AHA, ASA guidelines for stroke

Template:AHA, ASA stroke guidelines Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Tarek Nafee, M.D. [2]

2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association

DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION

Class I

"1.     In patients suspected of having a stroke or TIA, an ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac conditions. (Level of evidence: B-R)"

"2.      In patients with ischemic stroke or TIA, a diagnostic evaluation is recommended for gaining insights into the etiology of and planning optimal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms (Level of evidence: B-NR) "

"3.     In patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization, noninvasive cervical carotid imaging with carotid ultrasonography, CT angiography (CTA), or magnetic resonance angiography (MRA) is recommended to screen for stenosis (Level of evidence: B-NR) "

"4.     In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease (Level of evidence: B-NR) "

"5.     In patients with a confirmed diagnosis of symptomatic ischemic cerebrovascular disease, blood tests, including complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or non-fasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic goals (Level of evidence: B-NR) "

Class IIa

" 6.     In patients with cryptogenic stroke, echocardiography with or without contrast is reason-able to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism (Level of Evidence B-R)".

'' 7.     In patients with cryptogenic stroke who do not have a contraindication to anticoagulation, long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF. (Level of Evidence B R)''

'' 8.    In patients suspected of having an ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct, follow-up CT or MRI of the brain is reasonable to confirm a diagnosis. (Level of Evidence B- NR)''

'' 9.       In patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct, follow-up MRI is reasonable to predict the risk of early stroke and to support the diagnosis. (Level of Evidence B- NR)''

'' 10.    In patients with cryptogenic stroke, tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis (eg, HIV and syphilis), drug use (eg, cocaine and amphetamines), and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reason-able to perform as clinically indicated to identify contributors to or relevant risk factors for stroke. (Level of Evidence C-LD)''

'' 11.     In patients with ischemic stroke or TIA, noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebro-basilar arterial system with MRA or CTA can be effective to identify atherosclerotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies. (Level of Evidence C-LD)''

Class IIb

" 12.    In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction (Level of Evidence B-NR)".

'' 13.       In patients with ESUS, transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral embolism. (Level of Evidence C-LD)''

'' 14.      In patients with ischemic stroke or TIA in whom patent foramen ovale (PFO) closure would be contemplated, TCD (transcranial Doppler) with embolus detection might be reasonable to screen for right-to-left shun. (Level of Evidence C LD)''

NUTRITION

Class IIa

" 1.     In patients with stroke and TIA, it is reasonable to counsel individuals to follow a Mediterranean type diet, typically with empha-sis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce risk of recurrent stroke (Level of Evidence B-R)".

'' 2.       In patients with stroke or TIA and hypertension who are not currently restricting their dietary sodium intake, it is reasonable to recommend that individuals reduce their sodium intake by at least 1g/d sodium (2.5 g/d salt) to reduce the risk of cardiovascular disease (CVD) events (including stroke). (Level of Evidence B R)''

PHYSICAL ACTIVITY

Class I

"1.        In patients with stroke or TIA who are capable of physical activity, engaging in at least moderate-intensity aerobic activity for a minimum of 10 min-utes 4 times a week or vigorous-intensity aerobic activity for a minimum of 20 minutes twice a week is indicated to lower the risk of recurrent stroke and the composite cardiovascular end point of recurrent stroke, MI, or vascular death. (Level of evidence: C-LD)"

Class IIa

" 2.          In patients with stroke or TIA who are able and willing to increase physical activity, engaging in an exercise class that includes counseling to change physical activity behavior can be beneficial for reducing cardiometabolic risk factors and increasing leisure time physical activity participation. (Level of Evidence B-R)".

'' 3.           In patients with deficits after a stroke that impair their ability to exercise, supervision of an exercise program by a health care professional such as a physical therapist or cardiac rehabilitation professional, in addition to routine rehabilitation, can be beneficial for secondary stroke prevention. (Level of Evidence C-EO)''

Class IIb

" 4.       In individuals with stroke or TIA who sit for long periods of uninterrupted time during the day, it may be reasonable to recommend breaking up sedentary time with intervals as short as 3 minutes of standing or light exercise every 30 minutes for their cardiovascular health (Level of Evidence B-NR)".

