Interdisciplinary Patient-Centred Poststroke Care in Follow-Up After Stroke, Screening and Treatment (FASST) Clinic Model: A Proof-of-Concept Pilot Study

BACKGROUND: Although secondary stroke prevention is important, the optimal outpatient model that improves risk factor control and decreases post-stroke complications effectively has not been established. We created Follow-up After Stroke, Screening and Treatment (FASST), an interdisciplinary clinic involving stroke physicians and pharmacists to address poststroke complications and secondary stroke prevention systemically. We present our approach to assess its proof-of-concept in our pilot study. METHODS: We included the patients attending FASST clinic after their hospital discharge. We used validated survey screens to assess for complications: depression, anxiety, sleep disorders, cognitive impairment, disability, social support, quality of life and functional status. Data were collected including risk factors, complication screening results and outcome scores. Clinical pharmacists assessed risk factor control and health-related behaviours for modification. RESULTS: Of the 25 patients enrolled in the interdisciplinary clinic, all had comorbid hyperlipidaemia and hypertension, and 44% had diabetes mellitus. About one-third needed medication changes for risk factor control. On screening, 16% of patients were found to have depression, 12% had anxiety and 20% had sleep apnoea. These patients were either managed in the clinic or were referred to relevant subspeciality clinics. The status of risk factor control was assessed in all patients, and 32% had medications adjustments. CONCLUSION: Our preliminary data found that FASST clinic model is feasible and potentially useful. It represents an integrated approach to post-stroke care, with pharmacist collaboration to improve risk factor control, while assessing for poststroke complications. Further study is needed to improve health outcomes through integrated poststroke care

Abstract 163: Recognizing Sex Disparities Among Invited Speakers at the International Stroke Conference Motivates Change

Introduction: Females were significantly underrepresented as invited speakers at the International Stroke Conference (ISC) from 2014-2018. In 2019, there were increased efforts by the ISC program committee to recruit female speakers. Other efforts to increase female participation at the 2019 ISC included a session for women’s issues in stroke and a women’s luncheon. Methods: ISC invited speaker data were obtained (years 2014-2019) from the American Heart Association. Variables included sex, degree, race, speaker institution country, session type and category. Data were analyzed by Chi-square test, Fisher’s exact test or logistic regression models. Results: From 2014-2018, females represented 28% of ISC invited speakers, and in 2019 the proportion of females rose to 47%. Females represented 38% of physician speakers in 2019 as compared to 18% from 2014-2018. For Black speakers, in 2019 females represented the majority (64%), increased from 2014-2018 (17%). For Hispanic speakers, females remained one of the lowest proportions, but with an increase from 12% to 39%. Females represented the highest and lowest proportion of speakers from South America (100%) and Africa (0%) and the largest in invited symposium (48%), similar to 2014-2018. The odds of being invited for debate as a female increased in 2019 (OR 0.67 vs 0.37, p=0.36), but this did not reach significance. Females represented the largest proportion of speakers in recovery and rehabilitation (52%) in 2019, similar to 2014-2018. Females had higher odds of being invited as a speaker in the acute, in-hospital care category (OR 0.83 vs 0.53, p=0.22), but this did not reach significance. Females were more often invited as speakers more than once in 2019 (OR 0.94 vs 0.61, p=0.29). Conclusions: There is potential to increase female participation at major scientific conferences through initiatives by the program committee. Identifying gender disparities at a major conference like the ISC may help to close the gender gap

Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial

Background: Patent foramen ovale (PFO) is a contributor to embolic stroke of undetermined source (ESUS). Subgroup analyses from previous studies suggest that anticoagulation could reduce recurrent stroke compared with antiplatelet therapy. We hypothesised that anticoagulant treatment with rivaroxaban, an oral factor Xa inhibitor, would reduce the risk of recurrent ischaemic stroke compared with aspirin among patients with PFO enrolled in the NAVIGATE ESUS trial. Methods: NAVIGATE ESUS was a double-blinded, randomised, phase 3 trial done at 459 centres in 31 countries that assessed the efficacy and safety of rivaroxaban versus aspirin for secondary stroke prevention in patients with ESUS. For this prespecified subgroup analysis, cohorts with and without PFO were defined on the basis of transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE). The primary efficacy outcome was time to recurrent ischaemic stroke between treatment groups. The primary safety outcome was major bleeding, according to the criteria of the International Society of Thrombosis and Haemostasis. The primary analyses were based on the intention-to-treat population. Additionally, we did a systematic review and random-effects meta-analysis of studies in which patients with cryptogenic stroke and PFO were randomly assigned to receive anticoagulant or antiplatelet therapy. Findings: Between Dec 23, 2014, and Sept 20, 2017, 7213 participants were enrolled and assigned to receive rivaroxaban (n=3609) or aspirin (n=3604). Patients were followed up for a mean of 11 months because of early trial termination. PFO was reported as present in 534 (7·4%) patients on the basis of either TTE or TOE. Patients with PFO assigned to receive aspirin had a recurrent ischaemic stroke rate of 4·8 events per 100 person-years compared with 2·6 events per 100 person-years in those treated with rivaroxaban. Among patients with known PFO, there was insufficient evidence to support a difference in risk of recurrent ischaemic stroke between rivaroxaban and aspirin (hazard ratio [HR] 0·54; 95% CI 0·22–1·36), and the risk was similar for those without known PFO (1·06; 0·84–1·33; pinteraction=0·18). The risks of major bleeding with rivaroxaban versus aspirin were similar in patients with PFO detected (HR 2·05; 95% CI 0·51–8·18) and in those without PFO detected (HR 2·82; 95% CI 1·69–4·70; pinteraction=0·68). The random-effects meta-analysis combined data from NAVIGATE ESUS with data from two previous trials (PICSS and CLOSE) and yielded a summary odds ratio of 0·48 (95% CI 0·24–0·96; p=0·04) for ischaemic stroke in favour of anticoagulation, without evidence of heterogeneity. Interpretation: Among patients with ESUS who have PFO, anticoagulation might reduce the risk of recurrent stroke by about half, although substantial imprecision remains. Dedicated trials of anticoagulation versus antiplatelet therapy or PFO closure, or both, are warranted. Funding: Bayer and Janssen