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Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis
  1. Alan Flores1,
  2. Alvaro Garcia-Tornel2,
  3. Laia Seró1,
  4. Xavier Ustrell1,
  5. Manuel Requena2,
  6. Anna Pellisé1,
  7. Paula Rodriguez1,
  8. Angela Monterde1,
  9. Lidia Lara1,
  10. Jose María Gonzalez-de-Echavarri1,
  11. Carlos A Molina2,
  12. Antonio Doncel-Moriano3,
  13. Laura Dorado4,
  14. Pedro Cardona5,
  15. David Cánovas6,
  16. Jerzy Krupinski7,
  17. Natalia Más8,
  18. Francisco Purroy9,
  19. Jose Zaragoza-Brunet10,
  20. Ernesto Palomeras11,
  21. Dolores Cocho12,
  22. Jessica Garcia13,
  23. Carla Colom14,
  24. Yolanda Silva15,
  25. Manuel Gomez-Cocho16,
  26. Xavier Jiménez17,
  27. Josep Ros-Roig18,
  28. Sonia Abilleira18,
  29. Natalia Pérez de la Ossa19,20,
  30. Marc Ribo21
  31. On behalf of the RACECAT trial investigators
    1. 1 Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
    2. 2 Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
    3. 3 Stroke Unit, Department of Neurology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
    4. 4 Stroke Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Catalunya, Spain
    5. 5 Bellvitge University Hospital, L'Hospitalet de Llobregat, Catalunya, Spain
    6. 6 Department of Neurology, Consorci Sanitari Parc Taulí, Barcelona, Spain
    7. 7 Hospital Terrassa, Terrassa, Spain
    8. 8 Department of Neurology, Hospital Althaia, Manresa, Manresa, Catalunya, Spain
    9. 9 Hospital Arnau de Vilanova, Lleida, Spain
    10. 10 Stroke Unit, Department of Neurology, Hospital Verge de la Cinta, Tortosa, Catalunya, Spain
    11. 11 Department of Neurology, Hospital de Mataró, Mataro, Catalunya, Spain
    12. 12 Department of Neurology, Hospital General de Granollers, Granollers, Catalunya, Spain
    13. 13 Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedes, Catalunya, Spain
    14. 14 Department of Neurology, Hospital Universitario de Igualada, Igualada, Catalunya, Spain
    15. 15 Neurology Department, Stroke Unit, Doctor Josep Trueta University Hospital of Girona, Girona, Catalunya, Spain
    16. 16 Department of Neurology, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
    17. 17 Emergency Medical Services of Catalonia, Barcelona, Spain
    18. 18 Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
    19. 19 Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain
    20. 20 Catalan Stroke Program, Barcelona, Spain
    21. 21 Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
    1. Correspondence to Mrs Natalia Pérez de la Ossa, Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain; nperez.germanstrias{at}gencat.cat

    Abstract

    Background The influence of vascular imaging acquisition on workflows at local stroke centers (LSCs) not capable of performing thrombectomy in patients with a suspected large vessel occlusion (LVO) stroke remains uncertain. We analyzed the impact of performing vascular imaging (VI+) or not (VI− at LSC arrival on variables related to workflows using data from the RACECAT Trial.

    Objective To compare workflows at the LSC among patients enrolled in the RACECAT Trial with or without VI acquisition.

    Methods We included patients with a diagnosis of ischemic stroke who were enrolled in the RACECAT Trial, a cluster-randomized trial that compared drip-n-ship versus mothership triage paradigms in patients with suspected acute LVO stroke allocated at the LSC. Outcome measures included time metrics related to workflows and the rate of interhospital transfers and thrombectomy among transferred patients.

    Results Among 467 patients allocated to a LSC, vascular imaging was acquired in 277 patients (59%), of whom 198 (71%) had a LVO. As compared with patients without vascular imaging, patients in the VI+ group were transferred less frequently as thrombectomy candidates to a thrombectomy-capable center (58% vs 74%, P=0.004), without significant differences in door-indoor-out time at the LSC (median minutes, VI+ 78 (IQR 69–96) vs VI− 76 (IQR 59–98), P=0.6). Among transferred patients, the VI+ group had higher rate of thrombectomy (69% vs 55%, P=0.016) and shorter door to puncture time (median minutes, VI+ 41 (IQR 26–53) vs VI− 54 (IQR 40–70), P<0.001).

    Conclusion Among patients with a suspected LVO stroke initially evaluated at a LSC, vascular imaging acquisition might improve workflow times at thrombectomy-capable centers and reduce the rate of futile interhospital transfers. These results deserve further evaluation and should be replicated in other settings and geographies.

