Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance. 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. The Effects of “Physical Activity on Prescription” in Persons With Transient Ischemic Attack: A Randomized Controlled Study Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial The ExStroke Pilot Trial: rationale, design, and baseline data of a randomized multicenter trial comparing physical training versus usual care after an ischemic stroke. Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial Reductions in the risks of recurrent stroke in patients with and without diabetes: The PROGRESS Trial Lifestyle factors on the risks of ischemic and hemorrhagic stroke. 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 Closure or medical therapy for cryptogenic stroke with patent foramen ovale. Pioglitazone for secondary prevention after ischemic stroke and transient ischemic attack: rationale and design of the Insulin Resistance Intervention after Stroke Trial. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services Lower testosterone levels predict incident stroke and transient ischemic attack in older men. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Promoting physical activity after stroke via self-management: a feasibility study Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: a randomized trial. Effects of Pioglitazone for Secondary Stroke Prevention in Patients with Impaired Glucose Tolerance and Newly Diagnosed Diabetes: The J-SPIRIT Study. Clopidogrel and Aspirin in Acute Ischemic Stroke and High‐Risk TIA Subclinical atrial fibrillation in patients with recent transient ischemic attack Predictive factors of outcome and stroke recurrence in patients with unilateral atherosclerosis-related internal carotid artery occlusion. Outcomes With Edoxaban Versus Warfarin in Patients With Previous Cerebrovascular Events: Findings From ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) Symptomatic intracranial atherosclerosis
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 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 : Transient ischemic attack ( TIA ) is a strong predictor of stroke , and physical inactivity is one risk factor for TIA/stroke . “ Physical activity on Prescription ” ( PaP ) can increase physical activity , but the effect of PaP after TIA has not been described . Our goal was to objective ly measure the effect of PaP on physical activity and physical capacity , as well as self-rated health at 3 and 6 months after TIA . Methods : The primary outcome was moderate to vigorous intensities of physical activity objective ly assessed by accelerometry . Secondary outcomes were steps per day assessed by accelerometry , physical capacity assessed by the 6-minute walk test , and self-rated health assessed by EQ-5D VAS . Results : Eighty-eight individuals with TIA were r and omized to an intervention group ( n = 44 ) that received conventional treatment and PaP  or to a control group ( n = 44 ) that received conventional treatment alone . There was a 30 % dropout among the participants at 6 months . No significant differences between groups were found in physical activity at 3 and 6 months . At 6 months , participants in the intervention group were significantly more likely to have improved their physical capacity than the control group . There was no significant difference between groups in self-rated health . Discussion and Conclusions : PaP did not increase physical activity after TIA ; however , there was an increase in physical capacity . The nonsignificant results for physical activity may be the result of a relatively high baseline physical activity level . The results may also indicate that prior studies suggesting that PaP increases physical activity overestimated effects because of the self-reported nature of the previous outcomes . Video Abstract available for more insights from the authors ( see Supplemental Digital Content 1 , http://links.lww.com/JNPT/A134 ) 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 ) INTRODUCTION A high level of physical activity is associated with a decreased risk of first stroke and physical activity modifies recognized stroke risk factors and is recommended for stroke survivors . Available research shows that stroke patients can increase their level of physical performance over a short period . When the intervention period is over , physical performance often declines towards baseline level . Currently , there is no evidence on the association between physical activity and the risk of recurrent stroke . The ExStroke Pilot Trial is a r and omized clinical trial with the aim of increasing stroke patients ' level of physical activity and secondarily to associate the level of physical activity to the risk of recurrent stroke , myocardial infa rct ion , and all-cause mortality in the two groups . We