Secondary Prevention Interventions Research Articles

Persistent intracranial steno-occlusion from calcified embolism: a treatment challenge.

Calcified arterial cerebral embolism is a rare occurrence among large and medium vessel occlusions causing ischemic stroke and its diagnosis and treatment is a challenge. The sources of calcified embolism might be a calcific atheroma from the aortic arch and carotid artery, but also heart valve disease has been reported in the literature. Calcified embolism is frequently simultaneous on multiple vascular territories. The prognosis of patients is usually poor, including patients treated by using endovascular thrombectomy (EVT) and this diagnosis could be easily missed in the acute phase. In addition, the optimal secondary prevention has not been yet fully stated. We are presenting two cases of acute stroke due to calcified embolism in the middle cerebral artery (MCA) coming from a complicated carotid atheroma, non-stenosing in the first case (a 49years old man) and stenosing in the second case (a 71years old man) without clinical indications to intravenous thrombolysis and/or EVT, extensively investigated in the acute phase and followed-up for over 12months with a favorable clinical course and the persisting steno-occlusion in the involved MCA. In both cases, antiplatelet treatment and targeting of vascular risk factors were done without recurrences in the follow-up period. Cerebral calcified embolism has been reported in 5.9% of cases of acute ischemic stroke in a single center series and only in 1.2% of a large retrospective cohort of EVT-treated patients. In both series the prognosis was poor and only one third of EVT-treated patients had functional independence at 3-months follow-up. The natural history of these subtype of ischemic stroke is relatively poorly understood and both etiological diagnosis and treatment have not yet defined. It is possible that some cases might be underdiagnosed and underreported. Calcified cerebral embolism is a rare cause of stroke, but it is largely underreported and both acute phase and secondary preventive treatment have to be defined.

Effectiveness and Satisfaction with Telemedicine in Geriatric Patients at High Risk of Fragility Fractures.

Background: Telemedicine has increasingly widespread to improve the monitoring of patients with chronic diseases. Secondary prevention of fragility fractures is an urgent matter to be addressed by means of available technology, although supported by little evidence so far. We investigated the feasibility, efficacy, and satisfaction of managing older adults at high risk of fragility fractures during the COVID-19 lockdown. Methods: During the period January to July 2021, a prospective observational study for safety and adherence purposes was conducted among older adults (n = 407) with ongoing treatments for secondary prevention of fragility fractures. The study procedures comply with national and regional resolutions related to telemedicine service (TS), including equipment, staff behaviors, and patient reports. Results: A majority (86.48% [n = 352]) of the eligible patients joined the remote visits, mainly women (88.2%), 81.4 ± 8.8 years of age, 49.6% independent in 5 out of 6 BADL, despite high comorbidity (4.9 ± 1.5), and polypharmacy (4.9 ± 3.1). Almost all were on second-line antifracture treatments (95.58%) due to previous major (84.03%) and minor (42.5%) fragility fractures. About 58% reported good and very good reliability of the internet network, allowing easy access to the TS platform, and 54% declared the degree of satisfaction with TS as good and very good. About 75% of clinicians acknowledged the efficacy of TS and expressed willingness to recommend the use of TS to colleagues. Ultimately, 68% of specialists defined the time allocated for patients' remote visits as acceptable. Conclusion: TS may be an opportunity to improve the availability of appropriate health care services to satisfy patients' needs and optimize health care resource allocation.

Predicting post-stroke cognitive impairment using electronic health record data.

