AHA/ASA Stroke Secondary Prevention Guideline: Key Points

Kleindorfer DO, Towfighi A, Chaturvedi S, et al.
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. Stroke 2021;May 24:[Epub ahead of print].

The following are key points to remember from the American Heart Association/American Stroke Association (AHA/ASA) guideline for the prevention of stroke in patients with stroke and transient ischemic attack:

  1. Up to 90% of strokes may be preventable by addressing vascular risk factors, including blood pressure control, diet, physical activity, and smoking cessation. Targeting multiple risk factors has additive effects. Despite these data, most stroke survivors have poorly controlled risk factors.
  2. Secondary prevention strategies should be the same for patients with ischemic stroke and TIA.
  3. While control of vascular risk factors is important for secondary prevention of all types of ischemic stroke, there are specific strategies used for prevention of various ischemic stroke subtypes.
  4. For patients who have a stroke while prescribed secondary prevention medications, it is important to determine if patients were taking the medications as prescribed, and evaluate reasons for nonadherence, if applicable, before considering a change in therapy.
  5. Stroke survivors are at risk for developing a sedentary lifestyle and should be encouraged to be physically active. In patients with deficits that impair mobility, a supervised exercise program, such as one led by a physical therapist, can ensure exercise can be done safely.
  6. Atrial fibrillation is common in patients with ischemic stroke. Longer-term monitoring of heart rhythm increases the detection rate of atrial fibrillation. Most ischemic stroke patients with atrial fibrillation should be anticoagulated.
  7. The goal blood pressure for most stroke patients with hypertension is <130/80 mm Hg.
  8. In most stroke patients, atorvastatin 80 mg daily is recommended to reduce the risk of stroke recurrence and a low-density lipoprotein (LDL) of <70 mg/dl is recommended to reduce the risk of cardiovascular events. In patients on maximally tolerated statin therapy who have an LDL >70 mg/dl, consider adding ezetimibe. If the patient’s LDL is still not <70 mg/dl on maximally tolerated statin therapy and ezetimibe, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor can be considered.
  9. In stroke patients with diabetes, medical therapies and the goal for glycemic control should be individualized, but for most patients, a hemoglobin A1c of ≤7% is recommended. In selected patients, a glucagon-like protein 1 agonist or sodium glucose co-transporter 2 (SGLT2) inhibitor can be added to metformin.
  10. Patients with non-cardioembolic ischemic stroke should be treated with antiplatelet medication, rather than anticoagulation.
  11. For most ischemic stroke patients, there is no role for long-term dual antiplatelet therapy with the combination of aspirin and clopidogrel. Short-term dual antiplatelet treatment is recommended in selected patients with symptomatic intracranial atherosclerotic disease or with minor stroke or TIA.
  12. Patients with an embolic stroke of unclear source should not be treated empirically with anticoagulation or ticagrelor.
  13. In patients <60 years old with an embolic stroke of unclear source and patent foramen ovale (PFO), shared decision making between the patient and providers should determine if the PFO should be closed percutaneously. Closure is reasonable for high-risk PFOs, but the benefits of closure are not well established for lower-risk PFOs.
  14. Patients with a non-disabling ischemic stroke and ipsilateral severe extracranial carotid stenosis should have a carotid intervention soon after the stroke. The choice of intervention, between carotid endarterectomy and stenting, should be made based on patient comorbidities and vascular anatomy.
  15. Changing behavior to improve diet, exercise, and medication adherence can be challenging and multidisciplinary programs are generally more effective than simply advice or a written handout from a provider.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Diet, Exercise, Hypertension

Keywords: Aspirin, Atrial Fibrillation, Blood Pressure, Brain Ischemia, Carotid Stenosis, Diabetes Mellitus, Diet, Endarterectomy, Carotid, Exercise, Foramen Ovale, Patent, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Intracranial Arteriosclerosis, Ischemic Attack, Transient, Lipoproteins, LDL, Medication Adherence, Metformin, Platelet Aggregation Inhibitors, Secondary Prevention, Smoking Cessation, Stroke, Vascular Diseases

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