Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020.

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Call 911: Lower Ambulance Utilization Among Young Adults, Especially Women, with Stroke.

BACKGROUND: Delayed presentation to the emergency department influences acute stroke care and can result in worse outcomes. Despite public health messaging, many young adults consider stroke as a disease of older people. We determined the differences in ambulance utilization and delays to hospital presentation between women and men as well as younger (18-44 years) versus older (≥45 years) patients with stroke. METHODS: We conducted a population-based retrospective study using national administrative health data from the Canadian Institute of Health Information databases and examined data between 2003 and 2016 to compare ambulance utilization and time to hospital presentation across sex and age. RESULTS: Young adults account for 3.9% of 463,310 stroke/transient ischemic attack/hemorrhage admissions. They have a higher proportion of hemorrhage (37% vs. 15%) and fewer ischemic events (50% vs. 68%) compared with older patients. Younger patients are less likely to arrive by ambulance (62% vs. 66%, p < 0.001), with younger women least likely to use ambulance services (61%) and older women most likely (68%). Median stroke onset to hospital arrival times were 7 h for older patients and younger men, but 9 h in younger women. There has been no improvement among young women in ambulance utilization since 2003, whereas ambulance use increased in all other groups. CONCLUSIONS: Younger adults, especially younger women, are less likely to use ambulance services, take longer to get to hospital, and have not improved in utilization of emergency services for stroke over 13 years. Targeted public health messaging is required to ensure younger adults seek emergency stroke care.

Shifting Trend of Transient Ischemic Attack Admission and Prognosis in Canada.

BACKGROUND: Stroke is often preceded by transient symptoms. Although global stroke rates have been shown to be declining, previous studies have reported inconsistent temporal trends of transient ischemic attacks (TIA). The objective of the current study is to report the temporal trends of TIA admissions and outcomes in Canada over the last 11 years. METHODS: We conducted a complete population cohort study using a national administrative database to study the temporal trend of age- and sex-adjusted TIA admission rates in Canada from 2003 to 2013. We also determined the rates of TIA and stroke diagnoses in the emergency department in the province of Ontario during the same period. We used multivariable analyses to study discharge location after acute hospitalization as well as 90-day stroke and/or TIA readmission rates. RESULTS: Of 425,799 admissions to an acute care hospital for all stroke and TIA, 71,443 (16.8%) were TIA. The age- and sex-standardized rates of TIA admission decreased significantly during the study period from 30.0 to 20.6 per 100,000 (p<0.0001). In Ontario, decreasing TIA admissions is mirrored by decreasing rates of TIA directly discharged from the emergency department (55.1 to 46.8 per 100,000, p = 0.002). The odds of 90-day readmission rates for stroke or TIA are also decreasing (adjusted odds ratio, 0.97; 95% confidence interval, 0.96-0.99). CONCLUSIONS: We show that TIA admission rates have declined in the past 11 years in Canada, reflecting improved vascular risk reduction and stroke care. Future studies to confirm our findings on improved stroke or TIA recurrence rates are necessary.

The Impact of Transferring Stroke Patients: An Analysis of National Administrative Data.

BACKGROUND: Interhospital transfer is an important but resource-intensive pattern of care. The use for stroke patients is highly dependent upon health system structure. We examined the impact of hospital transfers for stroke care in Canada. METHODS: We analyzed hospital administrative data within the Canadian Institute for Health Information (CIHI) Database for the 3 fiscal years 2011/12, 2012/13 and 2013/14. Patients with clinical stroke syndrome (ischemic or hemorrhagic) were identified using International Classification of Diseases. Stroke centers were defined by Heart & Stroke Foundation of Canada stroke report. RESULTS: During the 3-year period,397 patients in Canada (excluding Quebec) were admitted to hospital for clinical stroke syndrome. Median age was 75 (interquartile range [IQR] 64-84) years; 50.6 % were male. Less than 5% (n=4030) of patients were transferred. Patients transferred to stroke centers were younger (p<0.001) and had shorter median length of stay (p<0.001). The highest probability of discharge home was associated with sole care at stroke center (43.8%). Transfer to stroke center from community hospital had the highest probability for discharge to rehabilitation facility (25%) and lowest to either long-term (2.1%) or complex community care (2.0%). Transferred patients had lower mortality at discharge. CONCLUSION: Younger patients were transferred more frequently to stroke centers; older patients were more likely treated in community hospitals. Sole stroke center care was associated with high discharge rate to home; transfer to a stroke center was associated with high discharge rate to rehabilitation and lower mortality rates.