Secondary prevention interventions to reduce post-stroke cognitive impairment (PSCI) can be aided by the early identification of high-risk individuals who would benefit from risk factor modification. To develop and evaluate a predictive model to identify patients at increased risk of PSCI over 5 years using data easily accessible from electronic health records. Cohort study that included primary care patients from two academic medical centers. Patients were aged 45 years or older, without prior stroke or prevalent cognitive impairment, with primary care visits and an incident ischemic stroke between 2003 and 2016 (development/internal validation cohort) or 2010 and 2022 (external validation cohort). Predictors of PSCI were ascertained from the electronic health record. The outcome was incident dementia/cognitive impairment within 5 years and beginning 3 months following stroke, ascertained using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) codes. For model variable selection, we considered potential predictors of PSCI and constructed 400 bootstrap samples with two-thirds of the model derivation sample. We ran 10-fold cross-validated Cox proportional hazards models using a least absolute shrinkage and selection operator (LASSO) penalty. Variables selected in >25% of samples were included. The analysis included 332 incident diagnoses of PSCI in the development cohort (n = 3741), and 161 and 128 incident diagnoses in the internal (n = 1925) and external (n = 2237) validation cohorts, respectively. The C-statistic for predicting PSCI was 0.731 (95% confidence interval (CI): 0.694-0.768) in the internal validation cohort, and 0.724 (95% CI: 0.681-0.766) in the external validation cohort. A risk score based on the beta coefficients of predictors from the development cohort stratified patients into low (0-7 points), intermediate (8-11 points), and high (12-23 points) risk groups. The hazard ratios (HRs) for incident PSCI were significantly different by risk categories in internal (high, HR: 6.2, 95% CI: 4.1-9.3; Intermediate, HR: 2.7, 95% CI: 1.8-4.1) and external (high, HR: 6.1, 95% CI: 3.9-9.6; Intermediate, HR: 2.8, 95% CI: 1.9-4.3) validation cohorts. Five-year risk of PSCI can be accurately predicted using routinely collected data. Model output can be used to risk stratify and identify individuals at increased risk for PSCI for preventive efforts. Mass General Brigham data contain protected health information and cannot be shared publicly. The data processing scripts used to perform analyses will be made available to interested researchers upon reasonable request to the corresponding author.

Effectiveness of behavior change and self-management theoretically-informed telehealth interventions for stroke secondary prevention: An overview of systematic reviews

Effectiveness of behavior change and self-management theoretically-informed telehealth interventions for stroke secondary prevention: An overview of systematic reviews

MRI in the Evaluation of Cryptogenic Stroke and Embolic Stroke of Undetermined Source.

Cryptogenic stroke refers to a stroke of undetermined etiology. It accounts for approximately one-fifth of ischemic strokes and has a higher prevalence in younger patients. Embolic stroke of undetermined source (ESUS) refers to a subgroup of patients with nonlacunar cryptogenic strokes in whom embolism is the suspected stroke mechanism. Under the classifications of cryptogenic stroke or ESUS, there is wide heterogeneity in possible stroke mechanisms. In the absence of a confirmed stroke etiology, there is no established treatment for secondary prevention of stroke in patients experiencing cryptogenic stroke or ESUS, despite several clinical trials, leaving physicians with a clinical dilemma. Both conventional and advanced MRI techniques are available in clinical practice to identify differentiating features and stroke patterns and to determine or infer the underlying etiologic cause, such as atherosclerotic plaques and cardiogenic or paradoxical embolism due to occult pelvic venous thrombi. The aim of this review is to highlight the diagnostic utility of various MRI techniques in patients with cryptogenic stroke or ESUS. Future trends in technological advancement for promoting the adoption of MRI in such a special clinical application are also discussed.

Polypill Strategy in Secondary Cardiovascular Prevention.

The polypill strategy, originally developed to improve medication adherence, has demonstrated efficacy in improving baseline systolic blood pressures and cholesterol levels in multiple clinical trials. However, the long-term clinical impact of improved major cardiovascular events (MACE) outcomes by the polypill remains uncertain. Recent trials with long-term follow-up, which included minority groups and people with low socioeconomic status, have shown non-inferiority with no difference in adverse effects rates for the secondary prevention of MACE. Although the polypill strategy was initially introduced to improve adherence to guideline-directed medical therapy (GDMT) for cardiovascular complications, the strategy has surpassed standard medical treatment for secondary prevention of MACE outcomes. Studies also showed improved medication compliance in underserved populations.

