Background: The clinical impact of blood pressure (BP) and of antihypertensive therapy (AHT) in acute ischemic stroke remains uncertain. Methods: We reviewed the charts of patients admitted to the Montreal General Hospital between April 1, 2002 and October 15, 2005. Ischemic stroke was considered severe if the Canadian Neurological Scale at presentation was ≤7. Poor outcome at 10 days after onset was defined as a modified Rankin Scale >3. Acute change in BP was defined as the percent difference between the mean 24-hour mean arterial pressure (MAP) and the baseline MAP. AHT was considered present if administered ≧5 days during the first week after stroke onset. The association between predictors and outcome was assessed using unconditional multivariable logistic regression. Covariates used included age, stroke severity, diabetes mellitus, coronary artery disease, atrial fibrillation, premorbid hypertension and hyperlipidemia. Results: Three hundred and sixty-four patients were included. Compared to patients with intermediate baseline BP, those with a MAP >130 mm Hg [OR = 2.47 (95% CI, 1.04–5.85)] or a MAP <90 mm Hg [OR = 2.94 (95% CI, 1.28–6.77)] were found to have an increased risk of poor outcome after covariate adjustment. A 15% increase in MAP was associated with an increased risk of poor outcome [OR = 5.34 (95% CI, 1.18–24.3)] while AHT in the first week after stroke onset was found to result in a decreased risk [OR = 0.39 (95% CI, 0.17–0.90)]. However, neither of these findings remained significant after adjustment for the described covariates. Conclusions: Both high and low MAP at presentation are associated with worse short-term outcome after ischemic stroke.

Objective: To assess whether adding clopidogrel to acetylsalicylic acid (ASA) has a long-term protective vascular effect in patients with lacunar stroke while taking ASA. Methods: Post hoc analysis of 838 patients with ASA failure and recent lacunar stroke from the Secondary Prevention of Small Subcortical Strokes Trial (SPS3) cohort randomly allocated to aspirin (325 mg/day) and clopidogrel (75 mg/day) or placebo. Primary efficacy outcome was stroke recurrence (ischemic and intracranial hemorrhage) and main safety outcome was major extracranial hemorrhage. Patients were followed for a mean period of 3.5 years. Results: The ASA failure group had a significantly higher risk of vascular events including ischemic stroke when compared with the non–ASA failure group (n = 2,151) in SPS3 (p = 0.03). Mean age was 65.6 years and 65% were men. The risk of recurrent stroke was not reduced in the dual antiplatelet group, 3.1% per year, compared to the aspirin-only group, 3.3% per year (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.61–1.37). There was also no difference between groups for ischemic stroke (HR 0.90; 95% CI 0.59–1.38). The risk of gastrointestinal bleeding was higher in the dual antiplatelet group (HR 2.7; 95% CI 1.1–6.9); however, the risk of intracranial hemorrhage was not different. Conclusions: In patients with a recent lacunar stroke while taking ASA, the addition of clopidogrel did not result in reduction of vascular events vs continuing ASA only. Classification of evidence: This study provides Class I evidence that for patients with recent lacunar stroke while taking ASA, adding clopidogrel as compared to continuing ASA alone does not reduce the risk of recurrent stroke.

More than 60% of new strokes each year are "mild" in severity and this proportion is expected to rise in the years to come. Within our current health care system those with "mild" stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving with regard to specific concerns that arise. Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization.

Background: Few studies have assessed the performance of stroke prevention clinics. In particular, limited information exists on patient compliance, achievement of therapeutic targets, and related occurrence of vascular events.Methods: We compared our clinical practice to recommendations from published guidelines in newly referred patients for transient ischemic attack (TIA) or ischemic stroke between 2008 and 2010. We monitored our cohort for at least 1 year and assessed for adequacy of vascular risk factor management, drug adherence, and occurrence of nonlethal vascular outcomes.Results: Of 408 patients, 57.8% had a stroke and 42.2% a TIA. The mean age was 68±13 years, and 52% male. Average follow-up was 15.8 months. During follow-up, 253 patients (70.3%) completely achieved their blood pressure target, 151 (45.5%) achieved their low-density lipoprotein (LDL) cholesterol target, and 407 (99.8%) were on antithrombotics. Eighty-nine patients (21.8%) attained optimal therapy status, defined as reaching targets for LDL cholesterol, blood pressure, and antithrombotic use. Adherence to drug therapy was associated with attainment of optimal therapy status (p=0.01). Diabetes was associated with lower probability of attaining optimal therapy status (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.20-0.66) and blood pressure targets (OR, 0.09; 95% CI, 0.05-0.17). During follow-up, 52 (12.7%) patients had a nonlethal vascular event.Conclusion: Our study shows good attainment of therapeutic goals associated with adherence to drug therapy. However, optimal therapy status and blood pressure targets were more difficult to attain in patients with diabetes; therefore, more intensive preventive efforts may be required for these individuals.

Background: In 2010, we published our stroke prevention clinic’s performance as compared to Canadian stroke prevention guidelines. We now compare our clinic’s adherence with guidelines to our previous results, following the implementation of an electronic documentation form.Methods: All new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008–2010) regarding vascular risk management and treatment.Results: Three hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04–2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.Conclusions: Our study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.