Combining Multiple Approaches for the Secondary Prevention of Vascular Events After Stroke: A Quantitative Modeling Study Trial of Secondary Prevention With Atenolol After Transient Ischemic Attack or Nondisabling Ischemic Stroke Discharge educational strategies for reduction of vascular events (DESERVE): design and methods Risk of Recurrent Stroke before Carotid Endarterectomy: The ANSYSCAP Study Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack Stroke recurrence within 2 years after ischemic infarction. The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788] 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. Predictors of major vascular events in patients with a transient ischemic attack or minor ischemic stroke and with nonrheumatic atrial fibrillation. European Atrial Fibrillation Trial (EAFT) Study Group. Effect of Peer Education on Stroke Prevention: The Prevent Recurrence of All Inner-City Strokes Through Education Randomized Controlled Trial Clopidogrel added to aspirin adds no benefit but bleeding risk in patients with recent lacunar stroke. Oxidized Phospholipids on Apolipoprotein B-100 and Recurrent Ischemic Events Following Stroke or Transient Ischemic Attack. Safety and efficacy of intensive vs. guideline antiplatelet therapy in high‐risk patients with recent ischemic stroke or transient ischemic attack: rationale and design of the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial (ISRCTN47823388) Preventive treatment of cerebral transient ischemia: comparative randomized trial of pentoxifylline versus conventional antiaggregants. The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry: design, rationale, and baseline patient characteristics. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Risk factors for early recurrence after ischemic stroke: the role of stroke syndrome and subtype. Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia Ischemic Conditioning Is Safe and Effective for Octo- and Nonagenarians in Stroke Prevention and Treatment Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (Socrates) Trial: Rationale and Design Use of ramipril in preventing stroke: double blind randomised trial The China Stroke Secondary Prevention Trial (CSSPT) Protocol: A Double-Blinded, Randomized, Controlled Trial of Combined Folic Acid and B Vitamins for Secondary Prevention of Stroke Pioglitazone for secondary prevention after ischemic stroke and transient ischemic attack: rationale and design of the Insulin Resistance Intervention after Stroke Trial.
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 : & 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 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 Carotid endarterectomy yields greater risk reduction for ipsilateral ischemic stroke when performed within two-weeks of the last cerebrovascular symptom than when performed two-weeks or more after the last symptom . However , additional benefit might be gained if carotid endarterectomy is performed earlier than within two-weeks . Aims To investigate the 90-day risk of ipsilateral ischemic stroke recurrence after amaurosis fugax , retinal artery occlusion , transient ischemic attack , or minor ischemic stroke in patients with 50–99 % carotid stenosis before carotid endarterectomy , with emphasis on the first 14 days . Methods Prospect i ve cohort study . 230 consecutive patients with symptomatic 50–99 % carotid stenosis ( North American Symptomatic Carotid Endarterectomy Trial grading method ) who underwent evaluation before carotid endarterectomy .  Of these , 183 underwent carotid endarterectomy ; the median delay to carotid endarterectomy was 29 days . Blood pressure lowering medication was used by 93 % and lipid-lowering medication by 90 % . Results The risk of ipsilateral ischemic stroke recurrence before carotid endarterectomy was 5·2 % ( n = 12 ) within two-days , 7·9 % ( n = 18 ) within seven-days , 11·2 % ( n = 25 ) within 14 days , and 18·6 % ( n = 33 ) within 90 days of the presenting event . The risk of ipsilateral ischemic stroke recurrence was higher if the presenting event was a stroke ( adjusted hazard ratio 12·4 , P = 0·015 ) or transient ischemic attack ( adjusted hazard ratio 10·2 , P = 0·026 ) compared with an amaurosis fugax . Discussion The risk of recurrent ipsilateral ischemic stroke was high within the first days of the presenting event . Many recurrences would likely have been avoided if carotid endarterectomy had