Introduction: Frailty is a clinical syndrome of increased vulnerability to stressors. Frailty is associated with adverse outcomes after stroke, but frailty and transient ischaemic attack (TIA) are less well described. Methods: We conducted a retrospective analysis of patients referred by the emergency department (ED) to TIA clinic (01/01/2016-12/03/2022) linked to hospital records for electronic follow-up. Only those with Clinical Frailty Scale (CFS) recorded within 2 weeks of clinic were included. Prevalence of frailty was determined based on CFS score >= 4. Hazard ratios (HRs) for mortality were determined through Cox proportional hazard regression, adjusted for prognostic factors. Where repeat CFS data were available, temporal change in frailty was recorded (similar to 15 months). Results: Of 1,185 patients included, 53.5% (n = 634) had frailty. Patients with frailty tended to be older (median age 81 vs. 74 years, p < 0.001) and female (53.9% vs. 39.9% p < 0.001). Of 335 diagnosed with TIA following review, 61.2% (n = 205) were frail. Prevalence of frailty by clinic diagnosis was as follows: TIA 61.2% (205/335), stroke 46.7% (128/274), other diagnoses 52.3% (301/575). In TIA patients and the whole cohort (WC), frailty (TIA: HR: 2.69 [95% confidence interval (CI): 1.23-5.87, p = 0.013], WC: 2.58 [95% CI: 1.64-4.08, p < 0.001]), and increasing age [HR: 1.07 95% CI: 1.04-1.12] were predictive of mortality. In stroke patients, only increasing age was predictive of death (HR: 1.11 [95% CI: 1.04-1.19, p = 0.003]). For 414 patients with repeat CFS, the median interval was 15 months and the median change was +1 point (inter-quartile range: 0-2). Conclusion: Frailty is common in TIA and becomes more common following TIA. The strength of the association of frailty with poor outcome was greater for TIA patients than for those with stroke. Routine assessment of frailty may be a useful addition to TIA services. (c) 2024 S. Karger AG, Basel

Introduction: Studies indicate a 13–27% mortality rate following a transient ischaemic attack (TIA). However, outcomes following TIA/minor stroke since the introduction of rapid-access TIA clinics and prompt vascular risk factor intervention are not known. Specifically, there is paucity of data comparing outcomes between people who are diagnosed with an “acute cerebrovascular” (CV) event or an alternative non-cardiovascular diagnosis (non-CV) in a rapid-access TIA clinic. We aimed to assess the mortality in such a setting. Methods: A retrospective observational study was undertaken at the Leicester rapid-access secondary care TIA clinic. Data included information collected at the first clinic visit (including comorbidities, and primary diagnosis, categorized as CV and non-CV) and the date of death for people dying during follow-up. Results: 11,524 subjects were included with 33,164 years of follow-up data; 4,746 (41.2%) received a CV diagnosis. The median follow-up time was 2.75 years (interquartile range 1.36–4.32). The crude mortality rate was 37.3 (95% CI: 35.3–39.5) per 1,000 person-years (PTPY). The mortality rate was higher following a CV diagnosis (50.8 [47.2–54.7] PTPY) compared to a non-CV diagnosis (27.9 [25.7–30.4] PTPY), and for males, older people, those of white ethnicity, and people with orthostatic hypotension (OH). Discussion: This study identified possible risk factors associated with a higher mortality in TIA clinic attendees, who may benefit from specific intervention. Future research should explore the underlying causes and the effect of specific targeted management strategies.

Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.

Introduction: Transient ischaemic attack (TIA) clinics are important for secondary prevention of fatal or disabling stroke. Non-adherence to prescribed medications is an important reason for treatment failure but difficult to diagnose. This study ascer-tained the utility of a novel biochemical tool in the objective biochemical diagnosis of non-adherence. Methods: One-hundred consecutive urine samples collected from patients attending the TIA clinic, at a tertiary centre, were analysed for presence or absence of prescribed cardiovascular medications using liquid chromatography -mass spectrometry (LC-MS/MS). Patients were classified as adherent or non -adher-ent, respectively. Demographic and clinical characteristics were compared between the two cohorts. Univariate regression analyses were performed for individual vari-ables and model fitting was undertaken for significant variables. Results: The mean duration of follow-up from the index event was 31 days [standard deviation (SD): 18.9]. The overall rate of non-adherence for at least one medication was 24%. In uni-variate analysis, the number of comorbidities [3.4 (SD: 1.9) vs. 2.5 (1.9), P = 0.032] and total number of all prescribed medications [6.0 (3.3) vs 4.4 (2.1), P = 0.032] were higher in the non-adherent group. On multivariate analysis, the total number of medications prescribed correlated with increased non-adherence (odds ratio: 1.27, 95% Confidence Intervals: 1.1-1.5, P = 0.01). Conclusions: LC-MS/MS is a clinically useful tool for the diagnosis of non-adherence. Nearly a quarter of TIA patients were non-adherent to their cardiovascular medications Addressing non-adherence early may reduce the risk of future disabling cardiovascular events. (c) 2022 Published by Elsevier Inc.