SMOKING CESSATION

Class I

"1.         In patients with stroke or TIA who smoke tobacco, counseling with or without drug therapy (nicotine replacement, bupropion, or varenicline) is recommended to assist in quitting smoking. (Level of evidence: A)"

"2.         Patients with stroke or TIA who continue to smoke tobacco should be advised to stop smoking (and, if unable, to reduce their daily smoking) to lower the risk of recurrent stroke (Level of evidence: B-NR) "

"3.       In patients with stroke or TIA. avoidance of environmental (passive) tobacco smoke is recommended to reduce the risk of recurrent stroke. (Level of evidence: B-NR) "

SUBSTANCE USE

Class I

"1.           Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alcoholic drink a day for women should be counseled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of evidence: B-NR)"

"2.            In patients with stroke or TIA who use stimulants (eg, amphetamines, amphetamine derivatives, cocaine, or khat) and in patients with infective endocarditis (IE) in the context of intravenous drug use, it is recommended that health care providers inform them that this behavior is a health risk and counsel them to stop. (Level of evidence: C-EO) "

"3.          In patients with stroke or TIA who have a substance use disorder (drugs or alcohol), specialized services are recommended to help manage this dependenc. (Level of evidence: C-EO) "

HYPERTENTION

Class I

"1.           Patients with ischemic stroke or TIA who drink >2 alcoholic drinks a day for men or >1 alco-holic drink a day for women should be coun-seled to eliminate or reduce their consumption of alcohol to reduce stroke risk. (Level of evidence: A)"

"2.            In patients with hypertension who experience a stroke or TIA, an office BP goal of <130/80 mm Hg is recommended for most patients to reduce the risk of recurrent stroke and vascular events. (Level of evidence: B-R) "

"3.          In patients with hypertension who experience a stroke or TIA, individualized drug regimens that take into account patient comorbidities, agent pharmacological class, and patient preference are recommended to maximize drug efficacy (Level of evidence: B-NR) "

Class IIa

" 4.              In patients with no history of hypertension who experience a stroke or TIA and have an aver-age office BP of ≥130/80 mm Hg, antihypertensive medication treatment can be beneficial to reduce the risk of recurrent stroke, ICH, and other vascular events (Level of Evidence B-R)".

Treatment

Class I

"1. In patients with ischemic stroke with no known coronary heart disease, no major cardiac sources of embolism, and LDL cholesterol (LDL-C) >100 mg/dL, atorvastatin 80 mg daily is indicated to reduce risk of stroke recurrence. (Level of evidence: A)"

"2.  In patients with ischemic stroke or TIA and ath-erosclerotic disease (intracranial, carotid, aortic, or coronary), lipid-lowering therapy with a statin and also ezetimibe, if needed, to a goal LDL-C of <70 mg/dL is recommended to reduce the risk of major cardiovascular events. (Level of evidence: A) "

Monitoring

Class I

"1. In patients with stroke or TIA and hyperlipidemia, patients’ adherence to changes in lifestyle and the effects of LDL-C–lowering medication should be assessed by measurement of fasting lipids and appropriate safety indicators 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter, based on the need to assess adherence or safety. (Level of evidence: A)"

Treatment of Hypertriglyceridemia

Class IIa

" 1. In patients with ischemic stroke or TIA, with fasting triglycerides 135 to 499 mg/dL and LDL-C of 41 to 100 mg/dL, on moderate- or high-intensity statin therapy, with HbA1c <10%, and with no history of pancreatitis, AF, or severe heart failure, treatment with icosapentethyl (IPE) 2 g twice a day is reasonable to reduce risk of recurrent stroke. (Level of Evidence B-R)".

'' 2. In patients with severe hypertriglyceridemia (ie, fasting triglycerides ≥500 mg/dL [≥5.7 mmol/L]), it is reasonable to identify and address causes of hypertriglyceridemia and, if triglycerides are persistently elevated or increasing, to further reduce triglycerides in order to lower the risk of ASCVD events by the implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consumption of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy. (Level of Evidence B-NR)''

Glucose

Class I

"1.  In patients with an ischemic stroke or TIA who also have diabetes, the goal for glycemic control should be individualized based on the risk for adverse events, patient characteristics, and preferences, and, for most patients, especially those <65 years of age and without life-limiting comorbid illness, achieving a goal of HbA1c ≤7% is recommended to reduce the risk for microvascular complications. (Level of evidence: A)"

"2. In patients with an ischemic stroke or TIA who also have diabetes, treatment of diabetes should include glucose-lowering agents with proven cardiovascular benefit to reduce the risk for future major adverse cardiovas-cular events (ie, stroke, MI, cardiovascular death) (Level of evidence: B-R) "

"3. In patients with an ischemic stroke or TIA who also have diabetes, multidimensional care (ie, lifestyle counseling, medical nutritional therapy, diabetes self-management education, support, and medication) is indicated to achieve glycemic goals and to improve stroke risk factors (Level of evidence: C-EO) "

Class IIa

" 4. In patients with prediabetes and ischemic stroke or TIA, lifestyle optimization (ie, healthy diet, regular physical activity, and smoking cessation) can be beneficial for the preven-tion of progression to diabetes (Level of Evidence B-R)".