been performed within the first days of the presenting event BACKGROUND Blood pressure is a determinant of the risk of stroke among both hypertensive and non-hypertensive individuals with cerebrovascular disease . However , there is uncertainty about the efficacy and safety of blood-pressure-lowering treatments for many such patients . The perindopril protection against recurrent stroke study ( PROGRESS ) was design ed to determine the effects of a blood-pressure-lowering regimen in hypertensive and non-hypertensive patients with a history of stroke or transient ischaemic attack . METHODS 6105 individuals from 172 centres in Asia , Australasia , and Europe were r and omly assigned active treatment ( n=3051 ) or placebo ( n=3054 ) . Active treatment comprised a flexible regimen based on the angiotensin- converting-enzyme inhibitor perindopril ( 4 mg daily ) , with the addition of the diuretic indapamide at the discretion of treating physicians . The primary outcome was total stroke ( fatal or non-fatal ) . Analysis was by intention to treat . FINDINGS Over 4 years of follow up , active treatment reduced blood pressure by 9/4 mm Hg . 307 ( 10 % ) individuals assigned active treatment suffered a stroke , compared with 420 ( 14 % ) assigned placebo ( relative risk reduction 28 % [ 95 % CI 17 - 38 ] , p<0.0001 ) . Active treatment also reduced the risk of total major vascular events ( 26 % [ 16 - 34 ] ) . There were similar reductions in the risk of stroke in hypertensive and non-hypertensive subgroups ( all p<0.01 ) . Combination therapy with perindopril plus indapamide reduced blood pressure by 12/5 mm Hg and stroke risk by 43 % ( 30 - 54 ) . Single-drug therapy reduced blood pressure by 5/3 mm Hg and produced no discernable reduction in the risk of stroke . INTERPRETATION This blood-pressure-lowering regimen reduced the risk of stroke among both hypertensive and non-hypertensive individuals with a history of stroke or transient ischaemic attack . Combination therapy with perindopril and indapamide produced larger blood pressure reductions and larger risk reductions than did single drug therapy with perindopril alone . Treatment with these two agents should now be considered routinely for patients with a history of stroke or transient ischaemic attack , irrespective of their blood pressure We prospect ively studied stroke recurrence in 1,273 patients with ischemic stroke who were entered into the Stroke Data Bank . Median follow-up was 13 months . The 2-year cumulative recurrence rate among these patients was 14.1 % . Age , sex , race , history of hypertension , atrial fibrillation , or transient ischemic attacks , and stroke location were not associated with a higher risk of stroke recurrence . Patients with an elevated blood pressure , an abnormal initial computed tomogram , or a history of diabetes mellitus were at a higher risk of stroke recurrence . In contrast , patients with an infa rct of unknown cause were at a lower risk of stroke recurrence than patients with a defined stroke mechanism , such as lacune , embolism , or atherosclerosis . A multivariate model suggests that patients at the lowest risk for stroke recurrence have a low diastolic blood pressure , no history of stroke , no history of diabetes mellitus , and an infa rct of unknown cause 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 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 BACKGROUND AND PURPOSE The risk of major vascular events after an initial episode of cerebral ischemia in patients with nonrheumatic atrial fibrillation ( NRAF ) varies from 2 % to 15 % in the first year and is approximately 5 % yearly thereafter . Few studies have reported on risk factors that can be used to identify high-risk subgroups within this patient population . METHODS We studied the predictive value of several easily obtainable clinical characteristics in a group of 375 placebo-treated patients with NRAF and a recent episode of transient or nondisabling cerebral ischemia who were entered in a multicenter clinical trial . The mean follow-up was 1.6 years . RESULTS By means of multivariate modeling , six independent variables were identified : history of previous thromboembolism , ischemic heart disease , enlarged cardiothoracic ratio on chest roentgenogram , systolic blood pressure greater than 160 mm Hg at study entry , NRAF for more than 1 year , and presence of an ischemic lesion on CT scan . These variables could also be used to stratify patients in low- , medium- , and high-risk subgroups for the other two arms of the trial , those treated with anticoagulation and aspirin .  