describe the rationale , design , and baseline data of the ExStroke Pilot Trial . METHODS Patients with ischemic stroke above 39 years were r and omized to intervention or control group . The intervention group will , over a 2-year period , receive information on and verbal instruction to exercise by a physiotherapist or a physician . The control group will receive the department 's usual care . Physical activity  is assessed in both groups seven times during follow-up using the  Physical Activity Scale for the Elderly ( PASE ) question naire , which quantifies the amount of physical activity done in the last seven days prior to interview . The PASE score constitutes the primary outcome measure . The secondary outcome is the time from r and omization to recurrent stroke , myocardial infa rct ion , or all-cause mortality . Further outcome measures include : time from r and omization to recurrent stroke , myocardial infa rct ion , and vascular death ; recurrent stroke ; modified Rankin Scale ; quality of life ; occurrence of falls and fractures . TRIAL STATUS From 9 centers in 4 countries , 314 patients were included and follow-up is ongoing . Mean age and st and ard deviation ( SD ) of the study participants was 68.4 ( 11.9 ) years and 56.4 % were male . Mean ( SD ) PASE score was 84.1 ( 55.9 ) and median ( interquartile range ) Sc and inavian Stroke Scale score was 54 ( 51 - 58 ) 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 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 : Analyses of the risks of stroke were conducted for subjects with and without diabetes , participating in a r and omized , double‐blind , placebo‐controlled  trial of a perindopril‐based blood pressure lowering regimen in 6105 people with prior stroke or transient ischaemic attack ( TIA ) , followed for a median of 3.9 years . Findings : Seven hundred and sixty‐one patients had diabetes at baseline . Diabetes increased the risk of recurrent stroke by 35 % ( 95 % CI 10–65 % ) principally through an effect on ischaemic stroke ( 1.53 , 95 % CI 1.23–1.90 ) . Active treatment reduced blood pressure by 9.5/4.6 mmHg in patients with diabetes and by 8.9/3.9 mmHg in patients without diabetes . The proportional risk reductions achieved for stroke in patients with diabetes , 38 % ( 95 % CI 8–58 % ) , and patients without diabetes , 28 % ( 95 % CI 16–39 % ) , were not significantly different ( p homogeneity = 0.5 ) . The absolute reduction in the risk of recurrent stroke in the patients with diabetes was equivalent to one stroke avoided among every 16 ( 95 % CI 9–111 ) patients treated for 5 years . Conclusions : Diabetes is an important risk factor for stroke in patients with established cerebrovascular disease . Treatment with the ACE inhibitor perindopril with discretionary use of the diuretic indapamide produced reductions in the risk of recurrent stroke in patients with diabetes that were at least as great as those achieved in patients without diabetes BACKGROUND The joint effects of different lifestyle factors on stroke risk are still to some extent unclear , especially regarding hemorrhagic stroke . METHODS We prospect ively investigated the association of different indicators of lifestyle ( smoking , body mass index , physical activity , and vegetable and alcohol consumption )  with total and type-specific stroke incidence among 36 686 Finnish participants who were 25 to 74 years old and free of coronary heart disease and stroke at baseline . RESULTS During a mean follow-up period of 13.7 years , 1478 people developed an incident stroke event ( 1167 ischemic and 311 hemorrhagic ) . The multivariate-adjusted ( age , sex , education , family history of stroke , history of diabetes mellitus , systolic blood pressure , and serum total cholesterol level ) hazard ratios associated with adherence to 0 to 1 ( reference group ) , 2 , 3 , 4 , and 5 healthy lifestyle indicators were 1 , 0.66 , 0.57 , 0.51 , and 0.33 ( P < .001 for trend ) for total stroke ; 1 , 0.67 , 0.60 , 0.50 , and 0.30 ( P < .001 for trend ) for ischemic stroke ; and 1 , 0.63 , 0.49 , 0.49 , and 0.40 ( P < .001 for trend ) for hemorrhagic stroke , respectively . These inverse associations were similar in both men and women . The partial population attributable risk percentages associated with adherence to 3 , 4 , and 5 healthy lifestyle indicators were 26.3 % , 43.8 % , and 54.6 % for total stroke ; 22.7 % , 45.3 % , and 59.7 % for ischemic stroke ; and 35.0 % , 35.0 % , and 36.1 % for hemorrhagic stroke , respectively . CONCLUSION Healthy lifestyle factors are associated with a lower risk of stroke , and there is a grade d inverse association between the number of healthy lifestyle indicators and the risks of total , ischemic , and hemorrhagic stroke 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 The prevalence of patent foramen ovale among patients