The Outbreak of Foot and Mouth Disease Serotype Sat-2 Infection in Al-Muthanna Province of Iraq

Introduction: prevalent in the majority of developing nations. Case report: The present study reported a foot and mouth disease Sat-2 outbreak in Al-Muthanna province in southern Iraq in March 2023. Three male Holstein Friesian cows, aged between 1 and 1.5 years and weighing approximately 550 ± 15 kg each, were affected. Clinical examination revealed symptoms, including fever, severe lameness, anorexia, depression, frothy salivation, and vesicular lesions on the mouth and feet. Confirmation of the Sat-2 serotype was achieved through serological testing and genotyping of the virus, conducted by the FMD Institute, Ankara, Türkiye. The Sat-2 serotype was recognized by genotyping the virus and submitting SAT-2 VP1 sequences. The treatments for secondary infection prevention included Ceftifur (2.2 mg/kg) for 5 days, and flunixin meglumine (2.2 mg/kg) for 2 days. The other animals that were not exposed to infected animals were vaccinated against FMD. Rigorous biosecurity measures were implemented, involving thorough disinfection of the environment and quarantine of the infected animals. Direct contact between the farmer and other animals, particularly the sick ones, was completely avoided. After 2 weeks, all infected animals began to eat normally again, and clinical signs disappeared. Notably, other animals on the farm did not exhibit any signs of FMD. Conclusion: In conclusion, the findings of this study underscore the importance of biosecurity measures and vaccination in FMD prevention. Additionally, administering antibiotics and non-steroidal anti-inflammatory drugs for the prevention of secondary infections proves to be crucial.

Cost-related medication nonadherence in adults with COPD in the United States 2013-2020.

Cost-related medication nonadherence (CRN) is associated with poor prognosis among patients with chronic obstructive pulmonary disease (COPD), a population that requires long-term treatment for secondary prevention. In this study, we aimed to estimate the prevalence and sociodemographic characteristics of CRN in individuals with COPD in the US. In a nationally representative survey of US adults in the National Health Interview Survey (2013-2020), we identified individuals aged ≥18 years with a self-reported history of COPD. Cross-sectional study. Of the 15,928 surveyed individuals, a weighted 18.56% (2.39 million) reported experiencing CRN, including 12.50% (1.61 million) missing doses, 13.30% (1.72 million) taking lower than prescribed doses, and 15.74% (2.03 million) delaying filling prescriptions to save costs. Factors including age < 65 years, female sex, low family income, lack of health insurance, and multimorbidity were associated with CRN. In the US, one in six adults with COPD reported CRN. The influencing factors of CRN are multifaceted and necessitating more rigorous research. Targeted interventions based on the identified influencing factors in this study are recommended to enhance medication adherence among COPD patients.

Management and outcome in foreign-born vs native-born patients with myocardial infarction in Sweden.

Previous studies on disparities in healthcare and outcome have shown conflicting results. The aim of this study was to assess differences in baseline characteristics, management, and outcome in myocardial infarction (MI) patients, by country of birth. In total, 194 259 MI patients (64% male, 15% foreign-born) from the nationwide SWEDEHEART registry were included and compared by geographic region of birth. The primary outcome was one-year major adverse cardiovascular events (MACE) including all-cause death, MI, and stroke. Secondary outcomes were long-term MACE (up to 12 years), the individual components of MACE, 30-day mortality, management, and risk factors. Logistic regression, Cox proportional hazard models and propensity score matching (PSM), accounting for baseline differences, were used. Foreign-born patients were younger, often male, and had a higher cardiovascular (CV) risk factor burden, including smoking, diabetes, and hypertension. In PSM analyses, Asia-born patients had higher likelihood of revascularisation (OR 1.16, 95% CI 1.04-1.30), statins and betablocker prescription at discharge and a 34% lower risk of 30-day mortality. Furthermore, no statistically significant differences were found in the primary outcomes except for Asia-born patients having lower risk of one-year MACE (HR 0.85, 95% CI 0.73-0.98), driven by lower mortality (HR 0.72, 95% CI 0.57-0.91). The results persisted over long-term follow-up. This study shows that in a system with universal healthcare coverage in which acute and secondary preventive treatments do not differ by country of birth, foreign-born patients, despite higher CV risk factor burden, will do at least as well as native-born patients.