Patients older than 75 years with three or more risk factors seemingly benefited less from both aspirin and anticoagulant treatment . CONCLUSIONS Easily obtainable patient characteristics are helpful in estimating the potential effect of adequate secondary prevention in patients with NRAF who recently suffered a transient ischemic attack or minor ischemic stroke Background and Purpose — Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success . We aim ed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors . Methods — Between 2009 and 2012 , we enrolled 600 stroke or transient ischemic attack survivors from diverse , low-income communities in New York City into a 2-arm r and omized clinical trial that compared a 6 week ( 1 session/week ) , peer-led , community-based , stroke prevention self-management group workshop ( N=301 ) to a wait-list control group ( N=299 ) . The primary outcome was the proportion with a composite of controlled blood pressure ( < 140/90 mm Hg ) , low-density lipoprotein cholesterol < 100 mg/dL , and use of antithrombotic medications at 6 months . Secondary outcomes included control of the individual stroke risk factors . All analyses were by intent-to-treat . Results — There was no difference in the proportion of intervention and control group participants achieving the composite outcome ( 34 % versus 34 % ; P=0.98 ) . The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group ( 76 % versus 67 % ; P=0.02 ) . This corresponded to a greater change in systolic blood pressure in the intervention versus control group ( −3.63 SD , 19.81 mm Hg versus + 0.34 SD , 23.76 mm Hg ; P=0.04 ) . There were no group differences in the control of cholesterol or use of antithrombotics . Conclusions — A low-cost peer education self-management workshop modestly improved blood pressure , but not low-density lipoprotein cholesterol or antithrombotic use , among stroke and transient ischemic attack survivors from vulnerable , predominantly minority urban communities . Clinical Trial Registration — URL : http://www . clinical trials.gov/show/NCT0102727 . Unique identifier : NCT01027273 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 , 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 ) Rationale The risk of recurrence following a stroke or transient ischemic attack is high , especially immediately after the event . Hypothesis Because two antiplatelet agents are superior to one in patients with non-cardioembolic events , more intensive treatment might be even more effective . Sample size estimates The sample size of 4100 patients will allow a shift to less recurrence , and less severe recurrence , to be detected ( odds ratio 0·68 ) with 90 % power at 5 % significance . Methods and design Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke ( IS RCT N47823388 ) is comparing the safety and efficacy of intensive ( combined aspirin , clopidogrel , and dipyridamole ) vs. guideline antiplatelet therapy , both given for one-month . This international collaborative parallel-group prospect i ve r and omized open-label blinded-end-point phase III trial plans to recruit 4100 patients with acute ischemic stroke or transient ischemic attack . R and omization and data collection are performed over a secure Internet site with real-time data validation and concealment of allocation . Outcomes , serious adverse events , and neuroimaging are adjudicated central ly with blinding to treatment allocation . Study outcome The primary outcome is stroke recurrence and its severity ( ‘ ordinal recurrence ’ based on modified Rankin Scale ) at 90 days , with masked assessment central ly by telephone . Secondary outcomes include vascular events , functional measures ( disability , mood , cognition , quality of life ) , and safety ( bleeding , death , serious adverse events ) . Discussion The trial has recruited more than 50 % of its target sample size ( latest number : 2399 ) and is running in 104 sites in 4 countries . One-third of patients presented with a transient ischemic attack A comparative study of the prevention of recurrences of  cerebral transient ischemic attacks  during a 6-month observation period was conducted in 73 patients treated with a combination of acetylsalicylic acid and dipyridamole ( ASAD , 1,050 mg + 150 mg/day ) and in 65 patients treated with pentoxifylline ( PTX 1,200 mg/day , Trental 400 t.d.s . ) . The patients were r and omly assigned to the treatments . Risk factor analysis showed high prevalence of arterial hypertension , hyperlipidemia and smoking in these patients . The two groups were matched in terms of age , sex , blood pressure and site of TIA origin ( carotid 63 % in the ASAD , 65 % in the PTX group ) . 