Stroke Prevention Research Articles

The diagnostic value of carotid ultrasound in stroke prevention: Cellular molecular biomechanics-anchored exploration of current applications and future trails

The diagnostic value of carotid ultrasound in stroke prevention: Cellular molecular biomechanics-anchored exploration of current applications and future trails

Stroke survivors with limited walking ability have unique barriers and facilitators to physical activity

Purpose Stroke is a leading cause of morbidity and mortality in Canada. Approximately 73% of stroke survivors experience limited walking ability, requiring a gait aid or assistance. Physical activity is important for secondary stroke prevention, in addition to its benefits for physical and mental health. Little is known about the barriers and facilitators to physical activity in stroke survivors with limited walking ability. Methods This qualitative study used inductive thematic analysis of structured interviews to explore the barriers and facilitators to physical activity in stroke survivors with limited walking ability. Results Perceived barriers to physical activity included scarcity of services, societal views, changes in ability, and inclement weather. Perceived facilitators included the desired benefits of physical activity, multidisciplinary rehabilitation services, durable medical equipment, encouragement, positive mindset, and self-efficacy. Conclusions Improving access to rehabilitation services in the chronic phase of stroke and increasing the availability of structured exercise programmes are important strategies to address barriers to physical activity in this population. Supporting self-efficacy, addressing disability stigma, and policy changes are also needed to facilitate participation.

Stroke Prevention in Hispanic Children with Sickle Cell Anemia: the SACRED trial.

Sickle cell anemia (SCA) is recognized globally, but little is known about affected Hispanic populations. In partnership with Dominican Republic, a Hispanic Caribbean Island with a large SCA population, a TCD screening program provided hydroxyurea to children with conditional velocities. Building local capacity, ten Dominican medical graduates were certified in TCD examinations and trained in hydroxyurea management. Stroke Avoidance for Children in REpública Dominicana trial (SACRED, NCT02769845) enrolled 283 children with average age 8.7±3.4 years and 130 (46%) females. At initial screening, treatment-naïve children with conditional velocities (170-199 cm/sec) were younger (6.6±2.7 versus 8.9±3.4 years, p=.0002) and more anemic (hemoglobin 7.4±0.8 versus 8.0±1.2 g/dL, p=.0046) than children with normal screening velocities (<170 cm/sec). Among 57 treatment-naïve children receiving six months of fixed-dose hydroxyurea at 20 mg/kg/day, average TCD velocities decreased 20 cm/sec and 61% became normal. Compared to fixed-dose hydroxyurea, dose escalation to maximum tolerated dose (MTD) led to fewer sickle-related events with incidence rate ratio 0.59, 95% Confidence Intervals 0.36-0.98, p=0.0420. At MTD, TCD benefits were sustained over 5 years, with 81% reverting to normal and average TCD velocity decrease of 27 cm/sec. Brain MRI documented substantial baseline parenchymal disease; during hydroxyurea treatment 10% developed new vasculopathy, plus one stroke and one death. SACRED documents a high burden of cerebrovascular disease among Hispanic children with SCA, but also demonstrates the feasibility of partnership to establish TCD screening programs, the utility of hydroxyurea to reduce TCD velocities and reduce stroke risk, and the sustained benefits of hydroxyurea dose escalation.

The impact of reduced skeletal muscle mass at stroke onset on 3-month functional outcomes in acute ischemic stroke patients.

