Ischemic stroke secondary prevention: Difference between revisions

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__NOTOC__
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{{Ischemic Stroke}}
{{Ischemic Stroke}}
{{CMG}}{{AE}}{{AA}}
{{CMG}}{{AE}}{{AA}}{{MHP}}
==Overview==
==Overview==
Secondary prevention of ischemic stroke is mainly directed to lifestyle modifications, treatment of modifiable risk factors, and treatment of specific cause of ischemic stroke.
==Secondary Prevention==
==Secondary Prevention==
Specific cause of ischemic stroke for secondary prevention:
Specific recommendations for prevention strategies often depend on the ischemic stroke/transient ischemic attack subtype. Patients presenting with signs and symptoms of acute stroke will undergo an evaluation tailored to ensure that, when appropriate, they receive reperfusion therapy.
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
Secondary stroke prevention includes antiplatelet therapy, statins and antihypertensives. Aspirin, clopidogrel, or a combination of aspirin with dipyridamole are first-line options for secondary stroke prevention in the absence of atrial fibrillation. Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time. Anticoagulants are indicated if the patient has atrial fibrillation. Avoid combinations of anticoagulants and antiplatelet drugs.
|+
Patients should be started on statins after an ischaemic stroke. High doses are recommended even if cholesterol concentrations are normal. Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140 mmHg. ACE inhibitors, calcium channel blockers and diuretics are first-line options.<ref name="pmid32299593">{{cite journal |vauthors=Diener HC, Hankey GJ |title=Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage: JACC Focus Seminar |journal=J Am Coll Cardiol |volume=75 |issue=15 |pages=1804–1818 |date=April 2020 |pmid=32299593 |doi=10.1016/j.jacc.2019.12.072 |url=}}</ref><ref name="pmid21750435">{{cite journal |vauthors=Berge E |title=Should high blood pressure be lowered in the acute stroke? |journal=J Hypertens |volume=29 |issue=8 |pages=1478–9 |date=August 2011 |pmid=21750435 |doi=10.1097/HJH.0b013e32834a019b |url=}}</ref><ref name="pmid31662037">{{cite journal |vauthors=Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, B<rown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL |title=Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association |journal=Stroke |volume=50 |issue=12 |pages=e344–e418 |date=December 2019 |pmid=31662037 |doi=10.1161/STR.0000000000000211 |url=}}</ref><ref name="pmid34024117">{{cite journal |vauthors=Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS |title=2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association |journal=Stroke |volume=52 |issue=7 |pages=e364–e467 |date=July 2021 |pmid=34024117 |doi=10.1161/STR.0000000000000375 |url=}}</ref>
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Cause of ischemic stroke}}
 
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Revascularisation}}
===Life style modification for secondary prevention===
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Multifacrorial risk reduction}}
Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:
*Increased physical activity
*Eating healthy balanced diet
*Smoking cessation
*Decreased alcohol intake
===Treatment of modifiable risk factors===
*Treatment and maintainence of hypertension, diabetes mellitus and hyperlipidemias<ref name="pmid19121254">{{cite journal| author=Adams HP| title=Secondary prevention of atherothrombotic events after ischemic stroke. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 1 | pages= 43-51 | pmid=19121254 | doi=10.1016/S0025-6196(11)60807-0 | pmc=2664570 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19121254  }} </ref>
*Treatment of underlying coronary artery disease
*Treatment of atrial fibrillation and maintaining anticoagulant prophylaxis in high risk patients
*Proper management and follow up of genetic hypercoaguable conditions
*Use of long term antiplatelet therapy such as aspirin, clopidogrel or combination therapy may be used to prevent recurrent ischemic stroke.<ref name="pmid19121254">{{cite journal| author=Adams HP| title=Secondary prevention of atherothrombotic events after ischemic stroke. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 1 | pages= 43-51 | pmid=19121254 | doi=10.1016/S0025-6196(11)60807-0 | pmc=2664570 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19121254  }} </ref>
 
