Guidelines for preventing second stroke released

A patient who has had a stroke or transient ischemic attack is at high risk of a second attack.

The American Heart Association/ American Stroke Association has issued an update to current guidelines for the treatment of stroke, which provides comprehensive recommendations for preventing recurrent strokes and transient ischemic attacks.

“The most frequent event that threatens a stroke survivor’s quality of life is another stroke, which can cause further disability or death,” said Ralph L. Sacco, MD, in an American Heart Association written statement.

The guidelines make a significant shift from earlier guidelines by strongly suggesting that stroke and transient ischemic attack (TIA) be treated interchangeably, said Sacco, chair of the American Stroke Association’s Stroke Advisory Board and Secondary Stroke Prevention Guidelines Committee. The guidelines have been published in Stroke: Journal of the American Heart Association.

“The new ASA guidelines for recurrent stroke prevention update existent scientific information on best medical practices in this burgeoning field. The guidelines bring clarity and up-to-date information on recurrent stroke prevention topics ranging from management of lifestyle risk factors, interventional approaches to treatment of extra- and intracranial occlusive disease, therapy for common and controversial causes of cardiac source embolism, proper use of antiplatelet agents, and best management practices for prevention of nonatherosclerotic causes of stroke,” said Philip B. Gorelick, MD, a coauthor of the guidelines.

TIA, stroke treatment

The guidelines suggest treating a TIA as aggressively as a stroke.

“Other documents have split the two conditions out, but we are treating TIA just as seriously as stroke. Both conditions increase the risk of a subsequent stroke and both require similar diagnostic work-ups and treatment,” said Sacco, who is associate chairman of neurology and professor of neurology and epidemiology at Columbia University Medical Center.

The Secondary Stroke Prevention Guidelines Committee reviewed recent medical literature and the results of recently completed clinical trials.

One of the recommendations concerns blood pressure control. The guidelines state that antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in people who have had an ischemic stroke or TIA and are beyond the hyperacute period. “An absolute target BP level and reduction are uncertain and should be individualized, but benefit has been associated with an average reduction of about 10/5 mm Hg, and normal BP levels have been defined as < 120/80 mm Hg by JNC-7.”

Another important change in these guidelines concerns pregnant women, menopausal women and ethnic minorities.

Hormone replacement therapy

For example, the guidelines make a strong recommendation against the use of hormone replacement therapy based on evidence from the Women’s Health Initiative. WHI examined hormone replacement therapy and its role in the prevention of cardiovascular disease and stroke in women who were postmenopausal. The trial was stopped early due to an increase in vascular events, and the evidence became available after the last guidelines were issued.

“Application of these guidelines now is important as it will lead to reduction in recurrent stroke risk. Prior surveys have shown that physicians often mistakenly apply stroke prevention therapies. These guidelines simply but comprehensively alert practicing physicians on what they should be doing to prevent recurrent stroke,” said Gorelick, who is the John S. Garvin Professor and head, director of the Center for Stroke Research, department of neurology and rehabilitation, University of Illinois College of Medicine at Chicago.

“Once stroke occurs, the application of these evidence-based guidelines by cardiologists will lead to better recurrent prevention outcomes in their patients. These guidelines also pave the way for additional research in the area of cardiac sources of embolism that will lead to a better understanding of which therapies should be used to prevent recurrent stroke in patients with cardiogenic brain embolism,” he said. – by Suzanne Bryla

For more information:

• Visit the American Stroke Association Web site at strokeassociation.org. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Stroke. 2006;37:577-617.