Sarcopenia, characterized by reduced skeletal muscle mass (RMM), is increasingly recognized as a significant factor influencing outcomes in various health conditions, including stroke. Although most studies focus on sarcopenia developing during stroke rehabilitation, the impact of sarcopenia present at the onset of acute ischemic stroke remains underexplored. This study aims to evaluate the effect of RMM at stroke onset on 3-month functional outcomes in acute ischemic stroke patients. We prospectively enrolled acute ischemic stroke patients admitted between May 2019 and December 2019. Muscle mass was accessed early during hospitalization using whole-body dual-energy X-ray absorptiometry (DXA), and patients were categorized into RMM and normal muscle mass (NMM) groups based on the Asian Working Group for Sarcopenia (AWGS) criteria. Functional outcomes at 3 months were assessed using the modified Rankin Scale (mRS), with unfavorable outcomes defined as mRS scores 2-5. Multivariable logistic regression and SHAP (Shapley Additive exPlanations) analyses were used to evaluate the independent impact of RMM on 3-months functional outcomes. A total of 99 patients were analyzed. The RMM group had a significantly higher prevalence of unfavorable outcomes at 3 months compared to the NMM group (p < 0.001). Patients with RMM were older and presented with more severe strokes. Multivariable analysis confirmed RMM as an independent predictor of unfavorable outcomes (adjusted OR: 8.07, 95% CI: 1.603-40.66, p = 0.011), even after adjusting for age and initial stroke severity. SHAP analysis ranked RMM as the second most influential predictor of unfavorable outcomes, following NIHSS on admission. These findings indicate that RMM not only worsens initial stroke severity but also independently hinders post-stroke recovery. Reduced muscle mass at the onset of acute ischemic stroke is a significant, independent predictor of unfavorable outcomes at 3 months. In addition to its impact on recovery, RMM is linked to older age and more severe strokes, worsening prognosis. Maintaining muscle mass is also crucial for stroke prevention, as it supports cardiovascular health and resilience. Early identification and intervention for sarcopenia can improve recovery and reduce future stroke risk.

Stroke Subtypes Mortality Attributable to Smoking in China: A Study Based on the Global Burden of Disease Database 2021

Background: The objective of this study was to analyze long-term trends in ischemic stroke (IS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) mortality from smoking in China from 1992 to 2021, to provide scientific advice on stroke prevention and treatment in China. Methods: The mortality data of smoking-related stroke and its subtypes in China during 1992–2021 were collected from the Global Burden of Disease 2021. Joinpoint regression model and Age-period-cohort (APC) model were used for trend analysis. Results: The age-standardized mortality rate of stroke and subtypes caused by smoking showed a decreasing trend in China from 1992 to 2021. The decline was greater for women than for men. According to APC model analysis, the age effect showed that ICH and IS showed an increasing trend, while SAH increased first and then decreased. The results of the cohort effect were similar to those of the period effect, with relative risk decreasing for all subtypes. The local drift showed that the stroke and subtypes in males showed a “U” shaped trend, a relatively stable trend for stroke and is in females, and a downward trend for SAH and ICH. Conclusions: Over the past 30 years, the burden of stroke and stroke subtype deaths attributable to smoking in China has decreased. However, future efforts should focus on preventing ICH. Strengthening tobacco control legislation, particularly targeting older men and young people, is crucial for further reducing smoking-related stroke risk.

Mobile Health delivered physical activity after mild stroke or transient ischaemic attack. Is it feasible and acceptable?

Physical activity is a key component of secondary stroke prevention. Mobile health (mHealth) interventions show promise for enhancing post-stroke physical activity, but most studies have combined mHealth with onsite services. This study evaluated the feasibility and acceptability of a fully digitalised mHealth intervention for physical activity among individuals post stroke or transient ischemic attack (TIA) in Sweden. In this two-arm feasibility randomised controlled trial, adults with stroke or TIA were randomised to one of the following six month interventions: i) the experiment group, receiving mHealth delivered supervised exercise (two sessions weekly during months one to three, one session weekly during months four to six) and behavioural change techniques for physical activity (including two individual counselling and six follow-up sessions) or, ii) the control group, receiving two mHealth delivered individual counselling and three follow-up sessions. Feasibility (reach, retention, adherence, fidelity, safety) and acceptability were assessed according to pre-specified progression criteria. Of 114 participants, 105 (92%) completed the 6-month intervention and 102 (89%) completed the 12-month follow-up assessment. The intervention reached individuals from 20 of 21 Swedish regions. Sixty-eight percent of participants had a stroke (of which 96% were mild), 64% were female, and average age was 71 years (SD 9). Ninety-five percent were born in Sweden, had a high level of education (61%) and an average daily step count of 6451 steps. Completion of outcome measures included digital questionnaires (98%), sensor-derived physical activity (92%), and blood pressure monitoring (97%). A total of 1781 supervised exercise sessions were delivered to the experiment group, with an adherence rate of 76%, and adherence to individual counselling and follow-up sessions was 96%. Ninety-five adverse events were recorded, of which 16 were related to the intervention (predominantly pain or muscle soreness) but non-serious. Overall satisfaction with the mobile app was 71%, and 76% of the experiment group believed the app could partly replicate in-person visits. The mHealth intervention was overall feasible and acceptable, however there is a need to develop recruitment procedures to increase diversity of included participants regarding socioeconomic status and physical activity level, prior to a Phase 3 trial. ClinicalTrials.gov (NCT05111951)Keywords: physical activity, mHealth, stroke, TIA, feasibility.

