Registry Of The Canadian Stroke Network Research Articles

Stroke and Heart Failure: Clinical Features, Access to Care, and Outcomes

Limited information is known regarding acute ischemic stroke (AIS) and heart failure (HF). The aim of the study was to evaluate clinical characteristics, predisposing factors, and outcomes in AIS with HF. We included AIS patients admitted to the institutions participating in the Registry of the Canadian Stroke Network. HF was defined as history of pre-existing HF or pulmonary edema present at the time of arrival. The primary outcome was death or disability at discharge (modified Rankin Scale score >3). Secondary outcomes included disposition, death at 3 months and at 1 year, and 30-day hospital readmissions. Among 12,396 patients, HF was found in 1124 (9.1%) patients. HF was associated with higher risk of death at 30 days (24.5% versus 11.2%, P < .0001), at 1 year (44.3% versus 20.6, P < .0001), and disability at discharge (70.4% versus 56%, P < .0001). In the multivariable analysis, HF was an independent predictor of death and disability (odds ratio 1.18, 95% confidence interval [CI] 1.01-1.37), death at 30 days (hazard ratio [HR] 1.22, 95% CI 1.05-1.41), and hospital readmissions (HR 1.32, 95% CI 1.05-1.65) at 30 days. The results were unaltered when adjusting for pneumonia with the exception of death or disability at discharge. In this large cohort study, HF was observed in 9.1% of AIS patients. HF is an independent predictor of death and disability and hospital readmissions after stroke at 30 days.

The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke.

Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission. The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA. This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables. The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size. These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.

CNS Francis McNaughton Memorial Prize

Background: This study examines whether abnormal blood hemoglobin concentration (bHB) is associated with worse clinical outcomes and poorer prognosis after acute ischemic stroke. Methods: We included data from the Registry of the Canadian Stroke Network on consecutive patients with ischemic stroke who were admitted between July/2003 and March/2008. Patients were divided into groups as follows: low bHB, normal bHB, and high bHB. Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale: &lt;8), greater degree of disability at discharge (modified Rankin score: 3-6), and 30-day and 90-day mortality. Results: Higher bHB than the superior normal limit is associated with greater degree of impairment (OR=1.45, 95%CI: 1.06-1.95, p=0.0195) and disability (OR=1.49, 95%CI: 1.03-2.15, p=0.0331), and higher 30-day mortality (HR=1.98, 95%CI: 1.44-2.74, p&lt;0.0001) after adjustment for major potential confounders. The Kaplan-Meier curves indicate that abnormal bHB is associated with higher mortality after acute ischemic stroke (p&lt;0.0001). Lower bHB than the inferior normal limit is associated with longer stay in the acute stroke care center (OR=1.11, 95%CI: 1.02-1.22, p=0.017). Conclusions: Polycythemia on the initial admission is associated with poorer prognosis regarding the degree of impairment and disability, and 30-day mortality after an acute ischemic stroke. Anemia on admission is associated with longer stay in the acute stroke center.

CNS / CSCN Platform Presentations

Background: We hypothesized that abnormal blood platelet count (BPC) is associated with poorer outcomes after acute ischemic stroke. Methods: We included data from the Registry of the Canadian Stroke Network on consecutive patients with acute ischemic stroke admitted between July/2003 and March/2008. Patients were divided into groups as follows: low BPC (&lt;150,000/mm3), normal BPC (150,000 to 450,000/mm3) and high BPC (&gt;450,000/mm3). Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale: &lt;8), greater degree of disability at discharge (modified Rankin score: 3-6), and 30-day and 90-day mortality. Results: We included 9,230 patients. Both low and high BPC were associated with higher 30-day mortality (p=0.0103) and 90-day mortality (p=0.0189) following acute ischemic stroke. The Kaplan-Meier curves indicate that abnormal BPC is associated with greater mortality after acute ischemic stroke (p=0.0002). Nonetheless, abnormal BPC was not associated with degree of impairment (p=0.3734), degree of disability (p=0.684), or length of stay (LOS) in the acute stroke care center (p=0.9541) after adjustment for major potential confounders. Conclusions: In patients with acute ischemic stroke, thrombocytopenia and thrombocytosis on the initial admission is associated with higher mortality after stroke. Abnormal BPC does not adversely affect the degree of impairment and disability, or LOS in the acute care center after acute ischemic stroke.

