combined formulation , or placebo . Primary endpoints were stroke , death , and stroke or death together . TIA and other vascular events were secondary endpoints . Patients were followed on treatment for two years . Data from 6,602 patients were analysed . Factorial analysis demonstrated a highly significant effect for ASA and for dipyridamole in reducing the risk of stroke ( p < or = 0.001 ) and stroke or death combined ( p < 0.01 ) . In pairwise comparisons , stroke risk in comparison to placebo was reduced by 18 % with ASA alone ( p = 0.013 ) ; 16 % with dipyridamole alone ( p = 0.039 ) ; and 37 % with combination therapy ( p < 0.001 ) . Risk of stroke or death was reduced by 13 % with ASA alone ( p = 0.016 ) ; 15 % with dipyridamole alone ( p = 0.015 ) ; and 24 % with the combination ( p < 0.001 ) . The treatment had no statistically significant effect on the death rate alone . Factorial analysis also demonstrated a highly significant effect of ASA ( p < 0.001 ) and dipyridamole ( p < 0.01 ) for preventing TIA . The risk reduction for the combination was 36 % ( p < 0.001 ) in comparison with placebo .  Headache was the most common adverse event , occurring more frequently in dipyridamole-treated patients . All-site bleeding and gastrointestinal bleeding were significantly more common in patients who received ASA in comparison to placebo or dipyridamole . We conclude that ( 1 ) ASA 25 mg twice daily and dipyridamole , in a modified-release form , at a dose of 200 mg twice daily have each been shown to be equally effective for the secondary prevention of ischemic stroke and TIA ; ( 2 ) when co-prescribed the protective effects are additive , the combination being significantly more effective than either agent prescribed singly ; ( 3 ) low-dose ASA does not eliminate the propensity for induced bleeding Abstract Objective To estimate the very early stroke risk after a transient ischaemic attack ( TIA ) or minor stroke and thereby inform the planning of effective stroke prevention services . Design Population based prospect i ve cohort study of patients with TIA or stroke . Setting Nine general practice s in Oxfordshire , Engl and , from April 2002 to April 2003 . Participants All patients who had a TIA ( n = 87 ) or minor stroke ( n = 87 ) during the study period and who presented to medical attention . Main outcome measures Risk of recurrent stroke at seven days , one month , and three months after TIAs and minor strokes . Results The estimated risk of recurrent stroke was 8.0 % ( 95 % confidence interval 2.3 % to 13.7 % ) at seven days , 11.5 % ( 4.8 % to 18.2 % ) at one month , and 17.3 % ( 9.3 % to 25.3 % ) at three months after a TIA . The risks at these three time periods after a minor stroke were 11.5 % ( 4.8 % to 11.2 % ) , 15.0 % ( 7.5 % to 22.5 % ) , and 18.5 % ( 10.3 % to 26.7 % ) . Conclusions The early risks of stroke after a TIA or minor stroke are much higher than commonly quoted . More research is needed to determine whether these risks can be reduced by more rapid instigation of preventive treatment Several studies have established the value of anticoagulation for primary prevention of thromboembolic events in patients with non-rheumatic atrial fibrillation ( NRAF ) . However , in patients with a recent transient ischaemic attack ( TIA ) or minor ischaemic stroke the preventive benefit of anticoagulation or aspirin remains unclear . Physicians in 108 centres from 13 countries collaborated to study this question . 1007 NRAF patients with a recent TIA or minor ischaemic stroke were r and omised to open anticoagulation or double-blind treatment with either 300 mg aspirin per day or placebo ( group 1 , 669 ) . Patients with contraindications to anticoagulation were r and omised to receive aspirin or placebo ( group 2,338 ) . The measure of outcome was death from vascular disease , any stroke , myocardial infa rct ion , or systemic embolism . During mean follow-up of 2.3 years , the annual rate of outcome events was 8 % in patients assigned to anticoagulants vs 17 % in placebo-treated patients in group 1 ( hazard ratio [ HR ] 0.53 ; 95 % confidence interval [ CI ] 0.36 - 0.79 ) . The risk of stroke alone was reduced from 12 % to 4 % per year ( HR 0.34 ; 95 % CI 0.20 - 0.57 ) . Among all patients assigned to aspirin ( groups 1 and 2 ) , the annual incidence of outcome events was 15 % , against 19 % in those on placebo ( HR 0.83 ; 95 % CI 0.65 - 1.05 ) . Anticoagulation was significantly more effective than aspirin ( HR 0.60 ; 95 % CI 0.41 - 0.87 ) . The incidence of major bleeding events was low , both on anticoagulation ( 2.8 % per year ) and on aspirin ( 0.9 % per year ) . No intracranial bleeds were identified in patients assigned to anticoagulation . We conclude that anticoagulation is effective in reducing the risk of recurrent vascular events in NRAF patients with a recent TIA or minor ischaemic stroke . In absolute terms : 90 vascular events ( mainly strokes ) are prevented if 1000 patients are treated with anticoagulation for one year . Aspirin is a safe , though less effective , alternative when anticoagulation is contraindicated ; it prevents 40 vascular events each year for every 1000 treated patients BACKGROUND Patients with ischaemic stroke or transient ischaemic attack ( TIA ) are at high risk of recurrent stroke or other cardiovascular events . We compared the selective thromboxane-prostagl and in receptor antagonist terutroban with aspirin in the prevention of cerebral and cardiovascular ischaemic events in patients with a recent non-cardioembolic cerebral ischaemic event . METHODS This r and omised , double-blind , parallel-group trial was undertaken in 802 centres in 46 countries . Patients who had an ischaemic stroke in the previous 3 months or a TIA in the previous 8 days were r and omly allocated with a central interactive response system to 30 mg per day terutroban or 100 mg per day aspirin . Patients and investigators were masked to treatment allocation . The primary efficacy endpoint was a composite of fatal or non-fatal ischaemic stroke , fatal or non-fatal myocardial infa rct ion , or other vascular death ( excluding haemorrhagic death ) . We planned a sequential statistical analysis of non-inferiority ( margin 1·05 ) followed by analysis of superiority . Analysis was by intention to treat . The study was stopped prematurely for futility on the basis of the recommendation of the Data Monitoring Committee . This study is registered , number IS RCT N66157730 . FINDINGS 9562 patients were assigned to terutroban ( 9556 analysed ) and 9558 to aspirin ( 9544 analysed ) ; mean follow-up was 28·3 months ( SD 7·7 ) . The primary endpoint occurred in 1091 ( 11 % ) patients receiving terutroban and 1062 ( 11 % ) receiving aspirin ( hazard ratio [ HR ] 1·02 , 95 % CI 0·94 - 1·12 ) . There was no evidence of a difference between terutroban and aspirin for the secondary or tertiary endpoints . We recorded some increase in minor bleedings  with terutroban compared with aspirin ( 1147 [ 12 % ] vs 1045 [ 11 % ] ; HR 1·11 , 95 % CI 1·02 - 1·21 ) , but no significant differences in other safety endpoints . INTERPRETATION The trial did not meet the predefined criteria for non-inferiority , but showed similar rates of the primary endpoint with terutroban and aspirin , without safety advantages for terutroban . In a worldwide perspective , aspirin remains the gold st and ard antiplatelet drug for secondary stroke prevention in view of its efficacy , tolerance , and cost . FUNDING Servier , France OBJECTIVES Based on the data of the Prospect i ve Cardiovascular Münster ( PROCAM ) study , a prospect i ve study of men and women at work in the north-west of Germany , we aim ed ( i ) to develop a refined scoring scheme for calculating the risk of acute coronary events among adult and elderly men and women ; and ( ii ) to generate a new scoring scheme for calculating the risk of ischaemic stroke or transient ischaemic attack ( TIA ) . METHODS The coronary risk score was derived from a Weibull function using data from 18 460 men and 8515 women who were recruited before 1996 and had a mean follow-up period of 12+/-6 years . The stroke score was derived using a Cox proportional hazards model using data of 5905 men and 2225 women aged 35 - 65 years with at least 10 years of unbroken follow-up . RESULTS The coronary risk score was based on 511 major coronary events , 462 ( 168 fatal , 294 non-fatal ) in men and 49 ( 18 fatal , 31 non-fatal ) in women and included the risk factors LDL cholesterol , HDL cholesterol , systolic blood pressure , smoking status , triglycerides and diabetes mellitus status . It was accurate in both sexes over an age range from 20 to 75 years with an area under the receiver-operating characteristics ( ROC ) curve of 0.82 . The stroke score was based on 85 cerebral ischaemic events ( 21 TIAs , 64 ischaemic strokes ) and included the risk factors age , sex , diabetes mellitus status , smoking status and systolic blood pressure . It had an area under the ROC curve of 0.78 and identified a high-risk group comprising only 4 % of the study population that contained 31 % of all cerebral ischaemic events . CONCLUSION Both new PROCAM risk scores provide simple and effective ways to assess the risk of acute coronary events and ischaemic stroke in the general population and will improve the ability of physicians to target measures in an effort to prevent these potentially devastating conditions Background Survivors of transient ischemic attack ( TIA ) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk . However , vascular risk factors , especially hypertension and high cholesterol , are not managed optimally even in those patients seen in specialized clinics . This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes . In this study , we will be testing a pharmacist case manager for delivery of stroke prevention services . We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes . Methods We will conduct a prospect i ve , r and omized , controlled open-label with blinded ascertainment of outcomes ( PROBE ) trial . Treatment allocation will be concealed from the study personnel , and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient 's clinical care or trial participation and who are masked to baseline measurements . Patients will be  r and omized to control or a pharmacist case manager treating vascular risk factors to guideline -recommended target levels . Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton , Alberta after an ischemic stroke or TIA who have uncontrolled hypertension ( defined as systolic blood pressure ( BP ) > 140 mm Hg ) or dyslipidemia ( fasting LDL-cholesterol > 2.00 mmol/L ) and who are not cognitively impaired or institutionalized . The primary outcome will be the proportion of subjects who attain ' optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L ) at six months compared to baseline ; 12-month data will also be collected for analyses of sustainability of any effects . A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected . Conclusions Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year . If our intervention improves the provision of secondary prevention therapies in these patients , the clinical ( and financial ) implication s will be enormous Background Secondary prevention after stroke and transient ischemic attack ( TIA ) is essential in order to reduce morbidity and mortality . Secondary stroke prevention studies have , however , been fairly small , or performed as clinical trials with non-representative patient selection . Long-term follow-up data is also limited . A nurse-led follow-up for risk factor improvement may be effective but the evidence is limited . The aims of this study are to perform an adequately sized , nurse-led , long-term secondary preventive follow-up with a population -based inclusion of stroke and TIA patients . The focus will be on blood pressure and lipid control as well as tobacco use and physical activity . Methods A r and omized , controlled , long-term , population -based trial with two parallel groups . The patients will be included during the initial hospital stay . Important outcome variables are sitting systolic and diastolic blood pressure , LDL cholesterol and total cholesterol . Outcomes will be measured after 12 , 24 and 36 months of follow-up . Trained nurses will manage the intervention group with a focus on reaching set treatment goals as soon as possible . The control group will receive usual care .  At least 200 patients will be included in each group , in order to reliably detect a difference in mean systolic blood pressure of 5 mmHg . This sample size is also adequate for detection of clinical ly meaningful group differences in the other outcomes . Discussion This study will test the hypothesis that a nurse-led , long-term follow-up after stroke with a focus on reaching set treatment goals as soon as possible , is an effective secondary preventive method . If proven effective , this method could be implemented in general practice at a low cost . Trial registration Current Controlled Trials IS RCT Rationale Stroke and vascular risk factors disproportionately affect minority population s , with Blacks and Hispanics experiencing a 2.5- and 2.0-fold greater risk compared with whites , respectively . Patients with transient ischemic attacks and mild , nondisabling strokes tend to have short hospital stays , rapid discharges , and inaccurate perceptions of vascular risk . Aim The primary aim of the Discharge Educational Strategies for Reduction of Vascular Events ( DESERVE ) trial is to evaluate the efficacy of a novel community health worker-based multilevel discharge intervention vs. st and ard discharge care on vascular risk reduction among racially/ethnically diverse transient ischemic attack/mild stroke patients at one-year postdischarge . We hypothesize that those r and omized to the discharge intervention will have reduced modifiable vascular risk factors as determined by systolic blood pressure compared with those receiving usual care . Sample size estimates Given 300 subjects per group and alpha of 0.05 , the power to detect a 6 mmHg reduction in systolic blood pressure is 89 % . Design DESERVE trial is a prospect i ve , r and omized , multicenter clinical trial of a novel discharge behavioral intervention .  Patients with transient ischemic attack/mild stroke are r and omized during hospitalization or emergency room visit to intervention or usual care . Intervention begins prior to discharge and continues postdischarge . Study outcomes The primary outcome is difference in systolic blood pressure reduction between groups at 12 months . Secondary outcomes include between-group differences in change in glycated hemoglobin , smoking rates , medication adherence , and recurrent stroke/transient ischemic attack at 12 months . Discussion DESERVE will evaluate whether a novel discharge education strategy leads to improved risk factor control in a racially diverse population BACKGROUND The risk of recurrent stroke is up to 10 % in the week after a transient ischaemic attack ( TIA ) or minor stroke . Modelling studies suggest that urgent use of existing preventive treatments could reduce the risk by 80 - 90 % , but in the absence of evidence many health-care systems make little provision . Our aim was to determine the effect of more rapid treatment after TIA and minor stroke in patients who are not admitted direct to hospital . METHODS We did a prospect i ve before ( phase 1 : April 1 , 2002 , to Sept 30 , 2004 ) versus after ( phase 2 : Oct 1 , 2004 , to March 31 , 2007 ) study of the effect on process of care and outcome of more urgent assessment and immediate treatment in clinic , rather than subsequent initiation in primary care , in all patients with TIA or minor stroke not admitted direct to hospital . The study was nested within a rigorous population -based incidence study of all TIA and stroke ( Oxford Vascular Study ; OXVASC ) , such that case ascertainment , investigation , and follow-up were complete and identical in both periods . The primary outcome was the risk of stroke within 90 days of first seeking medical attention , with independent blinded ( to study period ) audit of all events . FINDINGS Of the 1278 patients in OXVASC who presented with TIA or stroke ( 634 in phase 1 and 644 in phase 2 ) , 607 were referred or presented direct to hospital , 620 were referred for outpatient assessment , and 51 were not referred to secondary care . 95 % ( n=591 ) of all outpatient referrals were to the study clinic . Baseline characteristics and delays in seeking medical attention were similar in both periods , but median delay to assessment in the study clinic fell from 3 ( IQR 2 - 5 ) days in phase 1 to less than 1 ( 0 - 3 ) day in phase 2 ( p<0.0001 ) , and median delay to first prescription of treatment fell from 20 ( 8 - 53 ) days to 1 ( 0 - 3 ) day ( p<0.0001 ) . The 90-day risk of recurrent stroke in the patients referred to the study clinic was 10.3 % ( 32/310 patients ) in phase 1 and 2.1 % ( 6/281 patients ) in phase 2 ( adjusted hazard ratio 0.20 , 95 % CI 0.08 - 0.49 ; p=0.0001 ) ; there was no significant change in risk in patients treated elsewhere . The reduction in risk was independent of age and sex , and early treatment did not increase the risk of intracerebral haemorrhage or other bleeding . INTERPRETATION Early initiation of existing treatments after TIA or minor stroke was associated with an 80 % reduction in the risk of early recurrent stroke . Further follow-up is required to determine long-term outcome , but these results have immediate implication s for service provision and public education about TIA and minor stroke BACKGROUND The incidence of stroke is predicted to rise because of the rapidly ageing population . However , over the past two decades , findings of r and omised trials have identified several interventions that are effective in prevention of stroke . Reliable data on time-trends in stroke incidence , major risk factors , and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence . We aim ed to obtain these data . METHODS We ascertained changes in incidence of transient ischaemic attack and stroke , risk factors , and premorbid use of preventive treatments from 1981 - 84 ( Oxford Community Stroke Project ; OCSP ) to 2002 - 04 ( Oxford Vascular Study ; OXVASC ) . FINDINGS Of 476 patients with transient ischaemic attacks or strokes in OXVASC , 262 strokes and 93 transient ischaemic attacks were incident events . Despite more complete case-ascertainment than in OCSP , age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29 % ( relative incidence 0.71 , 95 % CI 0.61 - 0.83 , p=0.0002 ) . Incidence declined by more than 50 % for primary intracerebral haemorrhage ( 0.47 , 0.27 - 0.83 , p=0.01 ) but was unchanged for subarachnoid haemorrhage ( 0.83 , 0.44 - 1.57 , p=0.57 ) . Thus , although 28 % more incident strokes ( 366 vs 286 ) were expected in OXVASC due to demographic change alone ( 33 % increase in those aged 75 or older ) , the observed number fell ( 262 vs 286 ) . Major reductions were recorded in mortality rates for incident stroke ( 0.63 , 0.44 - 0.90 , p=0.02 ) and in incidence of disabling or fatal stroke ( 0.60 , 0.50 - 0.73 , p<0.0001 ) , but no change was seen in case-fatality due to incident stroke ( 17.2 % vs 17.8 % ; age and sex adjusted relative risk 0.85 , 95 % CI 0.57 - 1.28 , p=0.45 ) . Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers , mean total cholesterol , and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet , lipid-lowering , and blood pressure lowering drugs ( all p<0.0001 ) . INTERPRETATION The age-specific incidence of major stroke in Oxfordshire has fallen by 40 % over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors Abstract Background The effectiveness of medication is influenced by treatment adherence . After TIA or minor disabling stroke patients usually are advised to take antithrombotic medication .  Stroke patients are an interesting group of patients with respect to adherence , since cardiovascular risk factors and stroke may ( indirectly ) negatively influence brain function , which can affect adherence . We investigated determinants of non – adherence in patients who used aspirin or oral anticoagulation after cerebral ischaemia of arterial origin . Methods Data of patients prospect ively followed in two clinical trials ( the Dutch TIA Trial and the Stroke Prevention In Reversible Ischaemia Trial ) were analysed with Cox proportional hazards modelling . Results In the two trials 3796 patients were treated with aspirin .  During a mean follow – up of 2.1 years , 689 patients ( 18 % ) prematurely stopped treatment , 305 ( 8 % ) did so without a clear medical reason ( non – adherence ) . Age ≥ 65 years and the use of 300 instead of 30 mg of aspirin were independently associated with non – adherence . Diastolic blood pressure of ≥ 90 mmHg and dizziness were associated with better adherence . Of 651 patients on oral anticoagulation  , 143 patients ( 22 % ) stopped after a mean follow – up of 1.0 year , 66 ( 10 % ) did so because of nonadherence . No statistically significant determinants for non – adherence were identified . Conclusion As found in the literature on nonadherence in general , age of ≥ 65 years and a higher dose of aspirin ( 300 mg versus 30 mg ) were independently associated with non – adherence with aspirin treatment that was prescribed for secondary prevention after cerebral ischaemia of arterial origin . Older patients may require extra encouragement to continue antithrombotic treatment . Lower doses of aspirin may improve treatment adherence Rationale Recurrent stroke is prevalent in both developed and developing countries , contributing significantly to disability and death . Recurrent stroke rates can be reduced by adequate risk factor management . However , adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor , leading to a large number of preventable recurrent strokes . Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke . Aims and /or hypothesis The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke . Design Recruitment of 430 first-ever stroke participants will occur in the Auckl and and Waikato regions . R and omization will be to intervention or usual care groups . Participants r and omized to intervention will receive four motivational interviews and five follow-up assessment s over 12 months . Nonintervention participants will be assessed at the same time points . Study outcomes Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke . Secondary outcomes include self-reported adherence and barriers to prescribed medications , new cardiovascular events ( including stroke ) , changes in quality of life , and mood . Discussion The results of the motivational interviewing in stroke trial will add to our underst and ing of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant Background and Purpose — The SPARCL trial showed that atorvastatin 80 mg/d reduces the risk of stroke and other cardiovascular events in patients with recent stroke or transient ischemic attack ( TIA ) . We tested the hypothesis that the benefit of treatment varies according to index event stroke subtype . Methods — Subjects with stroke or TIA without known coronary heart disease were r and omized to atorvastatin 80 mg/d or placebo .  The SPARCL primary end point was fatal or nonfatal stroke . Secondary end points included major cardiovascular events ( MCVE ; stroke plus major coronary events ) . Cox regression models testing for an interaction with treatment assignment were used to explore potential differences in efficacy based on stroke subtype . Results — For subjects r and omized to atorvastatin versus placebo  , a primary end point occurred in 13.1 % versus 18.6 % of those classified as having large vessel disease ( LVD , 15.8 % of 4,731 participants ) , in 13.1 % versus 15.5 % of those with small vessel disease ( SVD , 29.8 % ) , in 11.2 % versus 12.7 % of those with ischemic stroke of unknown cause ( 21.5 % ) , in 7.6 % versus 8.8 % of those with TIA ( 30.9 % ) , and in 22.2 % versus 8.3 % of those with hemorrhagic stroke ( HS , 2 % ) at baseline . There was no difference in the efficacy of treatment for either the primary end point ( LVD hazard ratio [ HR ] 0.70 , 95 % confidence interval [ CI ] 0.49 to 1.02 , TIA HR 0.81 , CI 0.57 to 1.17 , SVD HR 0.85 , CI 0.64 to 1.12 , unknown cause HR 0.87 , CI 0.61 to 1.24 , HS HR 3.24 , CI 1.01 to 10.4 ; P for heterogeneity=0.421 ) , or MCVEs ( P for heterogeneity=0.360 ) based on subtype of the index event . As compared to subjects with LVD strokes , those with SVD had similar MCVE rates ( 19.2 % versus 18.5 % over the course of the trial ) , and similar overall reductions in stroke and MCVEs . Conclusions — Atorvastatin 80 mg/d is similarly efficacious in preventing strokes and other cardiovascular events , irrespective of baseline ischemic stroke subtype OBJECTIVES To estimate the impact of small reductions in the population distribution of diastolic blood pressure ( DBP ) , such as those potentially achievable by population -wide lifestyle modification , on incidence of coronary heart disease ( CHD ) and stroke . DESIGN Published data from the Framingham Heart Study , a longitudinal cohort study , and from the National Health and Nutrition Examination Survey II , a national population survey , were used to examine the impact of a population -wide strategy aim ed at reducing DBP by an average of 2 mm Hg in a population including normotensive subjects . SETTING / PARTICIPANTS White men and women aged 35 to 64 years in the United States . MAIN OUTCOME MEASURES Incidence of CHD and stroke , including transient ischemic attacks ( TIAs ) . RESULTS Data from overviews of observational studies and r and omized trials suggest that a 2-mm Hg reduction in DBP would result in a 17 % decrease in the prevalence of hypertension as well as a 6 % reduction in the risk of CHD and a 15 % reduction in risk of stroke and TIAs . From an application of these results to US white men and women aged 35 to 64 years , it is estimated that a successful population intervention alone could reduce CHD incidence more than could medical treatment for all those with a DBP of 95 mm Hg or higher . It could prevent 84 % of the number prevented by medical treatment for all those with a DBP of 90 mm Hg or higher . For stroke ( including TIAs ) , a population -wide 2-mm Hg reduction could prevent 93 % of events prevented by medical treatment for those with a DBP of 95 mm Hg or higher and 69 % of events for treatment for those with a DBP of 90 mm Hg or higher . A combination strategy of both a population reduction in DBP and targeted medical intervention is most effective and could double or triple the impact of medical treatment alone . Adding a population -based intervention to existing levels of hypertension treatment could prevent an estimated additional 67,000 CHD events ( 6 % ) and 34,000 stroke and TIA events ( 13 % ) annually among all those aged 35 to 64 years in the United States . CONCLUSIONS A small reduction of 2 mm Hg in DBP in the mean of the population distribution , in addition to medical treatment , could have a great public health impact on the number of CHD and stroke events prevented . Whether such DBP reductions can be achieved in the population through lifestyle interventions , in particular through sodium reduction , depends on the results of ongoing primary prevention trials as well as the cooperation of the food industry , government agencies , and health education professionals BACKGROUND This r and omized controlled trial tested the effectiveness of comprehensive , interdisciplinary postdischarge care management in improving a profile of indicators of health recovery and secondary prevention ( profile of health and prevention ) in stroke and transient ischemic attack ( TIA ) patients . METHODS Ninety-six stroke/TIA patients were r and omized to usual care or intervention at discharge from our acute stroke unit . The intervention group received an in-home biopsychosocial assessment by an advanced practice nurse at 1 month . A care plan was developed by an interdisciplinary team and implemented in collaboration with the patient 's primary care physician . The profile of health and prevention , measured at 3 months , was comprised of 5 domains : ( 1 ) Neuromotor Function , ( 2 ) Severe Complications , ( 3 ) Quality of Life , ( 4 ) Management of Risk for common poststroke complications and recurrent stroke , and ( 5 ) Stroke Knowledge . A single global hypothesis test across multiple end points was used to compare the 2 groups . RESULTS The intervention significantly improved the profile of health and prevention ( P < .0001 ) . In addition , each domain showed a positive effect of the intervention . Effect sizes ( in st and ard deviation units ) of the intervention on domains were .1 for Neuromotor Function ( 90 % confidence interval [ CI ] = -.3 to .5 ) ; .4 for Severe Complications ( 90 % CI = .1 to .8 ) ; .5 for Quality of Life ( 90 % CI = .1 to .9 ) ; .6 for Management of Risk for common poststroke complications and recurrent stroke ( 90 % CI = .3 to 1 . ) ; and 1.0 for Stroke Knowledge ( 90 % CI = .6 to 1.4 ) . CONCLUSIONS This model of care management result ed in a significantly better profile of health and prevention for stroke/TIA patients 3 months postdischarge OBJECTIVE Stroke survivors are at high risk of stroke recurrence yet current strategies to reduce recurrence risk are sub-optimal . The UK Medical Research Council ( MRC ) have proposed a framework for developing and evaluating complex interventions , such as community management of stroke secondary prevention . The Framework outlines a five-phased approach from theory through to implementation of effective interventions . This paper reports Phases I-III of the development of a novel intervention to improve risk factor management after stroke . METHODS The pre- clinical /theoretical phase entailed review ing the literature and undertaking quantitative and qualitative studies to identify current practice s and barriers to secondary prevention . In Phase I ( modelling ) , findings were used to design an intervention with the potential to overcome barriers to effective stroke secondary prevention management . The feasibility of delivering the intervention and its acceptability were tested in the Phase II exploratory trial involving 25 stroke survivors and their general practitioners . RESULTS This led to the development of the definitive risk factor management  intervention . This comprises multiple components and involves using an on-going population stroke register to target patients , carers and health care professionals with tailored secondary prevention advice . Clinical , socio-demographic and service use data collected by the stroke register are transformed to provide an individualised secondary prevention package for patients , carers and health care professionals at three time points : within 10 weeks , 3 and 6 months post-stroke . CONCLUSION The intervention is currently being evaluated in a r and omised controlled trial . Further research is needed to test generalisability to other aspects of stroke management and for other chronic diseases . PRACTICE IMPLICATION S The MRC Framework for complex interventions provides a structured approach to guide the development of novel interventions in public health . Implication s for practice in stroke secondary prevention will emerge when the results of our r and omised controlled trial are published BACKGROUND Pulse pressure ( PP ) has been shown to predict risk for cardiovascular events in men ; however , this association has not been well established in women .  Hormone replacement therapy may improve arterial compliance , but findings from cross-sectional and prospect i ve studies report inconsistent results . We sought to examine the relationship between PP and risk for cardiovascular events , and to determine the effect of hormone therapy on PP in postmenopausal women with coronary heart disease ( CHD ) . METHODS AND RESULTS A total of 2,763 postmenopausal women ( mean age , 66 + /- 7 years [ + /- SD ] ) with CHD in the Heart and Estrogen/Progestin Replacement Study , a r and omized , placebo-controlled , secondary CHD prevention trial of estrogen plus progestin , were followed up on average for 4.1 years . BP was measured at baseline and annually . Mean baseline PP was 62 + /- 16 mm Hg . There were 361 myocardial infa rct ions ( MIs ) or CHD deaths , 265 hospitalizations for congestive heart failure ( CHF ) , and 215 strokes or transient ischemic attacks ( TIAs ) . Women in the highest quartile of PP at baseline had a 47 % increase in risk for MI or CHD death and more than a twofold increase in risk for stroke and TIA events or hospitalization for CHF ( p < 0.01 for each outcome ) . After adjustment for other cardiovascular risk factors and mean arterial pressure , PP remained significantly associated with incident stroke or TIA events ( odds ratio , 1.25 ; p = 0.02 ) and hospitalizations for CHF ( odds ratio , 1.31 ; p < 0.01 ) but not with MI or CHD death . After adjustment for diastolic BP , systolic BP was similarly associated with stroke or TIA ( odds ratio , 1.30 ; p < 0.01 ) and hospitalized CHF ( odds ratio , 1.30 ; p < 0.01 ) and was also weakly associated with risk for MI and CHD death ( odds ratio , 1.18 ; p = 0.02 ) . Mean PP was 1- to 2-mm Hg higher in women r and omized to hormone replacement therapy vs those receiving placebo ( p < 0.01 ) . CONCLUSIONS PP had predictive value for CHF and stroke or TIA , but not MI or CHD death in this cohort of postmenopausal women with CHD . Use of hormone replacement therapy produced a small , statistically significant increase in PP . Further research is necessary to determine the clinical utility of PP as a potential therapeutic target BACKGROUND AND OBJECTIVES The SBP values to be achieved by antihypertensive therapy in order to maximize reduction of cardiovascular outcomes are unknown ; neither is it clear whether in patients with a previous cardiovascular event , the optimal values are lower than in the low-to-moderate risk hypertensive patients , or a more cautious blood pressure ( BP ) reduction should be obtained . Because of the uncertainty whether ' the lower the better ' or the ' J-curve ' hypothesis is correct , the European Society of Hypertension and the Chinese Hypertension League have promoted a r and omized trial comparing antihypertensive treatment strategies aim ing at three different SBP targets in hypertensive patients with a recent stroke or transient ischaemic attack . As the optimal level of low-density lipoprotein cholesterol ( LDL-C ) level is also unknown in these patients , LDL-C-lowering has been included in the design . PROTOCOL DESIGN The European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment trial is a prospect i ve multinational , r and omized trial with a 3 × 2 factorial design comparing : three different SBP targets ( 1 , < 145 - 135 ; 2 , < 135 - 125 ; 3 , < 125 mmHg ) ; two different LDL-C targets ( target A , 2.8 - 1.8 ; target B , < 1.8 mmol/l ) . The trial is to be conducted on 7500 patients aged at least 65 years ( 2500 in Europe , 5000 in China ) with hypertension and a stroke or transient ischaemic attack 1 - 6 months before r and omization .  Antihypertensive and statin treatments will be initiated or modified using suitable registered agents chosen by the investigators , in order to maintain patients within the r and omized SBP and LDL-C windows . All patients will be followed up every 3 months for BP and every 6 months for LDL-C. Ambulatory BP will be measured yearly . OUTCOMES Primary outcome is time to stroke ( fatal and non-fatal ) . Important secondary outcomes are : time to first major cardiovascular event ; cognitive decline ( Montreal Cognitive Assessment ) and dementia . All major outcomes will be adjudicated by committees blind to r and omized allocation . A Data and Safety Monitoring Board has open access to data and can recommend trial interruption for safety . SAMPLE SIZE CALCULATION It has been calculated that 925 patients would reach the primary outcome after a mean 4-year follow-up , and this should provide at least 80 % power to detect a 25 % stroke difference between SBP targets and a 20 % difference between LDL-C targets Background and Purpose — Patients with nonvalvular atrial fibrillation and prior stroke or transient ischemic attack ( TIA ) are at high risk for recurrent stroke . We investigated whether ximelagatran was noninferior to warfarin in patients with prior stroke or TIA . Methods — We analyzed pooled data from the SPORTIF III and V trials in patients with prior stroke/TIA . The primary outcome was the composite annual rate of both ischemic and hemorrhagic strokes and systemic embolic events . Secondary analyses considered ischemic and hemorrhagic strokes separately , bleeding , and nonr and omized , concomitant therapy with aspirin ≤100 mg/d . Results — Patients from SPORTIF III ( n=3407 ) and SPORTIF V ( n=3922 ) trials were categorized by prior stroke/TIA ( 21 % ) versus no prior stroke/TIA ( 79 % ) and by treatment group ( ximelagatran vs warfarin ) . The primary event rate in patients with prior stroke/TIA was 2.83%/y with ximelagatran and 3.27%/y with warfarin ( absolute difference , −0.44 % ; 95 % CI , −1.88 to1.01 ; P=0.625 ) . In those without prior stroke/TIA , the primary event rate was 1.31%/y with ximelagatran and 1.26%/y with warfarin ( P = NS ) . Ischemic strokes outnumbered cerebral hemorrhages with both warfarin ( 31 of 36 ) and ximelagatran ( 30 of 32 ) treatment ( difference between treatments was not significant ) . Combining aspirin with either anticoagulant was associated with higher rates of major bleeding ( 1.5%/y with warfarin and 4.95%/y with warfarin plus aspirin , P=0.004 ; 2.35%/y with ximelagatran and 5.09%/y with ximelagatran plus aspirin , P=0.046 ) but not lower rates of primary events . Conclusions — Ximelagatran was at least as effective as well-controlled warfarin for the secondary prevention of stroke . The nonr and omized , concomitant treatment with aspirin and anticoagulation was associated with increased bleeding without evidence of a reduction in primary outcome events Background Effective methods of secondary prevention after stroke or TIA are available but adherence to recommended evidence -based treatments is often poor . The study aim ed to determine the quality of secondary prevention in usual care and to develop a stepwise modeled support program . Methods Two consecutive cohorts of patients with acute minor stroke or TIA undergoing usual outpatient care versus a secondary prevention program were compared . Risk factor control and medication adherence were assessed in 6-month follow-ups ( 6M-FU ) . Usual care consisted of detailed information concerning vascular risk factor targets given at discharge and regular outpatient care by primary care physicians . The stepwise modeled support program additionally employed up to four outpatient appointments . A combination of educational and behavioral strategies was employed . Results 168 patients in the observational cohort who stated their openness to participate in a prevention program ( mean age 64.7 y , admission blood pressure ( BP ) : 155/84 mmHg ) and 173 patients participating in the support program ( mean age 67.6 y , BP : 161/84 mmHg ) were assessed at 6 months . Proportions of patients with BP according to guidelines were 50 % in usual-care and 77 % in the support program ( p<0.01 ) . LDL<100 mg/dl was measured in 62 versus 71 % ( p = 0.12 ) . Proportions of patients who stopped smoking were 50 versus 79 % ( p<0.01 ) . 