Factors associated with the detection of atrial fibrillation in patients with embolic stroke of undetermined source

BackgroundDetection of atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is important for the secondary prevention of stroke. We investigated the factors associated with the detection of newly diagnosed AF in ESUS patients during follow-up.MethodsPatients with acute ischemic stroke classified as ESUS were included. All patients underwent transthoracic echocardiography and Holter to detect the source of embolism. Structural, electrophysiological markers of left atrial cardiopathy (i.e., left atrial enlargement [LAE], non-sustained tachycardia [NSAT]) as well as lesion patterns of ischemic stroke were examined. Implantable loop recorder (ILR) was implanted in selective patients. Sensitivity and positive predictive value analysis was used to assess the predictive value for AF detection.ResultsAmong 312 patients with ESUS, AF was detected in 24 (7.7%) patients during follow-up. Patients with AF had a higher prevalence of LAE, NSAT, and the imaging pattern of confluent plus additional lesions in a single vascular territory. Multivariable analysis showed that ILR implantation (hazards ratio 11.497 [95% confidence interval 3.795–34.818]), LAE (3.204 [1.096–9.370]), NSAT (4.070 [1.378–12.018]), and confluent plus additional lesions (4.977 [1.649–15.019]) were independent predictors of AF detection. The sensitivity of detecting AF in those with LAE, NSAT, or confluent plus additional lesions pattern was 91.7%. The positive predictive value of detecting AF in those with LAE, NSAT and confluent plus additional lesions pattern was 40.0%.ConclusionIn conclusion, patients with LAE, NSAT, or confluent plus additional lesions may benefit from ILR monitoring detecting new AF.

WATCHMAN versus LACbes® device for percutaneous left atrial appendage closure: a single-center, propensity-matched study

BackgroundDifferent left atrial appendage closure (LAAC) devices have been introduced into the clinical setting. A new dual-seal mechanism LACbes® occluder with isogenous barbs for LAAC has been designed to facilitate easier delivery and improve safety. The purpose of this study is to compare the clinical outcomes of the WATCHMAN with those of the LACbes® device for LAAC.MethodsConsecutive patients with atrial fibrillation (AF) who had undergone LAAC performed using a WATCHMAN or LACbes® device from June 2016 to February 2022 were included. The primary efficacy endpoint included ischemic stroke, cardiovascular/unexplained death and device-related thrombus, while the primary safety endpoint included major peri-procedural complications and major bleeding events during clinical follow-ups. 1:1 propensity score matching (PSM) was performed.ResultsAfter PSM, 184 patients were included in each group. The mean CHA2DS2-VASc score was 3.1 ± 1.5 (LACbes®) vs. 3.1 ± 1.4 (WATCHMAN), and the HAS-BLED score was 2.7 ± 1.1 vs. 2.7 ± 1.0. At a mean follow-up of 2.5 ± 1.5 vs. 2.4 ± 0.9 years, the defined three endpoints were comparable between the two groups. The occurrence of all-cause stroke was lower in 5/452 (1.8%) with LACbes® vs. 16/433 (3.7%) with WATCHMAN occluders (HR, 0.40, 95% confidence interval (CI), 0.18–0.89, P = 0.023), and the incidence of any bleeding was higher in the WATCHMAN group (41/433, 9.5% vs. 8/452, 1.8%; HR, 0.19, 95% CI, 0.11–0.33).ConclusionThe LACbes® occluder exhibited comparable safety and efficacy of stroke prevention for AF when compared with the WATCHMAN device.

Cross-Cultural Validation of Knowledge About Atrial Fibrillation and Stroke Prevention Questionnaire: A Cross-Sectional Study Among Chinese Patients With Atrial Fibrillation.