Impact of language barriers on stroke care and outcomes.

Language barriers may lead to poor quality of care, particularly for conditions like acute stroke for which diagnosis and treatment decision making rely on taking an accurate patient history. The purpose of this study was to determine the impact of patient language barriers on quality of stroke care and clinical outcomes. This retrospective cohort study used data from the Registry of the Canadian Stroke Network. All Ontario patients who were admitted with acute stroke or transient ischemic attack between July 2003 and March 2008 were selected. Mortality, stroke outcomes, in-hospital complications, quality of care, and disposition were compared between those without (n=12 787) and with (n=1506) language barriers, which was defined based on the patient's preferred language. Hierarchical multivariable regression models determined the effect of language barriers, independent of baseline covariates. Patients with language barriers had better 7-day mortality than those without (7.0% versus 9.2%; OR, 0.69; 95% CI, 0.57-0.82; P<0.001). However, they were more likely to be discharged with a moderate-to-severe neurological deficit (65.9% versus 51.5%; OR, 1.25; 95% CI, 1.15-1.35). In-hospital complication rates did not differ, and quality of care indicators generally favored patients with language barriers. Patients who had language barriers had reduced mortality and better performance on some quality of care measures. These differences existed despite adjustment for many potential confounders, including ethnicity, prognostic factors, and stroke characteristics.

Academic Year-end Changeover and Stroke Outcomes

Lower quality of care and poorer outcomes are suspected when new trainees (eg, residents) start in July in teaching hospitals, the so-called "the July effect." We evaluated outcomes and processes of care among patients with an acute ischemic stroke (AIS) admitted in July versus other 11 months of the year. We evaluated AIS patients admitted to 11 tertiary stroke centers in Ontario, Canada between July 1, 2003, and March 31, 2008, identified from the Registry of the Canadian Stroke Network. The main outcomes were death at 30 days and poor functional outcome defined as death at 30 days or a modified Rankin Scale 3-5 at discharge. Of 10,319 eligible AIS patients, 882 (8.5%) were admitted in July and 9437 during the remaining months. There was no difference in baseline characteristics or stroke severity between the 2 groups. Patients admitted in July were less likely to receive thrombolysis (12% vs. 16%; odds ratio (OR), .72; 95% confidence interval (CI), .59-.89), dysphagia screening (64% vs. 68%; OR, .86; 95% CI, .74-.99), and stroke unit care (62% vs. 68%; OR, .78; 95% CI, .68-.90). July admission was not associated with either of higher death at 30 days (adjusted OR, .88; 95% CI, .74-1.03) or poor functional outcome (adjusted OR, .92; 95% CI, .74-1.14). Results remained consistent in the sensitivity analysis by including both July and August as part of the "July effect." AIS patients admitted to tertiary stroke centers during July had similar outcomes despite slightly less frequent thrombolysis and stroke unit care.

Restarting oral anticoagulants after intracerebral hemorrhage: pros.