23 ASAD patients and 9 PTX patients suffered a recurrence . There were 4 nonfatal stroke events with ASAD and 2 with PTX . 80 recurrent TIAs were recorded in 19 ASAD patients compared with 19 such episodes in 9 PTX subjects . The morbidity rates ( life table analysis ) were significantly lower ( p less than 0.05 ) in the PTX group . The results of the study point to a preventive effect of PTX in terms of the reduction in TIA recurrences 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 High blood pressure and stroke are associated with increased risks of dementia and cognitive impairment . This study aim ed to determine whether blood pressure lowering would reduce the risks of dementia and cognitive decline among individuals with cerebrovascular disease . METHODS The Perindopril Protection Against Recurrent Stroke Study ( PROGRESS ) was a r and omized , double-blind , placebo-controlled trial conducted among 6105 people with prior stroke or transient ischemic attack . Participants were assigned to either active treatment ( perindopril for all participants and indapamide for those with neither an indication for nor a contraindication to a diuretic ) or matching placebo(s ) . The primary outcomes for these analyses were dementia ( using DSM-IV criteria ) and cognitive decline ( a decline of 3 or more points in the Mini-Mental State Examination score ) . RESULTS During a mean follow-up of 3.9 years , dementia was documented in 193 ( 6.3 % ) of the 3051 r and omized participants in the actively treated group and 217 ( 7.1 % ) of the 3054 r and omized participants in the placebo group ( relative risk reduction , 12 % [ 95 % confidence interval , -8 % to 28 % ] ; P = .2 ) . Cognitive decline occurred in 9.1 % of the actively treated group and 11.0 % of the placebo group ( risk reduction , 19 % [ 95 % confidence interval , 4 % to 32 % ] ; P = .01 ) . The risks of the composite outcomes of dementia with recurrent stroke and of cognitive decline with recurrent stroke were reduced by 34 % ( 95 % confidence interval , 3 % to 55 % ) ( P = .03 ) and 45 % ( 95 % confidence interval , 21 % to 61 % ) ( P<.001 ) , respectively , with no clear effect on either dementia or cognitive decline in the absence of recurrent stroke . CONCLUSIONS Active treatment was associated with reduced risks of dementia and cognitive decline associated with recurrent stroke . These findings further support the recommendation that blood pressure lowering with perindopril and indapamide therapy be considered for all patients with cerebrovascular disease BACKGROUND AND PURPOSE Information regarding risk factors for early recurrence is limited . Our aim was to identify the clinical predictors of early recurrence after ischemic stroke . METHODS We prospect ively examined 297 patients ( mean age , 72.0+/-8.4 years ) hospitalized with ischemic stroke to identify recurrent strokes occurring within 90 days of the index stroke .  Survival free of recurrence was estimated using Kaplan-Meier analysis stratified by demographic variables ; vascular risk factors ; stroke syndrome , subtype , vascular territory , and severity ; scores on the Barthel Index and Mini-Mental State Examination during hospitalization ; blood pressure on admission ; and selected laboratory data . We estimated the relative risk ( RR ) of early recurrence associated with those variables using proportional hazards analysis . RESULTS We identified 22 recurrent events in the first 90 days after the index stroke , result ing in an early stroke recurrence rate of 7.4 % , and death occurred immediately after recurrence in 6 of the 22 patients . A major hemispheric stroke syndrome ( RR=2.9 ; 95 % confidence interval [CI]=1.2 to 7.1 ) , atherothrombotic stroke mechanism ( RR=3.3 ; CI=1.3 to 8.3 ) , and atrial fibrillation ( RR=2.2 ; CI=0.8 to 6.1 ) were independent predictors of early recurrence , after adjustment for demographic variables . Conclusions -Early recurrence was frequent and result ed in increased mortality . Attention to the clinical features of