AHA, ASA guidelines for stroke

Template:AHA, ASA stroke guidelines Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Tarek Nafee, M.D. [2]

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

DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION

Class I

"1.     In patients suspected of having a stroke or TIA, an ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions. (Level of evidence: B-R)"

"2.      In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms (Level of evidence: B-NR) "

"3.     In patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization, noninvasive cervical carotid imaging with carotid ultrasonography, CT angiography (CTA), or magnetic resonance angiography (MRA) is recommended to screen for stenosis (Level of evidence: B-NR) "

"4.     In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease (Level of evidence: B-NR) "

"5.     In patients with a confirmed diagnosis of symptomatic ischemic cerebrovascular disease, blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or non-fasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals (Level of evidence: B-NR) "

Class IIa

" 6.     In patients with cryptogenic stroke, echocardiography with or without contrast is reason-able to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism (Level of Evidence B-R)".

'' 7.     In patients with cryptogenic stroke who do not have a contraindication to anticoagulation, long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF. (Level of Evidence B R)''

'' 8.    In patients suspected of having an ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct, follow-up CT or MRI of the brain is reasonable to confirm a diagnosis. (Level of Evidence B- NR)''

'' 9.       In patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct, follow-up MRI is reasonable to predict the risk of early stroke and to support the diagnosis. (Level of Evidence B- NR)''

'' 10.    In patients with cryptogenic stroke, tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis (eg, HIV and syphilis), drug use (eg, cocaine and amphetamines), and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reason-able to perform as clinically indicated to identify contributors to or relevant risk factors for stroke. (Level of Evidence C-LD)''

'' 11.     In patients with ischemic stroke or TIA, noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebro-basilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies. (Level of Evidence C-LD)''

Class IIb

" 12.    In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction (Level of Evidence B-NR)".

'' 13.       In patients with ESUS, transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism. (Level of Evidence C-LD)''

'' 14.      In patients with ischemic stroke or TIA in whom patent foramen ovale (PFO) closure would be contemplated, TCD (transcranial Doppler) with embolus detection might be reasonable to screen for right-to-left shun. (Level of Evidence C LD)''

NUTRITION

Class IIa

" 1.     In patients with stroke and TIA, it is reasonable to counsel individuals to follow a Mediterranean type diet, typically with empha-sis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce risk of recurrent stroke (Level of Evidence B-R)".

'' 2.       In patients with stroke or TIA and hypertension who are not currently restricting their dietary sodium intake, it is reasonable to recommend that individuals reduce their sodium intake by at least 1g/d sodium (2.5 g/d salt) to reduce the risk of cardiovascular disease (CVD) events (including stroke). (Level of Evidence B R)''

PHYSICAL ACTIVITY

Class I

"1.        In patients with stroke or TIA who are capable of physical activity, engaging in at least moderate-intensity aerobic activity for a minimum of 10 min-utes 4 times a week or vigorous-intensity aerobic activity for a minimum of 20 minutes twice a week is indicated to lower the risk of recurrent stroke and the composite cardiovascular end point of recurrent stroke, MI, or vascular death. (Level of evidence: C-LD)"

Class IIa

" 2.          In patients with stroke or TIA who are able and willing to increase physical activity, engaging in an exercise class that includes counseling to change physical activity behavior can be beneficial for reducing cardiometabolic risk factors and increasing leisure time physical activity participation. (Level of Evidence B-R)".

'' 3.           In patients with deficits after a stroke that impair their ability to exercise, supervision of an exercise program by a health care professional such as a physical therapist or cardiac rehabilitation professional, in addition to routine rehabilitation, can be beneficial for secondary stroke prevention. (Level of Evidence C-EO)''

Class IIb

" 4.       In individuals with stroke or TIA who sit for long periods of uninterrupted time during the day, it may be reasonable to recommend breaking up sedentary time with intervals as short as 3 minutes of standing or light exercise every 30 minutes for their cardiovascular health (Level of Evidence B-NR)".