    • Thrombectomy
    • Stroke
    • CT Angiography

    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author(s) upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author(s) upon reasonable request.

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    Footnotes

    • Twitter @marcriboj

    • Collaborators RACECAT investigators: Hospital Vall d’Hebrón: Dr. Marc Ribó Jacobi. Estela Sanjuan, Katherine Santana, Dr. Carlos Molina, Dr. Marta Rubiera, Dra. Noelia Rodríguez, Dr. Jorge Pagola, Dr. David Rodriguez-Luna, Dra. Olga Maisterra, Dr. Estevo Santamarina, Dra. Marian Muchada, Dr. Jesús Juega, Dra. Sandra Boned, Dr. Antonio Palasi Franco, Dr. Álvaro García -Tornel, Dra. Marta Olivé Gadea, Dr. Matías Deck, Dr. Manuel Requena, Victoria Sala. Hospital Germans Trias i Pujol: Dra. Natalia Pérez de la Ossa, Lucía Muñoz, Dra. Mónica Millán, Dra. Meritxell Gomis, Dra. Elena López-Cancio, Dra. Laura Dorado, Dra. María Hernández-Pérez, Jordi Ciurans, Daniela Samaniego, Tamara Canento, Lorena Martin, Anna Planas, Joaquin Broto, Agustín Sorrentino, Martí Paré, Nuole Zhu, Alicia Garrido, Laia Grau, Ane Miren Crespo, Silvia Presas, Miriam Almendrote, Alba Ramos, Giuseppe Lucente, Lourdes Ispierto, Manuel Lozano, Juan Luis Becerra, Marta Jiménez, Dolores Vilas Rolán, Nicolas Guanyabens, Josep Sanchez-Ojanguren, Alicia Martínez-Piñeiro, Sara Forcén, Mireia Gea, Marta Álvarez, Anna Ramos, Manuel Domínguez Lizarbe, Sara, Rubio Guerra, Irene Bragado, Andrea Arbex, Luis Rodríguez, Alejandro Bustamante. Hospital Bellvitge: Dr. Pere Cardona Portela, Dra. Helena Quesada García, Dra. Blanca Lara Rodríguez, Dra. Nuria Cayuela, Dra. Julia Miró, Dra. Clara Marzal, Dr. Andrés Paipa, Dr. Sergio Campoy, Dra. Ana Núñez, Dr. Pablo Arroyo, Dra. Sarah Besora, Dra. Vanessa Adell, Dr. Jaume Campdelacreu, Dra. Montse Alemany Martí, Dra. Belén González, Dra. Laura Bau Vila, Dra. Marta Fiter Crespo, Anna Berbel, Ma. Cristina Villaescusa Urbaneja, Núria Guillen, Dra. Nuria Vidal, Patricia Valentina Vérez Santamaria, Diego Herrero Navarro, Marta Simó, Mercedes Falip, Elisabeth Matas, Neus Mongay Ochoa, Ariadna Gifreu, Albert Muñoz, Lucía Romero, Eduard Portell, Guillermo Hernández Perez, F. Ruiz Esteve, Silvia Teixidor, Augusto Salazar Talavera, Dra. Roser Gómez. Hospital Clínic i Provincial: Dr. Xabier Urra Nuin, Martha Vargas, Ángel Chamorro, Sergio Amaro, Laura Llull, Arturo Renú, Salvatore Rudilosso, Raquel Sánchez del Valle, Helena Ariño, Nuria Solà, Delón la Puma, Francisco Gil, Juan Bernardo Gómez, Nuria Matos, Neus Falgàs, Sergi Borrego, Almudena Sánchez, Mircea Balasa, Carmen Montejo, Mar Guasp, David Reyes, Pablo Sánchez Cervilla, Jose Miguel Contador, Victor Augusto Vera Monge, Oscar Ramos, Alejandro Rodríguez. Hospital del Mar: Dra. Ana Rodríguez Campello, Gemma Romeral Ballester, Mireia Llop Trujillano, Eva Giralt Steinhauer, Elisa Cuadrado Godia, Angel Javier Ois Santiago, Jordi Jimenez Conde. Hospital Sant Pau: Dr. Joan Martí Fábregas, Dr. Daniel Guisado, Dr. Luís Prats, Dr. Pol Camps, Dra. Raquel Delgado, Dr. Alejandro Martínez Domeño, Rebeca Marín. Hospital Parc Taulí Sabadell: David Cànovas, Jordi Estela, Marta Ros, Sonsoles Aranceta, Jordi Espinosa, Marta Rubio, Cristina Lafuente, Oriol Barrachina, Alicia Anguita, Anna Reverter, Carmen García, Gemma Sansa, Mariona