'' 5.   In patients with TIA or ischemic stroke, it is reasonable to screen for prediabetes/dia-betes using HbA1c which, among available methods (HbA1c, fasting plasma glucose, oral glucose tolerance), has the advantage of convenience because it does not require fasting and is measured in a single blood sample. (Level of Evidence C-EO)''

Class IIb

" 6.   In patients with an ischemic stroke or TIA who also have diabetes, the usefulness of achieving intensive glucose control (ie, HbA1c ≤7%) beyond the acute phase of the ischemic event for prevention of recurrent stroke is unknown. (Level of Evidence B-R)".

'' 7.  In patients with prediabetes and ischemic stroke or TIA, particularly those with a body mass index (BMI) ≥35 kg/mP2, ≥35 kg/m2those <60 years of age, or women with a history of gestational diabetes, metformin may be beneficial to control blood sugar and to prevent progression to diabetes (Level of Evidence B-R)''

'' 8. In patients ≤6 months after TIA or ischemic stroke with insulin resistance, HbA1c <7.0%, and without heart failure or bladder cancer, treatment with pioglitazone may be consid-ered to prevent recurrent stroke (Level of Evidence B-R)''

Obesity

Class I

"1. In patients with ischemic stroke or TIA and who are overweight or obese, weight loss is recommended to improve the ASCVD risk factor profile. (Level of evidence: B-R)"

"2. In patients with ischemic stroke or TIA who are obese, referral to an intensive, multicompo-nent, behavioral lifestyle-modification program is recommended to achieve sustained weight loss (Level of evidence: B-R) "

"3. In patients with ischemic stroke or ASCVD, calculation of BMI is recommended at the time of their event and annually thereafter, to screen for and to classify obesity. (Level of evidence: C-EO) "

Obstructive sleep apnea

Class IIa

" 1. In patients with an ischemic stroke or TIA and OSA, treatment with positive airway pressure (eg, continuous positive airway pressure [CPAP]) can be beneficial for improved sleep apnea, BP, sleepiness, and other apnea-related outcomes. (Level of Evidence B-R)".

Class IIb

" 2. In patients with an ischemic stroke or TIA, an evaluation for OSA may be considered for diagnosing sleep apnea (Level of Evidence B-R)".

Management of Intracranial Large Artery Atherosclerosis. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association

Antithombotic Therapy:

Class I

"1. In patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in preference to warfarin to reduce the risk of recurrent ischemic stroke and vascular death. (Level of evidence: B-R)"

Class IIa

" 2.     In patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk. (Level of Evidence B-NR)".

Class IIb

" 3.      In patients with recent (within 24 hours) minor stroke or high-risk TIA and concomitant ipsilateral >30% stenosis of a major intracranial artery, the addition of ticagrelor 90 mg twice a day to aspirin for up to 30 days might be considered to further reduce recurrent stroke risk. (Level of Evidence B-R)".

'' 4.     In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered to reduce recurrent stroke risk. (Level of Evidence C-LD)''

'' 5. In patients ≤6 months after TIA or ischemic stroke with insulin resistance, HbA1c <7.0%, and without heart failure or bladder cancer, treatment with pioglitazone may be consid-ered to prevent recurrent stroke (Level of Evidence C-EO)''

Risk factor Managment:

Class I

"6. In patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mm Hg, high-intensity statin therapy, and at least moderate physical activity are recom-mended to prevent recurrent stroke and vascular events. (Level of evidence: B-NR)"

Angioplasty and Stenting

Class IIb

" 7. In patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after the institution of aspirin and clopidogrel therapy, achievement of SBP <140  mm Hg, and high-intensity statin therapy (so-called medical failures), the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown (Level of Evidence C-LD)".

Class III (Harm)

"8. In patients with stroke or TIA attributable to severe stenosis (70%–99%) of a major intracranial artery, angioplasty and stenting should not be performed as an initial treatment, even for patients who were taking an antithrombotic agent at the time of the stroke or TIA. (Level of Evidence:A) "

" 9.      In patients with a stroke or TIA attributable to moderate stenosis (50%–69%) of a major intracranial artery, angioplasty or stenting is associated with excess morbidity and mortality compared with medical management alone. (Level of Evidence B-NR)".

