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Updated guideline advises BP control, lifestyle changes for stroke survivors
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BP control and a healthy lifestyle are crucial for stroke survivors, according to an updated American Heart Association/American Stroke Association guideline for the prevention of stroke in patients with a previous event.
“Treatment of hypertension is possibly the most important intervention for secondary prevention of ischemic stroke,” Walter N. Kernan, MD, chair of the guideline writing group, and colleagues wrote. “The risk for a first ischemic stroke is directly related to BP, starting with [systolic] BP as low as 115 mm Hg. The relationship with recurrent stroke has been less well studied, but is presumably similar.”
Therapy recommendations
The guideline recommends BP therapy for previously untreated stroke or TIA survivors with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg a few days after the event, and resumption of BP therapy for previously treated patients with known hypertension.
Statin therapy is recommended for survivors of stroke or TIA determined to be of atherosclerotic origin, even for those with LDL <100 mg/dL. The authors also suggest that survivors with other comorbid atherosclerotic CVD be managed according to the 2013 American College of Cardiology/AHA cholesterol guidelines. The 2011 guideline’s recommendation of niacin or fibrate drugs to raise HDL was removed due to a lack of evidence.
Lifestyle recommendations
Survivors are encouraged to engage in physical activity if possible, Kernan, from Yale University, and colleagues wrote. They recommend at least three to four weekly 40-minute sessions of moderate- to vigorous-intensity physical activity. Referral to a comprehensive, behaviorally oriented physical activity program is appropriate, they wrote.
The guidelines suggest conducting a nutritional assessment on survivors and referring those with signs of undernutrition to a nutritional counselor, but they do not recommend routine supplementation with vitamins. They also suggest that survivors reduce sodium to <2.4 g/day, and if possible to <1.5 g/day.
Also, Kernan and colleagues wrote, “It is reasonable to counsel patients with a history of stroke or TIA to follow a Mediterranean-type diet instead of a low-fat diet.”
Special population recommendations
Given the high prevalence of sleep apnea in patients with ischemic stroke or TIA, physicians can consider conducting a sleep study on survivors, and if the condition is found, treatment with continuous positive airway pressure is recommended, according to the guideline.
Survivors who smoke should be advised to quit, and all survivors should avoid passive tobacco smoke.
The guidelines also recommend that those who are heavy drinkers eliminate or reduce alcohol consumption, and those who are moderate drinkers limit intake to a maximum of two drinks per day for men and one drink per day for nonpregnant women.
The authors outline which survivors might be candidates for carotid endarterectomy and which might be candidates for carotid artery stenting. Carotid artery stenting was previously strongly recommended as an alternative to carotid endarterectomy in certain patients, but it has been downgraded to a reasonable recommendation because of new outcome studies favoring carotid endarterectomy.
Aspirin therapy of 325 mg/day is preferable to warfarin for patients with stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, and it might be reasonable to add clopidogrel 75 mg/day to aspirin for 90 days in patients with severe stenosis (70% to 99%), according to the guideline.
The importance of controlling arrhythmia disorders is also emphasized. One recommendation concerns prolonged rhythm monitoring for atrial fibrillation for approximately 30 days within 6 months of the stroke or TIA if there is no other apparent cause for the event.
For prevention of recurrent stroke in patients with nonvalvular AF, the guideline gives a strong recommendation to vitamin K antagonists such as warfarin, apixaban (Eliquis, Bristol Myers-Squibb/Pfizer) and dabigatran (Pradaxa, Boehringer Ingelheim), and a reasonable recommendation to rivaroxaban (Xarelto, Janssen Pharmaceuticals).
“The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including renal function and time in [international normalized ratio] therapeutic range if the patient has been taking [vitamin K antagonist] therapy,” Kernan and colleagues wrote.
The guideline does not recommend combining oral anticoagulation with antiplatelet therapy in most survivors with AF, but states that it is reasonable in those with ACS, a stent or other clinical CAD. Survivors with AF unable to take oral anticoagulants should take aspirin, and it may be reasonable to add clopidogrel.
The guideline contains a number of recommendations for survivors with valvular heart disease or prosthetic heart valves. For many of these patients, vitamin K antagonist therapy is recommended.
For survivors with noncardioembolic ischemic stroke or TIA, antiplatelet agents are recommended over oral anticoagulants to reduce risk for recurrent stroke and other CV events, the guideline states. Initial therapy should be aspirin alone or combined with extended-release dipyridamole, according to the guideline. Clopidogrel monotherapy is a reasonable alternative, especially in patients allergic to aspirin.
However, Kernan and colleagues wrote, combination aspirin/clopidogrel therapy is not recommended for long-term secondary prevention because of increased risk for hemorrhage.
For survivors with patent foramen ovale (PFO), PFO closure is not recommended unless there is evidence for deep vein thrombosis.
Disclosure: See the full guideline for the writing panel members’ relevant financial disclosures.
Perspective
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Larry B. Goldstein, MD, FAAN, FANA, FAHA
The new guidelines include dozens of recommendations, many of which are new or modified from the last statement. Recommendations for BP and lipid management, AF treatment and lifestyle are aligned with the recent ACC/AHA guidelines on these topics. A variety of lifestyle measures are recommended, although the majority remain level of evidence C (consensus opinion, case studies or current standard care.) Testing for sleep apnea, previously recommended in primary prevention guidelines, is now also recommended for appropriate patients with TIA or stroke.
Important changes for cardiologists include:
- Downgrading the recommendation for carotid artery stenting as an alternative to endarterectomy for appropriate low- or average-risk symptomatic patients from class I to class IIa.
- Recommending not beginning anticoagulants in patients with AF-associated ischemic stroke for 14 days if they are at high risk for hemorrhagic transformation (class IIa, level of evidence B).
- Not recommending PFO closure for patients with cryptogenic ischemic stroke or TIA and a PFO without evidence for deep vein thrombosis, based on the available evidence (class III, level of evidence A).
Another important recommendation is that the combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 90 days (class IIb, level of evidence B). This is based largely on a trial conducted in China; a US trial is in progress. The recommendation may be viewed as controversial.
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