New AHA/ASA Stroke Secondary Prevention Guidelines

May 02, 2014

The American Heart Association/American Stroke Association (AHA/ASA) has issued new guidelines on the secondary prevention of stroke.

Published online May 1 in Stroke, the new guidelines emphasize the importance of blood pressure, cholesterol, weight, and exercise but also include some important new recommendations.

These include:

  • screening stroke and transient ischemic attack (TIA) survivors for diabetes and obesity,

  • possible screening for sleep apnea,

  • possible nutritional assessment and advice to follow a Mediterranean-type diet,

  • long-term monitoring for atrial fibrillation (AF) for those who had a stroke of unknown cause,

  • use of the new oral anticoagulants in specific situations, and

  • awareness of the role of aortic arch atherosclerosis and prediabetes as causes of stroke.

The document is endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, and the American Academy of Neurology "affirms the value of this guideline as an educational tool for neurologists."

The publication notes that more than 690,000 adults experience an ischemic stroke each year in the United States, with an additional 240,000 having a TIA, with all these patients having an average annual risk for future ischemic stroke of 3% to 4%.

These new guidelines represent new approaches and improvements in existing strategies for the prevention of subsequent stroke in these patients that have emerged since the last statement in 2011, the authors write.

Long-term AF Monitoring

Walter Kernan, MD, chair of the guideline writing group and professor of medicine at Yale University School of Medicine in New Haven, Connecticut, commented to Medscape Medical News that one of new recommendations that was thought to be of particular importance is the advice to practice long-term monitoring for AF in patients who have had a stroke of unknown origin.

This follows the recent reporting of the CRYSTAL-AF study, which showed a detection rate of 9% with 6 months of monitoring.

"Many stroke physicians are already doing this, but many are not. It has the potential to be very beneficial, with those patients identified as having AF being able to use anticoagulants to reduce their risk substantially," Dr. Kernan commented. "This is the first time we have recommended long-term monitoring. While we don't know exactly how long monitoring should be continued, we suggest 30 days in the guidelines, although the longer the monitoring period, the more AF will be picked up."

For patients with AF, the guidelines now include the 3 new oral anticoagulants, as well as warfarin, as options for prophylactic treatment. "Dabigatran and apixaban were given class 1 recommendations, while rivaroxaban has a class 2a," Dr. Kernan noted.

Obesity/Nutrition Highlighted

The new guidelines include a particular emphasis on nutrition and lifestyle, with new recommendations to screen for diabetes and obesity and advice to refer patients to exercise programs.

On obesity screening, Dr. Kernan said, "Even though there is little evidence to prove that this will improve outcomes, the committee felt this was a sensible approach."

A similar conclusion was reached with regard to nutritional screening and advice. "Again there is not good science to show better nutrition after stroke leads to better outcomes, but we felt there needs to be better risk screening for under- and overnutrition, and we gave a 2a recommendation that eating a Mediterranean diet may have vascular benefit," he said. "While the data is not fully developed, we felt we needed to highlight this issue."

The guidelines also contain a new section on aortic atherosclerosis. Dr. Kernan said the committee wanted to highlight this as an important cause of stroke.

"There are no surprises here. There is a fairly robust literature of aortic atherosclerosis. We are not recommending that everyone undergoes a transesophageal echo, which is necessary to diagnose this, but we just wanted to highlight the great risk this plays in subsequent stroke risk. There is no specific treatment for aortic atherosclerosis, just aspirin and statins and blood pressure control, which is same for all other stroke patients."

The importance of intensive cholesterol-lowering for all patients is highlighted, especially in those with atherosclerosis, but the guidelines no longer recommend niacin or fibrate drugs to raise high-density lipoprotein cholesterol, "due to sparse data establishing their effectiveness at reducing secondary stroke risk."

Intracranial Stenosis and Patent Foramen Ovale Closure

Among other changes to the guidelines is a statement on intracranial stenosis highlighting data showing that stenting is no more effective than medical therapy. "This follows the [Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)] study and will be of no surprise to stroke physicians," Dr. Kernan commented.

Another new recommendation is advice against the closing of patent foramen ovale in patients who do not have deep vein thrombosis, based on 3 clinical trials that have been reported since the last secondary prevention guidelines.

New recommendations on sleep apnea include advice to consider sleep on the basis of the very high prevalence of this condition in this population and the strength of the evidence that the treatment of sleep apnea improves outcomes in the general population.

They also suggest that treatment with continuous positive airway pressure might be considered for patients with ischemic stroke or TIA and sleep apnea, given the emerging evidence in support of improved outcomes.

"The key to staying healthy after an ischemic stroke or TIA is careful and rapid assessment of the cause of the event and identification of stroke risk factors, so that appropriate preventive interventions can be quickly provided," Dr. Kernan said. "Then patients must work with their doctors regularly to stay on their prevention program. With this approach, every patient can look forward to a healthier future."

Stroke. Published online May 1, 2014. Full text


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