the index stroke , including the presenting syndrome and the ischemic mechanism , and the recognition of atrial fibrillation may help in the selection of patients for the initiation of targeted interventions to prevent early recurrence and subsequent mortality 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 Symptomatic intracranial arterial stenosis ( SIAS ) is very common in octo- and nonagenarians , especially in the Chinese population , and is likely the most common cause of stroke recurrence worldwide . Clinical trials demonstrate that endovascular treatment , such as stenting , may not be suitable for octogenarians with systemic diseases . Hence , less invasive methods for the octogenarian patients are urgently needed . Our previous study ( unique identifier : NCT01321749 ) showed that repetitive bilateral arm ischemic preconditioning ( BAIPC ) reduced the incidence of stroke recurrence by improving cerebral perfusion ( confirmed by single photon emission computed tomography and transcranial Doppler sonography ) in patients younger than 80 years of age ; however , the safety and effectiveness of BAIPC on stroke prevention in octo- and nonagenarians with SIAS are still unclear . The objective of this study was to evaluate the safety and effectiveness of BAIPC in reducing stroke recurrence in octo- and nonagenarian patients with SIAS . Fifty-eight patients with SIAS were enrolled in this r and omized controlled prospect i ve study for 180 consecutive days . All patients enrolled in the study received st and ard medical management . Patients in the BAIPC group ( n = 30 ) underwent 5 cycles consisting of bilateral arm ischemia followed by reperfusion for 5 min each twice daily . Those in the control group ( n = 28 ) underwent sham-BAIPC twice daily . Blood pressure , heart rate , local skin status , plasma myoglobin , and plasma levels of thrombotic and inflammatory markers were documented in both groups before beginning the study and for the first 30 days . Finally , the incidences of stroke recurrence and magnetic resonance imaging during the 180 days of treatment were compared . Compared with the control , BAIPC had no adverse effects on blood pressure , heart rate , local skin integrity , or plasma myoglobin , and did not induce cerebral hemorrhage in the studied cohort . BAIPC reduced plasma high sensitive C-reactive protein , interleukin-6 , plasminogen activator inhibitor-1 , leukocyte count , and platelet aggregation rate and elevated plasma tissue plasminogen activator ( all p < 0.01 ) . In 180 days , 2 infa rct ions and 7 transient ischemic attacks were observed in the BAIPC group compared with 8 infa rct ions and 11 transient ischemic attacks in the sham BAIPC group ( p < 0.05 ) . BAIPC may safely inhibit stroke recurrence , protect against brain ischemia , and ameliorate plasma biomarkers of inflammation and coagulation in octo- and nonagenarians with SIAS . A multicenter trial is ongoing . Clinical Trial Registration : www . clinical trials.gov , unique identifier : NCT01570231 Rationale The risk of recurrent ischemia is high in the acute period after ischemic stroke and transient ischemic attack . Aspirin is recommended by guidelines for this indication , but more intensive antiplatelet therapy may be justified . Aims We aim to evaluate whether ticagrelor , a potent antiplatelet agent that blocks the P2Y12 receptor without requiring metabolic activation , reduces the risk of major vascular events compared with aspirin when r and omization occurs within 24 h after symptom onset of a nonsevere ischemic stroke or high-risk transient ischemic attack . Design Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes ( SOCRATES ) is a r and omized , double-blind , event-driven trial and will include an estimated 13 600 participants r and omized in 33 countries worldwide to collect 844 primary events . Study outcomes The primary endpoint is the composite of stroke ( ischemic or hemorrhagic ) , myocardial infa rct ion , and death . Time to the first primary endpoint will be compared in the treatment groups during 90-day follow-up , with major hemorrhage serving as the primary safety endpoint . Participants will be followed for an additional 30 days after the r and omized treatment period . Discussion The SOCRATES trial fulfills an important clinical need by evaluating a potent antiplatelet agent as a superior alternative to current st and ard of care in patients presenting