Hervas, Monica Crosas, Tania Delgado. Mutua Terrassa: Dr. Jerzy Krupinski, Dra Sonia Huertas Folch, Gemma Muñoz Gamito, Josep Trenado Alvarez, Teresa Subirana, Jessica Molina, Sarah Besora, Laura Comes Romero, Gemma Guardia Valls, Miriam Jover, Javier Joaquín Sotova. Hospital Moisés Broggi: Dra. Sonia Mª García Sánchez, Dr. Sebastian Valenzuela (intensivista), Dr. Manuel Gómez-Choco, Dr. Juan José Mengual, M. Àngels Font, Mª Isabel Gómez Ruiz, Dra. Irati Zubizarreta, Susana Fernández González, Laura Gubieras, Carmen E. Cobos, Luis Mena Romo, Nuria Caballol, Luis Cano. Hospital Josep Trueta: Dr. Joaquín Serena Leal, Yolanda Silva Blas, Mikel Terceño Izarra, Irene Bragado Trigo, Saima Bashir Viturro, Laura Pardo Albiñana, Montserrat Reina Garrido, Carla Marco Cazcarra, Karol Enrique Uscamaita, Fabian Márquez, Cristina Coll, Mar Irida Lloret Villlas, Berta Solano Vila, Berta Alemany Perna, Daniel López Domínguezl, Mercedes de Lera, Anna Cots Foraster, Victor Augusto Vera Monge, Urszula Bojaryn. Hospital Arnau de Vilanova: Dr. Francesc Purroy García, Ikram Benabdelhak, Gerard Mauri Capdevila, Jordi Sanahuja Montesinos, Daniel Vázquez, José Vicente Hervás, Cristina González, Alejandro Quílez, Mikel Vicente Pascual, María Ruiz, Yolanda Riba, M. Pilar Gil Villar, Cristina García. Hospital Joan XXIII: Dr. Xavier Ustrell Roig, Mònica Baldrich Mora, Anna Pellisé Guinjoan, Judit Borras, Alba Mañé Martínez, Rafael Marés, Jaume Viñas i Gaya, Laia Seró, Alan Flores, Dra Paula Rodríguez, Gislaine Castilho, Angela Monterde Ortega. Hospital Verge de la Cinta: Silvia Reverté, Josep Zaragoza, Joan Josep Baiges, Josep Zaragoza, Gisela Martín Ozaeta, Dr. Sonia Escalante, Patricia Esteve Belloch, Dr Iago Payo. Hospital Fundació Althaia: Dra. Júlia Saura Salvado, Natalia Mas Sala, Josep M Soler Insa, Ester Tio Vilamala, Josep Abos Navarro, Dr Héctor Cruz Tabuenca, Dra. Tamara Canento Sánchez, Dra. Marta Ros, Dra. Nuria Matos, Elisabet Roldán. Hospital Residència Sant Camils: Dra. Elsa Puiggrós Rubiol, Elisabet Franquet, Lidia Fuentes, Javier Donaire, Elena Martí, Laura Giménez, Junior Gil Vázquez, Eloisa Nieto Clara Gris Ambrós, Puri Rodríguez, José Félix Oletta, Pilar Pons Mellado, Dra. Catena, Bárbara Gómez, Vergilin Raileau. Hospital Alt Penedès: Dra. Esther Catena Ruíz, Dr. Oscar Pardina, Jordi Mercadal, María López-Diéguez, Pilar Pérez, Lourdes Gabarró, María Orriols, José Carlos Molina, Joan Josep Canet, Mireia Roca, Muriel Álvaro, Francesc Boneu, Georgina Giménez, Jaume Albà, Francesc Gibert, Jéssica Garcia, Patricia Barragan, Gustavo Jurado. Hospital Igualada: Vanesa Pascual_Medicina Interna, Josep Sabaté Ortega, Joan Amaurys Martínez Solano, Víctor Fernández, Mónica Torres, Ana Belén Montero Alvaredo. Consorci Hospitalari de Vic: Dra. Laura Redondo Parejo, Dr. Josep Maria Aragonés Dra. Anna Bullón, Dra. Cora Loste, Dra. Paula González, Dr. Neker Bejarano, Dr. Francisco Sanchez, Dr. Gianni Lucchetti, Dr. Xavier Pla, Dr Javier Gimeno, Dr. Esteban Reynaga, Dra. Montse Barcons, Dr. Gabriel Celedón, Dr. Juan Ortiz, Dr Goran Anastasovski, Dr Oscar Mascaró, Dr Javier Diez de los Ríos, Dra. Meritxell Feliu, Dra. Anna Ribera, Dr. Cristhian Ruiz, Dr. Gerard Corominas, Dra Daniella Nunes, Dra. Claudia Roca, Dra. Nadina Latorre, Dra. Lizbeth Yataco, Dra. Maricelys