A Global Health Perspective on the 2026 AHA/ASA Stroke Guidelines: Lessons from the Indian Health System

Background: Contemporary evidence-based guidelines have substantially improved outcomes after acute ischemic stroke in well-resourced health systems. However, implementation gaps persist in low- and middle-income countries (LMICs), where health system capacity often diverges from assumptions underlying guideline development. The extent to which high-income reference guidelines can be translated into resource-constrained settings remains insufficiently examined. Methods: We conducted a structured systems-level review of recommendations from the 2026 American Heart Association/American Stroke Association guideline for early management of acute ischemic stroke. Recommendations were mapped across five domains of care and qualitatively assessed for feasibility, adaptability through service redesign, and dependence on advanced infrastructure or specialist workforce capacity. India served as an illustrative LMIC case to contextualize implementation pathways and constraints. Results: Translatability varied substantially across domains. Recommendations related to early recognition, protocol-driven workflows, and basic supportive management were largely directly implementable or adaptable with modest resources. In contrast, components dependent on advanced neuroimaging, comprehensive stroke units, and endovascular thrombectomy were predominantly constrained by infrastructure and workforce requirements. Feasibility gradients were domain-specific rather than guideline-wide. National stroke guidance in India reflects these gradients through resource-stratified pathways that emphasize organized care, referral networks, and telemedicine-supported models while concentrating advanced interventions within tertiary hubs. Conclusions: Many contemporary acute ischemic stroke guideline components can be implemented or adapted in resource-constrained systems without compromising evidence-based care. The principal barrier to equitable outcomes is not lack of evidence but misalignment between guideline assumptions and system capacity. Structured, domain-specific translation offers a pragmatic pathway toward more equitable global stroke care. Keywords Acute ischemic stroke, clinical practice guidelines, health system capacity, low- and middle-income countries, implementation and translatability, stroke systems of care, resource-stratified care