Restarting anticoagulants after an intracerebral hemorrhage (ICH) is one of the challenges that no physician feels happy to face: the available evidence is very weak to support any strong suggestion. Unfortunately, this is a rather frequent scenario given the large number of patients who are treated with anticoagulants, and the fact that intracerebral hemorrhage is not a rare complication of anticoagulants. Given the lack of any relevant randomized controlled trial, one needs to weigh the thromboembolic risk against the risk for re-bleeding to reach a clinical decision. Obviously, the long-term thromboembolic risk depends on the underlying condition with the most frequent causes being atrial fibrillation (AF), mechanical valves and venous thromboembolism (VTE). Moreover, one should keep in mind that a post-ICH patient is frequently bed-ridden, which further increases the risk for VTE regardless of and in addition to the underlying condition that initially required treatment with anticoagulants. On the other hand, the risk of ICH recurrence seems to be associated with ICH location [1], age [2], apolipoprotein E e2 or e4 alleles [3] and presence of microbleeds on T2*-weighted gradient-echo MRI [4]. Unfortunately, there are no randomized data available to guide our decision about reinitiating anticoagulation when encountering a patient with anticoagulant-associated ICH. Only a few observational studies have investigated whether reinitiation or avoidance of anticoagulants is the preferable strategy. Recently, the CHIRONE study shows that the rate of ICH recurrence after reinitiation of vitamin-K antagonists is 2.56 per 100 patient-years during a median followup of 16.5 months, (of which, only 0.4 cases per 100 patient-years were fatal) [5]. Of note, there was no hemorrhage outside the central nervous system during the follow-up of 778 patient-years [5]. A recent report by the Registry of the Canadian Stroke Network shows that reinitiation of warfarin after ICH does not increase mortality or bleeding in patients with high thrombotic risk [6]. In similar, another single-center study in 52 patients who survived a warfarin-associated ICH shows that there is no statistically significant difference in outcome between patients who restart warfarin and patients who do not [7]. Of note, the rate of recurrent ICH after reinstitution of warfarin therapy is numerically lower than the rate of recurrent thromboembolic events in patients who do not restart warfarin therapy [7]. Of course, one should be very cautious when trying to draw conclusions from these studies given the inherent limitations of any observational non-randomized study. This is also reflected in the Guidelines of the European Stroke Organization about the management of spontaneous ICH in which no specific evidence-based suggestion is made due to the very low quality of available data [8]. But still, these are the best data available and at the bottom line, any inferences need to be drawn from these data. And these data imply that the risk for ICH recurrence in patients who reinitiate warfarin is not higher than the thromboembolic risk in those who do not reinitiate warfarin. Nevertheless, our choice about our warfarin-associated ICH patients may finally be even more straightforward in the era of the new oral anticoagulants: during recent years, four new oral anticoagulants were launched based on a series of large randomized controlled trials. Apixaban, dabigatran, edoxaban and rivaroxaban were all shown to be at least as effective as warfarin for primary and secondary stroke prevention in patients with AF [9–14], as well as for G. Ntaios (&) Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Biopolis, 41110 Larissa, Greece e-mail: gntaios@med.uth.gr

A Prescription at Discharge Improves Long-term Adherence for Secondary Stroke Prevention

Medication adherence is important for optimal secondary stroke prevention. We evaluated short-term adherence to antihypertensive and lipid-lowering agents after a new ischemic stroke, as predictor of adherence at 1 and 2 years. A 5-year cohort of patients from 11 institutions in the Registry of the Canadian Stroke Network was linked to population-based administrative health records. Patients diagnosed with acute ischemic stroke and discharged home were included. Medication adherence was assessed through documented prescription filling at 7 days, 1 year, and 2 years. From 2003 to 2008, 6437 ischemic stroke patients were discharged home from hospital, and 1126 patients filled a prescription for antihypertensive and lipid-lowering agents within 7 days of discharge. Patients provided with a prescription at discharge were more likely to show adherence at 7 days. Adherence at 1 year remains higher in these patients for antihypertensive (93.8% vs. 87.7%; odds ratio [OR], 2.31; 95% confidence interval [CI], 1.69-3.16), lipid-lowering agents (88% vs. 81.6%; OR, 1.77; 95% CI, 1.36-2.32), or both (85.8% vs. 79.9%; OR, 1.72; 95% CI, 1.32-2.25). Findings are similar at 2 years for antihypertensive (92.2% vs. 87.7%; OR, 1.78; 95% CI, 1.3-2.43), lipid-lowering agents (82.6% vs. 79.0%; OR, 1.31; 95% CI, 1.01-1.69), or both (81.1% vs. 77.0%; OR, 1.4; 95% CI, 1.09-1.82). Provision of a prescription strengthens adherence at 1 week from discharge for both prior and new users of antihypertensive and lipid-lowering drugs. Medication adherence at 1 week after discharge for acute ischemic stroke predicts adherence for secondary preventive therapies at 1 and 2 years.

Impact of living alone on the care and outcomes of patients with acute stroke.

