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/* Secondary prevention for specific causes of ischemic stroke{{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-...
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==Overview==
==Overview==
==Secondary prevention==
==Secondary prevention==
The secondary prevention strategies for recurrent transient ischemic stroke and ischemic stroke may include the following:<ref name="pmid27375548">{{cite journal| author=Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S| title=Minor Stroke and Transient Ischemic Attack: Research and Practice. | journal=Front Neurol | year= 2016 | volume= 7 | issue=  | pages= 86 | pmid=27375548 | doi=10.3389/fneur.2016.00086 | pmc=4901037 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27375548  }} </ref><ref name="pmid26920158">{{cite journal| author=Yaghi S, Elkind MS| title=Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke. | journal=Curr Treat Options Cardiovasc Med | year= 2016 | volume= 18 | issue= 4 | pages= 27 | pmid=26920158 | doi=10.1007/s11936-016-0448-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26920158  }} </ref><ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
===Life style modification for 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:
Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:
Line 13: Line 14:
===Treatment of modifiable risk factors===
===Treatment of modifiable risk factors===
====Blood pressure====
====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
*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<ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
====Diabetes mellitus====
====Diabetes mellitus====
*Diabetes control with fasting blood glucose level <126mg/dl.
*Diabetes control with fasting blood glucose level <126mg/dl.<ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
====Hyperlipidemia====
====Hyperlipidemia====
*Initiation of statin for hyperlipidemia with goal LDL level<100mg/dl
*Initiation of statin for hyperlipidemia with goal LDL level<100mg/dl<ref name="pmid26920158">{{cite journal| author=Yaghi S, Elkind MS| title=Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke. | journal=Curr Treat Options Cardiovasc Med | year= 2016 | volume= 18 | issue= 4 | pages= 27 | pmid=26920158 | doi=10.1007/s11936-016-0448-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26920158  }} </ref><ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
====Antithrombotic stroke====
====Antithrombotic stroke====
*Long term antiplatelet therapy with aspirin, dipyrimadole plus aspirin, clopidogrel or aspirin alone
*Long term antiplatelet therapy with aspirin, dipyrimadole plus aspirin, clopidogrel or aspirin alone<ref name="pmid27375548">{{cite journal| author=Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S| title=Minor Stroke and Transient Ischemic Attack: Research and Practice. | journal=Front Neurol | year= 2016 | volume= 7 | issue=  | pages= 86 | pmid=27375548 | doi=10.3389/fneur.2016.00086 | pmc=4901037 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27375548  }} </ref><ref name="pmid22931315">{{cite journal| author=SPS3 Investigators. Benavente OR, Hart RG, McClure LA, Szychowski JM, Coffey CS et al.| title=Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. | journal=N Engl J Med | year= 2012 | volume= 367 | issue= 9 | pages= 817-25 | pmid=22931315 | doi=10.1056/NEJMoa1204133 | pmc=4067036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22931315  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23247951 Review in: Ann Intern Med. 2012 Dec 18;157(12):JC6-2] </ref><ref name="pmid23803136">{{cite journal| author=Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C et al.| title=Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 1 | pages= 11-9 | pmid=23803136 | doi=10.1056/NEJMoa1215340 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23803136  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24126666 Review in: Ann Intern Med. 2013 Oct 15;159(8):JC5]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24052397 Review in: Evid Based Med. 2014 Apr;19(2):58] </ref><ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
*Anticoagulation not required
*Anticoagulation not required
====Cardioembolic stroke====
====Cardioembolic stroke====
*Anticoagualtion for atrial fibrillation with Vit K antagonist 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)<ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
====TIA with ongoing non Q wave MI or unstable angina====
*Use of aspirin(75 mg-100mg) in combination with clopidogrel (75 mg) may be beneficial.<ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>
====Other situations====
*Patients having history of TIA undergoing endartectomy may benefit from aspirin (25 to 325mg) before surgery.<ref name="pmid16912978">{{cite journal| author=Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA et al.| title=National Stroke Association guidelines for the management of transient ischemic attacks. | journal=Ann Neurol | year= 2006 | volume= 60 | issue= 3 | pages= 301-13 | pmid=16912978 | doi=10.1002/ana.20942 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16912978  }} </ref>


===Secondary prevention for specific causes of transient 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>===
===Secondary prevention for specific causes of transient 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>===

Revision as of 21:43, 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

The secondary prevention strategies for recurrent transient ischemic stroke and ischemic stroke may include the following:[1][2][3]

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[3]

Diabetes mellitus

  • Diabetes control with fasting blood glucose level <126mg/dl.[3]

Hyperlipidemia

  • Initiation of statin for hyperlipidemia with goal LDL level<100mg/dl[2][3]

Antithrombotic stroke

  • Long term antiplatelet therapy with aspirin, dipyrimadole plus aspirin, clopidogrel or aspirin alone[1][4][5][3]
  • 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)[3]

TIA with ongoing non Q wave MI or unstable angina

  • Use of aspirin(75 mg-100mg) in combination with clopidogrel (75 mg) may be beneficial.[3]

Other situations

  • Patients having history of TIA undergoing endartectomy may benefit from aspirin (25 to 325mg) before surgery.[3]

Secondary prevention for specific causes of transient ischemic stroke[6]

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. ↑ 1.0 1.1 Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S (2016). "Minor Stroke and Transient Ischemic Attack: Research and Practice". Front Neurol. 7: 86. doi:10.3389/fneur.2016.00086. PMC 4901037. PMID 27375548.
  2. ↑ 2.0 2.1 Yaghi S, Elkind MS (2016). "Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke". Curr Treat Options Cardiovasc Med. 18 (4): 27. doi:10.1007/s11936-016-0448-8. PMID 26920158.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA; et al. (2006). "National Stroke Association guidelines for the management of transient ischemic attacks". Ann Neurol. 60 (3): 301–13. doi:10.1002/ana.20942. PMID 16912978.
  4. ↑ SPS3 Investigators. Benavente OR, Hart RG, McClure LA, Szychowski JM, Coffey CS; et al. (2012). "Effects of clopidogrel added to aspirin in patients with recent lacunar stroke". N Engl J Med. 367 (9): 817–25. doi:10.1056/NEJMoa1204133. PMC 4067036. PMID 22931315. Review in: Ann Intern Med. 2012 Dec 18;157(12):JC6-2
  5. ↑ Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C; et al. (2013). "Clopidogrel with aspirin in acute minor stroke or transient ischemic attack". N Engl J Med. 369 (1): 11–9. doi:10.1056/NEJMoa1215340. PMID 23803136. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC5 Review in: Evid Based Med. 2014 Apr;19(2):58
  6. ↑ 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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