Organising timely hospital discharge can be a challenge. In this hospital trust, a perceived barrier is delay in generating a TTO (‘to take out’ or discharge summary) letter. There are further steps dependent on this correspondence that must be undertaken before leaving hospital, including pharmacy check of discharge medication, dispensary, arranging transport, nurse sign-off and additional correspondence (eg anticoagulant handover). Projects to facilitate opportune TTO writing have met with limited success: principal barriers being precedence of clinical work, continuity of care at junior doctor level and unwieldy templates (a …

Orthostatic hypotension (OH) and atrial fibrillation (AF) are both regarded as independent risk factors for transient ischemic attack (TIA). However, the clinical implication of OH in the presence of AF is unclear. This study investigates, for the first time, the association between blood pressure (BP), OH and mortality in a cohort of patients with AF and TIA symptoms. To investigate the incidence of the association between OH, AF and TIA. This retrospective observational study utilised the Leicester one-stop transient TIA clinic patient database to consider the initial systolic and diastolic BP of 688 patients with a diagnosis of AF. The primary outcome was time until death. Covariant measures included status of AF diagnosis (known or new AF), cardiovascular risk factors, and primary clinic diagnosis [cerebrovascular (CV) versus non-cerebrovascular (non-CV)]. Statistical models adjusted for sex, age, previous AF diagnosis. Mortality rate was higher in the over 85 age group [191.5 deaths per 1000 person years (py) (95% CI 154.0–238.1)] and lower in the aged 75 and younger age group [40.0 deaths per 1000 py (95% CI 27.0–59.2)] compared to intermediate groups. A 10 mmHg increase in supine diastolic BP was associated with a significant reduction in the hazard of mortality for patients suspected of TIA with AF [adjusted HR 0.79 (95% CI 0.68–0.92), p < 0.001]. The mortality rate for patients with OH was 119.0 deaths per 1000 py compared with a rate of 98.0 for patients without OH (rate ratio 1.2, p = 0.275). Higher diastolic BP may be a marker for reduced mortality risk in patients with a previous AF diagnosis and non-CV diagnosis. Lower diastolic BP and the presence of AF pertain to a higher mortality risk. This study raises the importance of opportunistic screening for both OH and AF in patients presenting to TIA clinic.

In 2007, the UK Department of Health (DOH) published its National Stroke Strategy, which detailed 20 quality markers for delivering a high quality stroke service, one of which was that patients suffering a transient ischaemic attack (TIA) or minor stroke should be investigated and treated more quickly after symptom onset.1Department of Health National stroke Strategy.https://webarchive.nationalarchives.gov.uk/20130104224925/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdfDate: 2007Date accessed: December 5, 2019Google Scholar Interestingly, the National Stroke Strategy also advised that carotid endarterectomy (CEA) should be performed within 48 h of symptom onset, although no evidence was provided to support this threshold. The 2018 European Society of Vascular Surgery (ESVS) guidelines recommend a 14 day threshold,2Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Management of atherosclerotic carotid and vertebral artery disease: 2017 Clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-86Abstract Full Text Full Text PDF PubMed Scopus (435) Google Scholar and this is in line with most international guidelines. Three key drivers underpinning the National Stroke Strategy were: (i) awareness that the highest risk period for recurrent stroke was the first 7–14 days after the index TIA, (ii) “best medical therapy” (BMT) had to be started quickly, while (iii) meta-analyses showed that carotid endarterectomy (CEA) conferred maximum benefit (over BMT) when performed with minimal delay.3Rothwell P.M. Eliasziw M. Gutnikov S.A. Warlow C.P. Barnett H.J.M. For the Carotid Endarterectomy Trialists CollaborationEndarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.Lancet. 