AHA/ASA guideline recommendations for secondary prevention of stroke

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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]

2014 AHA/ASA Guidelines for the Secondary Prevention of Stroke

Hypertension

Class I

"1. Initiation of BP therapy is indicated for previously untreated patients with ischemic stroke or TIA who, after the first several days, have an established BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic.  (Level of Evidence: B)"

"2. Resumption of BP therapy is indicated for previously treated patients with known hypertension for both prevention of recurrent stroke and prevention of other vascular events in those who have had an ischemic stroke or TIA and are beyond the first several days (Level of Evidence: A)"

"3. The optimal drug regimen to achieve the recommended level of reductions is uncertain because direct comparisons between regimens are limited. The available data indicate that diuretics or the combination of diuretics and an angiotensin-converting enzyme inhibitor is useful. (Level of Evidence: A)"

Class IIb

"1. Goals for target BP level or reduction from pretreatment baseline are uncertain and should be individualized, but it is reasonable to achieve a systolic pressure <140 mm Hg and a diastolic pressure <90 mm Hg. (Level of Evidence: B)"

"2. Several lifestyle modifications have been associated with BP reductions and are a reasonable part of a comprehensive antihypertensive therapy.(Level of Evidence: C)"

"3. The choice of specific drugs and targets should be individualized on the basis of pharmacological properties, mechanism of action, and consideration of specific patient characteristics for which specific agents are probably indicated (eg, extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and DM). (Level of Evidence: B)"

Class IIb

"1. Initiation of therapy for patients with BP <140 mm Hg systolic and <90 mm Hg diastolic is of uncertain benefit (Level of Evidence: C)"

"2. For patients with a recent lacunar stroke, it might be reasonable to target an SBP of <130 mm Hg (Level of Evidence: B)"

Dyslipidemia

Class I

"1. Statin therapy with intensive lipid-lowering effects is recommended to reduce risk of stroke and cardiovascular events among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin and an LDL-C level ≥100 mg/dL with or without evidence for other clinical ASCVD. (Level of Evidence: B)"

"2. Statin therapy with intensive lipid-lowering effects is recommended to reduce risk of stroke and cardiovascular events among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin, an LDL-C level <100 mg/dL, and no evidence for other clinical ASCVD. (Level of Evidence: C)"

"3. Patients with ischemic stroke or TIA and other comorbid ASCVD should be otherwise managed according to the 2013 ACC/AHA cholesterol guidelines,16 which include lifestyle modification, dietary recommendations, and medication recommendations. (Level of Evidence: A)"

Disorders of Glucose Metabolism and DM

Class I

"1. Use of existing guidelines from the ADA for glycemic control and cardiovascular risk factor management is recommended for patients with an ischemic stroke or TIA who also have DM or pre-DM. (Level of Evidence: B)"

Class IIa

"1. After a TIA or ischemic stroke, all patients should probably be screened for DM with testing of fasting plasma glucose, HbA1c, or an oral glucose tolerance test. Choice of test and timing should be guided by clinical judgment and recognition that acute illness may temporarily perturb measures of plasma glucose. In general, HbA1c may be more accurate than other screening tests in the immediate postevent period. (Level of Evidence: C)"

Class I

"1. All patients with TIA or stroke should be screened for obesity with measurement of BMI . (Level of Evidence: C)"

Class IIb

"1. Despite the demonstrated beneficial effects of weight loss on cardiovascular risk factors, the usefulness of weight loss among patients with a recent TIA or ischemic stroke and obesity is uncertain. (Level of Evidence: C)"

Metabolic Syndrome

Class I

"1. Preventive care for patient with the metabolic syndrome should include appropriate treatment for individual components of the syndrome, which are also stroke risk factors, particularly dyslipidemia and hypertension. (Level of Evidence: A)"

"2. For patients who are screened and classified as having the metabolic syndrome, management should focus on counseling for lifestyle modification (diet, exercise, and weight loss) for vascular risk reduction. (Level of Evidence: C)"</nowiki |- |} {|class="wikitable" |- | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] |- |bgcolor="LemonChiffon"|<nowiki>"1. At this time, the usefulness of screening patients for the metabolic syndrome after stroke is unknown. (Level of Evidence: C)"

Physical Inactivity

Class IIa

"1. For patients with ischemic stroke or TIA who are capable of engaging in physical activity, at least 3 to 4 sessions per week of moderate- to vigorous-intensity aerobic physical exercise are reasonable to reduce stroke risk factors. Sessions should last an average of 40 minutes. Moderate-intensity exercise is typically defined as sufficient to break a sweat or noticeably raise heart rate (eg, walking briskly, using an exercise bicycle). Vigorous-intensity exercise includes activities such as jogging. (Level of Evidence: C)"