Cruz, Dra. Nerea Blanco, Dr. Santiago Castejón. Hospital Granollers: Dra. Dolores Cocho Calderón, Claustre Pont Sunyer, Jordi Espinosa Garcia, Rodrigo Paz Martin, Albert de Luis Sanchez, Dolores Espinosa Vivas, Juan Valencia Molina, Gemma, Planels Palome, Laia Tomas Chaume, Ares Villagrasa Vilella, Marco Bustamante, Anunciación Boltes, Fernando Rodríguez, Itziar Arrieta, Jordi Ciurans Molist, Dra. Barnés Andreu. Hospital Mataró: Dr. Ernest Palomeras Soler, Nicolau Guanyabens Buscà, Manuel Daza López, Jordi Bigas Farreres, Virginia Casado Ruiz, Desiree Muriana Batiste, Mª Pilar Sanz Cartagena, Eulalia Cabot de Vega, Josep Bassa Real, Hector Pelaez Roman, César Socolich, Josep Mª Alonso Camp, Antonio Tomás Cano Orgaz, Mª Pilar Fossas Felip, Nicolás Morón, Sandra Bacca, Mauricio Molina, Francesc Casarramona, Lorena Elias, Muhammad Zidane Bukaei, Jose Antonio Martos Gutierrez, Judith Lopez Escuin, Dra. Cristina Olaizola, Yolexis López Vargas, Juan Jiménez Oyonarte, Rashida Soultana. Hospital Comarcal del Pallars: Dr. Eduardo Sanjurjo Golpe, Dra. Esther Salvador, Dr. Guillem Vila, Dr. Marcos Serrano. Fundació Sant Hospital La Seu Urgell: Dra. Matilde Nuria López Claverol, Marian Lamolla, Miquel Amate, Adriana Rodriguez, Ruth Romero, Montgomery del Carpio, Ana Isabel Hernandez, Julián Martín, M Carmen Rosas, Antonio Nogueroles, Sorilandy Encarnación, Augusto Robles, Jose Antonio Herrera, Roger Gavilán, Toghrol Mameghani, Gastón Araujo, M.Angeles Garrido Morales, Enric Ramon Albert Segui, Eva Fernandez Climent, Francesc Paris Pujol, Mireia Judit Garrofé Seira, Lucía Gómez Pía, Fernando Salleres Nuñez, Cristina Aguar Peñalver, Cristina Vaz Lopes, Elisenda Ribera Tasa, Carmen Repullo, Vilchez, Modesto Sánchez Zambrana, Beatriu Suescun Ribas, Inés Vilà Panés, Montserrat Vila Planavila, Alicia Vaqueiro Lorenzo, Meritxell Sabartés Guixes, Jorge Medina, David Sambrano, Javi Zamarreño, Carmen Pirela, Paola Vélez, Luis Cajamarca, Honey Pérez, Yarles Martínez, Jesus Alexander Gonçalves, Carles Regordosa, Claudia Mormeneo, Laura Griu, Maria Francia Colina, Enric Farik. Hospital Mora d’Ebre: Dra. Dolors Carrión Duch, Dr. Carles Badenas, Oscar Bernal, Núria Agramunt, Shyrlei Morales, Victoria Reynoso, Miguel Guerrero, Primitivo Romera Cid, Mònica Folqué, Claudia Pedroza, Adnan Hachem. Hospital de la Cerdanya: Dr. Íñigo Soteras Martínez, Dr. Xavier Verdera García. Hospital Figueras: Dra. Mercè López Amorós, Dr. Xavier Costa Subirós, Dra. Marta Cufí Benet, Cecile Van Eendenburg, Teresa Osuna, Dra Gina Santos, Dra Mireia Pallisera, Dr Lluís Gonzalo Oliva, Dra Gemma Sanchez, Dr Xavier Basurto, Dr Ludgi Vivoda, Dr Richard Van der Kleyn, Dra Laura Robles. Hospital Palamós: Dra. Ana Cabanelas Barranco, Dra. Mª Cruz Almendros, Marc Pérez Oliveras, Amelia Fernández Álvarez. Hospital Olot: Maria Rybyeva, Antoni Viñas, Maria Barcons, Joaquim Danès Alberto Tavera, Pablo Burbano, Cintie López, David Cruz, Paula Bisbe, Nora Fernández, Juan Carlos Palacio, Eduardo Fraiz, Oriol Aguiló, Rollmy Amorodjo, John Velázquez, Elena Sánchez, Jaume Español, Judit Perez de Celis, Anna Coll. Hospital Campdevànol: Glòria Díaz, Margarida Vergés i Sala, Mª Ángels Casas Capdevila, Yosmairy Yoselin Ferrini, Aitor Gorriz, Diego-Javier Cucurell Navarro, Dulce Velásquez, Jaume Pla Soler, Josep González, Julian David