2004; 363: 915-924Abstract Full Text Full Text PDF PubMed Scopus (1135) Google Scholar However, when Leicester started planning its own rapid access TIA service, numerous conceptual, logistical, administrative, and financial barriers had to be overcome. These included: (i) family doctors saw no need for urgent referral, as they saw no evidence that secondary care offered expedited pathways for investigation/treatment; (ii) TIA patients were (historically) referred to multiple specialties (Vascular Surgery, Ophthalmology, Neurology, Stroke Medicine), who did not necessarily prioritise TIA referrals; (iii) TIA patients faced an average 32 day delay to be seen by a Stroke Physician/Neurologist and single visit investigations were unavailable; (iv) Vascular Surgeons tended to focus on identifying patients for CEA, while perhaps not always offering an effective service regarding risk factor modification and BMT implementation for the remainder. Only 8–10% of patients in a TIA clinic will have significant carotid stenoses that might benefit from CEA; (v) in Leicester (2006), the median time from symptom onset to CEA was 42 days and efforts by motivated surgeons (on their own) had little impact on reducing delays.4Brown C. Naylor A.R. Improving the provision of carotid endarterectomy in line with UK Government targets will require more than motivated surgeons!.Ann Roy Coll Surg Engl. 2009; 91: 326-329Crossref PubMed Scopus (10) Google Scholar Accordingly, it was clear that a radical overhaul of practice was required. During 2007–2008, a multidisciplinary Working Group (WG) involving Stroke Physicians, Vascular Surgeons, Radiologists, Vascular Technologists, Hospital Administrators, and Commissioners met to develop an integrated TIA service. The WG was positively influenced by the EXPRESS study.5Rothwell P.M. Giles M.F. Chandratheva A. Marquardt L. Geraghty O. Redgrave J.N. et al.Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population based sequential comparison.Lancet. 2007; 370: 1432-1442Abstract Full Text Full Text PDF PubMed Scopus (889) Google Scholar,6Luengo-Fernandez R. Gray A.M. Rothwell P.M. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): a prospective population based sequential comparison.Lancet Neurol. 2009; 8: 235-243Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar EXPRESS showed that a single visit clinic (including magnetic resonance [MR] brain imaging, carotid duplex ultrasound [DUS], electrocardiography [ECG], and baseline blood tests), along with risk factor modification and starting BMT in the clinic (antiplatelet, statins, antihypertensive therapy) was associated with an 80% decrease in 90 day stroke (2.1% vs. 10.3%), a significant reduction in fatal stroke (1% vs. 3%), significantly fewer readmissions for recurrent stroke (2% vs. 8%), and significantly reduced inpatient bed stay (four days per patient), with average hospital savings of £624 per patient.5Rothwell P.M. Giles M.F. Chandratheva A. Marquardt L. Geraghty O. Redgrave J.N. et al.Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population based sequential comparison.Lancet. 2007; 370: 1432-1442Abstract Full Text Full Text PDF PubMed Scopus (889) Google Scholar,6Luengo-Fernandez R. Gray A.M. Rothwell P.M. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): a prospective population based sequential comparison.Lancet Neurol. 2009; 8: 235-243Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar This meant that for a population of a million, an EXPRESS style clinic could prevent about 165 strokes per year, save 4790 hospital bed days per year, and provide a saving of £1.2 million per year (1.4 million Euros) through reduced bed usage and stroke rehabilitation costs.5Rothwell P.M. Giles M.F. Chandratheva A. Marquardt L. Geraghty O. Redgrave J.N. et al.Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population based sequential comparison.Lancet. 2007; 370: 1432-1442Abstract Full Text Full Text PDF PubMed Scopus (889) Google Scholar,6Luengo-Fernandez R. Gray A.M. Rothwell P.M. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): a prospective population based sequential comparison.Lancet Neurol. 2009; 8: 235-243Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar In October 2008, a TIA clinic was funded to run every day of the year. Six suspected TIA patients could be seen in a single visit clinic, staffed by a consultant in Stroke Medicine, supported by specialist nurses and administrative staff. TIA referrals to other specialties ceased. The referring doctor (primary care, ophthalmology, emergency department [ED]) started each patient on 300 mg aspirin and 40 mg simvastatin as soon as a diagnosis of suspected TIA was made and he/she faxed a referral to the clinic, where it was triaged and priority allocated on the basis of the patient's ABCD2 score.7Johnston S.C. Rothwell P.M. Nguyen-Huynh M.N. Giles M.F. Elkins J.S. Bernstein A.L. et al.Validation and refinement of scores to predict very early stroke after transient ischaemic attack.Lancet. 