77 Emerging strategies for head & neck cancer prevention

Head and neck squamous cell carcinoma (HNSCC) is a group of malignancies mostly involving the oral cavity, oropharynx, hypopharynx, and larynx. All together they represent the seventh most common cancer diagnosis worldwide. With 890,000 new cases and 450,000 deaths annually per GLOBOCAN estimates, HNSCC accounts for roughly 4.5% of cancer diagnoses and deaths. In the developing world, the incidence of HNSCC is growing with increasing consumption of tobacco (smoked or chewed), alcohol, and areca nut (betel quid). Alcohol and tobacco have a synergistic effect, with the heavy consumption of both increasing HNSCC risk 40-fold. In this context, the risk of second primary tumors in the field of cancerization is high. In developed nations, HPV-related HNSCC surpasses tobacco- and alcohol-related disease. HPV-related HNSCC more commonly affects the oropharynx, hypopharynx, and larynx than the oral cavity, and is associated with a significantly longer survival.Based on this epidemiological facts, different strategies involving primary, secondary and tertiary prevention will be discussed. For prevention of HPV-positive HNSCC, emphasis will be given to vaccination strategies and novel diagnostic biomarkers for early detection. HPV-negative HNSCC are mostly represented by oral cavity cancers. In this particular context, a Working Group of international experts was convened by the International Agency for Research on Cancer (IARC) to review and assess all available evidence on the effectiveness of primary and secondary preventive interventions in reducing the incidence of and mortality from oral cancer. Available evidence will be summarized. Finally, we will address the challenge of unmet oral cancer prevention in the context of oral potentially malignant disorders (OPMD) in terms of oral cancer risk assessment and pharmacological interception approachs.In conclusion, a lot remains to be done to improve the prevention of HNSCC but significant opportunities exist that will hopefully allow in the near future to significantly decrease its morbidity, mortality, and profound impact on patient's quality of life.

The CNIC-polypill (acetylsalicylic acid, atorvastatin, and ramipril), an effective and cost-saving secondary prevention strategy compared with other therapeutic options in patients with ischaemic heart disease.

The retrospective NEPTUNO study evaluated the effectiveness of the Centro Nacional de Investigaciones Cardiovasculares (CNIC)-polypill (including acetylsalicylic acid, ramipril, and atorvastatin) vs. other therapeutic approaches in secondary prevention for cardiovascular (CV) disease. In this substudy, the focus was on the subgroup of patients with ischaemic heart disease (IHD). Patients on four strategies: CNIC-polypill, its monocomponents as loose medications, equipotent medications, and other therapies. The primary endpoint was the incidence of recurrent major adverse CV events (MACEs) after 2 years. After matching, 1080 patients were included in each cohort. The CNIC-polypill cohort had a significantly lower incidence of recurrent MACE compared with monocomponents, equipotent drugs, and other therapies cohorts (16.1 vs. 24, 24.4, and 24.3%, respectively; P < 0.001). The hazard ratios (HRs) for recurrent MACE were higher in monocomponents (HR = 1.12; P = 0.042), equipotent drugs (HR = 1.14; P = 0.031), and other therapies cohorts (HR = 1.17; P = 0.016) compared with the CNIC-polypill, with a number needed to treat of 12 patients to prevent a MACE. The CNIC-polypill demonstrated a greater reduction in LDL cholesterol (LDL-c; -56.1 vs. -43.6, -33.3, and -33.2% in the monocomponents, equipotent drugs, and other therapies, respectively; P < 0.001) and systolic blood pressure (-13.7 vs. -11.5, -10.6, and -9.1% in the CNIC-polypill, monocomponents, equipotent drugs, and other therapies, respectively; P < 0.001) compared with other cohorts. The CNIC-polypill intervention was less costly and more effective than any other therapeutic option, with €2317-€2407 cost savings per event prevented. In IHD, the CNIC-polypill exemplifies a guideline-recommended secondary prevention treatment linked to better outcomes and cost saving compared with other therapeutic options.

Statin treatment in stroke patient with low‐density lipoprotein cholesterol levels below 70 mg/dL