"2. For patients who are able and willing to initiate increased physical activity, referral to a comprehensive, behaviorally oriented program is reasonable At this time, the usefulness of screening patients for the metabolic syndrome after stroke is unknown. (Level of Evidence: C)"

Class IIb

"1. For individuals with disability after ischemic stroke, supervision by a healthcare professional such as a physical therapist or cardiac rehabilitation professional, at least on initiation of an exercise regimen, may be considered . (Level of Evidence: C)"

Nutrition

Class I

"1. Patients with a history of ischemic stroke or TIA and signs of undernutrition should be referred for individualized nutritional counseling. (Level of Evidence: B)"

Class IIa

"1. It is reasonable to conduct a nutritional assessment for patients with a history of ischemic stroke or TIA, looking for signs of overnutrition or undernutrition. (Level of Evidence: C)"

"2. It is reasonable to recommend that patients with a history of stroke or TIA reduce their sodium intake to less than ≈2.4 g/d. Further reduction to <1.5 g/d is also reasonable and is associated with even greater BP reduction. (Level of Evidence: C)"

"3. It is reasonable to counsel patients with a history of stroke or TIA to follow a Mediterranean-type diet instead of a low-fat diet. The Mediterranean-type diet emphasizes vegetables, fruits, and whole grains and includes low-fat dairy products, poultry, fish, legumes, olive oil, and nuts. It limits intake of sweets and red meats. (Level of Evidence: C)"

Class III (Harm)

"1. Routine supplementation with a single vitamin or combination of vitamins is not recommended. (Level of Evidence: A)"

Obstructive Sleep Apnea

Class IIb

"1. A sleep study might be considered for patients with an ischemic stroke or TIA on the basis of the very high prevalence of sleep apnea in this population and the strength of the evidence that the treatment of sleep apnea improves outcomes in the general population. (Level of Evidence: B)"

"2. Treatment with CPAP might be considered for patients with ischemic stroke or TIA and sleep apnea given the emerging evidence in support of improved outcomes. (Level of Evidence: B)"

Cigarette Smoking

Class I

"1. Healthcare providers should strongly advise every patient with stroke or TIA who has smoked in the past year to quit. (Level of Evidence: C)"

"2. Counseling, nicotine products, and oral smoking cessation medications are effective in helping smokers to quit . (Level of Evidence: A)"

Class IIa

"1. It is reasonable to advise patients after TIA or ischemic stroke to avoid environmental (passive) tobacco smoke. (Level of Evidence: B)"

Alcohol Consumption

Class I

"1. Patients with ischemic stroke, TIA, or hemorrhagic stroke who are heavy drinkers should eliminate or reduce their consumption of alcohol. (Level of Evidence: C)"

Class IIb

"1. Light to moderate amounts of alcohol consumption (up to 2 drinks per day for men and up to 1 drink per day for nonpregnant women) may be reasonable, although nondrinkers should not be counseled to start drinking. (Level of Evidence: B)"

Interventional Approaches for the Patient With Large-Artery Atherosclerosis

Extracranial Carotid Disease

Class I

"1. For patients with a TIA or ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis as documented by noninvasive imaging, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6%. (Level of Evidence: A)"

"2. For patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid stenosis as documented by catheter-based imaging or noninvasive imaging with corroboration (eg, magnetic resonance angiogram or computed tomography angiogram), CEA is recommended depending on patient-specific factors, such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6%. (Level of Evidence: B)"

"3. CAS and CEA in the above settings should be performed by operators with established periprocedural stroke and mortality rates of <6% for symptomatic patients, similar to that observed in trials comparing CEA to medical therapy and more recent observational studies. (Level of Evidence: B)"

"4. Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification, is recommended for all patients with carotid artery stenosis and a TIA or stroke, as outlined elsewhere in this guideline. (Level of Evidence: A)"

Class IIa

"1. When revascularization is indicated for patients with TIA or minor, nondisabling stroke, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery if there are nocontraindications to early revascularization. (Level of Evidence: B)"

"2. CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the ICA is reduced by >70% by noninvasive imaging or >50% by catheter-based imaging or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is <6%. (Level of Evidence: B)"

"3. It is reasonable to consider patient age in choosing between CAS and CEA. For older patients (ie, older than ≈70 years), CEA may be associated with improved outcome compared with CAS, particularly when arterial anatomy is unfavorable for endovascular intervention. For younger patients, CAS is equivalent to CEA in terms of risk for periprocedural complications (ie, stroke, MI, or death) and long-term risk for ipsilateral stroke. (Level of Evidence: B)"

"4. Among patients with symptomatic severe stenosis (>70%) in whom anatomic or medical conditions are present that greatly increase the risk for surgery or when other specific circumstances exist such as radiation-induced stenosis or restenosis after CEA, CAS is reasonable. (Level of Evidence: B)"