acutely with ischemic stroke or transient ischemic attack Abstract Objective : To determine the effect of the angiotensin converting enzyme inhibitor ramipril on the secondary prevention of stroke . Design : R and omised controlled trial with 2 × 2 factorial design . Setting : 267 hospitals in 19 countries . Participants : 9297 patients with vascular disease or diabetes plus an additional risk factor , followed for 4.5 years as part of the HOPE study . Outcome measures : Stroke ( confirmed by computed tomography or magnetic resonance imaging when available ) , transient ischaemic attack , and cognitive function . Blood pressure was recorded at entry to the study , after 2 years , and at the end of the study . Results : Reduction in blood pressure was modest ( 3.8 mm Hg systolic and 2.8 mm Hg diastolic ) . The relative risk of any stroke was reduced by 32 % ( 156 v 226 ) in the ramipril group compared with the placebo group , and the relative risk of fatal stroke was reduced by 61 % ( 17 v 44 ) . Benefits were consistent across baseline blood pressures , drugs used , and subgroups defined by the presence or absence of previous stroke , coronary artery disease , peripheral arterial disease , diabetes , or hypertension . Significantly fewer patients on ramipril  had cognitive or functional impairment . Conclusion : Ramipril  reduces the incidence of stroke in patients at high risk , despite a modest reduction in blood pressure . What is already known on this topic Treatment with aspirin and lowering blood pressure reduce the incidence of stroke What this study adds Ramipril , an angiotensin converting enzyme inhibitor , reduces strokes in patients at high risk whose blood pressure is not elevated , despite only a modest lowering of blood pressure The benefits are observed even when patients receive aspirin and other blood pressure lowering Rationale Epidemiological studies suggest that elevated homocysteine is linked to stroke and heart disease . However , the results of lowering homocysteine levels in reducing the risk of stroke recurrence are controversial . Aims The study aims to evaluate whether homocysteine-lowering therapy with folic acid and vitamins B6 and B12 reduces recurrent stroke events and other combined incidence of recurrent vascular events and vascular death in ischemic stroke patients of low folate regions . Design This is a multicenter , r and omized , double-blinded , placebo-controlled trial . Patients ( n = 8000 , α = 0·05 , β = 0·10 ) within one-month of ischemic stroke ( large-artery atherosclerosis or small-vessel occlusion ) or hypertensive intracerebral haemorrhage with plasma homocysteine level ⩾15 μmol/l will be enrolled . Eligible patients will be r and omized by a web-based , r and om allocation system to receive multivitamins ( folic acid 0·8 mg , vitamin B610 mg , and vitamin B12 500 μg ) or matching placebo daily with a median follow-up of three-years . Study Outcomes Patients will be evaluated at six monthly intervals . The primary outcome event is the composite event ‘ stroke , myocardial infa rct ion , or death from any vascular cause ’ , whichever occurs first . Secondary outcome measures include nonvascular death , transient ischemic attack , depression , dementia , unstable angina , revascularization procedures of the coronary , and cerebral and peripheral circulations . Discussion This is the first multicenter r and omized trial of secondary prevention for ischemic stroke in a Chinese population with a higher homocysteine level but without folate food fortification 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
Heterogeneity was present for several outcomes and was partly related to the class of antihypertensive drugs used ; angiotensin-converting enzyme inhibitors and diuretics separately , and especially together , reduced vascular events , while beta-receptor antagonists had no discernable effect .
Evidence from r and omized controlled trials supports the use of antihypertensive agents in lowering blood pressure for the prevention of vascular events in patients with previous stroke or transient ischemic attack .
Vascular prevention is associated positively with the magnitude by which blood pressure is reduced
BACKGROUND High blood pressure is a risk factor for stroke recurrence .
We assessed the effectiveness of lowering blood pressure in preventing recurrent vascular events in patients with previous stroke or transient ischemic attack .