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[...]a motivational population-wide strategy using the free Stroke Riskometer app to reduce lifestyle and other risk factors in adults at any increased risk of stroke development. [...]a polypill strategy (consisting of two generic low-dose blood pressure drugs [eg, losartan 16 mg and amlodipine 2·5 mg] and one generic lipid lowering medication [eg, rosuvastatin calcium 10 mg]) for middle-age and older adults at risk of cardiovascular disease (ie, those with at least two behavioural or metabolic cardiovascular disease risk factors). [...]it excludes people with low-to-moderate cardiovascular disease risk who will ultimately comprise about 80% of future strokes and cardiovascular events, and thereby might have been falsely reassured that they are protected from developing these diseases. [...]evidence is lacking for the effectiveness of the high-risk approach in preventing stroke and acute cardiovascular events at the population level (appendix p1).

While formal screening for dysphagia following acute stroke is strongly recommended, there is little evidence on how multi-consistency screening and dietary modifications affect the rate of stroke-associated pneumonia (SAP). This observational study reports which factors affect formal screening on a stroke-unit and how dietary recommendations relate to SAP. Analyses from a database including 1394 patients admitted with acute stroke at our stroke-unit in Austria between 2012 and 2014. Dietary modifications were performed following the recommendations from the Gugging Swallowing Screen (GUSS). Patients evaluated with GUSS were compared to the unscreened patients. Overall, 993 (71.2%) patients were screened with GUSS; of these 50 (5.0%) developed SAP. In the 401 unscreened patients, the SAP rate was similar: 22 (5.5%). Multivariable analysis showed that either mild to very mild strokes or very severe strokes were less likely to undergo formal screening. Older age, pre-existing disability, history of hypertension, atrial fibrillation, stroke severity, cardiological and neurological complications, nasogastric tubes, and intubation were significant markers for SAP. Out of 216 patients, 30 (13.9%) developed SAP in spite of receiving nil per mouth (NPO). The routine use of GUSS is less often applied in either mild strokes or very severe strokes. While most patients with high risk of SAP were identified by GUSS and assigned to NPO, dietary modifications could not prevent SAP in 1 of 7 cases. Other causes of SAP such as silent aspiration, bacteraemia or central breathing disturbances should be considered.

Combining two medicines in a single pill can be cost-neutral and has important benefits for patients and for health systems, including improved patient adherence to daily medication regimens, which may improve clinical outcomes;2 improved blood pressure control rates and shortened time to blood pressure control;3 and more efficient hypertension management for health systems by simplifying drug supply and procurement logistics. In an analysis of more than 30 initial dual versus initial monotherapy trials, withdrawals due to adverse events were uncommon with two-drug combinations of a low-to-standard dose, with no significant difference in adverse events compared with those associated with standard-dose monotherapy.3 As organisations with a shared goal of improving hypertension control worldwide, the American Heart Association, European Society of Hypertension, International Society of Hypertension, Lancet Commission on Hypertension Group, Latin American Society of Hypertension, Resolve to Save Lives, World Heart Federation, World Hypertension League, and World Stroke Organization commend WHO for making single-pill combination antihypertensive medications more widely available by including them in the WHO Essential Medicines List. ACC/AHA 2017 ESC/ESH 2018 India 2013 China 2010 Thailand 2015 LASH 2017 WHO HEARTS When to use two blood pressure lowering drugs Not controlled on monotherapy Yes Yes Yes Yes Yes Yes Yes Initial treatment for all individuals No Yes* No No No Yes No Initial treatment for selected individuals, eg, those who are >20/10 mm Hg from goal† or at high cardiovascular risk Yes Yes Yes Yes Yes Yes* Yes When to use single-pill combinations Recommended to substitute for separate pills to improve adherence Yes Yes Yes Yes NR Yes NR Table Selected hypertension guidelines' recommendations for dual combination and fixed-dose combinations

Background Diabetes is an increasingly important risk factor for ischemic stroke and worsens stroke prognosis. Yet a large proportion of stroke patients who are eventually diabetic are undiagnosed. Therefore, it is important to have sensitive assessment of unrecognized hyperglycaemia in stroke patients. Design Secondary outcome analysis of a randomized controlled trial focussing on parameters of glucose metabolism and detection of diabetes and prediabetes in patients with acute ischemic stroke (AIS). Methods A total of 130 consecutively admitted patients with AIS without previously known type 2 diabetes mellitus (T2DM) were screened for diabetes or prediabetes as part of secondary outcome analysis of a randomized controlled trial that tested lifestyle intervention to prevent post-stroke cognitive decline. Patients had the oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) measurements in the second week after stroke onset and after 1 year. The detection rates of diabetes and prediabetes based on the OGTT or HbA1c values were compared. Results By any of the applied tests at the second week after stroke onset 62 of 130 patients (48%) had prediabetes or T2DM. Seventy-five patients had results from both tests available, the OGTT and HbA1c; according to the OGTT 40 (53.3%) patients had normal glucose metabolism, 33 (44%) had prediabetes, two (2.7%) T2DM. In 50 (66.7%) patients the HbA1c results were normal, 24 (32%) in the prediabetic and one (1.3%) in the diabetic range. The detection rate for disorders of glucose metabolism was 10% higher (absolute difference; relative difference 29%) with the OGTT compared with HbA1c. After 1 year the detection rate for prediabetes or T2DM was 7% higher with the OGTT (26% relative difference). The study intervention led to a more favourable evolution of glycemic status after 1 year. Conclusion The OGTT is a more sensitive screening tool than HbA1c for the detection of previously unrecognized glycemic disorders in patients with acute stroke with an at least a 25% relative difference in detection rate. Therefore, an OGTT should be performed in all patients with stroke with no history of diabetes. Trial registration http://clinicaltrials.gov . Unique identifier: NCT01109836.

Developing countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries, resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries, with areas of excellence intermixed with areas of severe need, depending upon patients' location, socioeconomic status, education, and cultural beliefs. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies, largely from developed countries, we discuss the need to develop basic organised stroke-unit care in developing countries.

Among them are the north–south disparity, with differences in the epidemiology of risk factors, and higher prevalence and incidence of stroke in the north; and rural–urban differences, to the disadvantage of rural regions.1 Nevertheless, a lot of variation is to be expected because of the vastness of the country, harbouring so many people with differing genetic backgrounds, risk behaviours, and access to health services. Following this road map for community health care, a lot can be done for patients with stroke, including basic stroke care that provides diagnosis, rapid assessment and symptomatic management of blood pressure, avoidance of aspiration pneumonia, detection and prevention of fever, and monitoring clinical course to decide whether a referral to a higher grade care-centre is needed. On the global scale, due to the ageing of the population, further population growth, and a trend towards increasing prevalence of risk factors, the global burden of stroke will likely increase, unless cost-effective primary stroke preventive strategies can be found and implemented.

Background To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU). Method We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU. Results Three thousand one hundred eleven patients (5.2 %) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence. Conclusion Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.