2007; 369: 283-292Abstract Full Text Full Text PDF PubMed Scopus (936) Google Scholar An ABCD2 score of 4–7 defined a “high risk” TIA patient, while a 0–3 score defined a “low risk” patient.7Johnston S.C. Rothwell P.M. Nguyen-Huynh M.N. Giles M.F. Elkins J.S. Bernstein A.L. et al.Validation and refinement of scores to predict very early stroke after transient ischaemic attack.Lancet. 2007; 369: 283-292Abstract Full Text Full Text PDF PubMed Scopus (936) Google Scholar Four “ring fenced” MR slots were allocated to each clinic, based on the assumption that 40% of referrals would be given a non-TIA diagnosis. The initial Key Performance Indicator (KPI) mandated by the Commissioners was that 60% of high risk patients should receive specialist assessment within 24 h of first healthcare contact. High risk patients comprised 50% of all referrals from the outset. The KPI for lower risk patients was that 90% should be seen within seven days of first healthcare contact. All patients received risk factor modification advice and BMT medications were prescribed and started in the clinic. Any patient with an ipsilateral 50–99% carotid stenosis was transferred directly from the clinic to the Vascular Surgery Unit for consideration for expedited CEA. The Vascular Surgery Unit ring fenced two “urgent CEA” theatre slots (Tuesday and Friday mornings) to minimise delays to CEA. The operations were performed by the consultant surgeon allocated to the CEA list, irrespective of whether the patient had been admitted under the care of another consultant surgeon. Over the next 11 years, the service has been accessible to a population of one million people in Leicestershire, but a variety of unforeseen practical and logistical issues had to be resolved. First, was the rapidly increasing referral numbers, which threatened to overwhelm the service. In 2009, 1193 referrals were made, increasing to 1919 in 2013 (60% increase) and 2549 in 2017 (113% increase). Interestingly, and despite repeated advice to referring doctors, 60% of referrals ultimately received a non-TIA diagnosis, a proportion that has not changed. One early lesson, therefore, was that the rapid access TIA clinic was in danger of becoming a “funny turn” service, thereby allowing primary care and the ED to offload non-TIA patients who should have been seen in a different environment. To date, we have not found a solution to this problem. The rapid increase in referrals led to a gradual failure to achieve the 60% KPI for high risk patients and this required a series of modifications to the service. These included: (i) daily appointments increasing from six to 10 (2016) and 13 (2018), provided a registrar was available; (ii) daily number of MR slots increased to six; and (iii) funded consultant Physician time increased from four to six hours daily; (iv) an online electronic referral system with automated appointment scheduling replaced faxes, which avoided delays associated with completing, sending, receiving, and triaging faxes; (v) mobile text messaging of appointments reduced DNA rates; (vi) weekend and bank holiday slots were prioritised for higher risk patients, with more lower risk slots on a Monday; (vii) the proportion of higher risk appointments per clinic was increased, but this led to a reduction in the 90% lower risk KPI; (viii) reallocating referrals, where the most recent symptom was more than four weeks to routine outpatient appointments, on the basis that the risk of stroke was now low; (ix) Ophthalmology referrals were restricted to carotid DUS and ECG, with risk factor management and BMT remaining the responsibility of the referring doctor; (x) overbooking daily appointments on the basis of an 8% DNA rate; (xi) specialist nurses now triaged patients in the morning, investigations were prioritised and ordered and the consultant Stroke Physician then saw each patient when the results were available; and (xii) identification of referrals where clinical details suggested a non-TIA diagnosis generated a standardised rejection letter to the referrer. The latter practice has, however, turned out to be risky, because primary clinical assessment in the community or ED is not always sufficiently rigorous. The next problem related to the definition of “high risk.” There was growing awareness that the ABCD2 score was not the best way to identify high risk patients, unless the patient scored 6 or 7, i.e. general “neurological” and “medical” diagnoses could generate an ABCD2 score of 3–4, if misdiagnosed as a TIA. In addition, the ABCD2 score was unable to predict the presence of a 50–99% carotid stenosis.8Walker J. Isherwood J. Eveson D. Naylor A.R. Triaging TIA/minor stroke patients using the ABCD2 score does not predict those with significant carotid disease.Eur J Vasc Endovasc Surg. 2012; 43: 495-498Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar In 2016, the Royal College of Physicians and then NICE (2018) recommended against the ABCD2 score in favour of considering all patients whose symptom onset was within the preceding seven days as being “high risk of stroke.” This led to over 80% of referrals being classed as “high risk” and 80% of daily appointments were reallocated to being “high risk.” The third issue related to delays in transferring patients to the Vascular Surgeons. It was not uncommon to receive CEA referrals at about 3:00–4:00 p.m., meaning that potential CEA patients did not arrive on the vascular ward until early evening, which delayed initiation of an effective workup for theatre. This was resolved by the Stroke Physician agreeing to review any TIA patient with a 50–99% stenosis first on his/her list, once the investigations were available. Most referrals are now made between 12:00 and13:00 p.m. The fourth issue was raised following an audit showing that 13% suffered recurrent TIA/stroke in the 48–72 h period between being seen in the TIA clinic and undergoing expedited CEA. It was, therefore, decided to add 75 mg clopidogrel to the pre-existing aspirin therapy, with dual antiplatelet therapy (DAPT) starting in the TIA clinic, once MR had excluded haemorrhage. A subsequent audit showed that recurrent TIA/stroke before CEA fell to 3%, without increasing bleeding complications after CEA.9Batchelder A.J. Hunter J. Robertson V. Sandford R. Munshi A. Naylor A.R. Dual antiplatelet therapy prior to expedited carotid surgery reduces recurrent events prior to surgery without increasing peri-operative bleeding complications.Eur J Vasc Endovasc Surg. 2015; 50: 412-419Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar The success of the DAPT policy also means that it is rarely necessary to undertake emergency CEA. The only remaining indications being crescendo TIAs despite DAPT (not encountered so far) or mobile intraluminal thrombus on DUS. To date, no guidelines recommend routine DAPT for ischaemic TIA patients, but this is likely to change following meta-analyses of the CHANCE and POINT randomised trials, which revealed a significant reduction in early recurrent stroke in patients with ischaemic TIAs randomised to DAPT.10Hao Q. Tampi M. O'Donnell M. Foroutan F. Siemieniuk R.A.C. Guyatt G. Clopidogrel plus aspirin versus aspirin alone for acute minor stroke or high risk transient ischaemic attack: systematic review and meta-analysis.BMJ. 2018; 363: k5108Crossref PubMed Scopus (61) Google Scholar The “Rapid Access” TIA clinic has greatly improved the management of TIA in our region (regardless of the aetiology), but it has required regular modifications to maintain its delivery. The 60% KPI for seeing high risk patients within 24 h of first healthcare contact has been exceeded and about 80% of patients with symptomatic 50–99% stenoses undergo CEA within 14 days of symptom onset (45% within seven days). The median delay to CEA in Leicester is currently nine days, compared with 42 in 2006 and the 30 day death/stroke rate remains around 1–2%. Interestingly, the introduction of the TIA clinic in 2008 was immediately associated with a 40% increase in annual CEA numbers, which have since declined considerably, especially over the last three years. This phenomenon (a 25–30% decline in annual symptomatic CEA numbers) has been noted throughout England and Wales and may reflect temporal changes in the aetiology of ischaemic stroke, possibly because more patients are now prescribed statins, antihypertensive, and antiplatelet therapy for primary/secondary risk prevention.11Johal A.S. Loftus I.M. Boyle J.R. Naylor A.R. Waton S. Heikkila K. et al.Changing patterns of carotid endarterectomy between 2011 and 2017 in England: a population based cohort study.Stroke. 2019; 50: 2461-2468Crossref PubMed Scopus (9) Google Scholar This will inevitably disappoint the surgeons, but the remaining TIA patients can be reassured that a dedicated physician led clinic ensures that risk factor modification and BMT implementation can now be delivered more quickly and effectively than ever before.