SMOKING CESSATION

Class I

"1.         In patients with stroke or TIA who smoke tobacco, counseling with or without drug therapy (nicotine replacement, bupropion, or varenicline) is recommended to assist in quitting smoking. (Level of evidence: A)"

"2.         Patients with stroke or TIA who continue to smoke tobacco should be advised to stop smoking (and, if unable, to reduce their daily smoking) to lower the risk of recurrent stroke (Level of evidence: B-NR) "

"3.       In patients with stroke or TIA. avoidance of environmental (passive) tobacco smoke is recommended to reduce the risk of recurrent stroke. (Level of evidence: B-NR) "

SUBSTANCE USE

Class I

"1.           Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alcoholic drink a day for women should be counseled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of evidence: B-NR)"

"2.            In patients with stroke or TIA who use stimulants (eg, amphetamines, amphetamine derivatives, cocaine, or khat) and in patients with infective endocarditis (IE) in the context of intravenous drug use, it is recommended that health care providers inform them that this behavior is a health risk and counsel them to stop. (Level of evidence: C-EO) "

"3.          In patients with stroke or TIA who have a substance use disorder (drugs or alcohol), specialized services are recommended to help manage this dependenc. (Level of evidence: C-EO) "

HYPERTENTION

Class I

"1.           Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alco-holic drink a day for women should be coun-seled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of evidence: A)"

"2.            In patients with hypertension who experience a stroke or TIA, an office BP goal of <130/80 mm Hg is recommended for most patients to reduce the risk of recurrent stroke and vascular events. (Level of evidence: B-R) "

"3.          In patients with hypertension who experience a stroke or TIA, individualized drug regimens that take into account patient comorbidities, agent pharmacological class, and patient preference are recommended to maximize drug efficacy (Level of evidence: B-NR) "

Class IIa

" 4.              In patients with no history of hypertension who experience a stroke or TIA and have an aver-age office BP of ≥130/80 mm Hg, antihypertensive medication treatment can be beneficial to reduce the risk of recurrent stroke, ICH, and other vascular events (Level of Evidence B-R)".

Treatment

Class I

"1. In patients with ischemic stroke with no known coronary heart disease, no major cardiac sources of embolism, and LDL cholesterol (LDL-C) >100 mg/dL, atorvastatin 80 mg daily is indicated to reduce risk of stroke recurrence. (Level of evidence: A)"

"2.  In patients with ischemic stroke or TIA and ath-erosclerotic disease (intracranial, carotid, aortic, or coronary), lipid-lowering therapy with a statin and also ezetimibe, if needed, to a goal LDL-C of <70 mg/dL is recommended to reduce the risk of major cardiovascular events. (Level of evidence: A) "

Monitoring

Class I

"1. In patients with stroke or TIA and hyperlipidemia, patients’ adherence to changes in lifestyle and the effects of LDL-C–lowering medication should be assessed by measurement of fasting lipids and appropriate safety indicators 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter, based on the need to assess adherence or safety. (Level of evidence: A)"

Treatment of Hypertriglyceridemia

Class IIa

" 1. In patients with ischemic stroke or TIA, with fasting triglycerides 135 to 499 mg/dL and LDL-C of 41 to 100 mg/dL, on moderate- or high-intensity statin therapy, with HbA1c <10%, and with no history of pancreatitis, AF, or severe heart failure, treatment with icosapentethyl (IPE) 2 g twice a day is reasonable to reduce risk of recurrent stroke. (Level of Evidence B-R)".

'' 2. In patients with severe hypertriglyceridemia (ie, fasting triglycerides ≥500 mg/dL [≥5.7 mmol/L]), it is reasonable to identify and address causes of hypertriglyceridemia and, if triglycerides are persistently elevated or increasing, to further reduce triglycerides in order to lower the risk of ASCVD events by implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consump-tion of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy. (Level of Evidence B-NR)''