Updated society guidelines address prevention of second stroke

Health care providers should perform diagnostic tests to determine the cause of a first stroke within 48 hours of symptom onset, according to an updated American Heart Association and American Stroke Association Clinical Practice Guideline.

The guideline also provides treatment recommendations based upon the cause of a first stroke or transient ischemic attack. Potential causes may include, but not limited to, blockages in large arteries in the neck or brain, damage to the small arteries in the brain from high blood pressure or diabetes, or irregular heart rhythms.

The treatment recommendations include:

• The use of multidisciplinary care teams for personalization of patient care and employment of shared decision-making with the patient to ensure that care plans incorporate the patient’s wishes, goals and concerns;

• Screening for and diagnose atrial fibrillation and initiating medications to reduce recurrence;

• Prescribing antithrombotic therapy for most patients without contraindications. Of note, antiplatelets combined with anticoagulants are typically not recommended for the prevention of a second stroke; dual antiplatelet therapy is only recommended short-term for patients with early arriving minor stroke and high-risk TIA or severe symptomatic stenosis;

• Carotid endarterectomy, or in certain cases stent placement in the carotid artery, should be considered for patients with narrowing of the arteries in the neck; and

• Aggressive medical management of risk factors and short-term dual anti-platelet therapy are ideal for individuals with severe intracranial stenosis thought to have caused the stroke.

In addition, the guideline states that it is now reasonable to consider percutaneously closing a patent foramen ovale.

“It is critically important to understand the best ways to prevent another stroke once someone has had a stroke or a TIA,” Dawn O. Kleindorfer, MD, FAHA, chair of the guideline writing group and professor and chair of the department of neurology at the University of Michigan School of Medicine, said in a press release. “If we can pinpoint the cause of the first stroke or TIA, we can tailor strategies to prevent a second stroke.”

Also included in the update are secondary guidelines for patients who survived a stroke or TIA. These include:

• Managing the patient’s vascular risk factors, such as high blood pressure, type 2 diabetes, cholesterol, triglyceride levels and smoking cessation;

• Limiting salt intake and/or following a Mediterranean diet; and

• Participating in 10-minute, four-times weekly moderate-intensity aerobic activity or 20-minute, twice-weekly vigorous-intensity aerobic activity for those who are capable of physical activity.

“The secondary prevention of stroke guideline is one of the American Stroke Association’s ‘flagship’ guidelines, last updated in 2014,” Kleindorfer said in the release. “There are also a number of changes to the writing and formatting of this guideline to make it easier for professionals to understand and locate information more quickly, ultimately greatly improving patient care and preventing more strokes in our patients.”

References:

American Heart Association Newsroom. Risk of second stroke can be reduced with prevention efforts based on cause of first stroke. Available at: https://newsroom.heart.org/news/risk-of-second-stroke-can-be-reduced-with-prevention-efforts-based-on-cause-of-first-stroke. Accessed June 3, 2021.

Kleindorfer DO, et al. Stroke. 2021;doi:10.1161/STR0000000000000375.