Outcomes among patients living alone at stroke onset could be directly affected by reduced access to acute therapies or indirectly through the effects of social isolation. We examined the associations between living alone at home and acute stroke care and outcomes in the Registry of the Canadian Stroke Network. Between 2003 and 2008, 10 048 patients with acute stroke (87% ischemic, 13% hemorrhagic) who were living at home were admitted to 11 Ontario hospitals. Outcomes included arrival≤2.5 hours of onset, thrombolytic treatment, discharge home, 30-day and 1-year mortality, and 1-year readmission. The effects of living alone versus living with others were determined using multivariable logistic regression. Overall, 22.8% (n=2288) of patients were living alone at home before stroke. Subjects living alone were significantly older (mean, 74.6 versus 71.5 years), more likely to be women (61.5% versus 41.4%), widowed (53.7% versus 12.3%), or single (21.5% versus 3.8%). Patients living alone were less likely to arrive within 2.5 hours (28.3% versus 40.0%; adjusted odds ratio, 0.54; 95% confidence interval, 0.48-0.60), to receive thrombolysis (8.0% versus 14.0%; adjusted odds ratio, 0.52; 95% confidence interval, 0.43-0.63), or to be discharged home (46.0% versus 54.7%; adjusted odds ratio, 0.65; 95% confidence interval, 0.58-0.73). There were no significant associations between living alone and mortality or readmission. Patients living alone had delayed hospital arrival, less thrombolytic therapy, and were less likely to return home. Greater understanding of the inter-relationships among living alone, social isolation, access to stroke care, and outcomes is needed.

Abstract W P348: Evaluating Gaps in the Continuum of Stroke Care

Background and Purpose: Medication adherence is an important factor for secondary stroke prevention in ambulatory care. We aimed to evaluate short-term adherence to antihypertensive and lipid-lowering agents after a new ischemic stroke as a predictor of adherence at one and two years after discharge. Methods: A five-year cohort (2003-2008) of patients from eleven institutions participating in the Registry of the Canadian Stroke Network (RCSN) was linked to population-based administrative health records. Patients with a diagnosis of an acute ischemic stroke who were discharged home were included in the study. Medication adherence was assessed through documentation of a filled prescription at seven days, one year and two years from hospital discharge. Results: From 2003 to 2008, 6,437 ischemic stroke patients were discharged home from hospital. A total of 1126 patients filled a prescription for antihypertensive and lipid-lowering agents within 7 days of hospital discharge. Patients provided with a prescription at discharge were more likely to be adherent to antihypertensive and lipid-lowering agents at seven days than patients who did not receive a prescription . Adherence at one year (X% vs Y%, p-value=?) was higher in patients who demonstrated adherence at seven days from discharge for antihypertensive (93.8% vs 87.7%, p&lt;0.0001), lipid-lowering agents (88% vs 81.9%, p&lt;0.0001), or both (85.8% vs 79.9%, p&lt;0.0001). Similar findings are noted at two years for antihypertensives (92.2% vs 87.7%, p=0.0003), lipid-lowering agents (82.6% vs 79.0%, p=0.0394), or both (81.1% vs 77.0%, p=0.0099). Conclusion: Filling prescriptions within one week of discharge from hospital for acute ischemic stroke predicts adherence for secondary preventive therapies at one and two years. Provision of a prescription at the time of discharge to both prior and new users of anti-hypertensive and lipid-lowering drugs is a simple and effective intervention to improve adherence to secondary preventive medications at seven days, one year and two years after ischemic stroke.

Abstract 21: Are Stroke Outcomes Influenced by New Starting Residents? The July Effect: Myth or Reality?

Background: Acute stroke care provided by comprehensive stroke centers usually follows prespecified protocols. However, there are concerns about lower quality of care and poorer stroke outcomes early after new trainnees (e.g.) residents start in July in academic/teaching hospitals. This has been called ‘the July effect’. Objective: To evaluate access to specialized care and outcomes among patients admitted with an acute ischemic stroke (AIS) in July and other months. Hypothesis: We hypothesized that there were no significant differences in access to stroke care and outcomes for patients admitted in July when new trainees start at academic centers. Methods: Patients presenting with an AIS at 11 stroke centers in Ontario, Canada, between 2003 and 2009 were identified from the Registry of the Canadian Stroke Network. We compared performance measures and functional outcomes (death at 30 days, modified Rankin Scale 3 to 5 at discharge) between AIS patients admitted in July of each studied year and those who admitted during other months. Results: Of 10,319 eligible patients with an AIS, 882 (8.5%) were admitted in July. There was not difference in age, sex, or baseline stroke severity between patients admitted in July or other months. Among the performance measures analyzed, AIS admitted in July were less likely to receive thrombolysis (12.1% vs. 16.0%, p=0.002), swallowing test (64.4% vs. 67.9%, p=0.033), and admission to stroke unit (61.9% vs. 67.6%, &lt;0.001). There was no difference in death at 30-days (16.4% vs. 16.1%, p=0.823) or poor functional outcome (61.0% vs. 63.5%, p=0.14) between two groups (Table). Conclusion: AIS patients admitted in July were less likely to receive thrombolysis and be admitted to stroke units compared to patients admitted on the rest of the year. However, there was no negative effect of “admission on July” on functional outcome or death.

