Health Equity and Actionable Disparities in Stroke: 2022 Update.

There are stark inequities in stroke incidence, prevalence, care, and outcomes. This issue of Stroke features manuscripts from the third annual HEADS-UP (Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving) symposium, which took place the day before the International Stroke Conference in February 2022. The 2022 HEADS-UP symposium focused on clinical trials to address stroke inequities. The 2022 Edgar J. Kenton III award was awarded to Moira Kapral. In Kenton Award Lecture-Stroke Disparities Research: Learning from the Past, Planning for the Future, Kapral details 10 key considerations for researchers interested in addressing inequities in stroke. These considerations provide an insightful, evidence-based roadmap for the future of stroke inequities research. In the article, Care Transition Interventions to Improve Stroke Outcomes, Reeves et al highlight barriers faced by historically disenfranchised populations navigating transitions in the stroke continuum of care; summarize clinical trials aimed at enhancing transitions in care, particularly in historically marginalized populations; and stress the importance of co-designing future interventions with patient populations to address inequities. In Telehealth Trials to Enhance Health Equity for Patients With Stroke, Sharrief et al detail how telehealth interventions have the potential to address inequities if they are implemented in a thoughtful manner, addressing the potential factors than can exacerbate a digital divide. Finally, in Polypill Programs to Prevent Stroke and Cut Costs in Low Income Countries: From Clinical Efficacy to Implementation, Sarfo et al review the evidence for polypill strategies in primary and secondary cardiovascular disease prevention in low- and middle-income countries, who bear the majority of the worldwide burden of stroke.

Race, Ethnic, Sex, and Socioeconomic Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States.

BACKGROUND: Patients with stroke in the United States can be transferred for higher level of care. Little is known about possible inequities in interhospital transfers (IHTs) for acute ischemic stroke. We hypothesized that historically marginalized populations would have lower odds of IHT. METHODS: A cross-sectional analysis was done for adults with a primary diagnosis of acute ischemic stroke in 2010 to 2017; n=747 982 were identified in the National Inpatient Sample. Yearly rates for IHT were assessed and adjusted odds ratios (aORs) of IHT in 2014 to 2017 were compared with that of 2010 to 2013. Multinomial logistic regression was used to determine the aOR of IHT, adjusting for sociodemographic variables (model 1), sociodemographic and medical variables such as comorbidity and mortality risk (model 2), and sociodemographic, medical, and hospital variables (model 3). RESULTS: After adjusting for sociodemographic, medical, and hospital characteristics, there were no significant temporal differences in IHT from 2010 to 2017. Overall, women were less likely than men to be transferred in all models (model 3: aOR, 0.89 [0.86-0.92]). Compared with those who were White, individuals who were Black (aOR, 0.93 [0.88-0.99]), Hispanic (aOR, 0.90 [0.83-0.97]), other (aOR, 0.90 [0.82-0.99]), or of unknown race, ethnicity (aOR, 0.89 [0.80-1.00]) were less likely to be transferred (model 2), but these differences dissipated when further adjusting for hospital-level characteristics (model 3). Compared with those with private insurance, those with Medicaid (aOR, 0.86 [0.80-0.91]), self-pay (aOR, 0.64 [0.59-0.70]), and no charge (aOR, 0.64 [0.46-0.88]) were less likely to be transferred (model 3). Individuals with lower income were less likely to be transferred compared with those with higher income (model 3: aOR, 0.85 [0.80-0.90], third versus fourth quartile). CONCLUSIONS: Adjusted odds of IHT for acute ischemic stroke remained stable from 2010 to 2017. There are numerous inequities in the rates of IHT by race, ethnicity, sex, insurance, and income. Further studies are needed to understand these inequities and develop policies and interventions to mitigate them.

Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control: A Scientific Statement From the American Heart Association.

