What are the AHA/ASA guidelines on secondary stroke prevention?

Updated: Jan 10, 2016
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In May 2014, the American Heart Association and American Stroke Association (AHA/ASA) released an update of their 2011 Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack. [7] These guidelines were endorsed and/or affirmed by the following organizations:

  • American Association of Neurological Surgeons
  • Congress of Neurological Surgeons
  • American Academy of Neurology

As with primary prevention, the guidelines emphasize the importance of blood pressure, cholesterol, weight, and exercise. In addition, new recommendations focus on sleep apnea, carotid disease, atrial fibrillation, aortic arch atherosclerosis, and oral anticoagulants.

The recommendations for risk factor control for all patients with transient ischemic attack (TIA) or ischemic stroke are summarized in Table 2, below. [7]

Table 2. Recommendations for Stroke Factor Control (Open Table in a new window)

Established Risk Factor




Initiate BP therapy for previously untreated patients with ischemic stroke or TIA who, after the first several days, have an established BP ≥140 mm  Hg systolic or ≥90 mm Hg diastolic

Resume BP therapy for patients with known hypertension who have had an ischemic stroke or TIA and are beyond the first several days

The optimal drug is uncertain because direct comparisons between regimens are limited. Diuretics or the combination of diuretics and an angiotensin-converting enzyme inhibitor is useful

Class I

Goals for target BP level or reduction from pretreatment baseline are uncertain and should be individualized, but it is reasonable to achieve a systolic pressure <140 mm Hg and a diastolic pressure <90 mm Hg

Class IIa

Initiation of therapy for patients with BP <140 mm Hg systolic and <90 mm Hg diastolic is of uncertain benefit

For patients with a recent lacunar stroke, an SBP of <130 mm  Hg may be a reasonable target

Class IIb


Statin therapy with intensive lipid-lowering effects in patients with ischemic stroke or TIA presumed to be of atherosclerotic origin

Patients with ischemic stroke or TIA and other comorbid ASCVD should be managed according to the 2013 ACC/AHA cholesterol guidelines, [8] which include lifestyle modification, dietary recommendations, and medication recommendations

Class I

Diabetes Mellitus

Glycemic control and cardiovascular risk factor management according to current guidelines from the American Diabetes Association for patients with DM or pre-DM

Class I

All patients should probably be screened for DM with testing of fasting plasma glucose, HbA1c, or an oral glucose tolerance test; HbA1c may be more accurate than other screening tests in the immediate postevent period

Class IIa


The usefulness of weight loss in patients with a recent TIA or ischemic stroke and obesity is uncertain

Class IIb

Metabolic Syndrome

For patients classified as having the metabolic syndrome, management should focus on counseling for lifestyle modification (diet, exercise, and weight loss) for vascular risk reduction

Preventive care for patient with the metabolic syndrome should include appropriate treatment for individual components of the syndrome, which are also stroke risk factors, particularly dyslipidemia and hypertension

Class I

Usefulness of screening for the metabolic syndrome after stroke is unknown

Class IIb

Physical Inactivity

Patients capable of engaging in physical activity: moderate- to vigorous-intensity aerobic activity at least 40 minutes per day, 3-4 days per week; referral to a comprehensive, behaviorally oriented program is reasonable

Class IIa

Patients with disability after ischemic stroke: consider supervision by a healthcare professional such as a physical therapist or cardiac rehabilitation professional, at least on initiation of an exercise regimen

Class IIb

Diet and Nutrition

Patients with signs of undernourishment:  referral for individualized counseling

Class I

Nutritional assessment is reasonable

Reduce sodium intake to >2.4 g/d. Further reduction to <1.5 g/d is associated with even greater BP reduction

Mediterranean diet over low-fat diet.

Class IIa

Routine vitamin supplements are not recommended

Class III

Sleep-Disordered Breathing

Screening and treatment of sleep apnea may be considered

Class IIb


Counseling plus drug therapy for smokers

Class I

Avoidance of environmental (passive) tobacco smoke

Class IIa

Alcohol Consumption

Heavy drinkers:  reduce or stop consumption

Class I

Persons who continue drinking: ≤2 drinks/day for men; ≤1 drink/day for nonpregnant women

Class IIb

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