Abstract T MP94: Congestive Heart (or Cardiac) Failure: Risk Factors, Clinical Features and Outcomes in Patients With an Acute Ischemic Stroke

Introduction: Congestive heart failure (CHF) is a relatively common comorbid condition in stroke patients. Limited information is known regarding CHF in patients with an acute ischemic stroke (AIS). Objective: We evaluated clinical characteristics, predisposing factors, and outcomes in stroke patients with history of CHF. Methods: We prospectively included AIS patients admitted to the institutions participating in the Registry of the Canadian Stroke Network (RCSN) between 2003 and 2008. History of chronic congestive heart failure (CHF) determined from medical records, physical examination and investigations. Primary outcome was death or disability at discharge (modified Rankin scale equal to or greater than 3). Secondary outcomes included admission ICU, disposition, length of hospital stay, death at 3 months and at 1 year and 30 day hospital readmissions. Logistic regression and survival analyses were performed to determine the association of risk factors with the outcomes of interest. Results: Among 12,686 patients with AIS, CHF was found in 1152 (9.1%) of patients. Mean age was 78.5±11 years. CHF patients were more likely to have hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, atrial fibrillation, vulvular heart disease and peripheral vascular disease. CHF more likely presented with a severe stroke (25.8% vs 14.1%, p&lt;0.0001) and cardioembolic stroke subtype (42.2% vs 21.3%, p&lt;0.0001). CHF was associated with higher risk of death at 30-days (24.2% vs 11.2%; p&lt;0.0001) and at 1-year (44% vs 20.6;p&lt;0.0001) and disability at discharge (70.3% vs 56%; p&lt;0.0001). Mean length of stay was longer in stroke patients with CHF (15.51±23.91 vs 12.65±19.76 ; p=0.013). In the multivariate analysis, CHF (OR 1.18; 95%CI 1.01- 1.37) was an independent predictor of death and disability after adjusting age, stroke severity, and other comorbid conditions. Conclusions: In this large cohort study, CHF occurred in 9.1% of AIS patients. Stroke patients with CHF had poorer outcomes and longer hospitalization. Furthermore, after adjusting age, stroke severity and comorbidity, CHF was an independent predictor of death and disability.

Abstract T MP102: Antithrombotic Therapy After Acute Ischemic Stroke in Patients With Atrial Fibrillation

