WSO October 2023 – Issue 1 - 898

1180067
WSO
International Journal of StrokeCaso et al.
Review
Six years of the Angels Initiative: Aims,
achievements, and future directions to
improve stroke care worldwide
Valeria Caso1 , Sheila Martins2, Robert Mikulik3,
Sandy Middleton4 , Stanislav Groppa5, Jeyaraj Durai Pandian6,
Nguyen Huy Thang7, Thierry Danays8 , Jan van der Merwe9,
Thomas Fischer9 and Werner Hacke10
International Journal of Stroke
2023, Vol. 18(8) 898 -907
© 2023 World Stroke Organization
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DOI: 10.1177/17474930231180067
journals.sagepub.com/home/wso
https://doi.org/10.1177/17474930231180067
Abstract
The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than
in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order
to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready
hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.
Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in
collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke
societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and
to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to
standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants
also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality
(RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals
across the world.
The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients
to become " stroke ready. " Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated
7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative
has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in
2015 vs 185 in 2021), reduced " door to treatment time " (e.g. in Egypt: 50% reduction vs baseline), and increased quality
monitoring substantially.
The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment
to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is
1University of Perugia, Perugia, Italy
2Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
3International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
4Australian Catholic University and St. Vincent's Health Network Sydney, Sydney, NSW, Australia
5State University of Medicine and Pharmacy 'Nicolae Testemitanu,' Chisinau, Moldova
6Christian Medical College, Ludhiana, India
7115 Hospital, Ho Chi Minh City, Vietnam
8TDC, Aix en Provence, France
9Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
10Ruprecht-Karl-University Heidelberg, Heidelberg, Germany
Corresponding author:
Jan van der Merwe, Boehringer Ingelheim International GmbH, Binger Strasse 173, 55216 Ingelheim am Rhein, Germany.
Email: jan.van_der_merwe@boehringer-ingelheim.com
International Journal of Stroke, 18(8)
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WSO October 2023 – Issue 1

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