===Secondary prevention of complications of ischemic stroke===
The preventive measures which may help prevent complications of ischemic stroke include:<ref name="pmid14683626">{{cite journal| author=Kappelle LJ, Van Der Worp HB| title=Treatment or prevention of complications of acute ischemic stroke. | journal=Curr Neurol Neurosci Rep | year= 2004 | volume= 4 | issue= 1 | pages= 36-41 | pmid=14683626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14683626  }} </ref><ref name="pmid20539816">{{cite journal| author=Anders J, Heinemann A, Leffmann C, Leutenegger M, Pröfener F, von Renteln-Kruse W| title=Decubitus ulcers: pathophysiology and primary prevention. | journal=Dtsch Arztebl Int | year= 2010 | volume= 107 | issue= 21 | pages= 371-81; quiz 382 | pmid=20539816 | doi=10.3238/arztebl.2010.0371 | pmc=2883282 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20539816  }} </ref>
*Use of intermittent pneumatic compressions and low molecular weight heparin in patients with high risk of thromboembolism
*There is no prophylaxis for prevention of seizures in patients with ischemic stroke. However, one episode of seizure may mandate the use of antiepileptic medication to prevent recurrence.<ref name="pmid14683626">{{cite journal| author=Kappelle LJ, Van Der Worp HB| title=Treatment or prevention of complications of acute ischemic stroke. | journal=Curr Neurol Neurosci Rep | year= 2004 | volume= 4 | issue= 1 | pages= 36-41 | pmid=14683626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14683626  }} </ref>
*Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex<ref name="pmid23983842">{{cite journal| author=Armstrong JR, Mosher BD| title=Aspiration pneumonia after stroke: intervention and prevention. | journal=Neurohospitalist | year= 2011 | volume= 1 | issue= 2 | pages= 85-93 | pmid=23983842 | doi=10.1177/1941875210395775 | pmc=3726080 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23983842  }} </ref>
*Pressure ulcers may be prevented by use of air mattress and regular change in position of patient<ref name="pmid20539816">{{cite journal| author=Anders J, Heinemann A, Leffmann C, Leutenegger M, Pröfener F, von Renteln-Kruse W| title=Decubitus ulcers: pathophysiology and primary prevention. | journal=Dtsch Arztebl Int | year= 2010 | volume= 107 | issue= 21 | pages= 371-81; quiz 382 | pmid=20539816 | doi=10.3238/arztebl.2010.0371 | pmc=2883282 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20539816  }} </ref>


===Secondary prevention for specific causes of ischemic stroke<ref name="pmid18468545">{{cite journal| author=Donnan GA, Fisher M, Macleod M, Davis SM| title=Stroke. | journal=Lancet | year= 2008 | volume= 371 | issue= 9624 | pages= 1612-23 | pmid=18468545 | doi=10.1016/S0140-6736(08)60694-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18468545  }} </ref>===
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! colspan="2" rowspan="2" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Cause of ischemic stroke}}
! colspan="3" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Revascularization}}
! style="background: #4479BA; padding: 5px 5px;" colspan=4 | {{fontcolor|#FFFFFF|Multifactorial risk reduction}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Large vessel atherosclerosis'''
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Carotid endartectomy}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Carotid stenting}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other Surgical options}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Antiplatelet therapy}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Statins}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Antihypertensives}}
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Anticoagulants}}
|-
| rowspan="5" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''Large artery disease''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Carotid Artery Stenosis
| style="padding: 5px 5px; background: #F5F5F5;" | ✔
| style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Carotid occlusion
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | ✔
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Vertebral artery stenosis
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |Angioplasty
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Large vessel atherosclerosis
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | ✔ 
| style="padding: 5px 5px; background: #F5F5F5;" | Percutaneous transluminal angioplasty
! style="padding: 5px 5px; background: #F5F5F5;" |✔✔
! style="padding: 5px 5px; background: #F5F5F5;" | ✔✔
! style="padding: 5px 5px; background: #F5F5F5;" | ✔✔
! style="padding: 5px 5px; background: #F5F5F5;" | ✔✔
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Arterial dissection
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | Endovascular surgical repair
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|-
| rowspan="6" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''Cardiac embolism''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Atrial fibrillation
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Valvular heart disease
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Mitral valve disease
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Recent MI/ left ventricular thrombus
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Heart failure
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |✔
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Small vessel disease'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Dilated cardiomyopathy
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Intracranial artery atherosclerosis'''
| rowspan="4" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''Hematological disorders''
| style="padding: 5px 5px; background: #F5F5F5;" |
| rowspan="1" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Protein C/S deficiency
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Cardiac embolism '''
| rowspan="1" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Sickle cell disease
*Myocardial infarction
! style="padding: 5px 5px; background: #F5F5F5;" |
*Cardiac failure
! style="padding: 5px 5px; background: #F5F5F5;" |
*Dilated cardiomyopathy
! style="padding: 5px 5px; background: #F5F5F5;" | Repeated blood transfusions and
*Valvular heart disease
Hydroxurea
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Blood dyscrasias'''
| rowspan="1" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Antithrombin III deficiency
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |  
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
|
|-
|-
| rowspan="1" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Antiphospholipid antibody syndrome
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ✔
! style="padding: 5px 5px; background: #F5F5F5;" |
|}
|}
A) Revascularization [carotid artery occlusion, stenosis, vertebral artery stenosis, intracranial large artery atherosclerosis,
'''For AHA/ASA guidelines on secondary prevention of ischemic stroke, please ''' [[AHA/ASA guideline recommendations for secondary prevention of stroke|click here]]<br>
*Carotid endartectomy :prefferd
*Carotid stenting
B)Multifactorial risk reduction
*Antiplatelet agents
*Antilipid
*Antihypertensive med
 