To cross-culturally adapt the Knowledge about Atrial Fibrillation and Stroke Prevention Questionnaire (KAFSP-Q) for Chinese AF patients and validate its effectiveness. Instrument adaptation and cross-sectional validation. The KAFSP-Q was translated into Chinese by using the forward and back translation method. Experts and patients were invited to revise the questionnaire domains and items. The psychometric properties of the Chinese version of the KAFSP-Q were evaluated, that is, its construct validity, discriminant validity, convergent validity, internal consistency and test-retest reliability. The Chinese version of the KAFSP-Q consists of 41 items and six domains, namely, bleeding knowledge, AF complications, stroke risk and stroke prevention, stroke symptoms, AF symptoms and general AF knowledge. The Chinese version of the KAFSP-Q demonstrated acceptable content validity (scale-content validity index = 0.859). The exploratory factor analysis revealed six factors, which accounted for 65.725% of the total variance, and the confirmatory factor analysis revealed acceptable fit indices. The convergent validity was poor, because the average variance extracted coefficient of the six domains was lower than 0.500. The square root of the average variance extracted coefficients was higher than the bivariate correlation between the domains, which indicated an acceptable discriminant validity. Meanwhile, the internal consistency and test-retest reliability were satisfactory (Cronbach's α coefficient = 0.973, intraclass correlation coefficient = 0.872). The Chinese version of the KAFSP-Q demonstrates acceptable validity and reliability and can be used as a valuable instrument for AF and stroke prevention knowledge evaluation. In clinical practice, the Chinese version of the KAFSP-Q can be used to help patients increase their disease management knowledge and engage in effective disease management behaviour. Future research is necessary to confirm the psychometric properties of the questionnaire with samples that are highly representative. No patient or public contribution.

Effectiveness of shared decision making strategies for stroke prevention among patients with atrial fibrillation: cluster randomized controlled trial

ObjectiveTo evaluate the effectiveness of multiple decision aid strategies in promoting high quality shared decision making for prevention of stroke in patients with non-valvular atrial fibrillation.DesignCluster randomized controlled trial.SettingSix academic...

Combination Antithrombotic Therapy for Reduction of Recurrent Ischemic Stroke in Intracranial Atherosclerotic Disease.

Stroke secondary to intracranial atherosclerotic disease (ICAD) is associated with high recurrence risk despite currently available secondary prevention strategies. In patients with systemic atherosclerosis, a significant reduction of stroke risk with no increase in intracranial or fatal hemorrhage was seen when rivaroxaban 2.5 mg twice daily was added to aspirin. However, there are no trials in ICAD using this combination. To facilitate the design of future ICAD trials, the CATIS-ICAD study (Combination Antithrombotic Treatment for Prevention of Recurrent Ischemic Stroke in Intracranial Atherosclerotic Disease) assessed (1) the feasibility of recruitment, (2) the safety of low-dose rivaroxaban plus aspirin compared with standard-of-care antiplatelet therapy, and (3) trends toward efficacy. This was a prospective, randomized, open-label, blinded end point pilot trial conducted in 10 Canadian centers. Eligible participants aged ≥40 years, with acute ischemic stroke or high-risk transient ischemic attack, were randomly assigned in a 1:1 ratio to receive low-dose rivaroxaban plus aspirin or aspirin alone within 7 to 100 days of their index event. The primary safety outcome was hemorrhagic stroke. The main efficacy end point was the composite of ischemic stroke or covert brain infarct on magnetic resonance imaging at the end of the study. A total of 101 participants were randomized. Average enrollment was 10 participants/site per year. Average follow-up was 20 months. Median time from index stroke to randomization was 67 days. The median age of participants was 67 years (±10.94), and 29% of participants were women. There was no hemorrhagic stroke in either arm. The composite efficacy outcome was less frequent in the combination arm (15.7%) compared with the aspirin arm (24.0%), with a hazard ratio of 0.78 ([95% CI, 0.32-1.93]; P=0.59) favoring the intervention. A multicenter randomized trial comparing the combination of low-dose rivaroxaban and aspirin in patients with recent ischemic stroke or transient ischemic attack due to ICAD is feasible and appears safe without an increased risk of hemorrhagic stroke. A numerical trend toward efficacy for the composite primary end point of symptomatic ischemic stroke and covert infarcts was observed. These findings will inform the design of a phase III trial. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04142125.

Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial

ObjectiveTo evaluate the relationship between infarct pattern, inferred stroke mechanism and risk of recurrence in patients with ischaemic stroke. The question is clinically relevant to optimise secondary stroke prevention investigations...

Stroke Epidemiology in Asia.