Higuera, Lina Cuellar, Liza Margarita Miniello, Lluis Pujol, Sorin Cracan. Sistema Emergènces Mèdiques Catalunya: Mora Vives, M Angela, Lopez Lopez, Anabel, Montse Gorchs Molist, Delofeu Anna, Silvia Solà Muñoz, Ferreres Yolanda, Carol Pujalte, Elisabeth Téllez Marín, Yolanda Font Casas, Sara Hernández Luque, Joaquim Mejias Sendra, Francesca Mellado Valero, Campos Escala, Olga, Galup De Lacanal, Carles, Lopez Diaz, Enric, Castillo Paramio, Xavier; Català Estopà, Xavier, Español Moreda, Jaime, Calafell Majo, Jordi, Carballo Almeida, Antonio, Castro Naval, M Elena, Cregut Ruiz, Pere Lluis, Deulofeu Font, Anna, Fabregat Sanjuan, Joan Pere, Fontquerni Gorchs, Anna, Forés Bellés, Joan Antoni, Gomez Herrera, Juan Carlos, Hijazo Prades, Sergio, Itzaina Torvisco, Zulma, Marti Rovira, Rafael, Obiols Gonzalez, Albert, Olive Cavero, Marta, Querol Gil, M Soledad, Rico Rodriguez, Javier, Rios Sambernardo, Joaquin, Ropero Molina, Jose Ramon, Sanchez Valero, Pere, Santos Arevalo, Maria Jose, Soto Garcia, Maria Angeles, Tebar Escribano, Francisco, Torres Garcia, Pedro José, Verdes Carrion, M Isabel, Verge Lopez, Juan Jose, Lopez Canela, M Angeles, Lucas Guarque, Isaac, Morales Alvarez, Jorge Arnulfo, Morell Fornieles, Olga, Subirats Gomez, Maria Teresa, Torello Masa, Miquel, Val Lopez, Maria Mercedes, Palmero Reyes, Juan Manuel, Rodriguez Forne, Marta, Ruana Turiel, Dominica, Sanchez Gonzalez, Jose, Sebastia Gornals, Meritxell, Abrio Rico, Sheila, Albert Gual Falip, Aznar Oliveros, Vanessa, Brugues Perotti, Stella, Calvet Molinero, Miriam, Catells Franco, Monica, Corrales Medina, Estefani, Daroca Miro, Nuria, Duran Marquez, Laura, Feliu Pradas, Margarita, Figueras Casanova, Sylvia, Garcia Tortajada, Georgina, Grajera Gallego, Azahara del Mar, Las Arroyo, Dulcenombre de Jesus, Laserreta Sanz, Pilar, Llambrich Vidal, Monica, Monllao Corral, Jordi, Morales de la Cruz, Raquel, Moreno Blanco, Arantxa, Orejuela Orgaz, Marcos, Piñana Suazo, Núria, Pons Minguillon, Sergi, Rodríguez Gómez, José Carlos, Rodriguez Pereira, Virginia, Sedo Porcel, Anna, Sevil Villar, Mireia, Sierra Lopez, Rossana, Torres Romero, Judit, Trepat Calveres, Anna, Ventura Arnella, Maria, Acera Gil, M Teresa, Biesot Vico, Silvia, Castro Galea, Rosa Maria, Escorcia Chafer, Juan Antonio, Español Moreda, Agusti, Gil Faure, Helena, Hernandez Luque, Sar, Jimenez Delgado, Sonia, Mallafre Gay, M.Angel, Olivares Sanzo, Pau, Pubill Fondevila, Noemi, Sabate Fort, Jesus, Segovia Agámez, Antonio Carlos, Turata Longaretti, Giovanna, Valle Hernandez, Sandra, Trayner Guixens, Marta, Aguilar Valor, Ada, Aguirre Alvarez, Sonia, Alastrue Naval, Laura, Alferez Baquero, Mar, Alonso Marne, Cristina, Aloy Orozco, Angels, Alvarez Colino, Jeannette, Alvarez Peñuela, Miriam, Ameller Cirilo, Maria Vanessa, Andujar Guerrero, Estefania Remedios, Auladell Sillero, Silvia, Azcarate Sorbet, Izaskun, Basany Genesca, Nuria, Benavent Barduena, Sergio, Benito Tudela, Teresa, Blanch Pardo, Roser, Boluda Pla, Ariadna, Bonilla Gonzalez, Isabel, Bru Serramalera, Nuria, Burnat Andreu, Laia, Caballero Calvo-Rayo, Salvador, Calvo Casellas, Arnau, Camps Mombiela, Iren, Cano Bresme, Nuria, Carcelen Fernandez, Daniel, Caro Solà, Marc, Casasas Matavacas, Teresa, Castanedo Bolado, Cristina, Cerdeña Cortina, Sandra, Abella Jane, Laia Collado