Key Points Question What are the contemporary clinical characteristics, management, and in-hospital outcomes in patients with acute stroke and transient ischemic attack in China? Findings In this quality improvement study that included more than 1 million admissions, in-hospital management measures and outcomes varied by type of cerebrovascular event and hospital level of care. Temporal improvements from 2015 to 2019 were also observed. Meaning Although improvements were seen over time, these findings suggest that ongoing support for evidence-based care is needed.

Objective: Dual antiplatelet therapy (DAT) with clopidogrel plus aspirin has been suggested by American Heart Association/American Stroke Association guidelines for minor stroke (MS) and transient ischemic attack (TIA) patients. The purpose of this study was to find the potential subgroups that benefit from DAT. We aimed to compare the efficacy of clopidogrel-aspirin therapy with that of aspirin therapy in MS/TIA patients stratified by CYP2C19 genotype and risk profiles. Methods: CYP2C19 loss-of-function allele (LoFA) carriers were defined as patients with LoFA of either *2 or *3. Lowand high-risk profile was defined as Essen Stroke Risk Score (ESRS) <3 and ≥3, respectively. Stroke recurrence at 1 year was considered primary outcome. Results: Of a total 2,933 MS/TIA patients, there were 1,726 (58.8%) LoFA carriers and 1,068 (36.4%) patients at high risk (ESRS ≥3). No significant difference for stroke recurrence between the clopidogrel-aspirin group and aspirin alone group was found in LoFA carriers (11.2% vs 13.3%, hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.64~1.09). In stratified analyses by CYP2C19 genotype and ESRS, HRs (95% CIs) of the clopidogrel-aspirin therapy for stroke recurrence were 1.00 (0.70~1.42), 0.63 (0.41~0.97), 0.62 (0.40~0.96), and 0.52 (0.31~0.88) among subgroups of LoFA carriers at low risk, LoFA carriers at high risk, LoFA noncarriers at low risk, and LoFA noncarriers at high risk, respectively, with p = 0.021 for interaction. Interpretation: Overall, LoFA carriers do not benefit from DAT, but there is significant benefit for LoFA carriers who are at high risk. The benefit of clopidogrel in Chinese MS/TIA patients depends on CYP2C19 genotype and risk profile. ANN NEUROL 2019;86:419-426 M inor stroke (MS) and transient ischemic attack (TIA) are warning signs of an impending stroke. The estimated risk of recurrent stroke occurring after an MS or TIA is estimated from 3.7% to 11.7% within 3 months. 1-4 Recent large clinical trial studies have shown that dual antiplatelet therapy (DAT) with clopidogrel and aspirin reduces the rate of recurrent stroke during the first 3 months after an MS or TIA. 3,4 The clopidogrel-aspirin antiplatelet therapy has been recommended for acute MS and TIA patients by the American Heart Association/American Stroke Association guidelines. 5,6 Clopidogrel blocks platelet aggregation as an adenosine diphosphate receptor antagonist, a mechanism that is synergistic with aspirin in platelet-aggregation assays. 7View this article online at wileyonlinelibrary.com.

Background Adherence to evidence‐based guidelines is an important quality indicator; yet, there is lack of assessment of adherence to performance measures in acute ischemic stroke for most world regions. Methods and Results We analyzed 19 604 patients with acute ischemic stroke in the China National Stroke Registry and 194 876 patients in the Get With The Guidelines––Stroke registry in the United States from June 2012 to January 2013. Compared with their US counterparts, Chinese patients were younger, had a lower prevalence of comorbidities, and had similar median, lower mean, and less variability in National Institutes of Health Stroke Scale (median 4 [25th percentile–75th percentile, 2–7], mean 5.4±5.6 versus median 4 [1–10], mean 6.8±7.7). Chinese patients were more likely to experience delays from last known well to hospital arrival (median 1318 [330–3209] versus 644 [142–2055] minutes), less likely to receive thrombolytic therapy (2.5% versus 8.1%), and more likely to experience treatment delays (door‐to‐needle time median 95 [72–112] versus 62 [49–85] minutes). Adherence to early and discharge antithrombotics, smoking cessation counseling, and dysphagia screening were relatively high (eg >80%) in both countries. Large gaps existed between China and the United States with regard to the administration of thrombolytics within 3 hours (18.3% versus 83.6%), door‐to‐needle time ≤60 minutes (14.6% versus 48.0%), deep venous thrombosis prophylaxis (65.0% versus 97.8%), anticoagulation for atrial fibrillation (21.0% versus 94.4%), lipid treatment (66.3% versus 95.8%), and rehabilitation assessment (58.8% versus 97.4%). Conclusions We found significant differences in clinical characteristics and gaps in adherence for certain performance measures between China and the United States. Additional efforts are needed for continued improvements in acute stroke care and secondary prevention in both nations, especially China.

