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Guidelines on Secondary Prevention of Ischemic Stroke

Updated guidelines from the American Heart Association and the American Stroke Association

The American Heart Association and the American Stroke Association have updated their 1999 guideline statement on secondary prevention of ischemic stroke. In this thoughtful and comprehensive review of the extensive evidence for clinical decision-making, the authors summarize various clinical situations and make recommendations according to the accepted AHA method (class of evidence and level of certainty of the treatment effect).

For patients who have had stroke or TIA, the document covers multiple topics: the management of stroke risk factors, interventional therapies, medical therapies for patients with cardiac disease that predisposes to embolism and for patients after strokes from causes other than cardioembolism, and management of several specific problems, including arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, sickle cell disease, and venous sinus thrombosis. The statement concludes with a discussion of special issues in women and the often-difficult decisions concerning the use of anticoagulation after cerebral hemorrhage.

The new guidelines address a much more complete range of clinical issues than did the 1999 statement. The changes are too numerous to list here, but two are prominent. On the basis of information published since 1999, including data from the HOPE and PROGRESS trials, the authors recommend antihypertensive therapy for stroke and TIA patients both without and with hypertension and suggest a tight target blood pressure of <120/80 mm Hg. Following the National Cholesterol Education Program Adult Treatment Panel III recommendations, they suggest the rigorous LDL-cholesterol targets of <100 mg/dL for stroke and TIA patients with symptomatic atherosclerotic disease and <70 mg/dL for stroke and TIA patients with very high risk due to multiple risk factors.

Comment: Current evidence suggests that successful implementation of these strict antihypertensive and lipid-lowering guidelines would prevent a significant number of recurrent strokes. For the many areas with inadequate data to support commonly accepted therapies, the authors fairly summarize the literature and, in some cases, offer the license to use such therapies, acknowledging that use is reasonable given our current state of knowledge. For example, they endorse anticoagulation during the first 3 to 6 months after extracranial arterial dissection. Such recommendations reflect the fact that the authors are clinicians who understand both the strengths and the limitations of evidence-based practice.

In the discussion of antiphospholipid antibody syndrome (APAS) management, the guidelines misstate the results of a prospective comparison of a high-intensity (3.1–4.0) with a moderate-intensity (2.0–3.0) International Normalized Ratio (INR) goal for warfarin therapy (N Engl J Med 2003; 349:1133). Contrary to the guidelines’ statement, this study showed no added benefit of the high-intensity target. These findings differed from those of two prior retrospective studies (N Engl J Med 1995; 332:993 and Ann Intern Med 1992; 117:303). However, the guidelines’ recommendation of a target INR of 2.0 to 3.0 in patients with APAS conforms to the correct interpretation of the prospective data.

This new guideline statement is an excellent resource with a prodigious list of references. It will greatly help all physicians who treat patients after stroke and TIA.

— Steven Feske, MD

Dr. Feske is Director, Stroke Division, Department of Neurology, Brigham and Women's Hospital, Boston.

Published in Journal Watch Neurology August 29, 2006

Citation(s):

Sacco RL et al. 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 Feb; 37:577-617.

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