Identifying the cause of a first stroke, whether it is blocked blood vessels or a transient ischemic attack (TIA), and then developing multidisciplinary strategies to mitigate these causes are important steps in prevention, according to the new clinical practice guidelines published in Stroke future strokes.
A new recommendation for health professionals in the American Heart Association (AHA) / American Stroke Association (ASA) 2021 guidelines is to perform diagnostic assessments to determine the cause or causes within 48 hours of the onset of symptoms of a first stroke or TIA determine. The guideline contains cause-based treatment recommendations.
Since approximately 87% of strokes in the United States are ischemic, the guidelines include a new section with detailed recommendations for performing a diagnostic evaluation for ischemic stroke, determining the etiology of ischemic stroke when possible, and identifying treatment goals. to reduce the risk of recurrence.
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Management of vascular risk factors in patients with a history of stroke is important. Prevention should include smoking cessation and treatment for type 2 diabetes, lipids, and especially high blood pressure. Recommendations include a Mediterranean and / or low-sodium diet, regular physical activity, and avoiding long periods of sitting.
Programs are needed that use theoretical models of behavior, proven techniques for change, and multidisciplinary support. Multidisciplinary teams should ensure intensive, personalized patient care and joint decision-making.
Patients should be evaluated for atrial fibrillation, a common condition that places patients at high risk of stroke. Patients diagnosed with atrial fibrillation should be started on blood thinners to reduce recurrent strokes.
Antithrombotic therapy, including antiplatelet drugs or anticoagulant drugs, should be prescribed to almost all stroke survivors without contraindications. However, the combination of antiplatelet drugs and anticoagulant drugs is usually not recommended for the prevention of a second stroke, and dual antiplatelet therapy should only be a short-term solution for patients with high-risk TIA and early-onset mild stroke or severe symptomatic intracranial stenosis.
An important treatable cause of stroke is extracranial carotid disease. The guidelines suggest that patients who are suitable candidates should have the stricture repaired relatively early after their ischemic stroke. Doctors should consider a carotid endarterectomy, surgical blockade removal, or, in select cases, a stent into the carotid artery. These decisions should be determined by comorbidities and features of the patient’s vascular anatomy.
Angioplasty and stenting are not recommended as first-line therapy in patients with severe intracranial stenosis in the vascular territory of the TIA or ischemic stroke. Aggressive medical management of stroke risk factors and short-term dual antiplatelet therapy are preferred.
Since the last guideline in 2014, several studies have investigated secondary stroke prevention of open foramen ovale occlusion. It is currently considered useful to percutaneously close an open foramen ovale in younger patients with non-lecunar stroke or patients of all ages with stroke without any other cause.
Empirically, patients diagnosed with embolic stroke of unknown origin should not be treated with ticagrelor or anticoagulants as they have been found to be of no benefit.
“Although this document contains guidelines based on a literature review, it is imperative for clinicians to work with patients to develop treatment plans that take into account the patient’s wishes, goals and concerns,” the study authors say.
Disclosure: Some guideline authors stated links with biotech, pharmaceutical, and / or device manufacturers. For a full list of the author’s disclosures, see the original reference.
reference
Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for Stroke Prevention in Patients with Stroke and Transient Ischemic Attack: A guideline from the American Heart Association / American Stroke Association. Stroke. Published online May 24, 2021. doi: 10.1161 / STR.0000000000000375
This article originally appeared on The Cardiology Advisor