Borrego, Adrian, Colom Orri, Gemma, Comellas Vilanova, Anna, Conillera Sole, Montserrat, Cots Torres, Nuria, Cuchi Estepa, Marc, de Sostoa Graell, Laura, del Rio Lopez, Beatriz, Delgado Compte, Sandra, Diaz Bueno, Carmen, Diaz Maneiro, Andrea Lucia, Domenech Palau, M.Carme, Duran Carasso, Pablo Javier, Duran Marquez, Laura, El Abidi, Khadija, Escoda Martin, Pau, Esteve Casanovas, David, Fernandez Perez, Daniel, Ferre Quintero, Sergi, Flores Escobar, Sergio, Fontcuberta Abad, Anna, Fortes del Valle, Africa, Fortes del Valle, Mª Luisa, Franco Quesada, Sara Maria, Franco Romero, Maria Teresa, Gallego Francisco, Rut, Gamiz Gala, Alicia, Garcia Castañeda, Laura, Garcia Rodriguez, Marina, Casajuana Gemma, Gomez Arroyo, Manuela, Gomez Girbau, Xavier, Gonzalez Fernandez, Beatriz, Gonzalez Gonzalez, Marta, Gonzalez Gonzalez, Ricardo, Gonzalez Lopez, Flor, Gual Obeso, Maria, Guerrero Blanco, Marta, Guillemas Roca, Susana, Guillermo Eudaldo, Albert, Hernandez Sebastia, Gemma, Homar Covas, Dolça, Hostench Alvarez, Lluis, Huerta Royo, Marta, Ibañez Barcelo, Paula, Inio, Alessandro, Izquiero Cruz, Marta, Jaione Urdangarin Etxetxikia; Juárez Gimenez, Jordi, Khlifi Alami, Rajaa, Laparra Gasco, Gustavo, Lara Moreales, Anna, Las Arroyo, Dulcenombre de Jesus, Lasaosa Medina, Maria Lourdes, Lazaro Cava, Aida, Leon Berrar, Monica, López Maturana, Laura, Lopez Ramirez, Cristian, López Romero, Pedro, Lorente Marco, Tania, Lorenzo Martin, Ruth, Lozano Casals, Jessica, Lujan Nicola, Alexia, Madrid Diaz, Jose Antonio, Maria Teresa Peris Morales, Marti Clemente, Albert, Martinez Castaño, David Natanael, Martinez Gamez, David, Martinez Gonzalez, Paula, Martinez Quesada, Maria de la Cabeza, Marzà Fusté, Mireia, Conillera M, Melendo Lasheras, Marta, Miralles Mestre, Jordi, Montserrat Puig Pastalle, Montserrate Vidal, Silvia, Mora Mellado, Emma, Morales Ponce, Christian, Morell Fornieles, Olga, Morera Cabre, Helena, Morera Vivet, Mireia, Mundi Souza, Guillem, Muñoz Quiles, Aldara, Navea Rosa, Natalia, Neira Iglesias, M Asuncion, Nuñez Manrique, Mª Pilar, Obiols Martinez, Judith, Pallares Reig, Roger, Partegas Torres, Xenia, Pascual Berengueras, Ivana, Perez Gamez, Anna, Perez Oset, Mireia, Perez Restrepo, Maria Alejandra, Planas Yeste, Raquel, Planells Mangado, Anna, Pons Minguillon, Sergi, Puertas Carbonell, Alba, Quinteiro Blanco, Lourdes, Rebollar Benavente, Cristina, Recasens Fernandez, Helena, Reyes Gomez, Maria del Carmen, Roca Pou, Joaquim, Rodriguez Ferrer, Inma, Rodriguez Franco, Amalia, Rodriguez Fuertes, Mariola, Rodriguez Muñoz, Raquel, Rodriguez Navarro, Yolanda, Roig Iniesta, Alicia, Romero Gracia, Albert, Rovira Brunet, Silvia, Rovira de Eugenio, Ramon, Rubio Baena, Antonio, Ruiz Llorens, Priscila, Sala Llamazares, Julia, San Juan Alaez, Carolina, Sanchez Segura, Daniel, Santasusana Soldevilla, Jordi, Sanz Salmeron, Marta, Segura Perez, Enriqueta, Serra Balcells, Maria, Sorina Dumitras, Ruth, Teixidor Montoya, Ignacio, Tena Vicente, Cristina, Tierno Salinas, Ester Ines, Toledo Testa, Soledad, Tomàs Figueras, Lluis, Tomas Ruperez, Marina, Torrano Garcia-Penche, Anna, Torres Esparza, Nuria, Uku, Florenc, Vazquez Blanco, Garazi, Vazquez De la Paz, Angel, Vazquez Gil, Fernando, Vazquez Gonzalez, Ingrit, Vidal Meler, Natalia, Vilalta Cots, Eva, Vilches Jimenez, Maria Jose, Visser