Background: For patients with atrial fibrillation (AF) and ischemic stroke (IS), current guidelines recommend oral anticoagulation (OAC) alone for secondary stroke prevention. In a large prospective cohort of patients with acute IS and AF, we describe adherence with antithrombotic guidelines at hospital discharge and the association between antithrombotic regimen on discharge and risk of major vascular events and bleeding. Methods: Consecutive patients admitted with acute IS and AF included in the Registry of the Canadian Stroke Network (Jul 03-Mar 08). Multivariable Cox proportional hazards models were used to determine the association between antithrombotic regimen on discharge and time to the composite of death or readmission for recurrent stroke, myocardial infarction or major bleeding. Results: 2,162 patients were hospitalized with acute IS and AF; 42% had severe stroke (mRankin 4-5 on discharge) and 29% had prior coronary heart disease (CHD). Median duration of follow-up was 3.3 (IQR 1.0-5.4) years. At discharge, 8.0% were prescribed no antithrombotic therapy, 21.6% antiplatelet (AP) alone, 39.3% OAC alone and 31.1% combination OAC and AP. Compared to OAC alone, no antithrombotic (HR 1.51, 95% CI 1.23-1.86) and AP therapy (HR 1.31, 95% CI 1.14-1.50), were associated with an increased risk of the primary outcome, while combination OAC and AP was associated with a trend towards a reduced risk of the composite (HR 0.91, 95% CI 0.80-1.04). No antithrombotic (HR 1.23, 95% CI 0.80-1.90) and AP therapy alone (HR 1.13 95% CI 0.86-1.48), were associated with a trend towards an increased risk of admission for a thrombotic event (recurrent IS or MI), while combination OAC and AP was associated with a trend towards a reduced risk (HR 0.85, 95% CI 0.66-1.09), compared to OAC alone on discharge. Results were consistent in subgroups with severe stroke. In those with CHD, use of OAC and AP was associated with a suggestion of a reduced risk of the composite (HR 0.79, 95% CI 0.61-1.02). Conclusions: Following IS in patients with AF, 30% of patients are not managed according to current antithrombotic guideline recommendations. Compared to antiplatelet therapy, OAC on discharge reduces the composite of mortality and major vascular events, even in patients with severe stroke.

Abstract T MP93: High 1- to 5-Year Mortality and Morbidity in Stable Patients Without Early Complications After Stroke or TIA

Introduction: Stroke prevention efforts are increasingly focused on early risk after TIA/stroke to facilitate initiation of risk-modifying therapies. Few clinics can follow patients for years after an event, yet even stable patients may remain at high risk. Hypothesis: Patients discharged from hospitals with TIA/stroke who survive 90 days without complications, will remain at high risk of adverse outcomes for years after their event. METHODS: We analyzed data from the Registry of the Canadian Stroke Network. We identified all patients discharged from hospital with a diagnosis of TIA or ischemic stroke from 2003-2011. We excluded patients with any event within 90 days of discharge: any hospitalization, stroke, TIA, myocardial infarct (MI), death, long-term care (LTC) admission. A composite outcome of stroke, MI, death or LTC admission was examined from 1 to 5 years after the first 90 days. RESULTS: 30% of patients (n=10, 293) were excluded for events in the first 90 days. Of the remaining 70% (n=24,011) event-free at 90 days, 53% were male and mean age was 69.9 +/- 14.1. 61% had ischemic stroke and 39% TIA. 86% were mild (Canadian Neurological Scale (CNS)&gt;=8), 9.9% were moderate (CNS 5-7) and 4.1% were severe (CNS 0-4). The combined outcome (stroke, MI, LTC or death) occurred in 9.4% of this “mild” group one year AFTER the highest risk period was over and in 35% by 5 years. Death was the most common event (1 year: 5.4%; 5 years: 26.8%), followed by stroke (1 year: 2.6%; 5 years: 7.9%). Among those who survived the first year, the event rate remained at 5% per year at both 3- and 5-years. CONCLUSIONS: Patients who survive the initial 90-day period after TIA/stroke without events are similar to those seen routinely in stroke clinics. These patients remain at high risk of negative outcomes: almost 10% patients have died, or had a stroke, MI or LTC admission in the first year and 5% more occur per year, up to 5 years. Strategies for efficient and effective long-term follow-up to modify these risks are needed for stroke clinic patients.

Abstract W P315: Cardio-Respiratory Arrest in Stroke (CAIS Study): Predisposing Factors, Clinical Features, Outcomes, and Process Measures

Objectives: Limited information is available on the prevalence of cardiorespiratory arrest (CA) and its predisposing factors in patients with acute ischemic stroke. We analyzed/evaluated clinical characteristics, risk factors, access to care, and survival in stroke patients who developed a cardiac arrest. Methods: This is a multicenter cohort study including consecutive patients with acute ischemic stroke admitted to regional stroke centers participating in the Registry of the Canadian Stroke Network from July 2003 to March 2008. Patients with DNR order on admission were excluded. CA was defined as cardiac or respiratory arrest within 30 days of admission documented by a physician and identified from resuscitation records. The main outcome measures were the 30-day and 1-year survival among patients with CA vs. no CA. We also assessed the association between medical complications during hospitalization and CA. Results: Overall, 9,019 patients with acute ischemic stroke were included. Cardiac arrest was observed in 352 patients (3.9%). In patients with CA, 30-day survival (17.9% vs. 90.7%, P&lt;0.001) and 1-year survival (4.5% vs. 80.1, p&lt;0.001) were significantly lower. Less than 1% of stroke patients with CA were discharged home (vs. 47.3%; p&lt;0.0001). Other outcome measures are summarized in Table 1. On multivariable analyses, older age, more severe stroke, previous history of myocardial infarction, congestive heart failure, atrial fibrillation, and diabetes were associated with CA. Conclusions: Cardiac arrest affects less than 5% of patients admitted with an acute ischemic stroke and is associated with poor outcomes. Less than 1% of patients were independent or discharged home.