Class IIb

"1. For patients with recurrent or progressive ischemic symptoms ipsilateral to a stenosis or occlusion of a distal (surgically inaccessible) carotid artery, or occlusion of a midcervical carotid artery after institution of optimal medical therapy, the usefulness of EC/IC bypass is considered investigational. (Level of Evidence: C)"

Class III (Harm)

"1. When the degree of stenosis is <50%, CEA and CAS are not recommended ( (Level of Evidence: A)"

"2. Routine, long-term follow-up imaging of the extracranial carotid circulation with carotid duplex ultrasonography is not recommended (Level of Evidence: B)"

"3. For patients with a recent (within 6 months) TIA or ischemic stroke ipsilateral to a stenosis or occlusion of the middle cerebral or carotid artery, EC/ IC bypass surgery is not recommended (Level of Evidence: A)"

Extracranial Vertebrobasilar Disease

Class I

"1. Routine preventive therapy with emphasis on antithrombotic therapy, lipid lowering, BP control, and lifestyle optimization is recommended for all patients with recently symptomatic extracranial vertebral artery stenosis. (Level of Evidence: C)"

Class IIb

"1. Endovascular stenting of patients with extracranial vertebral stenosis may be considered when patients are having symptoms despite optimal medical treatment. (Level of Evidence: C)"

"2. Open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, may be considered when patients are having symptoms despite optimal medical treatment (Level of Evidence: C)

Intracranial Atherosclerosis

Class I

"1. For patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in preference to warfarin. (Level of Evidence: B)"

"2. For patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mm Hg and high intensity statin therapy are recommended. (Level of Evidence: B)"

Class IIb

"1. For patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for 90 days might be reasonable. (Level of Evidence: B)"

"2. For patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the data are insufficient to make a recommendation regarding the usefulness of clopidogrel alone, the combination of aspirin and dipyridamole, or cilostazol alone. (Level of Evidence: C)"

"3. For patients with stroke or TIA attributable to severe stenosis (70%–99%) of a major intracranial artery, the usefulness of angioplasty alone or placement of stents other than the Wingspan stent is unknown and is considered investigational. (Level of Evidence: C)"

"4. For patients with severe stenosis (70%–99%) of a major intracranial artery and recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140 mm Hg, and high- intensity statin therapy, the usefulness of angioplasty alone or placement of a Wingspan stent or other stent is unknown and is considered investigational. (Level of Evidence: C)"

"5. For patients with severe stenosis (70%–99%) of a major intracranial artery and actively progressing symptoms after institution of aspirin and clopidogrel therapy, the usefulness of angioplasty alone or placement of a Wingspan stent or other stents is unknown and is considered investigational. (Level of Evidence: C)"

Class III (Harm)

"1. For patients with a stroke or TIA attributable to moderate stenosis (50%–69%) of a major intracranial artery, angioplasty or stenting is not recommended given the low rate of stroke with medical management and the inherent periprocedural risk of endovascular treatment. (Level of Evidence: B)"

"2. For patients with stroke or TIA attributable to severe stenosis (70%–99%) of a major intracranial artery, stenting with the Wingspan stent system is not recommended as an initial treatment, even for patients who were taking an antithrombotic agent at the time of the stroke or TIA. (Level of Evidence: B)"

"3. For patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, EC/IC bypass surgery is not recommended. (Level of Evidence: B)"

Medical Treatments for Patients With Cardiogenic Embolism

Atrial Fibrillation

Class I

"1. VKA therapy (Class I; Level of Evidence A), apixaban(Class I; Level of Evidence A), and dabigatran (Class I; Level of Evidence B) are all indicated for the prevention of recurrent stroke in patients with nonvalvular AF, whether paroxysmal or permanent. The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including renal function and time in INR therapeutic range if the patient has been taking VKA therapy. (Level of Evidence: A)"

"2. For patients with ischemic stroke or TIA with paroxysmal (intermittent), persistent, or permanent AF in whom VKA therapy is begun, a target INR of 2.5 is recommended (range, 2.0–3.0). (Level of Evidence: A)"

"3. For patients with ischemic stroke or TIA and AF who are unable to take oral anticoagulants, aspirin alone is recommended. (Level of Evidence: A)"

Class IIa

"1. For patients who have experienced an acute ischemic stroke or TIA with no other apparent cause, prolonged rhythm monitoring (≈30 days) for AF is reasonable within 6 months of the index event. (Level of Evidence: C)"

"2. Rivaroxaban is reasonable for the prevention of recurrent stroke in patients with nonvalvular AF. (Level of Evidence: B)"

"3. For most patients with a stroke or TIA in the setting of AF, it is reasonable to initiate oral anticoagulation within 14 days after the onset of neurological symptoms. (Level of Evidence: B)"