Stroke Prevalence, Mortality and Disability-Adjusted Life Years in Children and Youth Aged 0-19 Years: Data from the Global and Regional Burden of Stroke 2013.

BACKGROUND: There is increasing recognition of stroke as an important contributor to childhood morbidity and mortality. Current estimates of global childhood stroke burden and its temporal trends are sparse. Accurate and up-to-date estimates of childhood stroke burden are important for planning research and the resulting evidence-based strategies for stroke prevention and management. OBJECTIVES: To estimate the prevalence, mortality and disability-adjusted life years (DALYs) for ischemic stroke (IS), hemorrhagic stroke (HS) and all stroke types combined globally from 1990 to 2013. METHODOLOGY: Stroke prevalence, mortality and DALYs were estimated using the Global Burden of Disease 2013 methods. All available data on stroke-related incidence, prevalence, excess mortality and deaths were collected. Statistical models and country-level covariates were employed to produce comprehensive and consistent estimates of prevalence and mortality. Stroke-specific disability weights were used to estimate years lived with disability and DALYs. Means and 95% uncertainty intervals (UIs) were calculated for prevalence, mortality and DALYs. The median of the percent change and 95% UI were determined for the period from 1990 to 2013. RESULTS: In 2013, there were 97,792 (95% UI 90,564-106,016) prevalent cases of childhood IS and 67,621 (95% UI 62,899-72,214) prevalent cases of childhood HS, reflecting an increase of approximately 35% in the absolute numbers of prevalent childhood strokes since 1990. There were 33,069 (95% UI 28,627-38,998) deaths and 2,615,118 (95% UI 2,265,801-3,090,822) DALYs due to childhood stroke in 2013 globally, reflecting an approximately 200% decrease in the absolute numbers of death and DALYs in childhood stroke since 1990. Between 1990 and 2013, there were significant increases in the global prevalence rates of childhood IS, as well as significant decreases in the global death rate and DALYs rate of all strokes in those of age 0-19 years. While prevalence rates for childhood IS and HS decreased significantly in developed countries, a decline was seen only in HS, with no change in prevalence rates of IS, in developing countries. The childhood stroke DALY rates in 2013 were 13.3 (95% UI 10.6-17.1) for IS and 92.7 (95% UI 80.5-109.7) for HS per 100,000. While the prevalence of childhood IS compared to childhood HS was similar globally, the death rate and DALY rate of HS was 6- to 7-fold higher than that of IS. In 2013, the prevalence rate of both childhood IS and HS was significantly higher in developed countries than in developing countries. Conversely, both death and DALY rates for all stroke types were significantly lower in developed countries than in developing countries in 2013. Men showed a trend toward higher childhood stroke death rates (1.5 (1.3-1.8) per 100,000) than women (1.1 (0.9-1.5) per 100,000) and higher childhood stroke DALY rates (120.1 (100.8-143.4) per 100,000) than women (90.9 (74.6-122.4) per 100,000) globally in 2013. CONCLUSIONS: Globally, between 1990 and 2013, there was a significant increase in the absolute number of prevalent childhood strokes, while absolute numbers and rates of both deaths and DALYs declined significantly. The gap in childhood stroke burden between developed and developing countries is closing; however, in 2013, childhood stroke burden in terms of absolute numbers of prevalent strokes, deaths and DALYs remained much higher in developing countries. There is an urgent need to address these disparities with both global and country-level initiatives targeting prevention as well as improved access to acute and chronic stroke care.