Background Stroke is a major cause of death and disability globally, with different stroke burdens in different regions. This paper reviews the epidemiology of stroke in Asia. Summary There is a wide range in age and sex-standardised stroke incidence, highest in China, lowest in Bhutan. Geographically, incidence is highest in East Asia, lowest in South Asia. Stroke mortality is highest in Papua New Guinea, lowest in Singapore. There are variations in mortality within regions - in East Asia, it is higher in Mongolia and North Korea, lowest in Japan; in South Asia, it is higher in Bangladesh and Pakistan, lowest in Sri Lanka; in South-East Asia, it is higher in Papua New Guinea and Indonesia, lowest in Singapore. Stroke Disability Adjusted Life-Years lost (DALYs) is highest in Papua New Guinea, lowest in Singapore. There is intra-regional variation - in East Asia, it is higher in Mongolia and North Korea, lowest in Japan; in South Asia, higher in Bangladesh and Pakistan, lowest in Sri Lanka; in South-East Asia, it is highest in Papua New Guinea, lowest in Singapore. Among the stroke subtypes, ischaemic stroke (IS) has the highest incidence, intracerebral haemorrhage (ICH) second, subarachnoid haemorrhage (SAH) third. IS incidence is highest in China, lowest in Bhutan. The burden due to ICH is highest in Mongolia; ICH incidence is lowest in Sri Lanka, mortality and DALYs are lowest in Japan. SAH has a high incidence in Japan, Singapore, Brunei and Republic of Korea. In hospital-based registries, the frequency of ICH was highest in Myanmar, low in Mongolia. Among IS, based on the Trial of Org 10,172 in Acute Stroke Treatment classification, large artery atherosclerosis (LAA) is more frequent in some countries (eg China, India, Indonesia, Pakistan, Republic of Korea), but small artery occlusion (SAO) in most others (Bangladesh, Japan, Nepal, Singapore, Sri Lanka, Taiwan, Thailand, Vietnam); cardioembolism is third. Of the stroke risk factors, hypertension is the most frequent, diabetes mellitus (DM) is usually second, with varying positions for hyperlipidaemia, smoking and prior stroke or transient ischaemic attacks, obesity and insufficient physical activity. Key Messages Asis carries a particularly heavy burden of stroke, higher in some countries. IS is the most common subtype. Among IS, the more common mechanisms are LAA and SAO. Hypertension and DM are the more common risk factors. A greater understanding of stroke epidemiology and risk factors will help in healthcare planning for the prevention and management of stroke.

Impact of adherence to the Mediterranean diet on stroke risk.

Stroke is a leading cause of morbidity and mortality worldwide, and dietary patterns have emerged as a significant modifiable factor in stroke prevention. The Mediterranean diet, characterized by high intake of fruits, vegetables, whole grains, nuts, olive oil, and fish, has been widely recognized for its cardiovascular benefits. However, its specific impact on stroke risk requires further elucidation. We conducted a comprehensive meta-analysis of 30 studies, including both cohort and case-control designs, to evaluate the relationship between adherence to the Mediterranean diet and the risk of stroke. A systematic search was performed across multiple databases, and a random-effects model was used to estimate pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistic, and publication bias was examined through funnel plots and Egger's regression test. Additionally, trial sequential analysis was conducted to determine the adequacy of the sample size. The meta-analysis revealed a significant reduction in stroke risk among individuals adhering to the Mediterranean diet, with a pooled HR of 0.88 (95% CI: 0.84-0.91). Notably, a significant heterogeneity was detected (I2 = 34%). The Z-score plot from trial sequential analysis confirmed that the sample sizes were sufficient to draw definitive conclusions. However, a potential publication bias was identified. The case-control studies confirmed a highly significant effect (HR = 0.54, 95% CI: 0.4-0.73). The funnel plots in both settings hinted at the presence of a potential publication bias, supported by a significant Egger's test. Our findings provide robust evidence supporting the protective effect of the Mediterranean diet against stroke. Despite the presence of some heterogeneity and potential publication bias, the cumulative evidence suggests that promoting the Mediterranean diet could serve as an effective public health strategy for stroke prevention. Further research is recommended to explore the underlying mechanisms and to assess the diet's impact across diverse populations.

Prevalence and risk factors of stroke in patients with non-valvular atrial fibrillation: a case-control study.