Influence of seizures on stroke outcomes

We compared clinical characteristics of seizures at ischemic stroke presentation (SSP) to seizures during hospitalization post ischemic stroke (SDH), and their impacts on stroke outcome, using the Registry of the Canadian Stroke Network (RCSN) database. This cohort study included consecutive patients from the RCSN who had an acute ischemic stroke between July 2003 and March 2008. Outcome measures included morbidity, mortality, length of hospital stay, and discharge disposition. Clinical variables for either SSP or SDH were investigated and the stroke outcome was stratified by stroke severity. The study included 10,261 patients with ischemic strokes: 157 patients (1.53%) had SSP and 208 patients (2.03%) had SDH. Compared to stroke patients without seizures, patients with SSP and SDH were younger, had more severe strokes (p < 0.001), a higher admission rate to the intensive care unit (p < 0.001), higher morbidity, and higher mortality (p < 0.05). SSP was associated with female sex and less limb weakness, while SDH was associated with pneumonia and the presence of hemineglect. Importantly, patients with less severe strokes had higher morbidity and mortality (p < 0.005) if SDH occurred. Variables predicting overall mortality were SDH, older age, higher Charlson-Deyo index, more severe strokes, and nonalert status on arrival (all p < 0.001). SSP and SDH have different characteristics. SDH indicates a poorer prognosis in patients. Increased awareness of SSP and efforts to prevent SDH may be important in improving outcomes following clinical stroke care.

Association of atrial fibrillation with mortality and disability after ischemic stroke

We determined whether patient characteristics (age, sex, comorbidities), stroke severity, and quality of care explained a proportion of the association between atrial fibrillation (AF) and increased disability and mortality in patients with acute ischemic stroke. The study included a prospective cohort of consecutive patients admitted with acute ischemic stroke included in the Registry of the Canadian Stroke Network (July 1, 2003 to March 31, 2008). Multivariable logistic regression analyses were used to determine the magnitude of association between AF and modified Rankin score 4-5 at discharge, 30-day mortality, and 1-year mortality. There were 10,528 patients admitted with acute ischemic stroke. AF was associated with an increased risk of severe disability and mortality, but the magnitude of association was substantially attenuated in the full multivariable models: modified Rankin score 4-5 at discharge (univariate odds ratio [OR] 1.74, 95% confidence interval [CI] 1.57-1.93; multivariable OR 1.19, 95% CI 1.03-1.36), 30-day mortality (univariate OR 2.52, 95% CI 2.25-2.84; multivariable OR 1.36, 95% CI 1.17-1.58), and 1-year mortality (univariate OR 2.41, 95% CI 2.19-2.66; multivariable OR 1.25, 95% CI 1.10-1.42). Older age and increased stroke severity explained most of the association between AF and poor stroke outcomes. We found no association between AF and poor stroke outcomes in patients receiving therapeutic preadmission oral anticoagulant therapy. Older age and increased stroke severity explain most of the association between AF and poorer outcomes after acute ischemic stroke. Nonuse of oral anticoagulant therapy represents the most important modifiable care gap to mitigate the association between AF and poor outcomes after ischemic stroke.