Other Procedures

Class III (No Benefit)

"10. In patients with stroke or TIA attributable to 50% to 99% stenosis or occlusion of a major intracranial artery, extracranial-intracra-nial bypass surgery is not recommended (Level of Evidence:B-R) "

EXTRACRANIAL CAROTID STENOSIS

Class I

"1.  In patients with a TIA or nondisabling ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis, carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke, provided that perioperative morbidity and mortality risk is estimated to be <6%. (Level of evidence: A)"

"2.   In patients with ischemic stroke or TIA and symptomatic extracranial carotid stenosis who are scheduled for carotid artery stent-ing (CAS) or CEA, procedures should be performed by operators with established periprocedural stroke and mortality rates of <6% to reduce the risk of surgical adverse events.(Level of evidence: A) "

"3. In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid-lowering therapy, and treatment of hypertension, is recom-mended to reduce stroke risk (Level of evidence: A) "

"4. In patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid steno-sis as documented by catheter-based imaging or noninvasive imaging, CEA is recommended to reduce the risk of future stroke, 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-R) "

Class IIa

" 5.      In patients ≥70 years of age with stroke or TIA in whom carotid revascularization is being considered, it is reasonable to select CEA over CAS to reduce the periprocedural stroke rate (Level of Evidence B-R)".

'' 6.      In patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose CEA over CAS to reduce the periprocedural stroke rate. (Level of Evidence B-R)''

'' 7.        In patients with TIA or nondisabling stroke, when revascularization is indicated, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery to increase the likelihood of stroke-free outcome. (Level of Evidence C-LD)''

'' 8.       In patients with symptomatic severe stenosis (≥70%) in whom anatomic or medical condi-tions are present that increase the risk for surgery (such as radiation-induced stenosis or restenosis after CEA) it is reasonable to choose CAS to reduce the periprocedural complication rate. (Level of Evidence C-LD)''

Class IIb

" 9.        In symptomatic patients at average or low risk of complications associated with endovascular intervention, when the ICA stenosis is ≥70% by noninvasive imaging or >50% by catheter-based imaging and the anticipated rate of periprocedural stroke or death is <6%, CAS may be considered as an alternative to CEA for stroke prevention, particularly in patients with significant cardiovascular comorbidities predisposing to cardiovascular complications with endarterectomy (Level of Evidence A)".

'' 10.     In patients with a recent stroke or TIA (past 6 months), the usefulness of transcarotid artery revascularization (TCAR) for prevention of recurrent stroke and TIA is uncertain. (Level of Evidence B-NR)''

Class III (No Benefit)

"11. In patients with recent TIA or ischemic stroke and when the degree of stenosis is <50%, revascularization with CEA or CAS to reduce the risk of future stroke is not recommended.. (Level of Evidence:A) "

" 12. In patients with a recent (within 120 days) TIA or ischemic stroke ipsilateral to atherosclerotic stenosis or occlusion of the middle cerebral or carotid artery, extracranial intracranial bypass surgery is not recommended. (Level of Evidence B-NR)".

EXTRACRANIAL VERTEBRAL ARTERY STENOSIS

Class I

"1. In patients with recently symptomatic extra-cranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid lowering, BP control) is recommended to reduce stroke risk. (Level of evidence: A)"

Class IIb

" 2.   In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of stenting is not well established. (Level of Evidence B-R)".

'' 3.   In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, is not well established. (Level of Evidence C-EO)''

AORTIC ARCH ATHEROSCLEROSIS

Class I

"1. In patients with a stroke or TIA and evidence of an aortic arch atheroma, intensive lipid management to an LDL cholesterol target <70 mg/dL is recommended to prevent recur-rent stroke(Level of evidence: B-R)"

"2. In patients with a stroke or TIA and evidence of an aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke..(Level of evidence: C-LD) "

Moyamoya disease

Class IIa

" 1. In patients with moyamoya disease and a history of ischemic stroke or TIA, surgical revascularization with direct or indirect extracranial intracranial bypass can be beneficial for the prevention of ischemic stroke or TIA. (Level of Evidence C-LD)".

Class IIb

" 2. In patients with moyamoya disease and a history of ischemic stroke or TIA, the use of antiplatelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA may be reasonable. (Level of Evidence C-LD)".