Background and purposeThe effectiveness of hyperlipidemia treatment in strokes secondary prevention has been established. However, whether pretreatment with statins could confer protective effects when a patient's baseline low-density lipoprotein cholesterol (LDL-C) level is <70 mg/dL remains uncertain. Additionally, the ability of statin treatment to reduce poststroke complications, mortality, and recurrence in this patient group is unclear. Methods and resultsIn this retrospective observational study, we enrolled patients who had experienced an ischemic stroke with LDL-C levels <70 mg/dL. We analyzed the association of statin use with baseline characteristics, stroke severity, in-hospital complications, mortality rates, stroke recurrence rate, and mortality rate. Patients who used and patients who did not use statins were similar in terms of age and sex. Patients using statins had higher rates of diabetes mellitus, hypertension, prior stroke, and coronary artery disease but a lower incidence of atrial fibrillation. Stroke severity was less pronounced in those using statins. We also evaluated the relationship between in-hospital statin use and complications. We noted that in-hospital statin use was associated with lower rates of infection, hemorrhagic transformation, gastrointestinal hemorrhage, and mortality, as well as higher rates of positive functional outcomes. The 1-year recurrence rate was similar in both groups. ConclusionsStatin use is associated with milder strokes and improved poststroke outcomes, even in patients with well-controlled LDL levels. Neurologists may consider prescribing statins for patients with ischemic stroke who do not overt hyperlipidemia. Further research into potential underlying mechanisms is warranted.

Harnessing global networks to drive country evidence-based reproductive health practices toward universal health coverage

Jhpiego provides contextual evidence-based real-life solutions that contribute to saving lives, improving health, and transforming futures for women, children, and their families living in more than 42 countries. Over its 50 years of existence and a geographic footprint of more than 150 countries, this JHU-affiliated NGO has contributed to the introduction and scale-up of multiple life-saving innovations, has been a dot connector, a trusted partner to many governments and professional and local organizations, and an innovator. In Kenya, Jhpiego has worked for more than 45 years, partnering with KOGS in multiple initiatives, and has contributed to the development and review of multiple evidence-based policies and recommendations at the global, regional, and national levels. Evidence-based practice plays a critical role in improving the quality of reproductive health care. While global recommendations are important, they require adaptation to local contexts for full implementation to be practical. Introduction of heat-stable carbetocin and the scale-up of the E-MOTIVE bundle to manage PPH, respectful care, and mental health in RH, introduction and scale-up of post-pregnancy FP, introduction and scale-up of primary and secondary cervical prevention interventions, the use of blended learning that uses multiple delivery channels, including the use of AI-powered training tools that respond to the needs of health providers, and supporting the quality of services through approved pharmacies, including e-pharmacy.

Dabigatran for Treatment and Secondary Prevention of Venous Thromboembolism in Pediatric Congenital Heart Disease.

Congenital heart disease (CHD) is common in children and associated with greater risk of thrombotic complications. Management of these complications with standard-of-care treatment is suboptimal for these children. The effectiveness and safety of dabigatran were demonstrated in pivotal pediatric studies for the treatment of acute venous thromboembolism (VTE; NCT01895777) and secondary VTE prevention (NCT02197416). We report safety and efficacy outcomes from subgroup analyses of these studies for children with CHD (diagnosed according to local practice) and those without. In NCT01895777, 17/21 (81.0%) and 16/27 (59.3%) patients with CHD (including cyanotic) treated with dabigatran and standard of care, respectively, met the primary end point (complete thrombus resolution, freedom from recurrent VTE, and freedom from VTE-related death; odds ratio [OR], 0.34 [95% CI, 0.08-1.23]). In patients without CHD, 41.0% (n=64) versus 34.9% (n=22) achieved this end point with the respective treatments (OR, 0.77 [95% CI, 0.42-1.41]). Although numerical differences were observed, no heterogeneity in treatment effect of dabigatran on the composite primary end point was detected in patients with and without CHD (interaction P =0.2674). In NCT02197416, recurrent VTE at 12 months occurred in 0/17 patients with CHD versus 3/194 (1.5%) without. No patient with CHD experienced major or clinically relevant nonmajor bleeding events. Data on favorable anticoagulant alternatives for the unmet needs of children with CHD are emerging, and our exploratory results suggest that dabigatran could be an appropriate treatment choice, although challenging sample size limitations in pediatric studies require cautious interpretation of findings. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01895777, NCT02197416.

Stroke prevention strategies in Africa: a scoping review protocol.