 
Treatment of risk factors in patients who have already had strokes (secondary prevention) is also very important as they are at high risk of subsequent events compared with those who have never had a stroke. Medication or [[Pharmacology|drug therapy]] is the most common method of stroke prevention. Aspirin (usually at a low dose of 75 mg) is recommended for the primary and secondary prevention of stroke.  Also see [[Antiplatelet drug]] treatment.  Treating risk factors like [[hypertension]], [[diabetes mellitus]], [[smoking cessation]], control of  [[hypercholesterolemia]], [[physical exercise]], and avoidance of [[Illegal drug trade|illicit drugs]] and excessive alcohol consumption are all recommended ways of reducing the risk of stroke in a patient who already has a history of previous strokes.<ref name="americanheart risk">American Heart Association. (2007). [http://www.americanheart.org/presenter.jhtml?identifier=4716 Stroke Risk Factors] Americanheart.org. Retrieved on [[January 22]], [[2007]].</ref>
 
In patients who have strokes due to abnormalities of the heart, such as [[atrial fibrillation]], [[anticoagulation]] with medications such as [[warfarin]] is often necessary for stroke prevention.<ref>American Heart Association. (2007). [http://www.americanheart.org/presenter.jhtml?identifier=4451 Atrial Fibrillation] Americanheart.org. Retrieved on [[January 22]], [[2007]].</ref>
 
Procedures such as [[carotid endarterectomy]] or carotid [[angioplasty]] can be used to remove significant atherosclerotic narrowing (stenosis) of the [[carotid artery]], which supplies blood to the brain. These procedures have been shown to prevent stroke in certain patients, especially where carotid stenosis leads to [[ischemic]] events such as [[transient ischemic attack]]. (The value and role of carotid artery ultrasound scanning in [[Screening (medicine)|screening]] has yet to be established.)


==References==
==References==

Latest revision as of 22:05, 30 August 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]Maryam Hadipour, M.D.[3]

Overview

Secondary prevention of ischemic stroke is mainly directed to lifestyle modifications, treatment of modifiable risk factors, and treatment of specific cause of ischemic stroke.

Secondary Prevention

Specific recommendations for prevention strategies often depend on the ischemic stroke/transient ischemic attack subtype. Patients presenting with signs and symptoms of acute stroke will undergo an evaluation tailored to ensure that, when appropriate, they receive reperfusion therapy. Secondary stroke prevention includes antiplatelet therapy, statins and antihypertensives. Aspirin, clopidogrel, or a combination of aspirin with dipyridamole are first-line options for secondary stroke prevention in the absence of atrial fibrillation. Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time. Anticoagulants are indicated if the patient has atrial fibrillation. Avoid combinations of anticoagulants and antiplatelet drugs. Patients should be started on statins after an ischaemic stroke. High doses are recommended even if cholesterol concentrations are normal. Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140 mmHg. ACE inhibitors, calcium channel blockers and diuretics are first-line options.[1][2][3][4]

Life style modification for secondary prevention

Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:

  • Increased physical activity
  • Eating healthy balanced diet
  • Smoking cessation
  • Decreased alcohol intake