Fernandez, Angela, Viu Gavin, Carla, Vives Vives, Elisabeth, Carmona Jimenez, Francisco Jose, Galobardes Vilches, Agusti, Gonzalez Gomez, Albert, Jodar Manzanera, Laura, Marimon Cortes, Jose, Marrodan Orive, Felix, Martin Bosch, Maria Jose, Martorell Lopez, Manuel, Millares Roca, M Jesus, Miralles Guri, Carles, Muliterno Hernandez, Ricardo, Muñoz Oliva, Eva, Pons Pujol, Ramon, Postius Conde, Camilo, Prieto Arruñada, Jose Antonio, Quintana Mathé, Pol, Rosell Mata, Jordi, Aguirre Alvarez, Sonia, Alvarin Alvarez, Celia, Arrufat Flores, Lorena, Bañuelos Pago, Joan, Burnat Andreu, Laia, Campo Vilar, Francisco, Cardus Hidalgo, Jaume, Castello Gil, Maria Gloria, Castrillo Montsesinos, Gonzalo, Català Estopà, Xavier, Clave Garces, Enric, Comes Sanroma, Montserrat, Descalzo Sequi, Carlos, Errando Ricol, Javier, Escudero Campillo, Maria del Mar, Fernandez Alvarez, Joaquin, Fernandez Gomez, Carlos, Fernandez Perez, Patricia, Franch Espinosa, Laura, Freixes Graells, Cristina, Garcia Plaza, Marta, Garcia-Marron Gallego, Ainhoa, Hernandez Simancas, Rafael, Homar Covas, Dolça, Huerta Royo, Marta, Jaraba Armas, Sonia, Jimenez Ramos, Pedro, Lopez Canela, M Angeles, Lopez Lopez, Alejandro, Lopez Oganissian, Aleix, Madrona Romero, M Rosa, Martinez Millan, Daniel, Martínez Morón, Marta, Merchan Encinas, Noelia, Morell Fornieles, Olga, Moreno Jimenez, Sandra, Muñoz Rico, Matilde, Navarro Rodriguez, Jessica, Nogales Ibañez, Rita Maria, Novillo Viera, Raquel, Parella Torrabadella, Mari Alba, Pera Villar, Carla Montserrat, Puertas Carbonell, Alba, Rabella Miralles, Angels, Ramis Trilles, Alejandro, Ribera Ortiz, Merce, Rodriguez Fuertes, Mariola, Sanchez Gonzalez, Baltasar, Sastre Perez, Paola, Segura Perez, Enriqueta, Soro Borrega, Cristina, Soto Garcia, Maria Angeles, Tapia Fores, Meritxell, Tellez Bernad, Gemma, Trenado Alvarez, Jose, Español Moreda, Agusti, Felix Martin, Purificacion, Herrero Perez, Luis, Jodar Manzanera, Laura, Lanau Fuster, Pedro, Lopez Gomariz, Alfonso, Marrodan Orive, Felix, Martin Bosch, Maria Jose, Miralles Guri, Carles, Muñoz Oliva, Eva, Pardo Lozano, Ricardo, Pons Pujol, Ramon, Quintana Altimiras, Joan, Ventosa Lopez, Miguel, Almodovar Damian, Consuelo, Alvarez Colino, Jeannette, Alvarez Monterroso, Miguel, Arambudo Comas, Anna, Boullon Garzon, Raquel, Burgos Capella, Antonio, Campuzano Garcia, Maria Del Mar, Capdevila Olivas, Montserrat, Carcelen Fernandez, Daniel, Caro Solà, Marc, Carre Marti, Clara Isabel, Carretero Bacaicoa, Alexander, Castello Gil, Maria Gloria, Castrillo Montsesinos, Gonzalo, Cazorla Calderon, Sergio, Chacon Osuna, Alexandre, Cortes Planas, Lidia, Cortit Olio, Rita, Delhomme Estany, Carles, Duran Carasso, Pablo Javier, Escudero Campillo, Maria del Mar, Fructuos Martinez, Raquel, Garcia Lopez, Pascual Luis, Garcia Plaza, Marta, Genis Amill Vallve, Gomez Arroyo, Manuela, Gomez Girbau, Xavier, Gonzalez Muñoz, Carlos, Hernaez Ventura, Elena, Homar Covas, Dolça, Lavernia Gimenez, Cristina, Martin Rojo, Rafael, Martínez Medina, Marta, Martinez Millan, Daniel, Mayol Barrera, Sergi, Mercader Pi, Xavier, Merino Dalmau, Isabel, Miguel Campodarbe, Maria, Montserrat Puig Pastalle, Morales de la Cruz, Raquel, Morell Fornieles, Olga, Moreno Sanchez, Francisco Javier, Pallares Reig, Roger, Parella Torrabadella, Mari Alba, Penela