The objective of this scoping review is to map the existing strategies on methods and interventions for primary and secondary stroke prevention in Africa. Stroke is among the leading causes of disability globally. African nations have higher stroke mortality and case fatality rates than the industrialized world, leading to significant social and financial costs, which necessitates efficient preventative methods. Despite the high prevalence of stroke in Africa, the scope of stroke-prevention strategies in Africa is unknown. Consequently, mapping diverse approaches to preventing stroke in Africa could provide direction for future research into stroke prevention in Africa. This review will incorporate studies that report methods or strategies used for stroke prevention in Africa. All primary and gray literature will be considered for inclusion. No language or date restrictions will be applied. The JBI methodological framework for scoping reviews will be adopted for this scoping review. A 3-step search strategy consisting of an initial limited search, a full search, and a screening of the reference lists of all included articles will be undertaken. Databases such as CINAHL, Scopus, PubMed, PEDRo, DORIS, Global Health, Web of Science, and Open Access Thesis and Dissertations will be searched. All search results will be screened, and relevant data extracted by 2 independent reviewers. The findings will be presented in the final scoping review and illustrated in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Figshare https://doi.org/10.6084/m9.figshare.21679904.v1.

Abstract TMP45: Assessing Adaptations of a Complex Secondary Stroke Prevention Intervention

Introduction: S econdary stroke prevention by U niting C ommunity and C hronic care model teams E arly to E nd D isparities (SUCCEED) was a randomized trial of a multilevel complex intervention to enhance risk factor control after stroke. Subjects randomized to intervention were managed by an advanced practice clinician (APC)-community health worker (CHW) team. Within the framework of ≥3 clinic and ≥3 home visits, and Chronic Disease Self-Management Program (CDSMP) workshops, the team tailored the intervention to meet participants’ needs. To describe how the intervention was implemented and adapted, we used the form/function framework. Methods: We identified key domains (overall goals of intervention), motivating needs (importance of targeting each domain), functions (methods for addressing motivating needs), and forms (tools, resources, methods for accomplishing each function). Two study leaders conducted semi-structured interviews with 4 APCs and 4 CHWs to identify forms used. APCs and CHWs described how frequently they used each form and usefulness via a RedCap survey. Descriptive statistics were subsequently run with R version 4.2.3. Results: SUCCEED targeted 7 domains: medication adherence, stroke literacy, self-management skills, care coordination, healthcare system navigation, social support, and addressing barriers. Each domain had 1-7 motivating needs and 4-13 functions. Each function had 5-23 forms, resulting in a total of 365 forms for addressing all domains. Most providers (85%) reviewed medication bottles to assess medication adherence, strongly agreeing this was useful. Pill organizers and stickers were used 53% of the time to ensure patients knew what medications they should be taking; 71% strongly agreed this was useful. Providers identified physical/environmental/social/literacy barriers during both home visits and CDSMP workshops (71%); all providers found this combination helpful. Conclusion: The form/function framework is useful for describing real-world adaptations of complex interventions. We identified key aspects of the intervention that providers used frequently and found useful, to inform future development of secondary stroke prevention interventions.

Abstract HUP9: Assessing Adaptations of a Complex Secondary Stroke Prevention Intervention

Introduction: S econdary stroke prevention by U niting C ommunity and C hronic care model teams E arly to E nd D isparities (SUCCEED) was a randomized trial of a multilevel complex intervention to enhance risk factor control after stroke. Subjects randomized to intervention were managed by an advanced practice clinician (APC)-community health worker (CHW) team. Within the framework of ≥3 clinic and ≥3 home visits, and Chronic Disease Self-Management Program (CDSMP) workshops, the team tailored the intervention to meet participants’ needs. To describe how the intervention was implemented and adapted, we used the form/function framework. Methods: We identified key domains (overall goals of intervention), motivating needs (importance of targeting each domain), functions (methods for addressing motivating needs), and forms (tools, resources, methods for accomplishing each function). Two study leaders conducted semi-structured interviews with 4 APCs and 4 CHWs to identify forms used. APCs and CHWs described how frequently they used each form and usefulness via a RedCap survey. Descriptive statistics were subsequently run with R version 4.2.3. Results: SUCCEED targeted 7 domains: medication adherence, stroke literacy, self-management skills, care coordination, healthcare system navigation, social support, and addressing barriers. Each domain had 1-7 motivating needs and 4-13 functions. Each function had 5-23 forms, resulting in a total of 365 forms for addressing all domains. Most providers (85%) reviewed medication bottles to assess medication adherence, strongly agreeing this was useful. Pill organizers and stickers were used 53% of the time to ensure patients knew what medications they should be taking; 71% strongly agreed this was useful. Providers identified physical/environmental/social/literacy barriers during both home visits and CDSMP workshops (71%); all providers found this combination helpful. Conclusion: The form/function framework is useful for describing real-world adaptations of complex interventions. We identified key aspects of the intervention that providers used frequently and found useful, to inform future development of secondary stroke prevention interventions.