Treatment of modifiable risk factors

  • Treatment and maintainence of hypertension, diabetes mellitus and hyperlipidemias[5]
  • Treatment of underlying coronary artery disease
  • Treatment of atrial fibrillation and maintaining anticoagulant prophylaxis in high risk patients
  • Proper management and follow up of genetic hypercoaguable conditions
  • Use of long term antiplatelet therapy such as aspirin, clopidogrel or combination therapy may be used to prevent recurrent ischemic stroke.[5]

Secondary prevention of complications of ischemic stroke

The preventive measures which may help prevent complications of ischemic stroke include:[6][7]

  • Use of intermittent pneumatic compressions and low molecular weight heparin in patients with high risk of thromboembolism
  • There is no prophylaxis for prevention of seizures in patients with ischemic stroke. However, one episode of seizure may mandate the use of antiepileptic medication to prevent recurrence.[6]
  • Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex[8]
  • Pressure ulcers may be prevented by use of air mattress and regular change in position of patient[7]

Secondary prevention for specific causes of ischemic stroke[9]

Cause of ischemic stroke Revascularization Multifactorial risk reduction
Carotid endartectomy Carotid stenting Other Surgical options Antiplatelet therapy Statins Antihypertensives Anticoagulants
Large artery disease Carotid Artery Stenosis ✔ ✔
Carotid occlusion ✔ ✔
Vertebral artery stenosis Angioplasty ✔ ✔ ✔
Large vessel atherosclerosis ✔ Percutaneous transluminal angioplasty ✔✔ ✔✔ ✔✔ ✔✔
Arterial dissection Endovascular surgical repair ✔ ✔
Cardiac embolism Atrial fibrillation ✔ ✔
Valvular heart disease ✔
Mitral valve disease ✔
Recent MI/ left ventricular thrombus ✔
Heart failure ✔ ✔
Dilated cardiomyopathy ✔ ✔
Hematological disorders Protein C/S deficiency ✔
Sickle cell disease Repeated blood transfusions and

Hydroxurea

✔
Antithrombin III deficiency ✔
Antiphospholipid antibody syndrome ✔ ✔

For AHA/ASA guidelines on secondary prevention of ischemic stroke, please click here

References

  1. ↑ Diener HC, Hankey GJ (April 2020). "Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage: JACC Focus Seminar". J Am Coll Cardiol. 75 (15): 1804–1818. doi:10.1016/j.jacc.2019.12.072. PMID 32299593 Check |pmid= value (help).
  2. ↑ Berge E (August 2011). "Should high blood pressure be lowered in the acute stroke?". J Hypertens. 29 (8): 1478–9. doi:10.1097/HJH.0b013e32834a019b. PMID 21750435.
  3. ↑ Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, B<rown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL (December 2019). "Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 50 (12): e344–e418. doi:10.1161/STR.0000000000000211. PMID 31662037. Vancouver style error: non-Latin character (help)
  4. ↑ Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS (July 2021). "2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association". Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID 34024117 Check |pmid= value (help).
  5. ↑ 5.0 5.1 Adams HP (2009). "Secondary prevention of atherothrombotic events after ischemic stroke". Mayo Clin Proc. 84 (1): 43–51. doi:10.1016/S0025-6196(11)60807-0. PMC 2664570. PMID 19121254.
  6. ↑ 6.0 6.1 Kappelle LJ, Van Der Worp HB (2004). "Treatment or prevention of complications of acute ischemic stroke". Curr Neurol Neurosci Rep. 4 (1): 36–41. PMID 14683626.
  7. ↑ 7.0 7.1 Anders J, Heinemann A, Leffmann C, Leutenegger M, Pröfener F, von Renteln-Kruse W (2010). "Decubitus ulcers: pathophysiology and primary prevention". Dtsch Arztebl Int. 107 (21): 371–81, quiz 382. doi:10.3238/arztebl.2010.0371. PMC 2883282. PMID 20539816.
  8. ↑ Armstrong JR, Mosher BD (2011). "Aspiration pneumonia after stroke: intervention and prevention". Neurohospitalist. 1 (2): 85–93. doi:10.1177/1941875210395775. PMC 3726080. PMID 23983842.
  9. ↑ Donnan GA, Fisher M, Macleod M, Davis SM (2008). "Stroke". Lancet. 371 (9624): 1612–23. doi:10.1016/S0140-6736(08)60694-7. PMID 18468545.

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