Ten-year trends in stroke admissions and outcomes in Canada.

BACKGROUND: We analyzed a 10-year stroke administrative dataset to examine trends in admissions, mortality, and discharge destination in Canada. METHODS: We conducted an analysis of hospital administrative data from April 1st 2003 to March 31st 2013 from the Canadian Institute of Health Information's Discharge Abstract Database. Ten-year trends for population-based age- and sex-standardized admission rates were calculated. We reviewed 10-year trends in absolute stroke admissions for differences between provinces and age groups. Stroke 30-day in-hospital mortality rates were calculated and adjusted for sex, age, stroke type and comorbidities. We documented changes in discharge location for ischemic and hemorrhagic stroke patients discharged from acute care. RESULTS: The rate of hospital admissions has declined from 140.2 to 117.5 (per 100,000 people). The number of absolute stroke admissions within provinces increased in Alberta and British Columbia (21.7% and 16.2% respectively). The proportion of stroke patients aged 40-69 years old increased by 4.8% (p<0.0001) over the 10 years, whereas the proportion aged over 70 decreased by 4.9% (p<0.0001). Risk-adjusted 30-day in-hospital mortality decreased from: 18.5% to 14.9% for all strokes; 15.2% to 12.1% for ischemic strokes; 35.6% to 29.7% for intracerebral hemorrhage; and 25.1% to 18.0% for subarachnoid hemorrhage. The absolute increase in patients requiring inpatient and outpatient support increased by 4% (p<0.0001). CONCLUSION: The rate of admissions for stroke is decreasing but there is an increase in stroke admissions for younger patients. In-hospital mortality is decreasing; fewer patients are going directly home without services and more are requiring support services.

A Survey of Female-Specific Cardiovascular Protocols in Emergency Departments in Canada.

Background: Cardiovascular diseases (CVD) remain the leading cause of death for women. However, systematic inequalities exist in how women experience clinical cardiovascular (CV) policies, programs, and initiatives. Methods: In collaboration with the Heart and Stroke Foundation of Canada, a question regarding female-specific CV protocols in an emergency department (ED), or an inpatient or ambulatory care area of a healthcare site was sent via e-mail to 450 healthcare sites in Canada. Contacts at these sites were established through the larger initiative-the Heart Failure Resources and Services Inventory-conducted by the foundation. Results: Responses were received from 282 healthcare sites, with 3 sites confirming the use of a component of a female-specific CV protocol in the ED. Three sites noted using sex-specific troponin levels in the diagnosis of acute coronary syndromes; 2 of the sites are participants in the hs-cTn-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE MI) trial. One site reported the integration of a female-specific CV protocol component into routine use. Conclusions: We have identified an absence of female-specific CVD protocols in EDs that may be associated with the identified poorer outcomes in women impacted by CVD. Female-specific CV protocols may serve to increase equity and ensure that women with CV concerns have access to the appropriate care in a timely manner, thereby helping to mitigate some of the current adverse effects experienced by women who present to Canadian EDs with CV symptoms.