72 versus 89 % of patients with atrial fibrillation were on oral anticoagulation ( p = 0.09 ) . Conclusions Risk factor control remains unsatisfactory in usual care . Targets of secondary prevention were met more often within the supported cohort . Effects on (cerebro-)vascular recurrence rates are going to be assessed in a multicenter r and omized trial CONTEXT Lower circulating testosterone concentrations are associated with metabolic syndrome , type 2 diabetes , carotid intima-media thickness , and aortic and lower limb arterial disease in men . However , it is unclear whether lower testosterone levels predict major cardiovascular events . OBJECTIVE We examined whether lower serum testosterone was an independently significant risk factor for symptomatic cerebrovascular events  in older men . DESIGN This was a prospect i ve observational study with median follow-up of 3.5 yr . SETTING Community-dwelling , stroke-free older men were studied . PARTICIPANTS A total of 3443 men at least 70 yr of age participated in the study . MAIN OUTCOME MEASURES  Baseline serum total testosterone , SHBG , and LH were assayed . Free testosterone  was calculated using mass action equations . Incident stroke or transient ischemic attack ( TIA ) was recorded . RESULTS A first stroke or TIA occurred in 119 men ( 3.5 % ) .  Total and free testosterone concentrations in the lowest quartiles ( < 11.7 nmol/liter and < 222 pmol/liter ) were associated with reduced event-free survival ( P = 0.014 and P = 0.01 , respectively ) . After adjustment including age , waist-hip ratio , waist circumference , smoking , hypertension , dyslipidemia , and medical comorbidity , lower total testosterone predicted increased incidence of stroke or TIA ( hazard ratio = 1.99 ; 95 % confidence interval , 1.33 - 2.99 ) . Lower free testosterone was also associated ( hazard ratio = 1.69 ; 95 % confidence interval , 1.15 - 2.48 ) , whereas SHBG and LH were not independently associated with incident stroke or TIA . CONCLUSIONS In older men , lower total testosterone levels predict increased incidence of stroke or TIA after adjusting for conventional risk factors for cardiovascular disease . Men with low-normal testosterone levels had increased risk . Further studies are warranted to determine whether interventions that raise circulating testosterone levels might prevent cerebrovascular disease in men Background and Purpose — Although aspirin is effective in prevention of stroke , fewer studies have examined the impact of aspirin on stroke morbidity . Methods — The Women ’s Health Study is a completed r and omized , placebo-controlled trial design ed to test the effect of low-dose aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer , which enrolled 39 876 women . We used multinomial logistic regression to evaluate the relationship between r and omized aspirin assignment and functional outcomes from stroke . Possible functional outcomes were neither stroke nor transient ischemic attack ( TIA ) , modified Rankin scale ( mRS ) score 0 to 1 , 2 to 3 , and 4 to 6 . Results — After a mean of 9.9 years of follow-up , 460 confirmed strokes ( 366 ischemic , 90 hemorrhagic , and 4 unknown type ) and 405 confirmed TIAs occurred . With regard to total and ischemic stroke , women who were r and omized to aspirin had a nonsignificant decrease in risk of any outcome compared to women not r and omized to aspirin . This decrease in risk only reached statistical significance for those experiencing TIA compared to participants without stroke or TIA ( odds ratio=0.77 ; 95 % confidence interval , 0.63–0.94 ) . For hemorrhagic stroke , a nonsignificant increase in the risk of achieving an mRS score 2 to 3 or 4 to 6 compared with no stroke or TIA was observed for the women r and omized to aspirin compared to those r and omized to placebo . Conclusions — Results from this large r and omized clinical trial provide evidence that 100 mg of aspirin every other day may reduce the risk of ischemic cerebral vascular events but does not have differential effects on functional outcomes from stroke Background Although guidelines for secondary ischemic stroke have been developed , there is a gap between guidelines and clinic practice . Aims This study will investigate the current status of secondary ischemic stroke prevention in China , and implement a st and ard medical program in ischemic stroke and /or transient ischemic attack patients , and to examine the feasibility and efficacy of the program . Design This is a multicentre , parallel , r and omized , open label , controlled trial to evaluate the feasibility and efficacy of a recommended guideline based program ( SMART ) in secondary stroke prevention .  Forty-eight sites across Mainl and China will participate in the trial . The number of enrolled patients in the study will be 4074 . Primary outcome includes the proportion of patients adherent to eligible measures recommend by the SMART program  , which is derived from current prevention guidelines for ischemic stroke , and the proportion of the patients achieving the treatment target . Secondary outcomes include new onset ischemic stroke , hemorrhagic stroke , acute coronary syndrome and all causes of death . The study has been registered on Clinical trials.gov ( NCT00664846 ) ; to date , 3380 patients have been enrolled AIM The aim of this study was to determine whether the Comprehensive Reminder System based on the Health Belief Model improves health belief , health behaviours , medication adherence and blood pressure control as a means of decreasing the rate of stroke recurrence among hypertensive ischaemic stroke . BACKGROUND Hypertensive patients having experienced recent ischaemic strokes are at high risk for stroke recurrence . Several trials attempted to improve secondary stroke prevention via patient education , however , patient outcomes remained poor . Long-term follow-up studies regarding secondary stroke prevention are limited . DESIGN A multi-centre , 12-month , assessor-blinded , parallel-group , r and omized controlled longitudinal trial . METHODS Hypertensive patients having experienced an ischaemic stroke are the target population . The intervention consists of health belief education , a calendar h and book , a weekly automated short-message service and four telephone follow-up interviews . Outcomes will be assessed at baseline and at 3 , 6 and 12 months following discharge . The primary outcome is blood pressure control . The secondary outcomes include health belief , health behaviours and medication adherence . The clinical endpoint is the rate of stroke recurrence . DISCUSSION Although many efforts to improve secondary stroke prevention have been undertaken , research indicates that improvements remain possible and warranted . This research protocol based on the Health Belief Model will improve our underst and ing of stroke education and transitional care needed in China and with the world-wide target population Objective Central blood pressure ( CBP ) and carotid intima-media thickness ( CIMT ) are surrogate measures of cardiovascular risk . Allopurinol reduces serum uric acid and oxidative stress and improves endothelial function and may therefore reduce CBP and CIMT progression . This study sought to ascertain whether allopurinol reduces CBP , arterial stiffness and CIMT progression in patients with ischaemic stroke or transient ischaemic attack ( TIA ) . Methods We performed a r and omised , double-blind , placebo-controlled study , examining the effect of 1-year treatment with allopurinol ( 300 mg daily ) , on change in CBP , arterial stiffness and CIMT progression at 1 year and change in endothelial function and circulating inflammatory markers at 6 months . Patients aged over 18 years with recent ischaemic stroke or TIA were eligible . Results Eighty participants were recruited , mean age 67.8 years ( SD 9.4 ) . Systolic CBP [ −6.6 mm Hg ( 95 % CI −13.0 to −0.3 ) , p=0.042 ] and augmentation index [ −4.4 % ( 95 % CI −7.9 to −1.0 ) , p=0.013 ] were each lower following allopurinol treatment compared with placebo at 12 months . Progression in mean common CIMT at 1 year was less in allopurinol-treated patients compared with placebo [ between-group difference [ −0.097 mm ( 95 % CI −0.175 to −0.019 ) , p=0.015 ] . No difference was observed for measures of endothelial function . Conclusions Allopurinol  lowered CBP and reduced CIMT progression at 1 year compared with placebo in patients with recent ischaemic stroke and TIA . This extends the evidence of sustained beneficial effects of allopurinol to these prognostically significant outcomes and to the stroke population , highlighting the potential for reduction in cardiovascular events with this treatment strategy . Trial registration number IS RCT N11970568 Background and Purpose Few community-based studies have examined the long-term survival and prognostic factors for death within 5 years after an acute first-ever stroke . This study aim ed to determine the absolute and relative survival and the independent baseline prognostic factors for death over the next 5 years among all individuals and among 30-day survivors after a first-ever stroke in a population of Perth , Western Australia . Methods Between February 1989 and August 1990 , all individuals with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth , Western Australia , with a population of 138 708 people , were registered prospect ively  and assessed according to st and ardized diagnostic criteria . Patients were followed up prospect ively at 4 months , 12 months , and 5 years after the index event . Results Three hundred seventy patients with first-ever stroke were registered , and 362 ( 98 % ) were followed up at 5 years , by which time 210 ( 58 % ) had died . In the first year after stroke the risk of death was 36.5 % ( 95 % CI , 31.5 % to 41.4 % ) , which was 10-fold ( 95 % CI , 8.3 % to 11.7 % ) higher than that expected among the general population of the same age and sex . The most common cause of death was the index stroke ( 64 % ) . Between 1 and 5 years after stroke , the annual risk of death was approximately 10 % per year , which was approximately 2-fold greater than expected , and the most common cause of death was cardiovascular disease ( 41 % ) . The independent baseline factors among 30-day survivors that predicted death over 5 years were intermittent claudication ( hazard ratio [ HR ] , 1.9 ; 95 % CI , 1.2 to 2.9 ) , urinary incontinence ( HR , 2.0 ; 95 % CI , 1.3 to 3.0 ) , previous transient ischemic attack ( HR , 2.4 ; 95 % CI , 1.4 to 4.1 ) , and prestroke Barthel Index < 20/20 ( HR , 2.0 ; 95 % CI , 1.2 to 3.2 ) . Conclusions One-year survivors of first-ever stroke continue to die over the next 4 years at a rate of approximately 10 % per year , which is twice the rate expected among the general population of the same age and sex . The most common cause of death is cardiovascular disease . Long-term survival after stroke may be improved by early , active , and sustained implementation of effective strategies for preventing subsequent cardiovascular events SIR— Interventions with an educational or counselling component have been reported to be effective in a variety of patient groups to encourage smoking cessation [ 1 ] , lower blood pressure ( BP ) [ 2 , 3 ] , achieve modest reductions in cholesterol [ 4 ] , and promote weight loss [ 5 ] . Evaluation of the impact of education on physical outcomes is lacking in stroke disease , despite evidence that inadequate provision of information may adversely affect compliance with secondary prevention and psychosocial outcomes [ 6 ] . We describe a single-blind r and omised controlled trial of health education and counselling for patients with stroke or transient ischaemic attack ( TIA ) , and its effects on risk factors , satisfaction , mood and perceived health status OBJECTIVES To assess the optimal stroke prevention treatment for patients with atrial fibrillation ( AF ) and a low-medium risk ( < or = 4 % ) of stroke . DESIGN A total of 668 patients with persistent or permanent AF , without an indication for full dose and with adequate rate control on sotalol , were r and omized to warfarin 1.25 mg + aspirin 75 mg daily ( W/A , 334 patients ) or no anticoagulation ( C , 334 patients ) . The mean follow-up period was 33 months . The protocol intended to verify a 37 % relative risk reduction provided a 4 % stroke incidence in the C group . RESULTS The stroke incidence was less in the W/A group , although the reduction was not statistically significant ( W/A 9.6 % versus C 12.3 % ) . Four haemorrhagic strokes were identified , two in each group . Secondary end-points were transient ischaemic attacks ( TIA ) ( W/A 3.3 % versus C 4.5 % ) , all cause mortality ( W/A 9.3 % versus C 10.8 % ) , cardiovascular morbidity ( W/A 17.7 % versus C 22.2 % ) and the combination of stroke + TIA ( W/A 11.7 % versus C 16.5 % ) . Bleedings were documented in 19 versus four patients ( W/A 5.7 % versus C 1.2 % ) ( P = 0.003 ) , although none fatal . Sinus rhythm ( SR ) was recorded occasionally in 68 patients ( W/A 9.6 % versus C 10.8 % ) . The stroke incidence tended to be higher in those with SR than without , 16.2 % versus 10.4 % . CONCLUSIONS Our results were inconclusive , but consistent with a small beneficial effect of W/A for reduction of stroke and major vascular events in AF patients at moderate risk . The low-dose regiment produced , however , a significantly increased risk of bleedings . Documented SR occasionally recorded may represent a sub population that warrants full dose warfarin BACKGROUND Biomarkers to predict recurrent stroke and targets of therapy to prevent stroke are lacking . OBJECTIVES This study evaluated whether patients with prior cerebrovascular events and elevated levels of oxidized phospholipids on apolipoprotein B-100 ( OxPL-apoB ) , but without prior coronary artery disease ( CAD ) , are at risk for recurrent stroke and CAD events following high-dose statin therapy . METHODS In the SPARCL ( Stroke Prevention by Aggressive Reduction in Cholesterol Levels ) trial , OxPL-apoB levels were measured in 4,385 patients with stroke or transient ischemic attack at baseline and in 3,106 patients at 5 years following r and omization to placebo or 80 mg atorvastatin .  The primary endpoint was the time from r and omization to a second nonfatal or fatal stroke . Secondary endpoints included first major coronary events and any cardiovascular event . RESULTS Patients with recurrent stroke had higher baseline median OxPL-apoB levels than patients without ( 15.5 nmol/l vs. 11.6 nmol/l ; p < 0.0001 ) . After multivariable adjustment , elevated baseline OxPL-apoB predicted recurrent stroke ( hazard ratio [ HR ] : 4.3 ; p < 0.0001 ) , first major coronary events ( HR : 4.0 ; p < 0.0001 ) , and any cardiovascular event ( HR : 4.4 ; p < 0.0001 ) . These comparisons for any endpoint did not differ by treatment , shown as a nonsignificant interaction test . The net reclassification improvement , integrated discrimination improvement , and area under the receiver-operating characteristic curve ( AUC ) were all significantly improved by adding OxPL-apoB to the models , with ΔAUC + 0.0505 ( p < 0.0001 ) for recurrent stroke , ΔAUC + 0.0409 ( p < 0.0001 ) for first major coronary event , and ΔAUC + 0.0791 ( p < 0.0001 ) for any cardiovascular event . CONCLUSIONS Elevated OxPL-apoB levels predicted recurrent stroke and first major coronary events in patients with prior stroke or transient ischemic attack . The lack of statin-OxPL-apoB treatment interaction suggested that OxPLs might be statin-independent therapeutic targets to reduce risk of cardiovascular events . ( Lipitor in the Prevention of Stroke , for Patients Who Have Had a Previous Stroke [ SPARCL ] ; NCT00147602 ) Background Blood pressure ( BP ) lowering in people who have had a stroke or transient ischaemic attack ( TIA ) leads to reduced risk of further stroke . However , it is not clear what the target BP should be , since intensification of therapy may lead to additional adverse effects . PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting , and whether more intensive therapy is associated with adverse effects on quality of life . Methods / Design This is a r and omised controlled trial ( RCT ) in patients with a past history of stroke or TIA . Patients will be r and omised to two groups and will either have their blood pressure ( BP ) lowered intensively to a target of 130 mmHg systolic , ( or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg ) compared to a st and ard group where the BP will be reduced to a target of 140 mmHg systolic . Patients will be managed by their practice at 1 - 3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practice s. The following exclusion criteria will be applied : systolic BP < 125 mmHg at baseline , 3 or more anti-hypertensive agents , orthostatic hypotension , diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness . The primary outcome will be change in systolic BP over twelve months . Secondary outcomes include quality of life , adverse events and cardiovascular events . In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals underst and ing and views of BP management . Discussion The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care , and help determine whether or not further research is required before recommending such targets for this population .Trial Registration IS RCT Patients who had survived a stroke or transient ischaemic attacks ( TIA ) were admitted to a trial of low-dose aspirin ( 50 mg ) alone , sustained release dipyridamole ( 400 mg/day ) alone , or a combination of the two agents , and results compared with a placebo over 24 months . This low-dose aspirin regimen produced in pairwise comparisons a significant risk reduction of 18 % for stroke , 13 % for stroke and /or death but no reduction in all cause mortality . The sustained release dipyridamole produced a significant risk reduction of 16 % for stroke , 15 % for stroke and /or death but no significant reduction of mortality . In combination , aspirin and dipyridamole produced a risk reduction of 37 % in stroke , 24 % in stroke and /or death , and no reduction in mortality . Similar findings were found in TIA , which was a secondary endpoint . These results are highly significant in comparison with placebo . As expected , there were enhanced reports of alimentary side-effects in the aspirin groups and also enhanced bleeding .  