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

backgroundContemporary evidence-based guidelines have substantially improved outcomes after acute ischemic stroke in well-resourced health systems. However, their implementation remains uneven in low- and middle-income countries (LMICs), where infrastructure, specialist workforce, financing, and time-critical workflows often differ from the assumptions embedded in guideline development. The extent to which high-income reference guidelines can be translated into resource-constrained settings therefore requires systematic evaluation. SUMMARY: We conducted a structured systems-level review of the 2026 American Heart Association/American Stroke Association guideline for the early management of acute ischemic stroke, using India as an illustrative LMIC case. Acute implementation-relevant recommendations were grouped into clinically coherent clusters across eight domains of care and assessed using a predefined capacity-burden framework covering infrastructure and technology requirements, specialist workforce intensity, workflow complexity and time sensitivity, and financial or consumable dependency. Recommendation clusters were classified as directly implementable, adaptable, or infrastructure-constrained. Feasibility varied substantially across domains. Low-burden components, including stroke awareness, prehospital assessment, prenotification, stroke severity assessment, dysphagia screening, glucose monitoring, and pragmatic blood pressure protocols, were largely directly implementable. Moderate-capacity recommendations, including non-contrast computed tomography-first triage, protocolized intravenous thrombolysis, telestroke support, interhospital transfer agreements, and organized stroke-unit principles, were generally adaptable through service redesign, task-sharing, protocolization, and regional referral models. In contrast, advanced perfusion imaging, mobile stroke units, comprehensive thrombectomy pathways, and endovascular thrombectomy remained predominantly infrastructure constrained. The Indian case demonstrated similar feasibility gradients, while highlighting persistent rural-urban, public-private, and financing-related inequities. KEY MESSAGES: Many contemporary acute ischemic stroke guideline components can be implemented or adapted in resource-constrained health systems when translated according to available system capacity. The principal barrier to equitable stroke outcomes is not the absence of evidence but the misalignment between guideline assumptions and real-world infrastructure, workforce, financing, and workflow capacity. A capacity-burden approach offers a pragmatic framework for prioritizing stroke interventions, distinguishing immediately scalable components from those requiring service redesign or longer-term investment, and supporting more equitable global stroke care.