White blood cell count is an independent predictor of outcomes after acute ischaemic stroke

In patients with ischaemic stroke, elevated white blood cell count (WBC) has been associated with stroke severity on admission and poor functional outcome. However, previous studies did not control for confounding factors. We hypothesized that higher WBC is an independent predictor of stroke severity, greater degree of disability and 30-day mortality after acute ischaemic stroke. Data from the Registry of the Canadian Stroke Network on consecutive patients with acute ischaemic stroke admitted between July 2003 and March 2008 were used. Patients were divided into groups as follows: low WBC (0.1-4 × 10(-9) /l), normal WBC (4.1-10 × 10(-9) /l) and high WBC (10.1-40 × 10(-9) /l). Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale ≤ 8), greater degree of disability at discharge (modified Rankin score 3-6) and 30-day mortality. Regression analyses were performed adjusting for confounders. In total, 8829 patients were included. After adjustment for major potential confounders, every 1 × 10(-9) /l increase in WBC was associated with stroke severity on admission [odds ratio (OR) 1.09; 95%CI 1.07-1.10; P < 0.0001), disability at discharge (OR 1.04; 95%CI 1.02-1.06; P = 0.0005) and 30-day mortality (hazard ratio 1.07; 95%CI 1.05-1.08; P < 0.0001). The Kaplan-Meier curves indicate that elevated WBC is associated with higher mortality after acute ischaemic stroke (P = 0.001). In patients with acute ischaemic stroke, higher WBC on admission is an independent predictor of stroke severity on admission, greater degree of disability at discharge and 30-day mortality. These results reinforce the need for further studies focused on immunomodulation therapy targeting inflammatory response following acute ischaemic stroke.

Predicting Clinical Outcomes and Response to Thrombolysis in Acute Stroke Patients With Diabetes

OBJECTIVEFew tools are available to evaluate clinical outcomes and response to thrombolysis (tPA) in stroke patients with diabetes. We explored how the iScore (www.sorcan.ca/iscore), a validated risk score, predicts clinical outcomes in stroke patients with and without diabetes.RESEARCH DESIGN AND METHODSWe applied the iScore to stroke patients presenting to stroke centers participating in the Registry of the Canadian Stroke Network. Main outcomes included favorable outcome, defined as a modified Rankin scale (mRS) 0–2 at discharge, and intracerebral hemorrhage (ICH) after tPA.RESULTSAmong 12,686 patients with an acute ischemic stroke, 3,228 (25.5%) had diabetes. Among patients receiving tPA (n = 1,689), those with diabetes had a lower rate of a favorable outcome compared with their counterparts (24.3 vs. 31.1%; RR 0.90 [95% CI 0.82–0.98]). The risk of ICH was not significantly different in patients with or without diabetes (for any type 12.6 vs. 12.5%, RR 1.01 [0.72–1.40]; for symptomatic ICH 7.5 vs. 6.8%, RR 1.11 [0.70–1.72]). The regression analysis revealed a decline in the probability of a favorable outcome after tPA with increments in the iScore (P value for iScore × tPA interaction <0.001). There was no difference in the response to tPA predicted by the iScore between stroke patients with and without diabetes (P value = 0.07).CONCLUSIONSStroke patients with diabetes have poorer outcomes compared with patients without diabetes, which is not explained by ICH. The iScore similarly predicts response to tPA between stroke patients with and without diabetes.

The Prognostic Effect of Cigarette Smoking on Stroke Severity, Disability, Length of Stay in Hospital, and Mortality in a Cohort with Cerebrovascular Disease

The aim of this study was to determine the prognostic influence of cigarette smoking on stroke severity, disability, length of stay (LOS) in hospital, and mortality in different stroke types. A cohort separated by smoking status from the Registry of the Canadian Stroke Network was analyzed using logistic regression while controlling for key outcomes and clinical and demographic characteristics. There were 20,523 patients that were included for this study from July 2003 to March 2008. Multivariable analyses revealed that, in general, long-time smoking had a negative effect on functional outcome at discharge, mortality at 1year, and LOS in hospital. In general, former smoking had a positive impact in reducing the risk of severe stroke, mortality risk at 30days, and the LOS in hospital. Significant differences in clinical and demographics were found between smokers, nonsmokers, and former smokers with cerebrovascular disease. On average, smokers had an earlier initial stroke presentation of cerebrovascular disease. Our results provide empirical evidence regarding the prognostic influence of cigarette smoking on stroke severity, disability, and LOS in hospitaland mortality, but the magnitude of the effect varied by stroke type.