Dipyridamole was associated with a slight increase in headache , which resolved in most patients if therapy was continued . The conclusions are that 50 mg/day of aspirin alone or 400 mg/day of sustained release dipyridamole alone are equally effective in stroke and TIA prevention . When used in combination the effects were additive and were significantly more effective than the single agents Background : Stroke units and thrombolysis are evidence based treatments for stroke patients . Few studies have prospect ively assessed the success of , and obstacles to implementation of such strategies in patients admitted to district general hospitals . Objective : To document delays in admissions of acute stroke patients to hospital , failures in accessing a stroke unit and the clinical impact of missed opportunities for intervention in acute stroke patients . Design , setting and methods : Prospect i ve observational study in a district general hospital in Northern Irel and . Delays , demographic details , risk factors , stroke severity and classification were recorded prospect ively in all stroke patients admitted to a district general hospital from 22 March 2004 until 21 March 2005 . Using established numbers needed to treat to prevent disability or death , the clinical impact of the lost opportunities was determined . Results : Of 171 acute stroke patients 115 ( 67 % ) spent some or all of their hospital stay in a stroke unit . Less severe strokes , living alone and attending a general practitioner all independently delayed hospital admission . Nineteen ( 12.5 % ) ischaemic stroke patients would have been eligible for intravenous thrombolysis treatment . Admitting all patients to the stroke unit would have gained independence for two patients , allowed two more patients to live at home , and prevented one death . Failure to thrombolyse eligible acute ischaemic stroke patients result ed in six patients having more disability , two of whom may have lost their independence . Conclusions : Improved stroke unit access is required in this district general hospital . Reorganisation of acute stroke services should allow thrombolysis for acute ischaemic stroke in most district general hospitals Objective : To evaluate clinical and cost effectiveness of implementing evidence -based guidelines for the prevention of stroke . Design : Cluster-r and omised trial Setting : Three primary care organisations in the North of Engl and covering a population of 400 000 . Participants : Seventy six primary care teams in four clusters : North , South & West , City I and City II . Intervention : Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack ( TIA )  were developed and implemented using a multifaceted approach including evidence -based recommendations , audit and feedback , interactive educational sessions , patient prompts and outreach visits . Outcomes : Identification and appropriate treatment of patients with atrial fibrillation or TIA , and cost effectiveness . Results : Implementation led to 36 % increase ( 95 % CI 4 % to 78 % ) in diagnosis of atrial fibrillation , and improved treatment of TIA ( odds ratio of complying with guidelines 1.8 ; 95 % CI 1.1 to 2.8 ) . Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater ( OR 1.46 95 % CI 1.10 to 1.94 ) in the condition for which practice s had received the implementation programme . The development and implementation of guidelines cost less than £ 1500 per practice . The estimated costs per quality -adjusted life year gained by patients with atrial fibrillation or TIA were both less than £ 2000 , very much less than the usual criterion for cost effectiveness . Conclusions : Implementation of evidence -based guidelines  improved the quality of primary care for atrial fibrillation and TIA . The intervention was feasible and very cost effective . Key components of the model include context ual analysis , strong professional support , clear recommendations based on robust evidence , simplicity of adoption , good communication and use of established networks and opinion leaders Background The purpose of this research is to develop and evaluate methods for conducting pragmatic cluster r and omized trials in a primary care electronic data base . The proposal describes one application , in a less frequent chronic condition of public health importance , secondary prevention of stroke . A related protocol in antibiotic prescribing was reported previously . Methods / Design The study aims to implement a  cluster r and omized trial ( CRT )  using the electronic patient records of the General Practice Research Data base ( GPRD ) as a sampling frame and data source . The specific objective of the trial is to evaluate the effectiveness of a computer-delivered intervention at enhancing the delivery of stroke secondary prevention in primary care . GPRD family practice s will be allocated to the intervention or usual care . The intervention promotes the use of electronic prompts to support adherence with the recommendations of the UK Intercollegiate Stroke Working Party and NICE guidelines for the secondary prevention of stroke in primary care . Primary outcome measure will be the difference in systolic blood pressure between intervention and control trial arms at 12-month follow-up . Secondary outcomes will be differences in serum cholesterol , prescribing of antihypertensive drugs , statins , and antiplatelet therapy . The intervention will continue for 12 months . Information on the utilization of the decision-support tools will also be analyzed . Discussion The CRT will investigate the effectiveness of using a computer-delivered intervention to reduce the risk of stroke recurrence following a first stroke event . The study will provide method ological guidance on the implementation of CRTs in electronic data bases in primary care . Trial registration Current Controlled Trials IS RCT Background — Stroke is the leading cause of adult disability . Inpatient programs optimize secondary stroke prevention care at the time of hospital discharge , but such care may not be continued after hospital discharge . Methods — To improve the delivery of secondary stroke preventive services after hospital discharge , we have design ed a chronic care model – based program called SUSTAIN ( Systemic Use of STroke Averting INterventions ) . This care intervention includes group clinics , self-management support , report cards , decision support through care guides and protocol s , and coordination of ongoing care . The first specific aim is to test , in a r and omized , controlled trial , whether SUSTAIN improves blood pressure control among an analytic sample of 268 patients with a recent stroke or transient ischemic attack discharged from 4 Los Angeles County public hospitals . Secondary outcomes consist of control of other stroke risk factors , lifestyle habits , medication adherence , patient perceptions of care quality , functional status , and quality of life . A second specific aim is to conduct a cost analysis of SUSTAIN from the perspective of the Los Angeles County Department of Health Services by using direct costs of the intervention , cost equivalents of associated utilization of county system re sources , and cost equivalents of the observed and predicted averted vascular events . Conclusions — If SUSTAIN is effective , we will have the expertise and findings to advocate for its continued support at Los Angeles County hospitals and to disseminate the SUSTAIN program to other setting s serving indigent , minority population s. Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00861081 Carotid endarterectomy ( CA ) is an effective treatment for the secondary prevention of stroke in patients with carotid stenosis > 50 % . More recently , carotid angioplasty with stenting ( CAS ) has been introduced and found to be effective in case series and small clinical trials . Although CAS has been shown not to be inferior to CA , the comparative effects of early treatment ( i.e. , during the first month after transient ischaemic attack ( TIA ) or minor stroke ) with these techniques are unknown . Early treatment is advocated , as recurrent stroke tends to present frequently in this time period . On this background , we design ed a r and omised clinical trial comparing the efficacy and safety of CA vs. CAS in patients who had suffered TIA or minor stroke in the antecedent month . The study design and methods of this multicentre pragmatic r and omised parallel-group open trial are presented here AIM Prediabetes is an independent risk factor for future stroke . However , no effective treatment has yet been established for the recurrence of stroke in patients with prediabetes . Here we investigated the effects of pioglitazone , a potent peroxisome proliferator-activated receptor-gamma agonist , for the reduction of recurrent stroke in patients with prediabetes . METHODS Participants were patients who had a symptomatic ischemic stroke or transient ischemic attack ( TIA ) without a history of type 2 diabetes mellitus and who were diagnosed to have IGT or newly diagnosed diabetes by a 75-g oral glucose tolerance test . These patients were r and omized to either receive or not receive pioglitazone . The primary endpoint was a recurrence of ischemic stroke . RESULTS A total of 120 patients were enrolled in the study . Sixty-three patients received pioglitazone and 57 were enrolled in the control group that did not receive pioglitazone . The majority of patients ( 68.3 % ) were prescribed 15 mg of pioglitazone , while the remaining patients ( 31.7 % ) were treated with 30 mg of pioglitazone . Over a median follow-up period of 2.8 years , treatment with pioglitazone was found to be associated with a lower rate of the primary endpoint ( recurrence of stroke ) than that observed in the control group [ event rate=4.8 % pioglitazone vs 10.5 % control , hazard ratio=0.62 , 95 % confidence interval 0.13 - 2.35 , p=0.49 ] . However , differences were not statistically significant . CONCLUSIONS While this study was too underpowered to determine the effect of pioglitazone , the result failed to show beneficial effects in patients of ischemic stroke or TIA with impaired glucose tolerance and newly diagnosed diabetes BACKGROUND Survivors of ischemic stroke/transient ischemic attack ( TIA ) are at high risk for other vascular events . We evaluated the impact of 2 types of case management ( hard touch with pharmacist or soft touch with nurse ) added to usual care on global vascular risk . METHODS This is a prespecified secondary analysis of a 6-month trial conducted in out patients with recent stroke/TIA who received usual care  and were r and omized to additional monthly visits with either nurse case managers ( who counseled patients , monitored risk factors , and communicated results to primary care physicians ) or pharmacist case managers ( who were also able to independently prescribe according to treatment algorithms ) . The Framingham Risk Score [ FRS ] ) and the Cardiovascular Disease Life Expectancy Model ( CDLEM ) were used to estimate 10-year risk of any vascular event at baseline , 6 months ( trial conclusion ) , and 12 months ( 6 months after last trial visit ) . RESULTS Mean age of the 275 evaluable patients was 67.6 years . Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months : median 4.8 % ( Interquartile range ( IQR ) 0.3%-11.3 % ) for the pharmacist arm versus 5.1 % ( IQR 1.9%-12.5 % ) for the nurse arm on the FRS ( P = .44 between arms ) and median 10.0 % ( 0.1%-31.6 % ) versus 12.5 % ( 2.1%-30.5 % ) on the CDLEM ( P = .37 ) . These reductions persisted at 12 months : median 6.4 % ( 1.2%-11.6 % ) versus 5.5 % ( 2.0%-12.0 % ) for the FRS ( P = .83 ) and median 8.4 % ( 0.1%-28.3 % ) versus 13.1 % ( 1.6%-31.6 % ) on the CDLEM ( P = .20 ) . CONCLUSIONS Case management by nonphysician providers is associated with improved global vascular risk in patients with recent stroke/TIA . Reductions achieved during the active phase of the trial persisted after trial conclusion BACKGROUND Patients undergoing cardiovascular procedures remain at increased risk for myocardial infa rct ion , stroke , and cardiovascular death . Risk factor control in this patient population remains suboptimal and would likely benefit from strategies targeting education , lifestyle , and healthy behaviors . DESIGN The IMPACT trial is a 400-subject prospect i ve r and omized trial design ed to compare different cardiovascular prevention strategies in subjects following a cardiovascular intervention . The trial began enrollment in the Spring of 2012 and is r and omizing subjects in a 1:1:1 manner to usual care , a one-time cardiovascular prevention consult , or a one-time cardiovascular prevention consult plus behavioral intervention program ( telephone-based motivational interviewing and tailored text messages ) over a 6-month period . The primary end point is non-high-density lipoprotein cholesterol . Secondary end points include other plasma lipid values , metabolic risk , smoking cessation , physical activity , dietary intake , medication use and adherence , and quality of life . CONCLUSIONS The IMPACT trial provides data on different management strategies for risk factor optimization in subjects following cardiovascular procedures . The results will provide a platform for the continued development of novel multidisciplinary interventions in this high-risk population Background : The optimal management of patients with cryptogenic ischemic stroke found to have a patent foramen ovale ( PFO ) at diagnostic workup remains unclear . The aims of this observational multicenter study were to evaluate : ( 1 ) the risk of recurrent cerebrovascular events in patients with cryptogenic minor ischemic stroke or transient ischemic attack ( TIA ) and PFO who either underwent percutaneous PFO closure or received only medical treatment  , and ( 2 ) the risk factors associated with recurrent events . Methods : Consecutive patients ( aged 55 years or less ) with first-ever cryptogenic minor ischemic stroke or TIA and PFO were recruited in 13 Italian hospitals between January 2006 and September 2007 and followed up for 2 years . Results : 238 patients were included in the study ( mean age 42.2 ± 10.0 years ; 118 males ) ; 117 patients ( 49.2 % ) received only antithrombotic therapy while 121 patients underwent percutaneous PFO closure  ( 50.8 % ) . Stroke as the qualifying event was more common in the medical treatment group ( p = 0.01 ) . The presence of atrial septal aneurysm and evidence of 20 bubbles or more on transcranial Doppler were more common in the PFO closure group ( p = 0.002 and 0.02 ) . Eight patients ( 6.6 % ) experienced a nonfatal complication during PFO closure . At the 2-year follow-up , 17 recurrent events ( TIA or stroke ; 3.6 % per year ) were observed ; 7 of these events ( 2.9 % per year ) occurred in the percutaneous PFO closure group and 10 events ( 4.2 % per year ) in the medical treatment group . The rate of recurrent stroke was 0.4 % per year in patients who underwent percutaneous closure ( 1 event ) and 3.4 % per year in patients who received medical treatment ( 8 events ) . On multivariate analysis , percutaneous closure was not protective in preventing recurrent TIA or stroke ( OR = 0.1 , 95 % CI = 0.02–1.5 , p = 0.1 ) , while it was barely protective in preventing recurrent stroke ( OR = 0.1 , 95 % CI = 0.0–1.0 , p = 0.053 ) . Conclusions : The results of this observational , nonr and omized study suggest that PFO closure might be superior to medical therapy for the prevention of recurrent stroke . Periprocedural complications were the trade-off for this clinical benefit . Controlled r and omized clinical trials comparing percutaneous closure with medical management are required Background —This study explores health provider and patient attitudes toward the use of a cardiovascular polypill as a health service strategy to improve cardiovascular prevention . Methods and Results —In-depth , semistructured interviews ( n=94 ) were conducted with health providers and patients from Australian general practice , Aboriginal community-controlled and government-run Indigenous Health Services participating in a pragmatic r and omized controlled trial evaluating a polypill-based strategy for high-risk primary and secondary cardiovascular disease prevention . Interview topics included polypill strategy acceptability , factors affecting adherence , and trial implementation . Transcribed interview data were analyzed thematically and interpretively .  