Stroke is a disease of disparities, with tremendous racial and ethnic inequities in incidence, prevalence, treatment, and outcomes. The accumulating literature on the relationship between stroke and social determinants of health (ie, the structural conditions of the places where people live, learn, work, and play) contributes to our understanding of stroke inequities. Several interventions have been tested concurrently to reduce racial and ethnic inequities in stroke preparedness, care, recovery, and risk factor control. It is regrettable that no common theoretical framework has been used to facilitate comparison of interventions. In this scientific statement, we summarize, across the stroke continuum of care, trials of interventions addressing racial and ethnic inequities in stroke care and outcomes. We reviewed the literature on interventions to address racial and ethnic inequities to identify gaps and areas for future research. Although numerous trials tested interventions aimed at reducing inequities in prehospital, acute care, transitions in care, and poststroke risk factor control, few addressed inequities in rehabilitation, recovery, and social reintegration. Most studies addressed proximate determinants (eg, medication adherence, health literacy, and health behaviors), but upstream determinants (eg, structural racism, housing, income, food security, access to care) were not addressed. A common theoretical model of social determinants can help researchers understand the heterogeneity of social determinants, inform future directions in stroke inequities research, support research in understudied areas within the continuum of care, catalyze implementation of successful interventions in additional settings, allow for comparison across studies, and provide insight into whether addressing upstream or downstream social determinants has the strongest effect on reducing inequities in stroke care and outcomes.

Health Equity and Actionable Disparities in Stroke: 2021 Update.

There are stark inequities in stroke incidence, prevalence, acute care, rehabilitation, risk factor control, and outcomes. To address these inequities, it is critical to engage communities in identifying priorities and designing, implementing, and disseminating interventions. This issue of Stroke features health equity themed lectures delivered during the International Stroke Conference and Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving meetings in 2021 as well as articles covering issues of disparities and diversity in stroke. Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, received the 2021 William Feinberg Award Lecture for his lifetime achievements in seeking global and local solutions to cerebrovascular health inequities. The second annual Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving symposium, which took place the day before the International Stroke Conference in February 2021, focused on community-engaged research for reducing inequities in stroke. Phil Gorelick, MD was awarded the Edgar J. Kenton III Award for his lifetime achievements in using community engagement strategies to recruit and retain Black participants in observational studies and clinical trials. Walter Koroshetz, MD, Director of the National Institute of Neurological Disorders and Stroke delivered the keynote lecture on stroke inequities and Richard Benson, MD, PhD, Director of the Office of Global Health and Health Disparities at National Institute of Neurological Disorders and Stroke, gave a lecture focused on National Institute of Neurological Disorders and Stroke efforts to address inequities. Nichols et al highlighted approaches of community-based participatory research to address stroke inequities. Verma et al showcased digital health innovations to reduce inequities in stroke. Das et al showed that the proportion of underrepresented in medicine vascular neurology fellows has lowered over the past decade and authors provided a road map for enhancing the diversity in vascular neurology. Clearly, to overcome inequities, multipronged strategies are required, from broadening representation among vascular neurology faculty to partnering with communities to conduct research with meaningful impact.

Prevalence and Predictors of Food Insecurity Among Stroke Survivors in the United States.

BACKGROUND: Food insecurity (FI)-lack of consistent access to food due to poor financial resources-limits the ability to eat a healthy diet, which is essential for secondary stroke prevention. Yet, little is known about FI in stroke survivors. METHODS: Using data from the US National Health and Nutrition Examination Survey from 1999 to 2015, we analyzed the prevalence, predictors, and temporal trends in FI among adults with and without self-reported prior stroke in this cross-sectional study. Age-standardized prevalence estimates were computed by self-reported history of stroke over survey waves. Multivariable logistic regression models were performed for the National Health and Nutrition Examination Survey participants who had a prior stroke to identify independent predictors of FI by self-reported history of stroke. RESULTS: Among 48 242 adults ≥20 years of age, 1877 self-reported history of stroke. FI was more prevalent among people with prior stroke (17%) versus those without prior stroke (12%; P<0.001). Prevalence of FI increased over time from 7.8% in 1999 to 42.1% in 2015 among stroke survivors and from 8% to 17% among individuals without prior stroke (P<0.001). The age-standardized prevalence of FI over the entire time was 24% among stroke survivors versus 11% among individuals without prior stroke (P<0.001). In the adjusted model, younger age (adjusted odds ratio [aOR], 0.96 [0.95-0.97]; P<0.01), Hispanic ethnicity (aOR, 2.12 [1.36-3.31]; P<0.01), lower education (aOR, 1.67 [1.17-2.38]; P<0.01), nonmarried status (aOR, 1.49 [1.01-2.19]; P=0.04), and poverty income ratio <130% (aOR, 3.78 [2.55-5.59]; P<0.01) were associated with FI in those with prior stroke. CONCLUSIONS: One in 3 stroke survivors reported FI in 2015, nearly double the prevalence in those without stroke. Addressing the fundamental drivers of FI and targeting vulnerable demographic groups may have a profound influence on stroke prevalence.

Moving Towards Equity With Digital Health Innovations for Stroke Care.

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years.

