The following are key points to remember from the American Heart Association/American Stroke Association (AHA/ASA) guideline for stroke prevention in patients with stroke and transient ischemic attack:
- Up to 90% of strokes can be prevented 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, the majority of stroke survivors have poorly controlled risk factors.
- Secondary prevention strategies should be the same for patients with ischemic stroke and TIA.
- While control of vascular risk factors is important for secondary prevention of all types of ischemic stroke, there are specific strategies used for the prevention of various subtypes of ischemic stroke.
- For patients who experience a stroke while prescribed secondary prevention medications, it is important to determine whether the patients were taking the medications as prescribed and evaluate the reasons for noncompliance, if applicable, before considering a change in medication. therapy.
- Stroke survivors are at risk of developing a sedentary lifestyle and should be encouraged to engage in physical activity. In patients with deficits that affect mobility, a supervised exercise program, such as one led by a physical therapist, can ensure that exercise can be performed safely.
- Atrial fibrillation is common in patients with ischemic stroke. Long-term heart rhythm monitoring increases the detection rate of atrial fibrillation. Most patients with ischemic stroke with atrial fibrillation should receive anticoagulation.
- The target blood pressure for most stroke patients with hypertension is <130/80 mm Hg.
- In most stroke patients, high-dose statins are 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 receiving maximally tolerated statin therapy and who have an LDL > 70 mg/dl, consider adding ezetimibe. If the patient’s LDL is not already <70 mg/dl with maximally tolerated statin therapy and ezetimibe, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor may be considered.
- In patients with stroke and diabetes, medical therapies and goal of 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 cotransporter 2 (SGLT2) inhibitor may be added to metformin.
- Patients with non-cardioembolic ischemic stroke should be treated with antiplatelet medication , rather than anticoagulation.
- For most patients with ischemic stroke, long-term dual antiplatelet therapy with the combination of aspirin and clopidogrel is of no use. Short-term dual antiplatelet therapy is recommended in selected patients with symptomatic intracranial atherosclerotic disease or with stroke or minor TIA.
- Patients with embolic stroke of unclear origin should not be treated empirically with anticoagulation or ticagrelor.
- In patients <60 years of age with embolic stroke of unclear origin and patent foramen ovale (PFO), shared decision making between the patient and providers should determine whether the PFO should be closed percutaneously. Closure is reasonable for high-risk PFOs, but the benefits of closure are not well established for low-risk PFOs.
- Patients with non-disabling ischemic stroke and ipsilateral severe extracranial carotid stenosis should undergo carotid intervention soon after stroke. The choice of intervention, between carotid endarterectomy and stent placement, should be based on the patient’s comorbidities and vascular anatomy.
- Changing behavior to improve diet, exercise, and medication adherence can be challenging, and multidisciplinary programs are generally more effective than simple advice or a written pamphlet from a provider.