Polypill patients commented frequently on cost-savings , ease , and convenience of a daily-dosing pill . Most providers considered a polypill strategy to facilitate improved patient medication use . Indigenous Health Services providers and indigenous patients thought the strategy acceptable and beneficial for indigenous patients given the high disease burden . Providers noted the inflexibility of the fixed dose regimen , with dosages sometimes inappropriate for patients with complex management considerations . Future polypill formulations with varied strengths and classes of medications may overcome this barrier . Many providers suggested the polypill strategy , in its current formulations , might be more suited to high-risk primary prevention patients . Conclusions —The polypill strategy was generally acceptable to patients and providers in cardiovascular prevention . Limitations to provider acceptability of this particular polypill were revealed , as was a perception it might be more suitable for high-risk primary prevention patients , though future combinations could facilitate its use in secondary prevention . Participants suggested a polypill-based strategy as particularly appropriate for lowering the high cardiovascular burden  in indigenous population s. Clinical Trial Registration —URL : http://www.anzctr.org.au . ANZCTRN : 12608000583347 BACKGROUND There is an urgent need to develop effective strategies to improve stroke outcomes in Sub-Saharan Africa ( SSA ) , where use of evidence -based therapies among patients receiving conventional care is poor . Design s of behavioral interventions to improve stroke care in SSA need to be sensitive to both individual and community factors ( including local perceptions and public policies ) contributing to the likelihood of compliance with recommended therapeutic goals . This article presents a community-based participatory research protocol that will evaluate systems and processes affecting the continuum of stroke-preventive care in an SSA country . METHODS Phase 1 of the Tailored Hospital-based Risk Reduction to Impede Vascular Events study will be implemented from 2013 to 2014 at 4 different types of hospital setting s in Nigeria . Six adult stroke survivor focus group discussion s and  six caregiver focus group discussion s , each lasting about 120 minutes will be conducted . Each group will comprise 6 to 8 participants . We will also conduct 22 semi-structured key informant interviews ( informed by the Theoretical Domains Framework ) with several types of providers and hospital administrators . Purposive and maximum variation sampling will be used to identify and recruit participants from participating hospitals . Transcript data will be analyzed by review ers in an iterative process to identify recurrent and unifying themes using a constructivist variant of the grounded theory methodology , and will involve participatory co- analysis with key stakeholders to enhance authenticity and veracity of findings . DISCUSSION On the basis of the results of Tailored Hospital-based Risk Reduction to Impede Vascular Events phase 1 , we intend to develop a culturally sensitive , system-appropriate , multipronged intervention whose efficacy to boost adherence to evidence -based stroke-preventive care will be tested in a future r and omized trial ( phase 2 ) Background Transcatheter aortic valve implantation is a novel therapeutic option for patients at high risk for surgical heart valve replacement that carries a risk for periprocedural stroke . Patients and methods Consecutive patients undergoing transcatheter aortic valve implantation with the self-exp and able Medtronic-Corevalve Revalving system were included in a single-centre prospect i ve data base . Strokes complicating transcatheter aortic valve implantation in the first five-days following the procedure were documented , and the differences between patients with and without stroke were studied . Results Seventy-two patients ( 32 men , mean age 80·5 ± 6·2 ) underwent transcatheter aortic valve implantation from September 2008 to April 2011 . Of these , eight ( 11 % ) had focal neurological deficits in the periprocedural period ( three transient ischaemic attacks , five strokes of which three were minor , one moderate , and one major ) . Patients with stroke/ transient ischaemic attacks did not differ from those without cerebral ischaemia in baseline criteria or procedural variables . Six of the events were believed to be embolic result ing from dislodgement of calcific material from the aortic valve , and one transient ischaemic attack was secondary to hypoperfusion during severe bradycardia . One patient with basilar occlusion died , but the remaining six patients survived and all had a modified Rankin score ≤2 at 90 days . None of the patients had a recurrent stroke during follow-up . Discussion Periprocedural cerebral ischaemia following transcatheter aortic valve implantation is not uncommon , but most patients have good outcomes . There was no particular pre-transcatheter aortic valve implantation or procedural risk factor profile that increased the risk for periprocedural stroke . Further studies are warranted to examine whether patients that are at higher risk for developing stroke after transcatheter aortic valve implantation can be identified BACKGROUND Epidemiological studies suggest that raised plasma concentrations of total homocysteine might be a risk factor for major vascular events . Whether lowering total homocysteine with B vitamins prevents major vascular events in patients with previous stroke or transient ischaemic attack is unknown . We aim ed to assess whether the addition of once-daily supplements of B vitamins to usual medical care would lower total homocysteine and reduce the combined incidence of non-fatal stroke , non-fatal myocardial infa rct ion , and death attributable to vascular causes in patients with recent stroke or transient ischaemic attack of the brain or eye . METHODS In this r and omised , double-blind , parallel , placebo-controlled trial , we assigned patients with recent stroke or transient ischaemic attack ( within the past 7 months ) from 123 medical centres in 20 countries to receive one tablet daily of placebo or B vitamins ( 2 mg folic acid , 25 mg vitamin B6 , and 0.5 mg vitamin B12 ) . Patients were r and omly allocated by means of a central 24-h telephone service or an interactive website , and allocation was by use of r and om permuted blocks stratified by hospital . Participants , clinicians , carers , and investigators who assessed outcomes were masked to the assigned intervention . The primary endpoint was the composite of stroke , myocardial infa rct ion , or vascular death . All patients r and omly allocated to a group were included in the analysis of the primary endpoint . This trial is registered with Clinical Trials.gov , NCT00097669 , and Current Controlled Trials , IS RCT N74743444 . FINDINGS Between Nov 19 , 1998 , and Dec 31 , 2008 , 8164 patients were r and omly assigned to receive B vitamins ( n=4089 ) or placebo ( n=4075 ) . Patients were followed up for a median duration of 3.4 years ( IQR 2.0 - 5.5 ) . 616 ( 15 % ) patients assigned to B vitamins and 678 ( 17 % ) assigned to placebo reached the primary endpoint ( risk ratio [ RR ] 0.91 , 95 % CI 0.82 to 1.00 , p=0.05 ; absolute risk reduction 1.56 % , -0.01 to 3.16 ) . There were no unexpected serious adverse reactions and no significant differences in common adverse effects between the treatment groups . INTERPRETATION Daily administration of folic acid , vitamin B6 , and vitamin B12 to patients with recent stroke or transient ischaemic attack was safe but did not seem to be more effective than placebo in reducing the incidence of major vascular events . These results do not support the use of B vitamins to prevent recurrent stroke . The results of ongoing trials and an individual patient data meta- analysis will add statistical power and precision to present estimates of the effect of B vitamins . FUNDING Australia National Health and Medical Research Council , UK Medical Research Council , Singapore Biomedical Research Council , Singapore National Medical Research Council , Australia National Heart Foundation , Royal Perth Hospital Medical Research Foundation , and Health Department of Western Australia Background Stroke is the most common disabling neurological condition in adults . Falls and poor mobility are major contributors to stroke-related disability . Falls are more frequent and more likely to result in injury among stroke survivors than among the general older population . Currently there is good evidence that exercise can enhance mobility after stroke , yet ongoing exercise programs for general community-based stroke survivors are not routinely available . This r and omised controlled trial will investigate whether exercise can reduce fall rates and increase mobility and physical activity levels in stroke survivors . Methods and design Three hundred and fifty community dwelling stroke survivors will be recruited . Participants will have no medical contradictions to exercise and be cognitively and physically able to complete the assessment s and exercise program .  After the completion of the pre-test assessment , participants will be r and omly allocated to one of two intervention groups . Both intervention groups will participate in weekly group-based exercises and a home program for twelve months . In the lower limb intervention group , individualised programs of weight-bearing balance and strengthening exercises will be prescribed . The upper limb/cognition group will receive exercises aim ed at management and improvement of function of the affected upper limb and cognition carried out in the seated position . The primary outcome measures will be falls ( measured with 12 month calendars ) and mobility . Secondary outcome measures will be risk of falling , physical activity levels , community participation , quality of life , health service utilisation , upper limb function and cognition . Discussion This study aims to establish and evaluate community-based sustainable exercise programs for stroke survivors . We will determine the effects of the exercise programs in preventing falls and enhancing mobility among people following stroke . This program , if found to be effective , has the potential to be implemented within existing community services . Trial registration The protocol for this study is registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12606000479505 ) BACKGROUND In ROCKET AF , rivaroxaban was non-inferior to adjusted-dose warfarin in preventing stroke or systemic embolism among patients with atrial fibrillation ( AF ) . We aim ed to investigate whether the efficacy and safety of rivaroxaban compared with warfarin is consistent among the subgroups of patients with and without previous stroke or transient ischaemic attack ( TIA ) . METHODS In ROCKET AF , patients with AF who were at increased risk of stroke were r and omly assigned ( 1:1 ) in a double-blind manner to rivaroxaban 20 mg daily or adjusted dose warfarin ( international normalised ratio 2·0 - 3·0 ) . Patients and investigators were masked to treatment allocation . Between Dec 18 , 2006 , and June 17 , 2009 , 14 264 patients from 1178 centres in 45 countries were r and omly assigned . The primary endpoint was the composite of stroke or non-CNS systemic embolism . In this sub study we assessed the interaction of the treatment effects of rivaroxaban and warfarin among patients with and without previous stroke or TIA . Efficacy analyses were by intention to treat and safety analyses were done in the on-treatment population . ROCKET AF is registered with Clinical Trials.gov , number NCT00403767 . FINDINGS 7468 ( 52 % ) patients had a previous stroke ( n=4907 ) or TIA ( n=2561 ) and 6796 ( 48 % ) had no previous stroke or TIA .  The number of events per 100 person-years for the primary endpoint in patients treated with rivaroxaban compared with warfarin was consistent among patients with previous stroke or TIA ( 2·79 % rivaroxaban vs 2·96 % warfarin ; hazard ratio [ HR ] 0·94 , 95 % CI 0·77 - 1·16 ) and those without ( 1·44%vs 1·88 % ; 0·77 , 0·58 - 1·01 ; interaction p=0·23 ) . The number of major and non-major clinical ly relevant bleeding events per 100 person-years in patients treated with rivaroxaban compared with warfarin was consistent among patients with previous stroke or TIA ( 13·31 % rivaroxaban vs 13·87 % warfarin ; HR 0·96 , 95 % CI 0·87 - 1·07 ) and those without ( 16·69%vs 15·19 % ; 1·10 , 0·99 - 1·21 ; interaction p=0·08 ) . INTERPRETATION There was no evidence that the relative efficacy and safety of rivaroxaban compared with warfarin was different between patients who had a previous stroke or TIA and those who had no previous stroke or TIA . These results support the use of rivaroxaban as an alternative to warfarin for prevention of recurrent as well as initial stroke in patients with AF . FUNDING Johnson and Johnson Pharmaceutical Research and Development and Bayer HealthCare Objective : To evaluate whether enhanced secondary prevention more significantly influences readiness to change health behaviour after minor stroke/transient ischaemic attack , compared with conventional stroke secondary prevention . Design : Single-blind r and omized control trial . Setting : Rural district general hospital outpatient clinic . Subjects : Fifteen women and 37 men with a mean age of 68.3 years with first minor stroke or transient ischaemic attack . Interventions : The intervention group received ‘ enhanced secondary prevention ’ ( additional advice , motivational interviewing and telephone support ) to change health behaviour . Both groups received ‘ conventional care ’ which included advice given during routine care . Main measures : The primary outcome was ‘ readiness to change behaviour ’ measured using a vali date d stroke specific score based on the transtheoretical model . Secondary outcomes were the Hospital Anxiety and Depression Scale , and self-reported alcohol consumption , smoking behaviour , exercise frequency , and fruit and vegetable consumption . Results : Analysis of the data for the 52 participants showed no statistical difference in the groups for the primary outcome of readiness to change behaviour . Statistically significant improvements for change in self-reported exercise were demonstrated ( P = 0.007 ) ; to 2—3 times per week in the intervention group compared to 0—1 times per week in the control group , and in fruit and vegetable consumption ( P = 0.033 ) ; to 10 portions of fruit and vegetables consumed per week in the intervention group compared to 1 or 2 portions a week for the control group . No evidence of a difference between groups was seen for alcohol consumption or Hospital Anxiety and Depression Scale . Conclusions : While no difference was demonstrated between the groups for readiness to change behaviour , a clinical ly significant effect in reported exercise behaviour and diet were demonstrated in the intervention group . This interesting finding indicates a dissonance between the behaviour scale and actual behaviour change , potentially indicating a lack of sensitivity of the scale to detect a change in this patient group Patients with transient ischemic attack or ischemic stroke have a high risk of recurrent stroke .  Antiplatelet therapy has shown efficacy in secondary stroke prevention and is recommended by guidelines .1–3 In patients without cardiac source of embolism  aspirin , clopidogrel or the combination of aspirin and dipyridamole is recommended . In cardiology , the combination of aspirin and clopidogrel was superior to aspirin monotherapy in the prevention of vascular events after acute coronary syndrome4 but carried a higher bleeding risk . In patients with atrial fibrillation the combination of aspirin plus clopidogrel was superior to aspirin alone in preventing strokes,5 but was again associated with a significant higher risk of major bleeds . In early secondary stroke prevention after transient ischemic attack or minor stroke combination , antiplatelet therapy seems to be superior to monotherapy , but larger r and omized trials are needed.6,7 Combination antiplatelet therapy carries a consistent higher risk of major bleeding complications than monotherapy . Therefore , the possible benefit of a reduction in vascular events has to be balanced against the bleeding risk , especially in stroke patients . In the Management of Atherothrombosis with Clopidogrel in High-risk patients ( MATCH ) trial , aspirin plus clopidogrel was investigated against aspirin monotherapy in high-risk patients with recent transient ischemic attack or ischemic stroke.8 Similar to the Secondary Prevention of Small Subcortical Strokes ( SPS3 ) trial , patients with a cardiac source of embolism and significant carotid stenosis requiring surgery were excluded . About 50 % of patients were categorized to have small vessel disease with suspected lacunar strokes , but in contrast to the SPS3 trial , Objective Transient ischaemic attack ( TIA ) is a recognised risk factor for stroke in the older population requiring timely assessment and treatment by a specialist . The need for such TIA services is driven by the epidemiology of transient neurological symptoms , which may not be caused by TIA . We report prevalence and incidence of transient neurological symptoms in a large UK cohort study of older people . Design Longitudinal cohort study Setting The Medical Research Council Cognitive Function and Aging Study ( CFAS ) is a population representative study based on six centres across Engl and and Wales . Participants R and om sample s of people in their 65th year were obtained from Family Health Service Authority lists . The participation rate was 80 % ( n=13 004 ) . Interview at baseline included questions about stroke and three transient neurological symptoms , repeated in a sub sample after 2 years . Patients were flagged for mortality . Main outcome measures Prevalence and 2-year incidence of transient neurological symptoms . Results In 11 903 participants without a history of stroke , 271 ( 2.3 % ) reported transient problems with speech , 872 ( 7.6 % ) with sight and 596 ( 5.1 % ) weakness in a limb with 1456 ( 12.7 % ) reporting at least one symptom . Of those reinterviewed ( n=6748 ) , 675 ( 9.8 % ) reported at least one symptom over 2 years . Conclusions Lifetime prevalence and incidence of transient neurological symptoms in people aged 65 years and over is high and is substantially greater than the incidence of TIA in hospital-based and population -based studies . These high rates of transient neurological symptoms in the community in the older population should be considered when planning TIA services Background and Purpose : & bgr;‐Blockers prevent vascular events in patients after myocardial infa rct ion and lower blood pressure , the main risk factor for stroke . Hence , we assessed the effects of atenolol on the occurrence of death from vascular causes , stroke , or myocardial infa rct ion and on blood pressure in patients after a transient ischemic attack or nondisabling ischemic stroke . Methods : In a double‐blind , placebo‐controlled r and omized clinical trial we studied the occurrence of the outcome event death from vascular causes , nonfatal stroke , or nonfatal myocardial infa rct ion and the outcome event fatal or nonfatal stroke as well as blood pressure on follow‐up . A total of 1,473 aspirin‐treated patients with transient ischemic attack or nondisabling ischemic stroke were r and omized to 50 mg atenolol daily or placebo . The mean follow‐up was 2.6 years . Results : Patients on atenolol had a risk of 97/732 ( 13.3 % ) for the combined outcome event versus a risk of 95/741 ( 12.8 % ) for those on placebo ( adjusted hazard ratio , 1.00 ; 95 % confidence interval , 0.76‐1.33 ) . The adjusted hazard ratio for fatal or nonfatal stroke was 0.82 ( 95 % confidence interval , 0.57‐1.19 ) . More patients on & bgr;‐blocker ( 153 ) reported adverse effects than on placebo ( 103 ) . At the first follow‐up visit after r and omization ( median at 4 months ) systolic blood pressure in the atenolol group had dropped by 8.0 mm Hg compared with 2.2 mm Hg in the placebo group ( difference , 5.8 mm Hg ; 95 % confidence interval , 2.9‐8.6 mm Hg ) . For diastolic blood pressure this difference was 2.9 mm Hg ( 95 % confidence interval , 1.5‐4.4 mm Hg ) . Conclusions : Our data neither confirm nor rule out that atenolol prevents important vascular events in patients after transient ischemic attack or nondisabling ischemic stroke , given the modest effect on blood pressure , the restrictions in patient selection , and the limited number of patient‐years . ( Stroke 1993;24:543‐548 BACKGROUND AND PURPOSE Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke . This study aim ed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population -based series of people with first-ever stroke in Perth , Western Australia . METHODS Between February 1989 and August 1990 , all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth , Western Australia , with a population of 138 708 people , were registered prospect ively and assessed according to st and ardized diagnostic criteria . Patients were followed up prospect ively at 4 months , 12 months , and 5 years after the index event . RESULTS Three hundred seventy patients with a first-ever stroke were registered , of whom 351 survived > 2 days . Data were available for 98 % of the cohort at 5 years , by which time 199 patients ( 58 % ) had died and 52 ( 15 % ) had experienced a recurrent stroke , 12 ( 23 % ) of which were fatal within 28 days . The 5-year cumulative risk of first recurrent stroke was 22.5 % ( 95 % confidence limits [ CL ] , 16.8 % , 28.1 % ) . The risk of recurrent stroke was greatest in the first 6 months after stroke , at 8.8 % ( 95 % CL , 5.4 % , 12.1 % ) . After adjustment for age and sex , the prognostic factors for recurrent stroke were advanced , but not extreme , age ( 75 to 84 years ) ( hazard ratio [ HR ] , 2.6 ; 95 % CL , 1.1 , 6.2 ) , hemorrhagic index stroke ( HR , 2.1 ; 95 % CL , 0.98 , 4.4 ) , and diabetes mellitus ( HR , 2.1 ; 95 % CL , 0.95 , 4.4 ) . CONCLUSIONS Approximately 1 in 6 survivors ( 15 % ) of a first-ever stroke experience a recurrent stroke over the next 5 years , of which 25 % are fatal within 28 days . The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88 % of cases . The predictors of first recurrent stroke in this study were advanced age , hemorrhagic index stroke , and diabetes mellitus , but numbers of recurrent events were modest . Because the risk of recurrent stroke is highest ( 8.8 % ) in the first 6 months after stroke , strategies for secondary prevention  should be initiated as soon as possible after the index event Background Enhanced secondary preventive follow-up after stroke or transient ischemic attack ( TIA ) is necessary for improved adherence to recommendations regarding blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels . We investigated whether nurse-led , telephone-based follow-up was more efficient than usual care at improving BP and LDL-C levels at 12 months after hospital discharge . Methods We r and omized 537 patients to either nurse-led , telephone-based follow-up ( intervention ) or usual care ( control ) .  BP and LDL-C measurements were performed at 1 month ( baseline ) and 12 months post-discharge . Intervention group patients who did not meet target values at baseline received additional follow-up , including titration of medication and lifestyle counselling , to reach treatment goals ( BP < 140/90 mmHg , LDL-C < 2.5 mmol/L ) . Results At 12 months , mean systolic BP , diastolic BP and LDL-C was 3.3 ( 95 % CI 0.3 to 6.3 ) mmHg , 2.3 mmHg ( 95 % CI 0.5 to 4.2 ) and 0.3 mmol/L ( 95 % CI 0.1 to 0.4 ) lower in the intervention group compared to controls . Among participants with values above the treatment goal at baseline , the difference in systolic BP and LDL-C was more pronounced ( 8.0 mmHg , 95 % CI 4.0 to 12.1 , and 0.6 mmol/L , 95 % CI 0.4 to 0.9 ) . A larger proportion of the intervention group reached the treatment goal for systolic BP ( 68.5 vs. 56.8 % , p = 0.008 ) and LDL-C ( 69.7 % vs. 50.4 % , p < 0.001 ) . Conclusions Nurse-led , telephone-based secondary preventive follow-up , including medication adjustment , was significantly more efficient than usual care at improving BP and LDL-C levels by 12 months post-discharge . Trial Registration IS RCT N Registry IS RCT Background Patients discharged home after stroke face significant challenges managing residual neurological deficits , secondary prevention , and pre-existing chronic conditions . Post-discharge care is often fragmented leading to increased healthcare costs , readmissions , and sub-optimal utilization of rehabilitation and community services . The COMprehensive Post-Acute Stroke Services ( COMPASS ) Study is an ongoing cluster-r and omized pragmatic trial to assess the effectiveness of a comprehensive , evidence -based , post-acute care model on patient-centered outcomes . Methods Forty-one hospitals in North Carolina were r and omized ( as 40 units ) to either implement the COMPASS care model or continue their usual care . The recruitment goal is 6000 patients ( 3000 per arm ) . Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack . Patients discharged from intervention hospitals receive 2-day telephone follow-up ; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation , assessment s of social and functional determinants of health , and an individualized COMPASS Care Plan ™ integrated with a community-specific re source data base ; and additional follow-up calls at 30 and 60 days post-stroke discharge . This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessment s and coordinate follow-up services . Patients discharged from usual care hospitals represent the control group and receive the st and ard of care in place at that hospital . Patient-centered outcomes are collected from telephone surveys administered at 90 days . The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16 . Secondary outcomes are : caregiver strain , all-cause readmissions , mortality , healthcare utilization , and medication adherence . The study engages patients , caregivers , and other stakeholders ( including policymakers , advocacy groups , payers , and local community coalitions ) to advise and support the design , implementation , and sustainability of the COMPASS care model . Discussion Given the high societal and economic burden of stroke , identifying a care model to improve recovery , independence , and quality of life is critical for stroke survivors and their caregivers . The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful . Trial registration Clinical trials.gov : NCT02588664 ; October 23 , 2015 BACKGROUND In patients with prior myocardial infa rct ion ( MI ) , beta-blockers reduce mortality by 23 % to 40 % . However , despite this favorable effect , adverse effects limit compliance to this medication . The purpose of the study was to compare a beta-blocker-based strategy with a heart rate-lowering calcium antagonists-based strategy in patients with prior MI . METHODS We evaluated 7,218 patients with prior MI enrolled in the INternational VErapamil SR-Tr and olapril ( INVEST ) sub study r and omized to verapamil-sustained release (SR)- or atenolol-based strategies . Primary outcome was time to first occurrence of death ( all-cause ) , nonfatal MI , or nonfatal stroke . Secondary outcomes included death , total MI ( fatal and nonfatal ) , and total stroke ( fatal and nonfatal ) considered separately . RESULTS During the 2.8 + /- 1.0 years of follow-up , patients assigned to the verapamil-SR-based and atenolol-based strategies had comparable blood pressure control , and the incidence of the primary outcome was equivalent . There was no difference between the 2 strategies for the outcomes of either death or total MI . However , more patients reported excellent/good well-being ( 82.3 % vs 78.0 % , P = .02 ) at 24 months with a trend toward less incidence of angina pectoris ( 12.0 % vs 14.3 % , adjusted P = .07 ) , nonfatal stroke ( 1.4 % vs 2.0 % ; P = .06 ) , and total stroke ( 2.0 % vs 2.5 % , P = .18 ) in the verapamil-SR-based strategy group . CONCLUSIONS In hypertensive patients with prior MI , a verapamil-SR-based strategy was equivalent to a beta-blocker-based strategy for blood pressure control and prevention of cardiovascular events , with greater subjective feeling of well-being and a trend toward lower incidence of angina pectoris and stroke in the verapamil-SR-based group BACKGROUND Previous reports have associated acute coronary syndromes ( ACSs ) with cerebrovascular disease but in general have not included long-term patient follow-up or have not analyzed ischemic and hemorrhagic cerebrovascular events separately . METHODS We analyzed stroke outcomes from the OPUS-TIMI 16 study , a multicenter , r and omized , placebo-controlled trial . Patients were r and omized to aspirin plus either orbofiban or placebo and followed for up to 1 year .  Cerebrovascular events were prospect ively identified and classified by a committee of cardiologists and neurologists blinded to treatment assignment . RESULTS During 10 months of follow-up , there were 150 ( 1.5 % ) patients with cerebrovascular events . Risk factors for ischemic stroke ( n = 67 ) and transient ischemic attack ( TIA ) ( n = 44 ) were age , prior ischemic stroke , history of hypertension , and increased heart rate . Prior ischemic stroke and history of hypertension were not risk factors for 30-day ischemic stroke or TIA . Risk factors for intracranial hemorrhage ( ICH ) ( n = 14 ) were age , history of hypertension , history of TIA , and coronary angiography with evidence of coronary artery disease . Compared with placebo , treatment with orbofiban was associated with a nonsignificant increased risk of ischemic stroke or TIA ( HR 1.15 , 95 % CI 0.76 - 1.74 , P = .51 ) and ICH ( HR 1.25 , 95 % CI 0.39 - 4.00 , P = .70 ) . CONCLUSIONS The overall incidence of cerebrovascular events after ACS was highest in the first 30 days then declined ; risk factors for cerebrovascular events may be different in the different periods . Orbofiban , despite no significant excess risk of ICH , was not effective in preventing ischemic stroke or TIA AIM To assess the feasibility of recruiting and retaining patients newly diagnosed with a Transient Ischaemic Attack ( TIA ) into an 8-week exercise programme . METHODS The study was a single-centre , r and omised-controlled trial . TIA was confirmed by a specialist stroke physician within 7 days of symptom onset . Following baseline assessment , participants were r and omised to either an 8-week exercise intervention or control group ( usual care ) . Participants completed a further assessment 2 months after baseline . RESULTS Of the 285 individuals diagnosed with TIA , 97 patients were invited to participate in the trial , of which 60 were successfully recruited ( 62 % ) . Of those invited , 89 % were identified within outpatient care . Individuals were typically of European descent ( 87 % ) and lived within 20 km of the study site ( 81 % ) . Distance to travel was considered the primary barrier for non-participation ( 46 % ) . Three participants ( 5 % ) did not attend the follow-up assessment . CONCLUSION Individuals with TIA were successfully recruited and retained into a RCT . A different approach is required to study interventions in Maori , Pacific Isl and ers , Asian and Indian population s. If the exercise intervention improves vascular risk factors and reduces recurrent vascular events , it could be applied to a large number of people who suffer a TIA or non-disabling stroke From 1979 to 1985 2435 patients having had transient ischaemic attacks ( TIAs ) or minor ischaemic strokes , were enrolled in the UK TIA trial and were r and omised to receive either aspirin 300 mg , daily or aspirin 1200 mg or placebo . Analysis of reported upper gastrointestinal bleeding events ( defined as haematemesis or melaena , or both ) showed a risk of bleeding in a dose dependent manner , odds ratios ( 95 % CI ) for 300 mg of aspirin = 3.3 ( 1.2 to 9.0 ) and for 1200 mg = 6.4 ( 2.5 to 16.5 ) and , as would be expected , an increased risk of hospitalisation because of bleeding also in a dose dependent manner , odds ratio = 3.6 ( 0.7 to 17.2 ) for 300 mg and 8.7 ( 2.0 to 37.6 ) for 1200 mg . Further analysis suggested greater risks of bleeding from duodenal ulcers than gastric ulcers and that bleeding is more likely early in the course of treatment with aspirin used as secondary prevention . There was also an increased risk of lower gastrointestinal bleeding , defined as fresh blood per rectum for both doses of aspirin , odds ratio 1.8 ( 0.5 to 6.1 ) for 300 mg of aspirin , and 1.5 ( 0.4 to 5.3 ) for 1200 mg of aspirin Background ‐ The Second European Stroke Prevention Study ( ESPS2 ) was a r and omized , placebo‐controlled trial that investigated the efficacy of low‐dose acetylsalicylic acid ( ASA ) and modified‐release dipyridamole ( DP ) , alone or in combination , in the secondary prevention of ischemic stroke . The trial demonstrated that the combination was significantly more effective than either agent used alone . The aim of the present study was to evaluate the influence of age on the efficacy of ASA and DP , alone or in combination , in the secondary prevention of stroke in the ESPS2 population . Methods and results ‐ A total of 6602 patients were recruited to the ESPS2 and there were 4 treatment groups : ASA ( 25 mg twice daily ) , DP ( 200 mg twice daily ) , ASA and DP in a combined formulation , or placebo . Primary endpoints were stroke , death , and stroke or death together . The endpoints evaluated in the present study were stroke , stroke and /or death , and vascular events . Stroke was the qualifying event in 76 % of the patients , while 24 % had a transient ischaemic attack . Patients were review ed at 3‐month intervals for 2 years . The study population consisted of 2565 ( 39 % ) patients aged less than 65 years , 2240 ( 34 % ) patients aged between 65 and 74 years , and 1797 ( 27 % ) patients aged 75 years and over . Advancing age was associated with an increased incidence of endpoints in all 4 treatment groups . The combination of ASA and DP significantly reduced the incidence of all endpoints , compared with placebo , in each age group . There was no influence of age on the efficacy of antiplatelet therapy for any of the evaluated endpoints . Relative risk reductions of treatment compared with placebo were 11.1–27.6 % in the ASA group , 8.0–18.7 % in the DP group , and 20.3–45.2 % in patients receiving combination therapy . Conclusion ‐ This study clearly demonstrates that combination therapy with DP and ASA is superior to either agent used alone in the secondary prevention of ischemic stroke , irrespective of the age of the patient Objectives : L-arginine is the substrate for nitric oxide ( NO ) production and has been shown to induce an endothelium-dependent increase in cerebral blood flow in humans . We studied the hypothesis that L-arginine-mediated vasoreactivity is impaired in patients with cardiovascular risk factors and a risk of stroke . Methods : 55 patients with cardiovascular risk factors ( mean age 63.0 ± 8.5 years ) were included in the study . 45 of them had a history of previous minor stroke or transient ischemic attack ( TIA ) while 10 patients had cardiovascular risk factors but no previous cerebral ischemic event .  Endothelium-dependent changes in cerebral blood flow during the infusion of 30 g L-arginine were assessed by continuous transcranial Doppler sonography of both middle cerebral arteries , intima-media thickness ( IMT ) of the common carotid artery , by Duplex sonography . Associations between risk factors , IMT , L-arginine reactivity and previous cerebrovascular events were analyzed by stepwise multiple linear regression analysis and patient groups were compared . Results : Normal young volunteers showed an L-arginine-mediated increase in mean flow velocity of 22 ± 8 % ; L-arginine reactivity of the 55 patients was 28 ± 10 % . Patients with a history of stroke or TIA had significantly higher flow velocity responses to L-arginine ( 29 ± 10 % ) than patients with cardiovascular risk factors but no previous cerebrovascular event ( 21 ± 8 % , p < 0.05 ) . Stepwise multiple linear regression analysis showed a significant association of enhanced L-arginine reactivity with previous stroke/TIA ( p < 0.001 ) and elevated fibrinogen levels ( p < 0.05 ) but not with age , IMT , hypertension , cholesterol or other risk factors . The same regression model showed an association between IMT and previous stroke/TIA ( p < 0.001 ) and serum cholesterol levels ( p < 0.05 ) but not L-arginine reactivity . Conclusions : L-arginine reactivity of the cerebral vessels may be assessed by Doppler sonography and was enhanced in patients with a history of stroke or TIA . It was independent of IMT of the carotid arteries . We conclude that enhanced L-arginine reactivity is a potential marker for cerebral endothelial dysfunction and an independent indicator for an increased risk of stroke BACKGROUND Patients with transient ischaemic attack ( TIA ) or minor stroke are at high immediate risk of stroke . The optimum early treatment options for these patients are not known . METHODS Within 24 h of symptom onset , we r and omly assigned , in a factorial design , 392 patients with TIA or minor stroke to clopidogrel  ( 300 mg loading dose then 75 mg daily ; 198 patients ) or placebo ( 194 patients ) , and simvastatin ( 40 mg daily ; 199 patients ) or placebo ( 193 patients ) . All patients were also given aspirin and were followed for 90 days . Descriptive analyses were done by intention to treat . The primary outcome was total stroke ( ischaemic and haemorrhagic ) within 90 days . Safety outcomes included haemorrhage related to clopidogrel and myositis related to simvastatin . This study is registered as an International St and ard R and omised Controlled Trial ( number 35624812 ) and with Clinical Trials.gov ( NCT00109382 ) . FINDINGS The median time to stroke outcome was 1 day ( range 0 - 62 days ) . The trial was stopped early due to a failure to recruit patients at the prespecified minimum enrolment rate because of increased use of statins . 14 ( 7.1 % ) patients on clopidogrel had a stroke within 90 days compared with 21 ( 10.8 % ) patients on placebo ( risk ratio 0.7 [ 95 % CI 0.3 - 1.2 ] ; absolute risk reduction -3.8 % [ 95 % CI -9.4 to 1.9 ] ; p=0.19 ) . 