BACKGROUND: There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. METHODS: Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. RESULTS: The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups. CONCLUSIONS: Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association.

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium.

Race/ethnic minorities face significant inequities in stroke incidence, prevalence, care, and outcomes. The Health Equity and Actionable Disparities in Stroke: Understanding and Problem-solving symposium, a collaborative initiative of the American Heart Association and National Institute of Neurological Disorders and Stroke, was the first-ever annual multidisciplinary scientific forum focused on race/ethnic inequities in cerebrovascular disease, with the overarching goal of reducing inequities in stroke and accelerating the translation of research findings to improve outcomes for race/ethnic minorities. The symposium featured esteemed invited plenary speakers, lecturing on determinants of race/ethnic inequities in stroke and interventions aimed at redressing the inequities. The Edgar J. Kenton III Award recognized Ralph Sacco, MD, MS, for his lifetime contributions to investigation, management, mentorship, and community service in the field of stroke inequities. Early career investigators were provided with travel awards to attend the symposium; presented their research at moderated poster and Think Tank sessions; received career development advice at the Building Momentum session; and networked with experienced stroke inequities researchers. Future conferences-The Health Equity and Actionable Disparities in Stroke: Understanding and Problem-solving 2021 to 2024-will broaden the focus to include 5 major persistent inequities (race/ethnic, sex, geographic, socioeconomic, and global). Each year will focus on a different theme (community and stakeholder engagement; clinical trials; implementation science; and policy and dissemination). By fostering a community of stroke inequities researchers, we hope to highlight promising work, illuminate research gaps, facilitate networking, inform policy makers, recognize achievement, inspire greater interest among junior investigators to pursue careers in this field, and provide networking opportunities for underrepresented minority scientists.

Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality.

BACKGROUND AND PURPOSE: The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata. METHODS: Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme. RESULTS: There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51-0.59], P<0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57-0.73], P<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94-1.0], P=0.086; large towns, 1.05 [1.01-1.09], P=0.009; small towns, 1.10 [1.06-1.15], P<0.001; micropolitan rural, 1.16 [1.11-1.21], P<0.001; and remote rural 1.21 [1.15-1.27], P<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00-1.26], P<0.001) to 2017 (adjusted odds ratio, 1.27 [1.13-1.42], P<0.001). CONCLUSIONS: Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.

Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk.

Background and Purpose- Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods- We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results- The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions- A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00861081.

Factors Associated With Participation in the Chronic Disease Self-Management Program: Findings From the SUCCEED Trial.

BACKGROUND AND PURPOSE: Self-management programs may improve quality of life and self-efficacy for stroke survivors, but participation is low. In a randomized controlled trial of a complex, multidisciplinary, team-based secondary stroke prevention intervention, we offered participants Chronic Disease Self-Management Program (CDSMP) workshops in addition to clinic visits and home visits. To enhance participation, workshops were facilitated by community health workers who were culturally and linguistically concordant with most participants and scheduled CDSMP sessions at convenient venues and times. Over time, we implemented additional strategies such as free transportation and financial incentives. In this study, we aimed to determine factors associated with CDSMP participation and attendance. METHODS: From 2014 to 2018, 18 CDSMP workshop series were offered to 241 English and Spanish-speaking individuals (age ≥40 years) with recent stroke or transient ischemic attack. Zero-inflated Poisson regression was used to identify factors associated with participation and attendance (ie, number of sessions attended) in CDSMP. Missing values were imputed using multiple imputation methods. RESULTS: Nearly one-third (29%) of intervention subjects participated in CDSMP. Moderate disability and more clinic/home visits were associated with participation. Participants with higher numbers of clinic and home visits (incidence rate ratio [IRR], 1.06 [95% CI, 1.01-1.12]), severe (IRR, 2.34 [95% CI, 1.65-3.31]), and moderately severe disability (IRR, 1.55 [95% CI, 1.07-2.23]), and who enrolled later in the study (IRR, 1.12 [95% CI, 1.08-1.16]) attended more sessions. Individuals with higher chaos scores attended fewer sessions (IRR, 0.97 [95% CI, 0.95-0.99]). CONCLUSIONS: Less than one-third of subjects enrolled in the SUCCEED (Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities) intervention participated in CDSMP; however, participation improved as transportation and financial barriers were addressed. Strategies to address social determinants of health contributing to chaos and engage individuals in healthcare may facilitate attendance. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01763203.

Results of a Pilot Trial of a Lifestyle Intervention for Stroke Survivors: Healthy Eating and Lifestyle after Stroke.

