Secondary Prevention of Ischemic Stroke: Updated Guidelines From AHA/ASA

The American Heart Association and American Stroke Association (AHA/ASA) published updated guidelines for preventing recurrent ischemic stroke, focusing on overall cardiovascular risk reduction and targeted secondary prevention. AHA/ASA guidelines recommend a blood pressure treatment goal of less than 130/80 mm Hg after all strokes and low-density lipoprotein cholesterol goals of less than 70 mg per dL (1.81 mmol per L) for nonembolic strokes. Cardiovascular Risk Reduction After Stroke Risk domain Management strategy Explanation Alcohol Elimination or reduction in alcohol consumption in males drinking more than two and females drinking more than one alcoholic drink a day 3.8% of strokes are estimated to be attributed to alcohol intake Drugs Cessation Especially intravenous drug users treated for infective endocarditis Glycemic control Goal A1C of 7% or less to decrease microvascular complications Metformin combined with a glucagon-like peptide-1 agonist or a sodium-glucose cotransporter 2 inhibitor are recommended Hyperlipidemia After nonembolic stroke, treat with atorvastatin (Lipitor), 80 mg daily, if low-density lipoprotein cholesterol level is greater than 100 mg per dL (2.59 mmol per L);in high-risk patients, consider adding ezetimibe (Zetia) and proprotein convertase subtilisin/kexin type 9 inhibitor to lower stroke risk Consistent with 2018 American College of Cardiology/American Heart Association hyperlipidemia guidance Hypertension Lower blood pressure to less than 130/80 mm Hg Evidence for secondary prevention in patients previously diagnosed with hypertension; lowering blood pressure to 130/80 mm Hg in most patients with a history of ischemic stroke seems safe based on trial data Hypertriglyceridemia When triglycerides are 135 to 499 mg per dL (1.53 to 5.64 mmol per L) in patients already taking a moderate- or high-intensity statin, consider adding icosapent ethyl In one study, icosapent ethyl reduced cardiovascular events including stroke complicated by increased atrial fibrillation Nutrition Mediterranean-style diet, consider reducing sodium to 1 g per day — Obesity Weight loss Risk improves with modest weight loss, although evidence is limited Physical activity Moderate-intensity exercise for 10 minutes four times per week or 20 minutes of vigorous activity twice a week In one study, exercise reduced recurrent stroke by an odds ratio of 6.7 Smoking Cessation using multibehavioral and evidence-based interventions, including avoidance of secondhand smoke Smoking doubles the risk of a recurrent event Stimulants Cessation Methamphetamine and cocaine increase risk Stroke-Specific Secondary Prevention Stroke-specific secondary prevention depends on the stroke subtype and identified cause as described in Table 2. Management of Specific Etiologies of Ischemic Stroke Cause of ischemic stroke Recommended management Antiphospholipid syndrome In confirmed cases, warfarin (Coumadin) titrated to an international normalized ratio of 2 to 3 is recommended If antibody test is positive only once, antiplatelet therapy is recommended Cardiac tumor Tumor resection reduces recurrent stroke Cardiomyopathy with or without a left ventricular assist device Anticoagulation with warfarin for 3 months If a mechanical assist device is in place, combination therapy with warfarin and aspirin is recommended Congenital heart disease after Fontan palliation Anticoagulation with warfarin Dissection of carotid or vertebral arteries Anticoagulation is recommended for 3 months to prevent embolism despite lack of evidence Warfarin or aspirin offers similar benefit over the following 3 months Extracranial carotid stenosis If severe carotid artery stenosis (≥ 70%), carotid endarterectomy recommended within 7 days If moderate carotid artery stenosis, consider carotid endarterectomy Carotid artery stenting is a reasonable alternative in limited situations Extracranial vertebral stenosis Antiplatelet therapy and cardiovascular risk reduction Neither stenting nor surgery has shown benefit Fibromuscular dysplasia Urgent cardiovascular risk reduction per Table 1 Consider antiplatelet therapy if dissection Giant cell arteritis High-dose oral glucocorticoids Consider adjunctive methotrexate or tocilizumab (Actemra), but avoid infliximab (Remicade) Hypercoagulable states (prothrombin 20210A, activated protein C resistance, elevated Factor VIII levels, or protein C, protein S, or antithrombin III deficiencies) Antiplatelet therapy is reasonable Infective endocarditis Surgery recommended without intracranial hemorrhage or a major ischemic stroke Intracranial atherosclerosis Aspirin; for minor stroke or transient ischemic attack, consider adding clopidogrel (Plavix) for up to 90 days with severe stenosis or ticagrelor (Brilinta) for up to 30 days Left ventricle thrombus Anticoagulation with warfarin for 3 months, most often due to acute myocardial infarction Moyamoya disease (occlusive disease of the circle of Willis) Surgical revascularization with direct or indirect extracranial-intracranial bypass Sickle cell disease Blood transfusions to reduce hemoglobin S to less than 30% of total hemoglobin If transfusion is not practical, hydroxyurea (Siklos) therapy appears to reduce risk Antithrombotic therapy recommendations after a stroke depend on the stroke subtype and complicating conditions.