21 ( 10.6 % ) patients on simvastatin had a stroke within 90 days compared with 14 ( 7.3 % ) patients on placebo ( risk ratio 1.3 [ 0.7 - 2.4 ] ; absolute risk increase 3.3 % [ -2.3 to 8.9 ] ; p=0.25 ) . The interaction between clopidogrel and simvastatin was not significant ( p=0.64 ) . Two patients on clopidogrel had intracranial haemorrhage compared with none on placebo ( absolute risk increase 1.0 % [ -0.4 to 2.4 ] ; p=0.5 ) . There was no difference between groups for the simvastatin safety outcomes . INTERPRETATION Immediately after TIA or minor stroke , patients are at high risk of stroke , which might be reduced by using clopidogrel in addition to aspirin . The haemorrhagic risks of the combination of aspirin and clopidogrel do not seem to offset this potential benefit . We were unable to provide evidence of benefit of simvastatin in this setting . This aggressive prevention approach merits further study BACKGROUND The role of lipid modification in stroke prevention is controversial , although increasing evidence suggests that HMG-CoA reductase inhibition may reduce cerebrovascular events in patients with prevalent coronary artery disease . METHODS AND RESULTS To test the hypothesis that cholesterol reduction with pravastatin may reduce stroke incidence after myocardial infa rct ion , we followed 4159 subjects with average total and LDL serum cholesterol levels ( mean , 209 and 139 mg/dL , respectively ) who had sustained an infa rct ion an average of 10 months before study entry and who were r and omized to pravastatin 40 mg/d or placebo in the Cholesterol and Recurrent Events ( CARE ) trial . Using prospect ively defined criteria , we assessed the incidence of stroke , a prespecified secondary end point , and transient ischemic attack ( TIA ) over a median 5-year follow-up period . Patients were well matched for stroke risk factors and the use of antiplatelet agents ( 85 % of subjects in each group ) . Compared with placebo , pravastatin lowered total serum cholesterol by 20 % , LDL cholesterol by 32 % , and triglycerides by 14 % and raised HDL cholesterol by 5 % over the course of the trial . A total of 128 strokes ( 52 on pravastatin , 76 on placebo ) and 216 strokes or TIAs ( 92 on pravastatin , 124 on placebo ) were observed , representing a 32 % reduction ( 95 % CI , 4 % to 52 % , P=0.03 ) in all-cause stroke and 27 % reduction in stroke or TIA ( 95 % CI , 4 % to 44 % , P=0.02 ) . All categories of strokes were reduced , and treatment effect was similar when adjusted for age , sex , history of hypertension , cigarette smoking , diabetes , left ventricular ejection fraction , and baseline total , HDL , and LDL cholesterol and triglyceride levels . There was no increase in hemorrhagic stroke in patients on pravastatin compared with placebo ( 2 versus 6 , respectively ) . CONCLUSIONS Pravastatin significantly reduced stroke and stroke or TIA incidence after myocardial infa rct ion in patients with average serum cholesterol levels despite the high concurrent use of antiplatelet therapy BACKGROUND Ticagrelor is an effective antiplatelet therapy for patients with coronary atherosclerotic disease and might be more effective than aspirin in preventing recurrent stroke and cardiovascular events in patients with acute cerebral ischaemia of atherosclerotic origin . Our aim was to test for a treatment-by-ipsilateral atherosclerotic stenosis interaction in a subgroup analysis of patients in the Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes ( SOCRATES ) trial . METHODS SOCRATES was a r and omised , double-blind , controlled trial of ticagrelor versus aspirin in patients aged 40 years or older with a non-cardioembolic , non-severe acute ischaemic stroke , or high-risk transient ischaemic attack from 674 hospitals in 33 countries . We r and omly allocated patients ( 1:1 ) to ticagrelor ( 180 mg loading dose on day 1 followed by 90 mg twice daily for days 2 - 90 , given orally ) or aspirin ( 300 mg on day 1 followed by 100 mg daily for days 2 - 90 , given orally ) within 24 h of symptom onset . Investigators classified all patients into atherosclerotic and non-atherosclerotic groups for the prespecified , exploratory analysis reported in this study . The primary endpoint was the time to occurrence of stroke , myocardial infa rct ion , or death within 90 days . Efficacy analysis was by intention to treat . The SOCRATES trial is registered with Clinical Trials.gov , number NCT01994720 . FINDINGS Between Jan 7 , 2014 , and Oct 29 , 2015 , we r and omly allocated 13 199 patients ( 6589 [ 50 % ] to ticagrelor and 6610 [ 50 % ] to aspirin ) . Potentially symptomatic ipsilateral atherosclerotic stenosis was reported in 3081 ( 23 % ) of 13 199 patients . We found a treatment-by-atherosclerotic stenosis interaction ( p=0·017 ) . 103 ( 6·7 % ) of 1542 patients with ipsilateral stenosis in the ticagrelor group and 147 ( 9·6 % ) of 1539 patients with ipsilateral stenosis in the aspirin group had an occurrence of stroke , myocardial infa rct ion , or death within 90 days ( hazard ratio 0·68 [ 95 % CI 0·53 - 0·88 ] ; p=0·003 ) . In 10 118 patients with no ipsilateral stenosis , 339 ( 6·7 % ) of 5047 patients in the ticagrelor group had an occurrence of stroke , myocardial infa rct ion , or death within 90 days compared with 350 ( 6·9 % ) of 5071 in the aspirin group ( 0·97 [ 0·84 - 1·13 ] ; p=0·72 ) . There were no significant differences in the proportion of life-threatening bleeding or major or minor bleeding events in patients with ipsilateral stenosis in the ticagrelor group compared with the aspirin group . INTERPRETATION In this prespecified exploratory analysis , ticagrelor was superior to aspirin at preventing stroke , myocardial infa rct ion , or death at 90 days in patients with acute ischaemic stroke or transient ischaemic attack when associated with ipsilateral atherosclerotic stenosis . An underst and ing of stroke mechanisms and causes is important to deliver safe and efficacious treatments for early stroke prevention . FUNDING AstraZeneca BACKGROUND Statins reduce the incidence of strokes among patients at increased risk for cardiovascular disease ; whether they reduce the risk of stroke after a recent stroke or transient ischemic attack ( TIA ) remains to be established . METHODS We r and omly assigned 4731 patients who had had a stroke or TIA within one to six months before study entry , had low-density lipoprotein ( LDL ) cholesterol levels of 100 to 190 mg per deciliter ( 2.6 to 4.9 mmol per liter ) , and had no known coronary heart disease to double-blind treatment with 80 mg of atorvastatin per day or placebo .  The primary end point was a first nonfatal or fatal stroke . RESULTS The mean LDL cholesterol level during the trial was 73 mg per deciliter ( 1.9 mmol per liter ) among patients receiving atorvastatin and 129 mg per deciliter ( 3.3 mmol per liter ) among patients receiving placebo . During a median follow-up of 4.9 years , 265 patients ( 11.2 percent ) receiving atorvastatin and 311 patients ( 13.1 percent ) receiving placebo had a fatal or nonfatal stroke ( 5-year absolute reduction in risk , 2.2 percent ; adjusted hazard ratio , 0.84 ; 95 percent confidence interval , 0.71 to 0.99 ; P=0.03 ; unadjusted P=0.05 ) . The atorvastatin group had 218 ischemic strokes and 55 hemorrhagic strokes , whereas the placebo group had 274 ischemic strokes and 33 hemorrhagic strokes . The five-year absolute reduction in the risk of major cardiovascular events was 3.5 percent ( hazard ratio , 0.80 ; 95 percent confidence interval , 0.69 to 0.92 ; P=0.002 ) . The overall mortality rate was similar , with 216 deaths in the atorvastatin group and 211 deaths in the placebo group ( P=0.98 ) , as were the rates of serious adverse events . Elevated liver enzyme values were more common in patients taking atorvastatin . CONCLUSIONS In patients with recent stroke or TIA and without known coronary heart disease , 80 mg of atorvastatin per day reduced the overall incidence of strokes and of cardiovascular events , despite a small increase in the incidence of hemorrhagic stroke . ( Clinical Trials.gov number , NCT00147602 [ Clinical Trials.gov ] . ) Background Falls are common in stroke survivors returning home after rehabilitation , however there is currently a lack of evidence about preventing falls in this population . This paper describes the study protocol for the FLASSH ( FaLls prevention After Stroke Survivors return Home ) project . Methods and design This r and omised controlled trial aims to evaluate the effectiveness of a multi-factorial falls prevention program for stroke survivors who are at high risk of falling when they return home after rehabilitation . Intervention will consist of a home exercise program as well as individualised falls prevention and injury minimisation strategies based on identified risk factors for falls . Additionally , two sub- studies will be implemented in order to explore other key areas related to falls in this population . The first of these is a longitudinal study evaluating the relationship between fear of falling , falls and function over twelve months , and the second evaluates residual impairment in gait stability and obstacle crossing twelve months after discharge from rehabilitation . Discussion The results of the FLASSH project will inform falls prevention practice for stroke survivors . If the falls prevention program is shown to be effective , low cost strategies to prevent falls can be implemented for those at risk around the time of discharge from rehabilitation , thus improving safety and quality of life for stroke survivors . The two sub- studies will contribute to the overall underst and ing and management of falls risk in stroke survivors . Trial registration This trial is registered with the Australian and New Zeal and Clinical Trials Registry ( ACTRN012607000398404 ) OBJECTIVE The Insulin Resistance Intervention after Stroke ( IRIS ) trial recently found that pioglitazone reduced risk for stroke and myocardial infa rct ion in patients with insulin resistance but without diabetes who had had a recent ischemic stroke or transient ischemic attack ( TIA ) . This report provides detailed results on the metabolic effects of pioglitazone and the trial ’s prespecified secondary aim of diabetes prevention . RESEARCH DESIGN AND METHODS A total of 3,876 patients with recent ischemic stroke or TIA , no history of diabetes , fasting plasma glucose ( FPG ) < 126 mg/dL , and insulin resistance by homeostasis model assessment of insulin resistance ( HOMA-IR ) score > 3.0 were r and omly assigned to pioglitazone or placebo . Surveillance for diabetes onset during the trial was accomplished by periodic interviews and annual FPG testing . RESULTS At baseline , the mean FPG , HbA1c , insulin , and HOMA-IR were 98.2 mg/dL ( 5.46 mmol/L ) , 5.8 % ( 40 mmol/mol ) , 22.4 μIU/mL , and 5.4 , respectively . After 1 year , mean HOMA-IR and FPG decreased to 4.1 and 95.1 mg/dL ( 5.28 mmol/L ) in the pioglitazone group and rose to 5.7 and 99.7 mg/dL ( 5.54 mmol/L ) , in the placebo group ( all P < 0.0001 ) . Over a median follow-up of 4.8 years , diabetes developed in 73 ( 3.8 % ) participants assigned to pioglitazone compared with 149 ( 7.7 % ) assigned to placebo ( hazard ratio [ HR ] 0.48 [ 95 % CI 0.33–0.69 ] ; P < 0.0001 ) . This effect was predominately driven by those with initial impaired fasting glucose ( FPG > 100 mg/dL [ 5.6 mmol/L ] ; HR 0.41 [ 95 % CI 0.30–0.57 ] ) or elevated HbA1c ( > 5.7 % [ 39 mmol/mol ] ; HR 0.46 [ 0.34–0.62 ] ) . CONCLUSIONS Among patients with insulin resistance but without diabetes who had had a recent ischemic stroke or TIA  , pioglitazone decreased the risk of diabetes while also reducing the risk of subsequent ischemic events . Pioglitazone is the first medication shown to prevent both progression to diabetes and major cardiovascular events as prespecified outcomes in a single trial Background and Purpose — Compliance with pharmacological therapy is essential for the efficiency of secondary prevention of ischemic stroke . Few data exist regarding patient compliance with antithrombotic and risk factor treatment outside of controlled clinical trials . The aim of the present study was to assess the rate of and predictors for compliance with secondary stroke prevention 1 year after cerebral ischemia and to identify reasons for noncompliance . Methods — Patients with a diagnosis of ischemic stroke or TIA and antithrombotic discharge medication were prospect ively recruited . At 1 year , the proportion of patients compliant with antithrombotic treatment and with medication for risk factors ( eg , hypertension , diabetes , hyperlipidemia ) was evaluated through structured telephone interviews . In addition , the reasons for nontreatment with antithrombotic and risk factor medication were determined . Independent predictors for compliance were analyzed by logistic regression analyses . Results — Of 588 consecutive patients admitted to our stroke unit , 470 had a discharge diagnosis of cerebral ischemia ( TIA 26.2 % , cerebral infa rct 73.8 % ) and recommendations for  antithrombotic therapy . At 1 year , 63 patients ( 13.4 % ) had died and 21 ( 4.5 % ) were lost to follow-up , thus , 386 could finally be evaluated . Of the patients , 87.6 % were still on antithrombotic medication , and 70.2 % were treated with the same agent prescribed on discharge . Of the patients with hypertension , diabetes , and hyperlipidemia , 90.8 % , 84.9 % , and 70.2 % were still treated for their respective risk factors . Logistic regression analyses revealed age ( OR 1.03 , 95 % CI 1.00 to 1.06 ) , stroke severity on admission ( OR 1.09 , 95 % CI 1.00 to 1.20 ) , and cardioembolic cause ( OR 4.13 , 95 % CI 1.23 to 13.83 ) as independent predictors of compliance . Conclusions — Compliance with secondary prevention in patients with ischemic stroke is rather good in the setting of our study . Higher age , a more severe neurological deficit on admission , and cardioembolic stroke cause are associated with better long-term compliance . Knowledge of these determinants may help to further improve the quality of stroke prevention BACKGROUND hypertension is a common risk factor for stroke/transient ischaemic attack ( TIA ) and there is good evidence that blood pressure ( BP ) control prevents recurrent stroke . We investigated whether telephone follow-up ( TFU ) improved risk factor management in hypertensive patients after stroke/TIA . METHODS we conducted a r and omised controlled trial and assigned hypertensive patients within 1 month of stroke or TIA to receive usual care ( n = 27 ) or usual care plus regular TFU ( n = 29 ) . Primary outcome was the difference in 12 h ambulatory systolic BP change from baseline to 6 months ( DeltaSBP ) in both groups . TFU at 7 days , 1 , 2 and 4 months included patient-focussed education and goal setting . RESULTS mean baseline BP was 145/83 mm Hg ( st and ard deviation ( SD ) 21/14 ) . There was no significant difference in DeltaSBP over 6 months with TFU . Median DeltaSBP was 0 mm Hg ( interquartile range 19.5 ) in the TFU group and 3.0 mm Hg ( 20 ) fall in the usual care group ( P = 0.29 ) . Post hoc analysis showed that statin use increased from baseline to 6 months ( P = 0.02 ) and cholesterol was significantly lower at 6 months in all patients ( mean reduction 0.95 mmol/l ; P < 0.001 ) . CONCLUSION our study found TFU that promoted patient-led management of risk factors did not improve BP control over 6-month follow-up in primary care after stroke/TIA BACKGROUND Patients with ischemic stroke or transient ischemic attack ( TIA ) are at increased risk for future cardiovascular events despite current preventive therapies . The identification of insulin resistance as a risk factor for stroke and myocardial infa rct ion raised the possibility that pioglitazone , which improves insulin sensitivity , might benefit patients with cerebrovascular disease . METHODS In this multicenter , double-blind trial , we r and omly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either  pioglitazone ( target dose , 45 mg daily ) or placebo .  Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance ( HOMA-IR ) index . The primary outcome was fatal or nonfatal stroke or myocardial infa rct ion . RESULTS By 4.8 years , a primary outcome had occurred in 175 of 1939 patients ( 9.0 % ) in the pioglitazone group and in 228 of 1937 ( 11.8 % ) in the placebo group ( hazard ratio in the pioglitazone group , 0.76 ; 95 % confidence interval [ CI ] , 0.62 to 0.93 ; P=0.007 ) . Diabetes developed in 73 patients ( 3.8 % ) and 149 patients ( 7.7 % ) , respectively ( hazard ratio , 0.48 ; 95 % CI , 0.33 to 0.69 ; P<0.001 ) . There was no significant between-group difference in all-cause mortality ( hazard ratio , 0.93 ; 95 % CI , 0.73 to 1.17 ; P=0.52 ) . Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo ( 52.2 % vs. 33.7 % , P<0.001 ) , edema ( 35.6 % vs. 24.9 % , P<0.001 ) , and bone fracture requiring surgery or hospitalization ( 5.1 % vs. 3.2 % , P=0.003 ) . CONCLUSIONS In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA , the risk of stroke or myocardial infa rct ion was lower among patients who received pioglitazone than among those who received placebo . Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain , edema , and fracture . ( Funded by the National Institute of Neurological Disorders and Stroke ; Clinical Trials.gov number , NCT00091949 . ) Background and Purpose — High rates of ischemic stroke and poor adherence to secondary prevention measures are observed in the Chinese population . Methods — We used a national , multicenter , cluster-r and omized controlled trial in which 47 hospitals were r and omized to either a  structured care program group ( n=23 ) or a usual care group ( n=24 ) . The structured care program consisted of a specialist-administered , guideline -recommended pharmaceutical treatment and a lifestyle modification algorithm associated with written and Internet-accessed educational material for patients for the secondary prevention of ischemic stroke . The primary efficacy outcome was the proportion of patients who adhered to the recommended measures at 12-month postdischarge . This trial is registered with Clinical Trial.gov ( NCT00664846 ) . Results — At 12 months , 1287 ( 72.1 % ) patients in the St and ard Medical Management in Secondary Prevention of Ischemic Stroke in China ( SMART ) group and 1430 ( 72 % ) patients in the usual care group had completed the 12-month follow-up ( P=0.342 ) . Compared with the usual care group , those in the SMART group showed higher adherence to statins ( 56 % versus 33 % ; P=0.006 ) but no difference in adherence to antiplatelet ( 81 % versus 75 % ; P=0.088 ) , antihypertensive ( 67 % versus 69 % ; P=0.661 ) , or diabetes mellitus drugs ( 73 % versus 67 % ; P=0.297 ) . No significant difference in the composite end point ( new-onset ischemic stroke , hemorrhagic stroke , acute coronary syndrome , and all-cause death ) was observed ( 3.56 % versus 3.59 % ; P=0.921 ) . Conclusions — The implementation of a program to improve adherence to secondary ischemic stroke prevention efforts in China is feasible , but these programs had only a limited impact on adherence and no impact on 1-year outcomes . Further development of a structured program to reduce vascular events after stroke is needed . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00664846 Background Good blood pressure ( BP ) control reduces the risk of recurrence of stroke/transient ischaemic attack ( TIA ) . Although there is strong evidence that BP telemonitoring helps achieve good control , none of the major trials have considered the effectiveness in stroke/TIA survivors . We therefore conducted a feasibility study for a trial of BP telemonitoring for stroke/TIA survivors with uncontrolled BP in primary care . Method Phase 1 was a pilot trial involving 55 patients stratified by stroke/TIA r and omised 3:1 to BP telemonitoring for 6 months or usual care . Phase 2 was a qualitative evaluation and comprised semi-structured interviews with 16 trial participants who received telemonitoring and 3 focus groups with 23 members of stroke support groups and 7 carers . Results Overall , 125 patients ( 60 stroke patients , 65 TIA patients ) were approached and 55 ( 44 % ) patients were r and omised including 27 stroke patients and 28 TIA patients . Fifty-two participants ( 95 % ) attended the 6-month follow-up appointment , but one declined the second daytime ambulatory blood pressure monitoring ( ABPM ) measurement result ing in a 93 % completion rate for ABPM − the proposed primary outcome measure for a full trial . Adherence to  telemonitoring  was good ; of the 40 participants who were  telemonitoring  , 38 continued to provide readings throughout the 6 months . There was a mean reduction of 10.1 mmHg in systolic ABPM in the telemonitoring group compared with 3.8 mmHg in the control group , which suggested the potential for a substantial effect from telemonitoring . Our qualitative analysis found that many stroke patients were concerned about their BP and telemonitoring increased their engagement , was easy , convenient and reassuring . Conclusions A full-scale trial is feasible , likely to recruit well and have good rates of compliance and follow-up . Trial Registration IS RCT N61528726 15/12/2011 PURPOSE Plasma fibrinogen has emerged as an important predictor of cardiovascular disease , but few data are available on its association with stroke . We sought to determine if plasma fibrinogen is a marker of increased risk or a direct causative risk factor for stroke . SUBJECTS AND METHODS Patients from the Bezafibrate Infa rct ion Prevention Study , a placebo-controlled , r and omized clinical trial of secondary prevention of coronary heart disease by lipid modification with bezafibrate retard ( 400 mg daily ) , were studied .  Plasma fibrinogen levels were measured at baseline and yearly thereafter . Stroke , a prospect ively monitored endpoint , was systematic ally assessed regarding stroke type , subtype , and functional outcome . RESULTS Mean baseline fibrinogen levels were significantly higher in patients subsequently having a cerebrovascular event ( 140 strokes , 36 transient ischemic attacks ; mean follow-up , 6.2 years ) than in patients who did not ( 375 vs. 349 mg/dL , P < 0.0001 ) . Fibrinogen levels did not differ significantly by the type , subtype , or severity of the cerebrovascular event . Risk of ischemic stroke increased from 3.3 % in the lowest tertile ( baseline fibrinogen < 314 mg/dL ) to 7.% in the middle tertile ( fibrinogen 314 to 373 mg/dL ) to 10 % in the upper tertile ( fibrinogen > 373 mg/dL , P < 0.001 ) . Adjusting for age , blood pressure , and other covariates , fibrinogen levels in the upper tertile were associated with more than a twofold increase in risk of ischemic stroke compared with in the lowest tertile ( hazard ratio = 2.6 ; 95 % confidence interval : 1.5 to 4.3 ) . We did not find fibrinogen change from baseline to be related to subsequent ischemic stroke events . CONCLUSION Plasma fibrinogen is a strong predictor of , rather than a direct causative factor for , subsequent stroke among patients at increased risk owing to manifest coronary heart disease BACKGROUND In the AVERROES study , apixaban , a novel factor Xa inhibitor , reduced the risk of stroke or systemic embolism in patients with atrial fibrillation who were at high risk of stroke but unsuitable for vitamin K antagonist therapy . We aim ed to investigate whether the subgroup of patients with previous stroke or transient ischaemic attack ( TIA ) would show a greater benefit from apixaban compared with aspirin than would patients without previous cerebrovascular events . METHODS In AVERROES , 5599 patients ( mean age 70 years ) with atrial fibrillation who were at increased risk of stroke and unsuitable for vitamin K antagonist therapy were r and omly assigned to receive apixaban ( 5 mg twice daily ) or aspirin ( 81 - 324 mg per day ) . The mean follow-up was 1·1 years . The primary efficacy outcome was stroke or systemic embolism ; the primary safety outcome was major bleeding . Patients and investigators were masked to study treatment . In this prespecified subgroup analysis , we used Kaplan-Meier estimates of 1-year event risk and Cox proportional hazards regression models to compare the effects of apixaban in patients with and without previous stroke or TIA . AVERROES is registered at Clinical Trials.gov , number NCT00496769 . FINDINGS In patients with previous stroke or TIA , ten events of stroke or systemic embolism occurred in the apixaban group ( n=390 , cumulative hazard 2·39 % per year ) compared with 33 in the aspirin group ( n=374 , 9·16 % per year ; hazard ratio [ HR ] 0·29 , 95 % CI 0·15 - 0·60 ) . In those without previous stroke or TIA , 41 events occurred in the apixaban group ( n=2417 , 1·68 % per year ) compared with 80 in the aspirin group ( n=2415 , 3·06 % per year ; HR 0·51 , 95 % CI 0·35 - 0·74 ) . The p value for interaction of the effects of aspirin and apixaban with previous cerebrovascular events was 0·17 . Major bleeding was more frequent in patients with history of stroke or TIA than in patients without ( HR 2·88 , 95 % CI 1·77 - 4·55 ) but risk of this event did not differ between treatment groups . INTERPRETATION In patients with atrial fibrillation  , apixaban is similarly effective whether or not patients have had a previous stroke or TIA . Given that those with previous stroke or TIA have a higher risk of stroke , the absolute benefits might be greater in these patients . FUNDING Bristol-Myers Squibb and Pfizer Background Small subcortical strokes , also known as lacunar strokes , comprise more than 25 % of brain infa rcts , and the underlying vasculopathy is the most common cause of vascular cognitive impairment . How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear . The aim of the Secondary Prevention of Small Subcortical Strokes study ( Trial registration : NCT00059306 ) is to define strategies for reducing stroke recurrence , cognitive decline , and major vascular events . Methods Secondary Prevention of Small Subcortical Strokes is a r and omised , multicentre clinical trial ( n=3000 ) being conducted in seven countries , and sponsored by the US NINDS/NIH . Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously r and omised , in a 2 × 2 factorial design , to antiplatelet therapy – 325 mg aspirin daily plus 75 mg clopidogrel daily , vs. 325 mg aspirin daily plus placebo , double-blind – and to one of two levels of systolic blood pressure targets –‘intensive ’ ( < 130 mmHg ) vs. ‘ usual ’ ( 130–149 mmHg ) . Participants are followed for an average of four-years . Time to recurrent stroke ( ischaemic or haemorrhagic ) is the primary outcome and will be analysed separately for each intervention . The secondary outcomes are the rate of cognitive decline and major vascular events . The primary and most secondary outcomes are adjudicated central ly by those unaware of treatment assignment . Conclusions Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infa rcts , which are likely due to small vessel disease . The results will inform the management of millions of patients with this common vascular disorder Background and Purpose — Treatment with statins reduces the rate of cardiovascular events in high-risk patients , but residual risk persists . At least part of that risk may be attributable to atherogenic dyslipidemia characterized by low high-density lipoprotein cholesterol ( ⩽40 mg/dL ) and high triglycerides ( triglycerides ≥150 mg/dL ) . Methods — We studied subjects with stroke or transient ischemic attack in the Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin With Terutroban  in Patients With a History of Ischemic Stroke or Transient Ischemic Attack ( PERFORM ; n=19 100 ) and Stroke Prevention by Aggressive Reduction in Cholesterol Levels ( SPARCL ; n=4731 ) trials who were treated with a statin and who had high-density lipoprotein cholesterol and triglycerides measurements 3 months after r and omization ( n=10 498 and 2900 , respectively ) . The primary outcome measure for this exploratory analysis was the occurrence of major cardiovascular events ( nonfatal myocardial infa rct ion , nonfatal stroke , or cardiovascular death ) . We also performed a time-varying analysis to account for all available high-density lipoprotein cholesterol and triglyceride measurements . Results — A total of 10 % of subjects in PERFORM and 9 % in SPARCL had atherogenic dyslipidemia after ≥3 months on start statin therapy . After a follow-up of 2.3 years ( PERFORM ) and 4.9 years ( SPARCL ) , a major cardiovascular event occurred in 1123 and 485 patients in the 2 trials , respectively . The risk of major cardiovascular events was higher in subjects with versus those without atherogenic dyslipidemia in both PERFORM ( hazard ratio , 1.36 ; 95 % confidence interval , 1.14–1.63 ) and SPARCL ( hazard ratio , 1.40 ; 95 % confidence interval , 1.06–1.85 ) . The association was attenuated after multivariable adjustment ( hazard ratio , 1.23 ; 95 % confidence interval , 1.03–1.48 in PERFORM and hazard ratio , 1.24 ; 95 % confidence interval , 0.93–1.65 in SPARCL ) . Time-varying analysis confirmed these findings . Conclusions — The presence of atherogenic dyslipidemia was associated with higher residual cardiovascular risk in PERFORM and SPARCL subjects with stroke or transient ischemic attack receiving statin therapy . Specific therapeutic interventions should now be trialed to address this residual risk The overall purpose of this study was to pilot a multibehavioral , brief , stroke self-care treatment adapted for implementation with underserved racial/ethnic minority groups and to test the moderating effects of anxiety and depression on engagement in secondary stroke-prevention behaviors . Fifty-two participants were r and omized to the secondary stroke prevention ( STOP ) ( N = 27 ) or usual care ( N = 25 ) group . The STOP program consisted of 3 culturally tailored information sessions and goal - setting activities that were delivered in person by a research assistant . Participants were assessed at baseline and 4-week follow-up for stroke knowledge , exercise , fruit and vegetable consumption , tobacco and alcohol use , and medication adherence ( primary outcomes ) and anxiety and depression ( moderator variables ) . Between-groups analysis of covariance and logistic multiple regressions revealed significant between-group differences for stroke knowledge , tobacco use and moderating effects between tobacco and anxiety , and improved alcohol use . The STOP program decreased secondary stroke risk factors  among underserved racial/ethnic minorities and should be tested in large-scale trials Background The complexity of treatment regimens , costs and pill burden decrease the medication adherence and contribute to shortfall in cardiovascular preventive drug coverage . The polypill , a fixed dose combination pill of established drugs , is expected to increase adherence and reduce the costs whilst preventing major cardiovascular events ( MCVE ) . Design and methods The PolyIran trial is a pragmatic cluster r and omized trial nested within the Golestan Cohort Study ( GCS ) . Subjects were r and omized to either non-pharmacological preventive interventions alone ( minimal care arm ) or together with a polypill ( polypill arm ) comprising hydrochlorothiazide , aspirin , atorvastatin and either enalapril or valsartan . This study benefits from the infrastructure of the primary health care system in Iran and the interventions are delivered by the local auxiliary health workers ( Behvarz ) to the participants . The primary outcome of the study is the occurrence of first MCVE within five years defined as non-fatal and fatal myocardial infa rct ion , unstable angina , sudden death , heart failure , coronary artery revascularization procedures , and non-fatal and fatal stroke . Trial status From February 2011 to April 2013 , 8410 individuals ( 236 clusters ) attended the eligibility assessment . Of those , 3421 in the polypill arm and 3417 in the minimal care arm were eligible . The study is ongoing . Conclusion The infrastructure of GCS and the primary health care system in Iran enabled the conduct of this pragmatic large-scale trial . If the polypill strategy proves effective , it may be implemented to prevent cardiovascular disease in developing countries OBJECTIVES To compare outcomes between stroke patients managed on the stroke unit , on general wards with stroke team support or at home by specialist domiciliary team and to derive prognostic variables that will identify patients most suitable for management by each strategy . To describe organisational aspects of individual strategies of stroke care and to evaluate cost-effectiveness of each strategy and its acceptability to patients , carers and professionals . DESIGN Prospect i ve single-blind r and omised controlled trial undertaken in patients recruited from a community-based stroke register . SETTING Suburban district in south-east Engl and . PARTICIPANTS Patients with disabling stroke who could be supported at home . INTERVENTIONS The stroke unit gave 24-hour care provided by specialist multidisciplinary team based on clear guidelines for acute care , prevention of complications , rehabilitation and secondary prevention . The stroke team provided management on general wards with specialist team support . The team undertook stroke assessment s and advised ward-based nursing and therapy staff on acute care , secondary prevention and rehabilitation aspects . Domiciliary care involved management at home under the supervision of a GP and stroke specialist with support from specialist team and community services . Support was provided for a maximum of 3 months . MAIN OUTCOME MEASURES The primary measure was death or institutionalisation at 1 year . Secondary measures were dependence , functional abilities , mood , quality of life , re source use , length of hospital stay , and patient , carer and professional satisfaction . RESULTS Of the 457 patients r and omised , 152 patients were allocated to the stroke unit ; 152 patients to stroke team and 153 patients to domiciliary stroke care ( average age 76 years , 48 % women ) . The groups were well matched for baseline characteristics , stroke type and severity , level of impairment and initial disability . Fifty-one ( 34 % ) patients in the domiciliary group were admitted to hospital after r and omisation . Mortality and institutionalisation at 1 year were lower on stroke unit compared with stroke team or domiciliary care . Significantly fewer patients on the stroke unit died compared with those managed by the stroke team . The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team or domiciliary care . These differences were present at 3 and 6 months after stroke . Stroke survivors managed on the stroke unit showed greater improvement on basic activities of daily living compared with other strategies . Achievement of higher levels of function was not influenced by strategy of care . Quality of life at 3 months was significantly better in stroke unit and domiciliary care patients . There was greater dissatisfaction with care on general wards compared with stroke unit or domiciliary care . Poor outcome with domiciliary care and on general wards was associated with Barthel Index < 5 , incontinence and , on general wards , age over 75 years . The total costs of stroke per patient over the 12-month period were pound 11,450 for stroke unit , pound 9527 for stroke team and pound 6840 for home care . However , the mean costs per day alive for the stroke unit were significantly less than those for the specialist stroke team patients , but no different from domiciliary care patients . Costs for the domiciliary group were significantly less than for those managed by the specialist stroke team on general wards . CONCLUSIONS Stroke units were found to be more effective than a specialist stroke team or specialist domiciliary care in reducing mortality , institutionalisation and dependence after stroke . A role for specialist domiciliary services for acute stroke is not supported by this study . Management of patients with strokes on general medical wards , even with specialist team input , is not supported by this study . The stroke unit intervention was less costly per patient day alive and more effective than the stroke team intervention . The stroke unit was more effective and of equivalent cost when compared to home care . Hence , the stroke unit is a more cost-effective intervention than either stroke team or home care . Further research is needed to underst and processes contributing to the reduction in mortality on stroke units and to determine the generalisability of these results and the factors that will influence the implementation of the findings of this study in clinical practice
There were no significant effects of organisational  interventions on lipid profile , HbA1c , medication adherence or recurrent cardiovascular events .
Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes .
The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors .
BACKGROUND People with stroke or transient ischaemic attack ( TIA ) are at increased risk of future stroke and other cardiovascular events .
Evidence -based strategies for secondary stroke prevention have been established .
However , the implementation of prevention strategies could be improved .
OBJECTIVES To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control , including patient adherence to prescribed medications , and the occurrence of secondary cardiovascular events .