Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial Early invasive treatment (endarterectomy vs. stenting) of moderate-to-severe carotid stenosis in patients with transient ischaemic attack or minor stroke The impact of stroke nurse specialist input on risk factor modification: a randomised controlled trial. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke Terutroban versus aspirin in patients with cerebral ischaemic events (PERFORM): a randomised, double-blind, parallel-group trial 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) Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance. Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF Aspirin at any dose above 30 mg offers only modest protection after cerebral ischaemia. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison A randomized controlled trial to assess the psychosocial effects of early exercise engagement in patients diagnosed with transient ischaemic attack and mild, non-disabling stroke A Randomised Controlled Trial of Triple Antiplatelet Therapy (Aspirin, Clopidogrel and Dipyridamole) in the Secondary Prevention of Stroke: Safety, Tolerability and Feasibility Secondary stroke prevention with low-dose aspirin, sustained release dipyridamole alone and in combination. ESPS Investigators. European Stroke Prevention Study. Efficacy and safety of a TIA/stroke electronic support tool (FASTEST) trial: Study protocol Risks of gastrointestinal bleeding during secondary prevention of vascular events with aspirin--analysis of gastrointestinal bleeding during the UK-TIA trial.
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 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 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 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 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 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 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 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 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 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 There is continuing debate about the relative efficacy of low ( < 100 mg per day ) , medium ( 300 to 325 mg per day ) , and high ( > 900 mg per day ) doses of aspirin in patients after a transient ischaemic attack or non-disabling stroke . The purpose of this study was to resolve the issue . Thus a minimeta- analysis was performed on data from 10 r and omised trials of aspirin only v control treatment in 6171 patients after a transient ischaemic attack or nondisabling stroke . The data on the trials were listed in an appendix of the report on the second cycle of the Antiplatelet Trialists ' Collaboration . There was virtually no difference in relative risk reduction for low , medium , and high doses of aspirin ( 13 % , 9 % , and 14 % respectively ) . This equivalence corresponds with the results of the UK-TIA trial in a direct comparison of 300 and 1200 mg . The Dutch TIA trial showed no difference in efficacy of 30 and 283 mg . It is concluded that aspirin at any dose above 30 mg daily prevents 13 % ( 95 % confidence interval 4 - 21 ) of vascular events and that there is a need for more efficacious drugs 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 Objective : To examine the effect of an early exercise and education programme on psychosocial health of transient ischaemic attack ( TIA ) and mild , non-disabling stroke patients . Design : R and omized , parallel-group , clinical trial . Setting : Hospital and academic institution . Participants : A total of 55 newly diagnosed transient ischaemic attack/mild stroke patients ( Mean[SD ] ; 69[11]y ) . Intervention : Participants were r and omized to either an eight-week , twice weekly , 90-minute exercise and education programme ( experimental group ) or to a usual care control group . Main measures : Psychosocial measures ( SF-36 , Hospital Anxiety and Depression Scale , Profile of Mood States , International Physical Activity Question naire , Stroke Awareness Question naire ) were assessed at baseline and eight-week and 12-month follow-up . Results : The experimental group demonstrated improvements in the Physical Component Score ( Mean[SD ] ; 44.1[11.7 ] to 47.4[11.3]% ) , Vitality ( 46.5[12.4 ] to 54.2[14.2]% ) , Physical Functioning ( 45.6[10.7 ] to 51.9[14.7]% ) , Role Physical ( 38.7[10.8 ] to 43.1[13.6]% ) and Global Health ( 49.1[10.3 ] to 54.4[13.6]% ) from the SF-36 , at the eight-week follow-up assessment ( P < 0.05 ) . There were no further changes in these measures between the eight-week and 12-month follow-up assessment ( P > 0.05 ) . The experimental group demonstrated a greater awareness of the signs and symptoms associated with stroke ( P < 0.05 ) . There were no differences in the Mental Component Score ( SF-36 ) , the Hospital Anxiety and Depression Scale or the International Physical Activity Question naire between treatment groups ( P > 0.05 ) . Conclusion : Early engagement in an exercise and education programme may improve physical health perceptions in transient ischaemic attack/mild stroke patients . However , secondary prevention exercise and education programmes warrant further research with regards to their effects on perceptions of mental health in this population group 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 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 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 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
Similar results were reported for total cholesterol .
Blood pressure reductions were noted but were non-significant when corrected for multimodal packages including enhanced pharmacotherapy compliance .
Conclusions There is currently insufficient high quality research to support lifestyle interventions post-stroke or TIA on mortality , CVD event rates and cardio-metabolic risk factor profiles .
Promising blood pressure reductions were noted in multimodal interventions which addressed lifestyle
Background and purpose Secondary prevention in ischaemic stroke and transient ischaemic attack ( TIA ) is dominated by pharmacological interventions with evidence for non-pharmacological interventions being less robust .
This systematic review and meta- analysis examines the impact of lifestyle interventions on secondary prevention in stroke or TIA .