with cryptogenic stroke is higher than that in the general population . Closure with a percutaneous device is often recommended in such patients , but it is not known whether this intervention reduces the risk of recurrent stroke . METHODS We conducted a multicenter , r and omized , open-label trial of closure with a percutaneous device , as compared with medical therapy alone , in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack ( TIA ) and had a patent foramen ovale . The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up , death from any cause during the first 30 days , or death from neurologic causes between 31 days and 2 years . RESULTS A total of 909 patients were enrolled in the trial . The cumulative incidence ( Kaplan-Meier estimate ) of the primary end point was 5.5 % in the closure group ( 447 patients ) as compared with 6.8 % in the medical-therapy group ( 462 patients ) ( adjusted hazard ratio , 0.78 ; 95 % confidence interval , 0.45 to 1.35 ; P=0.37 ) . The respective rates were 2.9 % and 3.1 % for stroke ( P=0.79 ) and 3.1 % and 4.1 % for TIA ( P=0.44 ) . No deaths occurred by 30 days in either group , and there were no deaths from neurologic causes during the 2-year follow-up period . A cause other than paradoxical embolism was usually apparent in patients with recurrent neurologic events . CONCLUSIONS In patients with cryptogenic stroke or TIA who had a patent foramen ovale , closure with a device did not offer a greater benefit than medical therapy alone for the prevention of recurrent stroke or TIA . ( Funded by NMT Medical ; Clinical Trials.gov number , NCT00201461 . ) 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 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 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 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 Abstract Background : Many people with mild disability after stroke are physically inactive despite the risk of recurrent stroke . A self-management program may be one strategy to increase physical activity in stroke survivors . Objectives : To investigate the feasibility of a self-management program , and determine whether self-management can increase daily physical activity levels and self-efficacy for exercise , decrease cardiovascular risk , and improve walking ability , participation , and quality of life in people with mild disability after stroke . Method : A Phase I , single-group , pre-post intervention study was carried out with twenty stroke survivors who had mild disability and were discharged directly home from acute stroke units . A self-management program was delivered via five home-based sessions over 3 months , incorporating : education , goal setting , barrier identification , self-monitoring , and feedback .  Feasibility of the intervention was determined by examining adherence , duration , usefulness , and safety . Clinical outcomes were amount of physical activity ( duration of moderate physical activity in min/day and counts of physical activity in steps/day ) , self-efficacy , cardiovascular risk , walking ability , participation , and quality of life . Results : The intervention was feasible with 96 % of sessions being delivered , each taking less than an hour ( 41 min , SD 12 ) . Participants perceived the self-management program to be useful and there were few adverse events . At 3 months , participants completed 27 min/day ( 95 % CI 4–49 ) more moderate physical activity than at baseline and 16 min/day ( 95 % CI −10 to 42 ) at 6 months . Conclusion : Self-management appears to be feasible and has the potential to increase physical activity in people with mild disability after stroke . A Phase II r and omized trial is warranted 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 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 Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack ( TIA ) . A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke . We tested this combination in an international population . METHODS In a r and omized trial , we assigned patients with minor ischemic stroke or high‐risk TIA to receive either clopidogrel at a loading dose of 600 mg on day 1 , followed by 75 mg per day , plus aspirin ( at a dose of 50 to 325 mg per day ) or the same range of doses of aspirin alone . The dose of aspirin in each group was selected by the site investigator . The primary efficacy outcome in a time‐to‐event analysis was the risk of a composite of major ischemic events , which was defined as ischemic stroke , myocardial infa rct ion , or death from an ischemic vascular event , at 90 days . RESULTS A total of 4881 patients were enrolled at 269 international sites . The trial was halted after 84 % of the anticipated number of patients had been enrolled because the data and safety monitoring board had determined that the combination of clopidogrel