Randomized Secondary Prevention Trials in Participants With Symptomatic Intracranial Atherosclerotic Stenosis.

Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts.

Abstract TP76: Step by Step: Implementing Post-Acute Stroke Standards

Introduction: Certification programs and quality improvement initiatives improve outcomes among patient populations. Stroke rehab expertise, care processes, and educational resources vary among sites where post-acute care (PAC) is delivered. The Misson: Lifeline Stroke PAC Initiatives are recruiting sites in four states to implement the AHA PAC Stroke Program Standards. Purpose Developed from evidence-based rehab and proven secondary prevention interventions, the American Heart Association (AHA) created quality standards based on the AHA 2016 Guidelines for Adult Stroke Rehabilitation and Recovery to address gaps in PAC care. Methods: Nursing facilities (SNFs), critical access hospitals (CAHs) with swing beds, and inpatient rehab facilities (IRFs) in Iowa, Montana, Nebraska, and North Dakota were recruited to participate in the Initiative. Sites received education on the PAC Stroke Program standards and individualized quality improvement support. Sites were enrolled in the Healthcare Network, a collaborative tool to start discussions, share resources, and discuss patient care processes, and the Quality and Certification Tool, used to track clinical measures and outcome metrics. Monthly virtual learning collaboratives were held to share educational materials, community resources, and processes for patient care.Statewide AHA conferences and workshops facilitated in-person collaboration across settings. A pre-implementation survey was utilized to identify gaps in existing practices. A post-implementation survey will be used to assess the effectiveness of these initiatives. Results: Forty-seven facilities were recruited including 10 IRFs, 17 CAHs and 20 SNFs. Additional sites will be added throughout the project. 100% of facilities completed orientation. Nine learning collaboratives have been hosted and 26 facilities completed the pre-implementation survey. Data submissions and review are ongoing through 2025. Conclusions: Future evaluation of implementation of standards is needed to assess improvements in patient outcomes. The participation of 47 facilities shows a need for more organized initiatives that help health care professionals incorporate research proven standards for stroke rehab.

Abstract WP128: Using Clinical Data to Reclassify ESUS Patients to Either Large Artery Atherosclerotic or Cardioembolic Stroke Mechanisms

Introduction: Defining the specific underlying pathophysiology of ischemic stroke is critical for minimizing the risk of recurrent events with personalized secondary prevention treatments. A notable portion of ischemic strokes are classified as embolic stroke of undetermined source (ESUS), leaving these patients without optimal treatment tailored to their pathophysiology. Hypothesis: Standard clinically collected data can reliably reclassify a substantial portion of ESUS patients into either a large artery atherosclerotic (LAA) or cardioembolic (CE) cause. Methods: A statistical model was developed to discriminate LAA from CE using a retrospective cohort of ischemic stroke patients treated at the University of Washington. A total of 189 patients were included (79 CE and 61 LAA to train the model, 49 ESUS patients to assess reclassification). Sixteen candidate predictors were collected across several sources: clinical risk factors, blood tests, echocardiography, ECG, and neurovascular imaging (Table 1). The LASSO (least absolute shrinkage and selection operator) was used to select important predictors in a penalized logistic regression model with stroke etiology (LAA vs. CE) as the outcome. ESUS patients were considered reclassified if the model-based probability of CE or LAA was at least 75%. Results: Of 189 patients, the mean (SD) age was 68 (14) years and 40% were women. The LASSO selected 12 predictors to discriminate CE vs. LAA (Table 1), with a corresponding cross-validated C-statistic = 0.87 (95% CI: 0.82-0.94). When the model was applied to the 49 ESUS patients, 23 (47%) were reclassified to LAA and 6 (12%) to CE. Conclusions: A multivariate model based on standard clinical data can separate LAA from CE with a high degree of discrimination. Applying this model led to reclassification to either LAA or CE in 59% of ESUS patients. Such approaches may enable more personalized secondary prevention strategies, but need to be tested in future trials.