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
Risk Factor Control for All Patients With TIA or Ischemic 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 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
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|}
{|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)"
|
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
| 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)"
|
Intracranial Atherosclerosis
Medical Treatments for Patients With Cardiogenic Embolism
Atrial Fibrillation
Acute MI and LV Thrombus
Cardiomyopathy
Mitral Stenosis, Mitral Regurgitation, Mitral Prolapse, Mitral Annular Calcification, and Aortic Valve Disease
Prosthetic Heart Valve
Antithrombotic Therapy for Noncardioembolic Stroke or TIA
Antiplatelet Agent
Oral Anticoagulant
Treatments for Stroke Patients With Other Specific Conditions
Aortic Arch Atheroma
Arterial Dissection
Patent Foramen Ovale
Hyperhomocysteinemia
Hypercoagulable States
Antiphospholipid Antibodies
Sickle Cell Disease
Cerebral Venous Sinus Thrombosis
Recommendations During Pregnancy
Recommendations for Breastfeeding Women
Special Approaches in High-Risk Populations Recommendations
References
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