To analyze the prevalence and influencing factors of stroke in patients with non-valvular atrial fibrillation (SIPWNVAF), and to provide a reference basis for the prevention and control of stroke. Data were obtained from the China National Stroke Screening Survey (CNSSS). From January 2016 to December 2023, a total of 15471 permanent residents aged ≥ 40 years in Yinchuan were screened. Patients with non-valvular atrial fibrillation (PWNVAF)who had their first stroke were selected as the stroke group(86 patients), and PWNVAF who had never had a stroke as the control group (477 patients). In 563 residents, the crude prevalence of SIPWNVAF was 15.28%, and the standardized prevalence was 9.33%. The multivariable logistic regression analysis revealed that age (OR 1.42, 95%Cl 1.17-1.71), Smoking (OR 2.10, 95%Cl 1.46-3.01), Drinking (OR 2.00, 95%Cl 1.28-3.13), Lack of exercise (OR 2.18, 95%Cl 1.18-4.03), Family history of stroke (OR 4.39, 95%Cl 1.82-10.57), Hypertension (OR 1.94, 95%Cl 1.03-3.63), Diabetes (OR 3.10, 95%Cl 1.37-7.05), Dyslipidemia (OR 2.15, 95%Cl 1.16-3.99), HCY ≥ 15 umol/l (OR 2.13, 95%Cl 1.14-3.97), Carotid atherosclerosis (CAS) (OR 2.86, 95%Cl 1.53-5.37) was an independent risk factor, but educational level (OR 0.31, 95%Cl 0.17-0.58) was a protective factor for SIPWNVAF. The stroke group is significantly more burdened by other independent common risk factors for stroke.

Two-year clinical outcomes of Taiwanese and other Asian ethnicities with atrial fibrillation treated with edoxaban in the ETNA-AF Asia registry.

The non-vitamin K oral anticoagulant (NOAC), edoxaban, is approved for stroke prevention in patients with atrial fibrillation (AF) in many Asian countries. Nonetheless, data on its long-term effectiveness and safety in routine clinical practice are limited in Taiwan. The Global ETNA-AF (Edoxaban Treatment in routiNe clinical prActice) registry is an observational study that integrates data of AF patients receiving edoxaban from multiple regional registries. Here, we report the subgroup analysis of two-year outcomes in Taiwan (N = 973) and three Asian countries (South Korea, Hong Kong, Thailand; N = 2326). Compared with other Asian ethnicities, edoxaban users in Taiwan were older and had lower creatinine clearance levels. The incidence of clinical events was low and comparable in four Asian countries. Upon 2 years of observation, the annualized rates of cardiovascular death and ischemic stroke/systemic embolic event were 0.50% and 0.90% in Taiwan and 0.33% and 0.91% in other Asian ethnicities, respectively. The annualized rates of major/clinically relevant non-major bleeding and major gastrointestinal bleeding were 2.06% and 0.39% in Taiwan and 2.06% and 0.49% in other Asian ethnicities, respectively. Intracranial hemorrhage was rarely reported in four Asian countries (annualized rate: 0.35%). Although some differences in patient characteristics were observed among Asian ethnicities, the low clinical event rates in two-year ETNA-AF data reassure the effectiveness and safety of edoxaban in routine care for AF patients in Taiwan, South Korea, Hong Kong, and Thailand.

Roadmap for Health Equity: Understanding the Importance of Community-Engaged Research.

Achieving health equity in stroke prevention, treatment, and recovery has continued to be a significant challenge. This article highlights the significance of health equity and the role of community-engaged research in addressing stroke disparities, including concepts around health equity as the fair and just opportunity for everyone to attain their highest level of health and well-being. Social determinants impact stroke incidence, prevalence, morbidity, and mortality, which emphasizes the importance of intersectionality and social risk-informed care. A comprehensive roadmap for achieving health equity in stroke through the integration of community-engaged research is presented, including the necessity of community involvement in all aspects of research. Community is defined beyond geographic boundaries, highlighting the importance of shared identities and values. The process of developing targeted goals with communities toward social justice reform is reviewed, including an evolved community engagement framework, emphasizing the need for training to inform about issues and collaborative leadership models. Several stroke disparities intervention studies are highlighted, demonstrating the successful incorporation of community engagement into intervention design and intervention platforms. For enhanced engagement, the use of community health workers and better integration of community health worker models are essential. There may be a critical need for community engagement to optimize inclusion in clinical trials. Finally, acknowledging the complexities of research around decreasing stroke disparities in prevention, treatment, and recovery, this article delves into a framework for understanding the mechanisms by which interventions affect inequities and the need for multifaceted solutions with the community as a partner. Highlighting the roadmap to health equity, this research argues that community engagement is an integral component at all steps along the road to achieving optimum brain health through equitable stroke treatment, prevention, and recovery.