OBJECTIVES: Although healthy lifestyle practices mitigate recurrent stroke risk and mortality, few stroke survivors adhere to them, particularly among socioeconomically disadvantaged communities. We developed and pilot tested a occupational therapy-based lifestyle management intervention, Healthy Eating And Lifestyle after Stroke (HEALS), to improve stroke survivors' self-management skills relating to diet and physical activity and evaluated it in a diverse safety-net population. MATERIALS AND METHODS: One hundred English- or Spanish-speaking participants with stroke or transient ischemic attack were randomized to a 6-week occupational therapist-led group lifestyle intervention vs. usual care. Each of the six 2-h group sessions included didactic presentations on diet and physical activity, peer exchange, personal exploration with goal setting, and direct experience through participation in a relevant activity. Primary outcomes at 6 months were change in body mass index, fruit/vegetable intake, and physical activity. Secondary outcomes included change in waist circumference, smoking, blood pressure, high-density lipoprotein, low-density lipoprotein, triglyceride, total cholesterol, glycosylated hemoglobin levels, quality of care, and perceptions of care. Effect sizes were determined in preparation for a larger randomized controlled trial powered to detect a difference in primary outcomes. A nested formative evaluation assessed facilitators and barriers to implementation, acceptance, and intervention adherence. RESULTS: There were no significant changes in primary or secondary outcomes at 6 months. Effect sizes for all outcomes were small (< 0.2). Focus group participants recommended extending the intervention program duration with more sessions, additional information on stroke and vascular risk factors, an interdisciplinary approach, additional family involvement, and incentives. Providers recommended longer program duration, more training, fidelity checks to ensure standardized program delivery, and additional incentives for participants. CONCLUSIONS: The HEALS intervention was feasible in a safety-net setting, but effect sizes were small. A longer-duration intervention, with intervener fidelity checks may be warranted. TRIAL REGISTRATION: NCT01550822.

Low-Calorie Sweetened Beverages and Cardiometabolic Health: A Science Advisory From the American Heart Association.

In the United States, 32% of beverages consumed by adults and 19% of beverages consumed by children in 2007 to 2010 contained low-calorie sweeteners (LCSs). Among all foods and beverages containing LCSs, beverages represent the largest proportion of LCS consumption worldwide. The term LCS includes the 6 high-intensity sweeteners currently approved by the US Food and Drug Administration and 2 additional high-intensity sweeteners for which the US Food and Drug Administration has issued no objection letters. Because of a lack of data on specific LCSs, this advisory does not distinguish among these LCSs. Furthermore, the advisory does not address foods sweetened with LCSs. This advisory reviews evidence from observational studies and clinical trials assessing the cardiometabolic outcomes of LCS beverages. It summarizes the positions of government agencies and other health organizations on LCS beverages and identifies research needs on the effects of LCS beverages on energy balance and cardiometabolic health. The use of LCS beverages may be an effective strategy to help control energy intake and promote weight loss. Nonetheless, there is a dearth of evidence on the potential adverse effects of LCS beverages relative to potential benefits. On the basis of the available evidence, the writing group concluded that, at this time, it is prudent to advise against prolonged consumption of LCS beverages by children. (Although water is the optimal beverage choice, children with diabetes mellitus who consume a balanced diet and closely monitor their blood glucose may be able to prevent excessive glucose excursions by substituting LCS beverages for sugar-sweetened beverages [SSBs] when needed.) For adults who are habitually high consumers of SSBs, the writing group concluded that LCS beverages may be a useful replacement strategy to reduce intake of SSBs. This approach may be particularly helpful for persons who are habituated to a sweet-tasting beverage and for whom water, at least initially, is an undesirable option. Encouragingly, self-reported consumption of both SSBs and LCS beverages has been declining in the United States, suggesting that it is feasible to reduce SSB intake without necessarily substituting LCS beverages for SSBs. Thus, the use of other alternatives to SSBs, with a focus on water (plain, carbonated, and unsweetened flavored), should be encouraged.

Less Than Ideal: Trends in Cardiovascular Health Among US Stroke Survivors.