"4. In the presence of high risk for hemorrhagic conversion (ie, large infarct, hemorrhagic transformation on initial imaging, uncontrolled hypertension, or hemorrhage tendency), it is reasonable to delay initiation of oral anticoagulation beyond 14 days. (Level of Evidence: B)"

Class IIb

"1. The combination of oral anticoagulation (ie, warfarin or one of the newer agents) with antiplatelet therapy is not recommended for all patients after ischemic stroke or TIA but is reasonable in patients with clinically apparent CAD, particularly an acute coronary syndrome or stent placement. (Level of Evidence: C)"

"2. The addition of clopidogrel to aspirin therapy, compared with aspirin therapy alone, might be reasonable. (Level of Evidence: B)"

"3. (Level of Evidence: B)"

Acute MI and LV Thrombus

Class I

"1. (Level of Evidence: C)"

Class IIb

"1. (Level of Evidence: C)"

"2. (Level of Evidence: C)"

Cardiomyopathy

Class I

"1. (Level of Evidence: C)"

Class IIa

"1. (Level of Evidence: C)"

Class IIb

"1. (Level of Evidence: C)"

"2. (Level of Evidence: C)"

Mitral Stenosis, Mitral Regurgitation, Mitral Prolapse, Mitral Annular Calcification, and Aortic Valve Disease

Class I

"1. (Level of Evidence: A)"

"2. (Level of Evidence: C)"

"3. (Level of Evidence: C)"

"4. (Level of Evidence: C)"

Class IIb

"1. (Level of Evidence: C)"

"2. (Level of Evidence: C)"

Class III (Harm)

"1. (Level of Evidence: C)"

Prosthetic Heart Valve

Class I

"1. (Level of Evidence: B)"

"2. (Level of Evidence: C)"

"3. (Level of Evidence: B)"

"4. (Level of Evidence: C)"

Class IIa

"1. (Level of Evidence: C)"

Class IIb

"2. (Level of Evidence: C)"

Antithrombotic Therapy for Noncardioembolic Stroke or TIA

Antiplatelet Agent

Class I

"1. (Level of Evidence: A)"

"2. (Level of Evidence: A)"

"3. (Level of Evidence: C)"

Class IIa

"1. (Level of Evidence: B)"

Class IIa

"1. (Level of Evidence: B)"

"2. (Level of Evidence: C)"

"3. (Level of Evidence: C)"

Class III (Harm)

"1. (Level of Evidence: A)"

Oral Anticoagulant

Class I

"1. (Level of Evidence: A)"

Treatments for Stroke Patients With Other Specific Conditions

Aortic Arch Atheroma

Class I

"1. (Level of Evidence: A)"

"2. (Level of Evidence: B)"

Class IIb

"1. (Level of Evidence: C)"

Class III (Harm)

"1. (Level of Evidence: C)"

Arterial Dissection

Class IIa

"1. (Level of Evidence: B)"

Class IIb

"1. (Level of Evidence: B)"

"2. (Level of Evidence: C)"

"3. (Level of Evidence: C)"

Patent Foramen Ovale

Class I

"1. (Level of Evidence: B)"

Class IIa

"1. (Level of Evidence: C)"

Class IIb

"1. (Level of Evidence: B)"

"2. (Level of Evidence: C)"

Class III (Harm)

"1. (Level of Evidence: A)"

Hyperhomocysteinemia

Class III (Harm)

"1. (Level of Evidence: C)"

"1. (Level of Evidence: B)"

Hypercoagulable States

Class I

"1. (Level of Evidence: A)"

Class IIb

"1. (Level of Evidence: C)"

"2. (Level of Evidence: C)"

"3. (Level of Evidence: C)"

Antiphospholipid Antibodies

Class I

"1. (Level of Evidence: B)"

"2. (Level of Evidence: A)"

Class IIb

"1. (Level of Evidence: C)"

Class III (Harm)

"1. (Level of Evidence: C)"

Sickle Cell Disease

Class I

"1. (Level of Evidence: B)"

Class IIa

"1. (Level of Evidence: B)"

Class IIb

"1. (Level of Evidence: B)"

Cerebral Venous Sinus Thrombosis

Class IIa

"1. (Level of Evidence: B)"

"2. (Level of Evidence: C)"

Recommendations During Pregnancy

Class IIa

"1. (Level of Evidence: C)"

"2. (Level of Evidence: C)"

"3. (Level of Evidence: B)"

Class IIb

"1. (Level of Evidence: C)"

Recommendations for Breastfeeding Women

Class IIa

"1. (Level of Evidence: C)"

Class IIb

"1. (Level of Evidence: C)"

Special Approaches in High-Risk Populations Recommendations

Class I

"1. (Level of Evidence: C)"

"2. (Level of Evidence: B)"