and aspirin was associated with both a lower risk of major ischemic events and a higher risk of major hemorrhage than aspirin alone at 90 days . Major ischemic events occurred in 121 of 2432 patients ( 5.0 % ) receiving clopidogrel plus aspirin and in 160 of 2449 patients ( 6.5 % ) receiving aspirin plus placebo ( hazard ratio , 0.75 ; 95 % confidence interval [ CI ] , 0.59 to 0.95 ; P=0.02 ) , with most events occurring during the first week after the initial event . Major hemorrhage occurred in 23 patients ( 0.9 % ) receiving clopidogrel plus aspirin and in 10 patients ( 0.4 % ) receiving aspirin plus placebo ( hazard ratio , 2.32 ; 95 % CI , 1.10 to 4.87 ; P=0.02 ) . CONCLUSIONS In patients with minor ischemic stroke or high‐risk TIA , those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major hemorrhage at 90 days than those who received aspirin alone . ( Funded by the National Institute of Neurological Disorders and Stroke ; POINT Clinical Trials.gov number , NCT00991029 . BACKGROUND Atrial fibrillation ( AF ) is a major risk factor of stroke , but the association between AF and transient ischemic attack ( TIA ) is less clear . Despite this , patients with TIA are included in stroke trials . AIMS To determine the 1-year incidence of AF in TIA patients using an insertable cardiac monitor ( ICM ) ; second , to determine factors associated with incident AF in these patients . METHODS Prospect i ve cohort study of patients with TIA with normal st and ard electrocardiogram ( ECG ) and 72-hour Holter monitoring ( HM ) . Exclusion criteria were as follows : age < 18 or > 81 years ; prior AF/stroke ; ongoing oral anticoagulation therapy or contraindication for it ; significant carotid artery stenosis ; uncertain TIA diagnosis . Eligible patients received an ICM and were followed for 12 months . RESULTS From November 2013 to October 2015 , 809 patients were diagnosed with TIA . In total , 235 patients were eligible . Nine ( 3.8 % ) of these had AF on st and ard ECG or HM . Of the remaining patients , 121 refused ICM implantation . In total , 105 patients ( median age 65.4 years [ range 27.1 - 80.8 ] , 46 % males ) received an ICM , which revealed AF in 7 ( 6.7 % ) . Factors associated with new-onset AF were a history of recurrent TIA ( odds ratio [ OR ] 11.5 , 95 % confidence interval [ CI ] 2.1 - 63.6 ) and heart failure ( OR 12.7 , 95 % CI 1.71 - 96.83 ) . CONCLUSIONS The 1-year incidence of AF in TIA patients with normal ECG and HM was 6.7 % using an ICM . Factors associated with development of AF were recurrent TIA and heart failure BACKGROUND Clinical outcome of internal carotid artery ( ICA ) occlusion is highly variable and the reason is uncertain . AIM To study the predictive factors of clinical outcome and stroke recurrence in patients with ischemic stroke associated with unilateral atherosclerosis-related ICA occlusion . SETTING S AND DESIGN Prospect i ve study in neurology department of a single hospital . MATERIAL S AND METHODS We prospect ively studied 66 patients who suffered from first-ever ischemic stroke associated with unilateral atherosclerosis-related ICA occlusion over a period of two years . The end point was death or stroke recurrence . STATISTICAL ANALYSIS Chi-square or Fisher 's exact test was used to analyze predictors of early functional outcome . Multivariate analysis was used to analyze predictors of death or stroke recurrence within two years . RESULT Higher age ( > or=70 years ) predicted a worse functional outcome ( P=0.049 ) . Total anterior circulation syndrome ( TACS ) was associated with a poor functional outcome ( P<0.001 ) , but lacunar syndrome had a better outcome ( P=0.001 ) . Stroke in evolution predicted a poor outcome ( P=0.001 ) , while those with symptom improvement had a better outcome ( P=0.016 ) . Pneumonia predicted a poor outcome ( P=0.021 ) . Five patients expired and 22 patients suffered from recurrent stroke in the following 24 months . Previous transient ischemic attack ( TIA ) and anemia were associated with a higher risk of death or recurrent stroke within two years ( P=0.036 , P=0.012 ) . CONCLUSION High age , TACS , stroke in evolution and pneumonia were predictors for poor functional outcome . Previous TIA and anemia were predictors for death and recurrent stroke within two years Background and Purpose — Patients with atrial fibrillation and previous ischemic stroke (IS)/transient ischemic attack ( TIA ) are at high risk of recurrent cerebrovascular events despite anticoagulation . In this prespecified subgroup analysis , we compared warfarin with edoxaban in patients with versus without previous IS/TIA . Methods — ENGAGE AF-TIMI 48 ( Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infa rct ion 48 ) was a double-blind trial of 21 105 patients with atrial fibrillation r and omized to warfarin ( international normalized ratio , 2.0–3.0 ; median time-in-therapeutic range , 68.4 % ) versus once-daily edoxaban ( higher-dose edoxaban regimen [ HDER ] , 60/30 mg ; lower-dose edoxaban regimen , 30/15 mg ) with 2.8-year median follow-up . Primary end points included all stroke/systemic embolic events ( efficacy ) and major bleeding ( safety ) . Because only HDER is approved , we focused on the comparison of HDER versus warfarin . Results — Of 5973 ( 28.3 % ) patients with previous IS/TIA , 67 % had CHADS2 ( congestive heart failure , hypertension , age , diabetes , prior stroke/transient ischemic attack ) > 3 and 36 % were ≥75 years . Compared with 15 132 without previous IS/TIA , patients with previous IS/TIA were at higher risk of both thromboembolism and bleeding ( stroke/systemic embolic events 2.83 % versus 1.42 % per year ; P<0.001 ; major bleeding 3.03 % versus 2.64 % per year ; P<0.001 ; intracranial hemorrhage , 0.70 % versus 0.40 % per year ; P<0.001 ) . Among patients with previous IS/TIA , annualized intracranial hemorrhage rates were lower with HDER than with warfarin ( 0.62 % versus 1.09 % ; absolute risk difference , 47 [ 8–85 ] per 10 000 patient-years ; hazard ratio , 0.57 ; 95 % confidence interval , 0.36–0.92 ; P=0.02 ) . No treatment subgroup interactions were found for primary efficacy ( P=0.86 ) or for intracranial hemorrhage ( P=0.28 ) . Conclusions — Patients with atrial fibrillation with previous IS/TIA are at high risk of recurrent thromboembolism and bleeding . HDER is at least as effective and is safer than warfarin , regardless of the presence or the absence of previous IS or TIA . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00781391 Objective : To determine the prognosis of patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy .  Background : The outcome of patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy  is unknown . These patients may represent the target group for investigation of more aggressive therapies such as intracranial angioplasty . Methods : The authors performed a chart review and telephone interview of patients with symptomatic intracranial atherosclerosis identified in the Stanford Stroke Center clinical data base . A Cox regression model was created to identify factors predictive of failure of antithrombotic therapy . The authors generated Kaplan – Meier survival curves to determine the timing of recurrent TIA , stroke , or death after failure of antithrombotic therapy . Results : Fifty-two patients had symptomatic intracranial atherosclerosis and fulfilled entry criteria . Twenty-nine of the 52 patients ( 55.8 % ) had cerebral ischemic events while receiving an antithrombotic agent ( antiplatelet agents [ 55 % ] , warfarin [ 31 % ] , or heparin [ 14 % ] ) . In a Cox regression model , older age was an independent predictor of failure of antithrombotic therapy , and warfarin use was associated with a decrease in risk . Recurrent TIA ( n = 7 ) , nonfatal/fatal stroke ( n = 6/1 ) , or death ( n = 1 ) occurred in 15 of 29 ( 51.7 % ) of the patients who failed antithrombotic therapy . The median time to recurrent TIA , stroke , or death was 36 days ( 95 % CI 13 to 59 ) . Conclusions : Patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy  have extremely high rates of recurrent TIA/stroke or death . Recurrent ischemic events typically occur within a few months after failure of st and ard medical therapy . The high recurrence risk observed warrants testing of alternative treatment strategies such as intracranial angioplasty
The overall best evidence syntheses showed moderate quality evidence that lifestyle interventions do not lead to significant improvements in the physical activity level of people with stroke or TIA .
There is low quality evidence that lifestyle interventions that specifically target physical activity are effective at improving the levels of physical activity of people with stroke or TIA .
Based on the results of this review , general lifestyle interventions on their own seem insufficient in improving physical activity levels after stroke or TIA .
Lifestyle interventions that specifically encourage increasing physical activity may be more effective .
Insufficient amounts of physical activity is a risk factor for ( recurrent ) stroke .
People with a stroke or transient ischemic attack ( TIA ) have a high risk of recurrent stroke and have lower levels of physical activity than their healthy peers .
Though several review s have looked at the effects of lifestyle interventions on a number of risk factors of recurrent stroke , the effectiveness of these interventions to increase the amounts of physical activity performed by people with stroke or TIA are still unclear .
Therefore , the research question of this study was : what is the effect of lifestyle interventions on the level of physical activity performed by people with stroke or TIA ?