A Real-World, Prospective, Observational Study of Rivaroxaban on Prevention of Stroke and Non-Central Nervous Systemic Embolism in Renally Impaired Korean Patients With Non-Valvular Atrial Fibrillation: XARENAL.

Several real-world studies have been done in patients with nonvalvular atrial fibrillation (NVAF); however, information on its safety profile in patients with renal impairment is limited. XARENAL, a real-world study, aimed to prospectively investigate the safety profile of rivaroxaban in patients with NVAF with renal impairment (creatinine clearance [CrCl], 15-49 mL/min). XARENAL is an observational single-arm cohort study in renal impairment NVAF patients. Patients were followed up approximately every 3 months for 1 year or until 30 days following early discontinuation. The primary endpoint was major bleeding events. All adverse events, symptomatic thromboembolic events, treatment duration, and renal function change from baseline were the secondary endpoints. XARENAL included 888 patients from 29 study sites. Overall, 713 (80.3%) had moderate renal impairment (CrCl, 30-49 mL/min), and 175 (19.7%) had severe renal impairment (CrCl, 15-29 mL/min) with a mean estimated glomerular filtration rate (eGFR) of 45.2±13.0 mL/min/1.73 m². The mean risk scores were 3.3±1.4 and 1.7±0.9 for CHA₂DS₂-VASc score and HAS-BLED score, respectively. An incidence proportion of 5.6% (6.2 events per 100 patient-years) developed major bleeding; however, fatal bleeding occurred in 0.5% (0.5 events per 100 patient-years). The mean change in the eGFR was 2.22±26.47 mL/min/1.73 m² per year. XARENAL observed no meaningful differences in major bleeding events from other previous findings as well as renal function changes in rivaroxaban-treated NVAF patients with renal impairment, which is considered to be acceptable in clinical practice. ClinicalTrials.gov Identifier: NCT03746301.

Peak and Trough Concentrations of Apixaban and Rivaroxaban in Adult Patients: A Systematic Review and Meta-Analysis.

Apixaban and rivaroxaban are factor Xa inhibitors commonly used for treatment of venous thromboembolism and stroke prevention in patients with atrial fibrillation. While routine monitoring of their concentrations is not recommended, but it may be beneficial in certain situations. Expected peak and trough concentrations remain poorly understood, with most data derived from small studies OBJECTIVES: To establish the average peak and trough concentrations of apixaban and rivaroxaban from real-world studies. PubMed, Scopus, and Web of Science were searched until October 2023 for observational studies reporting apixaban and rivaroxaban concentrations. Meta-regression was used to examine factors influencing these concentrations. Sixteen studies involving 1054 apixaban and 1321 rivaroxaban patients were pooled using random-effects model. Mean apixaban peak concentrations were 157 ng/mL (95% CI, 127-187) for 2.5 mg and 228 ng/mL (95% CI, 204-252) for 5 mg, with trough concentrations of 77 ng/mL (95% CI, 56-98) and 113 ng/mL (95% CI, 101-124), respectively. Mean rivaroxaban peak concentrations were 168 ng/mL (95% CI, 104-232) for 10 mg, 225 ng/mL (95% CI, 192-257) for 15 mg, and 229 ng/mL (95% CI, 193-264) for 20 mg, with trough concentrations of 23 ng/mL (95% CI, 13-32), 31 ng/mL (95% CI, 26-36), and 36 ng/mL (95% CI, 25-47), respectively. Meta-regression revealed age and creatinine clearance correlated with apixaban peak concentrations. Creatinine clearance correlated with apixaban and rivaroxaban trough concentrations. The pooled mean concentrations align with expected concentration ranges reported in different pharmacokinetic studies.

Integration of a specialist pharmacist-led multidisciplinary team in primary care: preventing strokes in people with atrial fibrillation across North East London

Public Health England outlines a national ambition of anticoagulating 90% of eligible patients with atrial fibrillation (AF) by 2029. In 2019/2020, two out of three boroughs reviewed in this study...