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About one in four strokes that occur annually are recurrent events. The American Heart Association/American Stroke Association has now updated its 2006 evidence-based recommendations for the prevention of stroke among survivors of ischemic stroke or transient ischemic attack (TIA). The guidelines include recommendations, rated by class (degree of treatment effect) and evidence level, for risk-factor control, antithrombotic therapies, interventional approaches for atherosclerotic disease, and treatment of unusual stroke mechanisms.
Several previous recommendations are reiterated with additional support from new research. For example, stenting is considered a viable alternative to endarterectomy for patients with symptomatic, severe carotid stenosis and low risk for endovascular complications, based on the Carotid Revascularization Endarterectomy versus Stenting Trial (Class I; Level of Evidence B).
New recommendations include the following:
For patients with carotid artery stenosis and a TIA, optimal medical therapy should include antiplatelet therapy, statin treatment, and risk factor modification (Class I; Level B).
Patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery should receive aspirin (preferably at doses of 50–325 mg/day) and not warfarin (Class I; Level B); may “reasonably” have a blood pressure goal of <140/90 mm Hg and a total cholesterol goal of <200 mg/dL (Class IIb; Level B); and should not undergo extracranial/intracranial bypass (Class III; Level B).
Stroke patients with the metabolic syndrome should be counseled on lifestyle modification. (Class I; Level C), and components of the syndrome that are stroke risk factors should be treated (Class I; Level A).
For patients with atherosclerotic ischemic stroke or TIA and without known coronary heart disease, LDL cholesterol ≥100 mg/dL should be treated, with the aim of at least a 50% reduction or a target of <70 mg/dL (Class IIa; Level B).
For atrial fibrillation patients at high risk for stroke who require brief interruption of oral anticoagulation, low-molecular-weight heparin, administered subcutaneously, can be used as bridging therapy (Class IIa; Level C).
For atrial fibrillation patients with a hemorrhagic contraindication to warfarin, the committee advises using aspirin alone, rather than with clopidogrel, because the combination carries a bleeding risk similar to that of warfarin (Class III; Level B).
Furie KL et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011 Jan; 42:227.
Comment
In general, these updated guidelines emphasize a more intensive, multimodal medical treatment approach to reducing recurrent stroke risk, especially for patients with histories of atherosclerotic stroke or TIA. The new guidelines were written before publication of trials of various novel stroke risk-reduction strategies, including direct thrombin inhibitors; interval recommendations incorporating such research are expected before the next major guideline update.