Background and Purpose- The American Heart Association's Life's Simple 7 (LS7) defines ideal cardiovascular health by 7 metrics: not smoking, regular physical activity, normal body mass index, blood pressure, plasma glucose, and total cholesterol levels, and a healthy diet. We assessed prevalence and predictors of ideal LS7 among US stroke survivors. Methods- Among 67 514 participants in the National Health and Nutrition Examination Surveys from 1988 to 1994 and 1999 to 2014, 1597 adults (≥18 years) had self-reported history of stroke. LS7 metrics were categorized as poor, intermediate, and ideal; ideal LS7 scores were calculated (1 point for each ideal metric met). Trends in poor, intermediate, and ideal cardiovascular health were assessed. Odds of low (0-1) versus high (≥4) ideal LS7 scores were assessed according to sex, race, poverty income ratio, and education level, before and after adjusting for covariates. Results- Only 1 participant met all ideal LS7 metrics. The proportion with low LS7 score increased from 17.9% in 1988 to 1994 to 35.4% in 2011 to 2014 (P<0.001). Over that time frame, prevalence of poor blood pressure (≥140/90 mm Hg) and poor cholesterol (≥240 mg/dL) decreased (45.2%-26.5% and 37.2%-10.3%), whereas prevalence of poor body mass index (≥30 kg/m2), poor diet (healthy eating index score <50), and poor physical activity (0 minutes moderate/vigorous activity per week) increased (26.9%-39.0%; 14.2%-50.6%; 44.6%-70.9%; all P<0.05). After adjustment, black race (odds ratio, 2.29; 95% CI, 1.17-4.48), poverty income ratio ≤200% (odds ratio, 2.20, 95% CI, 1.11-4.36), and ≤12th grade education (odds ratio, 4.50; 95% CI, 2.27-8.92) were associated with low ideal LS7 scores. Conclusions- Over the past 3 decades, blood pressure and cholesterol control among stroke survivors improved, but rates of obesity, poor diet, and physical inactivity increased. Stroke survivors who are black, poor, or less educated are less likely to have ideal cardiovascular health.

Effect of Dysphagia Screening Strategies on Clinical Outcomes After Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke.

INTRODUCTION: Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. The American Heart Association convened an evidence review committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke. METHODS: The Medline, Embase, and Cochrane databases were searched on November 1, 2016, to identify randomized controlled trials (RCTs) comparing dysphagia screening protocols or quality interventions with increased dysphagia screening rates and reporting outcomes of pneumonia, death, or dependency. RESULTS: Three RCTs were identified. One RCT found that a combined nursing quality improvement intervention targeting fever and glucose management and dysphagia screening reduced death and dependency but without reducing the pneumonia rate. Another RCT failed to find evidence that pneumonia rates were reduced by adding the cough reflex to routine dysphagia screening. A smaller RCT randomly assigned 2 hospital wards to a stroke care pathway including dysphagia screening or regular care and found that patients on the stroke care pathway were less likely to require intubation and mechanical ventilation; however, the study was small and at risk for bias. CONCLUSIONS: There were insufficient RCT data to determine the effect of dysphagia screening protocols on reducing the rates of pneumonia, death, or dependency after stroke. Additional trials are needed to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia.

Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke.

INTRODUCTION: Endovascular thrombectomy is a highly efficacious treatment for large vessel occlusion (LVO). LVO prediction instruments, based on stroke signs and symptoms, have been proposed to identify stroke patients with LVO for rapid transport to endovascular thrombectomy-capable hospitals. This evidence review committee was commissioned by the American Heart Association/American Stroke Association to systematically review evidence for the accuracy of LVO prediction instruments. METHODS: Medline, Embase, and Cochrane databases were searched on October 27, 2016. Study quality was assessed with the Quality Assessment of Diagnostic Accuracy-2 tool. RESULTS: Thirty-six relevant studies were identified. Most studies (21 of 36) recruited patients with ischemic stroke, with few studies in the prehospital setting (4 of 36) and in populations that included hemorrhagic stroke or stroke mimics (12 of 36). The most frequently studied prediction instrument was the National Institutes of Health Stroke Scale. Most studies had either some risk of bias or unclear risk of bias. Reported discrimination of LVO mostly ranged from 0.70 to 0.85, as measured by the C statistic. In meta-analysis, sensitivity was as high as 87% and specificity was as high as 90%, but no threshold on any instruments predicted LVO with both high sensitivity and specificity. With a positive LVO prediction test, the probability of LVO could be 50% to 60% (depending on the LVO prevalence in the population), but the probability of LVO with a negative test could still be ≥10%. CONCLUSIONS: No scale predicted LVO with both high sensitivity and high specificity. Systems that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. More prospective studies are needed to assess the accuracy of LVO prediction instruments in the prehospital setting in all patients with suspected stroke, including patients with hemorrhagic stroke and stroke mimics.

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.