ObjectiveMany patients receiving dual antiplatelet therapy still had recurrent strokes. We aimed to identify factors associated with recurrent stroke at 90 days in patients receiving dual antiplatelet therapy in Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events trial.MethodsPatients with transient ischaemic attack or minor stroke receiving clopidogrel and aspirin in the trial were analysed in the study. The primary outcome was recurrent stroke within 90 days after the index event. Cox proportional hazard model with backward selection was used to identify factors associated with stroke.ResultsAmong 2584 patients, 212 (8.2%) had a recurrent stroke, 216 (8.4%) had a composite of stroke, myocardial infarction, or vascular death and 204 (7.9%) had ischaemic stroke within 90 days. Multivariate analysis identified the following factors associated with stroke: history of hypertension with poor blood pressure control (HR, 1.92; 95% CI 1.22 to 3.03), the high baseline National Institute of Health Stroke Scale (NIHSS) score of 2 and 3 (2.12 (1.07 to 4.21) and 4.11 (2.05 to 8.22), respectively), time from onset to randomisation of <12 hours (1.47 (1.12 to 1.94)), the lipid-lowering therapy (0.61 (0.47 to 0.83)), the open-label aspirin dose at day 1 of ≥300 mg (1.98 (1.45 to 2.69)). Intracranial arterial stenosis (ICAS) was significantly associated with stroke in the sensitivity analysis (2.17 (1.16 to 4.04)).ConclusionsThe high baseline NIHSS score, hypertension with poor blood pressure control, ICAS, time from onset to randomisation of less than 12 hours and no lipid-lowering therapy were associated with stroke, suggesting that patients with identified predictors still remain to be at high risk of recurrent stroke although being under the dual antiplatelet therapy.Trial registration numberhttp://clinicaltrials.gov/show/NCT00979589. ClinicalTrials.gov number: NCT00979589

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Background and Purpose: Infection occurs commonly in patients with acute ischemic stroke. We aimed to investigate the association of infection with short- and long-term risk of recurrent stroke in patients with ischemic stroke. Methods: Data were derived from ischemic stroke patients in 2 stroke registries: the CSCA (Chinese Stroke Center Alliance) program recorded medical data during hospitalization, and the CNSR-III (Third China National Stroke Registry) recorded the medical data during hospitalization and finished 1-year follow-up. Associations of infection (pneumonia or urinary tract infection) during hospitalization with recurrent stroke in short (during hospitalization) and long term (since 30 days to 1 year after stroke onset) were analyzed. Short-term outcomes were analyzed with logistic models and long-term outcomes with Cox models. Results: In the CSCA (n=789 596), the incidence of infection during hospitalization reached 9.6%. Patients with infection had a higher risk of stroke recurrence during hospitalization compared with patients without infection (10.4% versus 5.2%; adjusted odds ratio, 1.70 [95% CI, 1.65–1.75]; P <0.0001). In the CNSR-III (n=13 549), the incidence of infection during hospitalization was 6.5%. Infection during hospitalization was significantly associated with short-term risk of recurrent stroke (7.4% versus 3.9%; adjusted odds ratio, 1.40 [95% CI, 1.05–1.86]; P =0.02) but not with long-term risk of recurrent stroke (7.2% versus 5.2%; adjusted hazard ratio, 1.16 [95% CI, 0.88–1.52]; P =0.30). Conclusions: Infection was an independent risk factor for high risk of early stroke recurrence during hospitalization, but we have not found its sustained effect on long-term recurrent risk in patients with acute ischemic stroke.

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