Contexte: Les maladies cardiovasculaires (MCV) demeurent la principale cause de décès chez les femmes. Toutefois, il existe des inégalités systématiques à l'égard des femmes dans les politiques, les programmes et les initiatives cliniques cardiovasculaires (CV). Méthodologie: En collaboration avec la Fondation des maladies du cœur et de l'AVC du Canada, une question relative à l'utilisation de protocoles de prise en charge des manifestations cardiovasculaires spécifiques aux femmes dans les services d'urgence ou les services de soins pour patients hospitalisés et ambulatoires a été envoyée par courriel à 450 établissements de santé au Canada. Les contacts ont été établis dans ces centres dans le cadre d'une initiative de plus grande envergure, l'inventaire des ressources et des services en matière d'insuffisance cardiaque, menée par la Fondation. Résultats: Des réponses ont été reçues de 282 établissements de santé; dont trois ont confirmé l'utilisation d'une composante spécifique aux femmes dans leurs protocoles de prise en charge des manifestations CV dans leur service des urgences. Trois centres ont déclaré utiliser un taux de troponine adapté au sexe pour le diagnostic du syndrome coronarien aigu; or, deux de ces centres participent à l'essai CODE MI (hs-cTn­Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women), qui porte sur l'optimisation du diagnostic de l'infarctus du myocarde aigu ou des atteintes myocardiques chez les femmes. Un seul centre a signalé l'intégration d'une composante spécifique aux femmes dans son protocole CV en pratique courante. Conclusions: Nous avons constaté que l'absence de protocoles spécifiques aux femmes en matière de prise en charge des manifestations CV dans les services d'urgences pourrait être associée aux moins bons résultats observés chez les femmes atteintes de MCV. Des protocoles spécifiques aux femmes en matière de prise en charge des manifestations CV pourraient contribuer à accroître l'équité et à faire en sorte que les femmes souffrant de problèmes CV aient accès aux soins appropriés en temps opportun. Une telle initiative contribuerait à atténuer certains des effets indésirables dont sont victimes les femmes qui se présentent aux urgences des établissements de soins canadiens avec des symptômes CV.

Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory.

BACKGROUND: The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. METHODS: A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings. RESULTS: HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks. CONCLUSIONS: Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

Exploring the Poststroke Experiences and Needs of South Asian Communities Living in High-Income Countries: Findings from a Scoping Review.

Despite the high prevalence of stroke among South Asian communities in high-income countries, a comprehensive understanding of their unique experiences and needs after stroke is lacking. This study aimed to synthesize the literature examining the experiences and needs of South Asian community members impacted by stroke and their family caregivers residing in high-income countries. A scoping review methodology was utilized. Data for this review were identified from seven databases and hand-searching reference lists of included studies. Study characteristics, purpose, methods, participant characteristics, results, limitations, recommendations, and conclusions were extracted. Data were analyzed using descriptive qualitative analysis. In addition, a consultative focus group exercise with six South Asian community members who had experienced a stroke and a program facilitator was conducted to inform the review interpretations. A total of 26 articles met the inclusion criteria and were analyzed. Qualitative analysis identified four descriptive categories: (1) rationale for studying the South Asian stroke population (e.g., increasing South Asian population and stroke prevalence), (2) stroke-related experiences (e.g., managing community support versus stigma and caregiving expectations), (3) stroke service challenges (e.g., language barriers), and (4) stroke service recommendations to address stroke service needs (e.g., continuity of care). Several cultural factors impacted participant experiences, including cultural beliefs about illness and caregiving. Focus group participants from our consultation activity agreed with our review findings. The clinical and research recommendations identified in this review support the need for culturally appropriate services for South Asian communities across the stroke care continuum; however, more research is necessary to inform the design and structure of culturally appropriate stroke service delivery models.

