Transient ischemic attack secondary prevention: Difference between revisions

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*Anticoagulation not required
*Anticoagulation not required
====Cardioembolic stroke====
====Cardioembolic stroke====
*Anticoagualtion for atrial fibrillation with Vit K or NOACs.  
*Anticoagualtion for atrial fibrillation with Vit K antagonist or NOACs.  
*If intolerant to anticoagulation, aspirin 325 mg or clopidogrel 75 mg (if aspirin intolerant)
*If intolerant to anticoagulation, aspirin 325 mg or clopidogrel 75 mg (if aspirin intolerant)
===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="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: #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: #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; 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;" | ✔
|-
| rowspan="4" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''Hematological disorders''
| 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;" | ✔
|-
| rowspan="1" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Sickle cell disease
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | Repeated blood transfusions and
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;" | ✔
|
|-
| 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;" | ✔
|
|-
| 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;" |
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 20:03, 8 December 2016

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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]

Overview

Secondary prevention

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->10 min of exercise such as walking, running, bicycling or swimming >3 times/wk
  • Eating healthy balanced diet
  • Smoking cessation
  • Decreased alcohal intake

Treatment of modifiable risk factors

Blood pressure

  • BP control to less than 140/90mmHg or 130/90mm Hg with an angiotensin inhibitor alone or in combination with a diuretic or angiotensin receptor blocker

Diabetes mellitus

  • Diabetes control with fasting blood glucose level <126mg/dl.

Hyperlipidemia

  • Initiation of statin for hyperlipidemia with goal LDL level<100mg/dl

Antithrombotic stroke

  • Long term antiplatelet therapy with aspirin, dipyrimadole plus aspirin, clopidogrel or aspirin alone
  • Anticoagulation not required

Cardioembolic stroke

  • Anticoagualtion for atrial fibrillation with Vit K antagonist or NOACs.
  • If intolerant to anticoagulation, aspirin 325 mg or clopidogrel 75 mg (if aspirin intolerant)

Secondary prevention for specific causes of ischemic stroke[1]

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 ✔ ✔

References

  1. ↑ 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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