Objective: Limited data exist to inform blood pressure (BP) thresholds for patients with atrial fibrillation prescribed direct oral anticoagulants (DOAC) therapy in the real world setting. Methods: SBP was measured in 9051 primary care patients in England on DOACs for atrial fibrillation with postinitiation BP levels available within the Clinical Practice Research Datalink. The incidence rate for the primary outcome of the first recorded event (defined as a diagnosis of first stroke, recurrent stroke, myocardial infarction, symptomatic intracranial bleed, or significant gastrointestinal bleed) and of secondary outcomes all-cause mortality and cardiovascular mortality were calculated by postinitiation BP groups. Results: The Cox proportional hazard ratio of an event [crude and adjusted hazard ratio 1.04 (95% confidence interval (CI) 1.00–1.08), P = 0.077 and 0.071, respectively] did not differ significantly with a 10 mmHg increase in SBP. The hazard of all-cause mortality [crude hazard ratio 0.83 (95% CI 0.80–0.86), P = 0.000; adjusted hazard ratio 0.84 (95% CI 0.81–0.87), P = 0.000] and cardiovascular mortality [crude hazard ratio 0.92 (95% CI 0.85–0.99), P = 0.021; adjusted hazard ratio 0.93 (95% CI 0.86–1.00), P = 0.041] demonstrated a significant inverse relationship with a 10 mmHg increase in SBP. Patients with a SBP within 161–210 mmHg had the lowest all-cause death rate, while patients with SBP within 121–140 mmHg had the lowest cardiovascular death rate. Conclusion: SBP values below 161 mmHg are associated higher all-cause mortality, but lower event risk in patients with atrial fibrillation on DOAC therapy. The nadir SBP for lowest event rate was 120 mmHg, for lowest cardiovascular mortality was 130 mmHg and for lowest all-cause mortality was 160 mmHg. This demonstrates a need for a prospective interventional study of BP control after initiation of anticoagulation.

Background: Hypertension immediately after acute ischemic stroke is associated with impaired morbidity and mortality, although there are few data on antihypertensive use immediately after ictus. This randomized, double-blinded, placebo-controlled, parallel-group study explored the hemodynamic effect and safety of oral lisinopril initiated within 24 h after an ictus.Methods: Forty hypertensive (systolic blood pressure [BP] >= 140 or diastolic BP >= 90 mm Hg) acute ischemic stroke patients (14 lacunar, 13 partial anterior, 7 total anterior, 6 posterior circulation infarct) were randomized to 5 mg of oral lisinopril (n = 18) or matching placebo (n = 22). Dose was increased to 10 mg (or 2 X placebo) on day 7 if casual systolic BP was 140 mm Hg and continued to day 14. After the initial dose, automated BP levels were monitored for 16 h. The BP levels and stroke outcome measures were assessed at day 14, and all patients were followed to day 90.Results: At h 4 after the first dose, systolic/diastolic BP change was -20 +/- 21/-6 +/- 10 mm Hg (mean +/- SE) in the lisinopril group and 1 +/- 11/0 +/- 8 mmHg in the placebo group (group differences: systolic BP, P < .05; diastolic BP, P =.07). With a daily dosing regime, systolic BP, mean arterial pressure (MAP), diastolic BP, and pulse pressure (PP) were significantly lower in the lisinopril group compared to the placebo group at day 14 (P < .01). Neurologic and functional measures were similar between groups at follow-up.Conclusions: Lisinopril, even at small dosages, is well tolerated and an effective hypotensive agent after acute ischemic stroke, gradually reducing BP by 4 h after oral first-dose administration. Oral lisinopril is now being studied in a larger outcome-based trial in acute hypertensive stroke patients.

Cardiac BRS (baroreceptor reflex sensitivity) is impaired following ischaemic stroke and predicts the risk of subsequent long-term death and disability. Impaired cardiac BRS may be due to impaired central processing of baroreceptor information following stroke or reduced baroreceptor activity due to increased large artery stiffness. We evaluated the relationship between large (aortic) artery stiffness and cardiac BRS during the acute phase of ischaemic stroke and in comparison with a group of stroke-free control subjects. Thirty-one ischaemic stroke patients were studied within 48 h of onset and again on day 14, along with 26 control subjects free of cerebrovascular disease. Cardiac BRS (determined by spectral analyses) and arterial stiffness estimated by PWVcf (carotid-femoral pulse wave velocity) using applanation tonometry were obtained. At baseline, cardiac BRS was lower in the stroke compared with the control group (4.3+/-2.3 compared with 6.5+/-4.2 ms/mmHg; P < 0.05). Cardiac BRS values were correlated with PWVcf at < 48 h (r = -0.51, P < 0.01) and on day 14 (r = -0.54, P < 0.01), but not in the control group (r = -0.27, P = not significant). In quantile regression models, taking into account the effect of all cardiovascular variables, cardiac BRS was independently related to PWVcf at baseline and on day 14 in the stroke patients, but stroke was not related to cardiac BRS level when other cardiovascular variables were considered. Wall stiffness of the arterial vessels involved in the baroreflex arc may account for, at least in part, the reduced cardiac BRS observed in acute stroke patients.