Endovascular thrombectomy with or without intravenous alteplase for acute ischemic stroke due to large vessel occlusion: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Among patients who had an ischaemic stroke presenting directly to a stroke centre where endovascular thrombectomy (EVT) is immediately available, there is uncertainty regarding the role of intravenous thrombolysis agents before or concurrently with EVT. To support a rapid guideline, we conducted a systematic review and meta-analysis to examine the impact of EVT alone versus EVT with intravenous alteplase in patients who had an acute ischaemic stroke due to large vessel occlusion. METHODS: In November 2021, we searched MEDLINE, Embase, PubMed, Cochrane, Web of Science, clincialtrials.gov and the ISRCTN registry for randomised controlled trials (RCTs) comparing EVT alone versus EVT with alteplase for acute ischaemic stroke. We conducted meta-analyses using fixed effects models and assessed the certainty of evidence using the GRADE approach. RESULTS: In total 6 RCTs including 2334 participants were eligible. Low certainty evidence suggests that, compared with EVT and alteplase, there is possibly a small decrease in the proportion of patients independent with EVT alone (risk ratio (RR) 0.97, 95% CI 0.89 to 1.05; risk difference (RD) -1.5%; 95% CI -5.4% to 2.5%), and possibly a small increase in mortality with EVT alone (RR 1.07, 95% CI 0.88 to 1.29; RD 1.2%, 95% CI -2.0% to 4.9%) . Moderate certainty evidence suggests that there is probably a small decrease in symptomatic intracranial haemorrhage (sICH) with EVT alone (RR 0.75, 95% CI 0.52 to 1.07; RD -1.0%; 95%CI -1.8% to 0.27%). CONCLUSIONS: Low certainty evidence suggests that there is possibly a small decrease in the proportion of patients that achieve functional independence and a small increase in mortality with EVT alone. Moderate certainty evidence suggests that there is probably a small decrease in sICH with EVT alone. The accompanying guideline provides contextualised guidance based on this body of evidence. PROSPERO REGISTRATION NUMBER: CRD42021249873.

Canadian Stroke Best Practice Recommendations: Virtual Stroke Rehabilitation Interim Consensus Statement 2022.

ABSTRACT: The seventh edition of the Canadian Stroke Best Practice Recommendations for Rehabilitation and Recovery following Stroke includes a new section devoted to the provision of virtual stroke rehabilitation. This consensus statement uses Grading of Recommendations, Assessment, Development and Evaluations methodology and Appraisal of Guidelines for Research & Evaluation II principles. A literature search was conducted using PubMed, Embase, and Cochrane databases. An expert writing group reviewed all evidence and developed recommendations, as well as consensus-based clinical considerations where evidence was insufficient for a recommendation. All recommendations underwent internal and external review. These recommendations apply to hospital, ambulatory care, and community-based settings where virtual stroke rehabilitation is provided. This guidance is relevant to health professionals, people living with stroke, healthcare administrators, and funders. Recommendations address issues of access, eligibility, consent and privacy, technology and planning, training and competency (for healthcare providers, patients and their families), assessment, service delivery, and evaluation. Virtual stroke rehabilitation has been shown to safely and effectively increase access to rehabilitation therapies and care providers, and uptake of these recommendations should be a priority in rehabilitation settings. They are key drivers of access to high-quality evidence-based stroke care regardless of geographical location and personal circumstances in Canada.

Endovascular thrombectomy and intravenous alteplase in patients with acute ischemic stroke due to large vessel occlusion: A clinical practice guideline.

AIM: Whether or not use of intravenous alteplase in combination with endovascular thrombectomy (EVT) improves outcomes versus EVT alone, for acute stroke patients with large vessel occlusion presenting directly to a comprehensive stroke center, is uncertain. METHODS: Six randomized trials exploring this issue were published, and we synthesized this evidence to inform a rapid guideline based on the Guidelines International Network principles and guided by the GRADE approach. RESULTS: We enlisted an international panel that included 4 patient partners and 1 caregiver, individuals from 6 countries. The panel considered low certainty evidence that EVT alone, relative to EVT with intravenous alteplase, possibly results in a small decrease in the proportion of patients that achieve functional independence and possibly a small increase in mortality. Both effect estimates were downgraded twice due to very serious imprecision. The panel also considered moderate certainty evidence that EVT alone probably decreases symptomatic intracranial hemorrhage, versus EVT with alteplase, and combination therapy was more costly than EVT alone. As a result of the low certainty for improved recovery without impairment and mortality for combination therapy versus EVT alone, and moderate certainty for increased harm with combination therapy, the panel made a weak recommendation in favor of EVT alone for stroke patients eligible for both treatments, and initially presenting directly to a comprehensive stroke center that provides both treatments. CONCLUSIONS: Consistent with this weak recommendation, optimal patient management will likely often include co-treatment with intravenous alteplase, depending on local circumstances and patient presentation.

Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada.

OBJECTIVES: To determine the incidence rate of inpatient stroke-induced aphasia in Ontario, Canada, and to examine the demographic and clinical characteristics for stroke patients with and without aphasia. DESIGN: Age- and sex-specific incidence rates for aphasia in Ontario were calculated using the Ontario Stroke Audit. In addition, data collected from the Registry of the Canadian Stroke Network (RCSN) were used to determine the demographic and clinical characteristics for stroke patients with and without aphasia. SETTING: All hospitals and regional stroke centers in Ontario, Canada. PARTICIPANTS: The Ontario Stroke Audit is a representative weighted sample of more than 3000 stroke inpatients admitted to emergency departments in all hospitals in Ontario within the 2004/2005 fiscal year. RCSN data included a cohort of more than 15,000 consecutive patients presenting with stroke at 12 regional stroke centers in Ontario from 2003 to 2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Presence of aphasic symptoms on admission to hospital and at discharge, age and sex, stroke type and severity, severity of disability, services received in hospital, length of stay, and discharge destination. RESULTS: Thirty-five percent (1131/3207) of adult patients admitted with a diagnosis of stroke in the province of Ontario during the 2004 to 2005 Ontario Stroke Audit had symptoms of aphasia at the time of discharge. This amounts to an incidence rate of 60 per 100,000 persons per year. Risk of aphasia increased significantly with age. In comparison with nonaphasic stroke patients, patients with aphasia were older, presented with more severe strokes on admission, had more severe disability, and were more frequently discharged to long-term care and/or rehabilitation (unadjusted results). Adjusting for stroke severity, age, sex, comorbidity, and stroke subtype, the presence of aphasia was found to be an independent predictor of longer hospital stays, increased use of rehabilitation services, and higher rates of thrombolytic therapy. CONCLUSIONS: A significant number of people with stroke experience aphasia, with advancing age associated with a higher risk. The profile and patterns for stroke patients with aphasia differed significantly from those who did not experience aphasia as a residual disability after stroke, particularly in relation to service usage. Given the personal and system cost associated with aphasia, best practices in the area of stroke should include recommendations on how to best serve this population throughout the clinical pathway.

People With Lived Experience at the Centre of Canadian Stroke Best Practice Recommendations: A Model for Guideline Developers.

Actively engaging people with lived experience (PWLE) in stroke-related clinical practice guideline development has not been effectively implemented. This pilot project evaluated the feasibility, perceived value, and effectiveness of the Community Consultation and Review Panel (CCRP), a new model to engage PWLE in the writing and review of Canadian Stroke Best Practice Recommendations. Responses to a standardized evaluation tool indicated that participants perceived the CCRP as valued, impactful, effective, and beneficial to stroke care. This project successfully demonstrated that values, experiences, and recommendations of PWLE can be effectively incorporated into guideline content and is applicable to all guideline development processes.

Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD)5: Guidelines for management of vascular cognitive impairment.

INTRODUCTION: Vascular disease is a common cause of dementia, and often coexists with other brain pathologies such as Alzheimer's disease to cause mixed dementia. Many of the risk factors for vascular disease are treatable. Our objective was to review evidence for diagnosis and treatment of vascular cognitive impairment (VCI) to issue recommendations to clinicians. METHODS: A subcommittee of the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed areas of emerging evidence. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assign the quality of the evidence and strength of the recommendations. RESULTS: Using standardized diagnostic criteria, managing hypertension to conventional blood pressure targets, and reducing risk for stroke are strongly recommended. Intensive blood pressure lowering in middle-aged adults with vascular risk factors, using acetylsalicylic acid in persons with VCI and covert brain infarctions but not if only white matter lesions are present, and using cholinesterase inhibitors are weakly recommended. CONCLUSIONS: The CCCDTD has provided evidence-based recommendations for diagnosis and management of VCI for use nationally in Canada, that may also be of use worldwide.