Barrameda, Feliciano, Prieto Ajenjo, Monica, Rebollar Benavente, Cristina, Rodriguez Pareja, Obed, Rodríguez Piñar, Francisco Javier, Rodriguez Tello, Mar, Romero Pereda, Sandra, Sainz Saborido, Laura, Santacana Martin, Yolanda, Santos Martinez, Sheila, Sierra Chavez, Eduardo, Toledo Testa, Soledad, Tomàs Figueras, Lluis, Torres Garcia, Pedro José, Turbau Torres, Ricard, Vicente Domenech, Narcis, Villena Esteo, Olga, Vives Pertegaz, Nuria, Baena Gonzalez, Andres, Bagaria Pont, Marc, Beltran Sanchez, Cristina, Bonet Alarcon, Victor, Borch Ballescà, Gemma, Buhils Clanchet, Estel, Closa Garcia, Alejandro, Colomina Carril, Esther, Cristina Fernandez Sanchez, Edurne Judith Fernandez Toledo, Espases Rodriguez, Roger, Espert Resa, F Xavier, Fernández Sol, Mireia, Gonzalez Lugo, Jordi, Gracia Llesera, Daniel, Herrada Lendinez, Jorge, Juliench Liesa, Sandra Alicia, Lopez Ortega, Joel, Lopez Yuste, Samuel, Lozano Villanueva, Marta, Lucia Sola Soto, Madrid Castellano, Nicolas, Megias Cano, Daniel Jesus, Montasell Ponce, Arich, Montesinos Sospedra, Susana, Moya Martinez, Raul, Muñoz Herrera, M Isabel, Ocaña Fernandez, Maria Jose, Palau Bernal, Bàrbara, Perez Sole, Pedro, Ramon Carbonell, Judith, Ribas Lop, Marc, Rubio López, Verònica, Rueda Lopez, Silvina, Sabat Castaño, Gerard, Sabata Lara, Marc, Salmerón Ramírez, Manel, Sebastia Gornals, Meritxell, Serra Creus, Albert, Serrano Dalmau, Noemí, Sumasi Mainero, Gonzalo Gabriel, Torello Masa, Miquel, Valencia Primo, Ana Maria Viñuales Muñoz, Silvia. Oficina seguiment Pla Director: Mercè Salvat-Plana; Josep Roig; Verònica Hidalgo.

    • Contributors AF, AG-T, NPdlO, and MR conceptualized the study, performed data analyses, wrote the manuscript, and are the guarantors of the study; All the authors contributed to the preparation of the material and data collection; LS, XU, MR, AP, SA, and NPdIO, supervised the clinical aspects of the study. All authors critically reviewed the manuscript and approved the final version.

    • Funding The RACECAT trial was supported by Fundació Ictus Malaltia Vascular through an unrestricted grant from Medtronic, by a grant from the Spanish Ministry of Health co-financed by Fondo Europeo de Desarrollo Regional (Instituto de Salud Carlos III, Red Temática de Investigación Cooperativa RETICS-INVICTUS-PLUS RD0016/0019/0020), and from the PERIS programme from the Catalan Health Government (project SLT008/18/0007).

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    • Competing interests NPdIO: grant from the Spanish Ministry of Health co-financed by Fondo Europeo de Desarrollo Regional (Instituto de Salud Carlos III, Red Temática de Investigación Cooperativa RETICS-INVICTUS-PLUS RD0016/0019/0020), and from the PERIS programme from the Catalan Health Government (project SLT008/18/0007). CAM has received honoraria for participation in clinical trials, contribution to advisory boards, or oral presentations from AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Bristol-Myers-Squibb, Covidien, Cerevast, and Brainsgate. MR is advisor and shareholder in Anaconda Biomed and Methinks and received grants and personal fees from Medtronic, personal fees from Stryker, Cerenovus, Philips, and Apta Targets.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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