After a Stroke or TIA: New Guidelines to Prevent Recurrence

Neil Skolnik, MD


August 23, 2021

This transcript has been edited for clarity.

I'm Dr Neil Skolnik.

Today we are going to discuss the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack (TIA) from the American Heart Association/American Stroke Association.

We won't be talking about recognition or criteria for acute reperfusion therapy, which is important, but rather I'll focus on prevention of recurrent stroke. I'll talk first about diagnosis, and then treatment, focusing on their high-level recommendations.

It's important to complete the diagnostic workup within 48 hours because the risk for recurrent stroke is highest early on. On admission, we check the following:

  • ECG looking for atrial fibrillation (AF) or evidence of acute myocardial infarction. Admit to telemetry primarily to look for AF.

  • CT or MRI to confirm the diagnosis and to distinguish between and rule out the 10% of people with hemorrhagic rather than ischemic stroke. If initial imaging does not show a cerebrovascular accident, it is reasonable to repeat the test in a few days.

  • Carotid imaging with either a CTA or MRA to get a good view of the carotid and intracranial, and vertebrobasilar circulation. If you can't get CTA or MRA, get an ultrasound of the carotids, but it's far less sensitive.

  • Echocardiogram to look for cardiomyopathy or valvular heart disease.

Long-term monitoring for AF is a new, high-level grade 2a recommendation in this guideline. This means using an implantable loop recorder, an external monitoring device, or even a watch that screens for AF for 3 months (up to 6-12 months).

The rationale for this is that the detection rate with long-term monitoring is about fivefold higher than monitoring just for 24-48 hours when only 2%-3% of people appear to have AF. That goes up to 15%-18% of people with 6-12 months of monitoring.

Lab testing should include CBC, PT/PTT, complete metabolic panel, A1c, and lipids to assess risk factors and to plan for subsequent risk factor reduction. When clinically indicated, usually in younger patients, tests looking for less common causes of stroke — including hypercoagulable states, infections, vasculitis, drug use (eg, cocaine and amphetamines), and markers of systemic inflammation — can be done.

Let's talk about therapy: lifestyle and medications.

Diet. Two studies have shown that a Mediterranean-type diet with low salt intake, compared with a usual low-fat diet, can decrease recurrent vascular events by 30%-60%.

Physical activity, particularly aerobic activity. After a stroke, those who exercise have a 40% lower risk for stroke, MI, or other vascular event at 3 years. That's big.

Smoking and alcohol. In those who smoke or have excessive alcohol intake, it's important to address those issues with smoking cessation and alcohol avoidance. There is about a twofold risk for stroke recurrence in persistent smokers compared with nonsmokers. Alcohol should be reduced or eliminated if more than two alcoholic drinks a day are taken by men or more than one alcoholic drink a day by women.

Blood pressure control. A blood pressure goal of < 130/80 mmHg is recommended for most patients who have experienced stroke, perhaps liberalizing this goal to 140/90 for those who have large-artery intracerebral stenosis. The recommended first-line agents are diuretics, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers. Neither beta-blockers nor calcium channel blockers have the evidence for stroke prevention and therefore are not the recommended first-line agents.

Cholesterol management. Everyone who has had a stroke or TIA should receive atorvastatin 80 mg daily. The LDL goal is < 70 mg/dL. Many people, if not most, will need ezetimibe and/or a PCSK9 inhibitor in addition.

New in this guideline are recommendations for hypertriglyceridemia. For those who have fasting triglyceride levels > 135 mg/dL, we can consider treatment with icosapent ethyl (IPE) 2 g twice a day in addition to a statin, based on the results of the REDUCE-IT trial, but only in patients without AF, because it can increase the risk for AF.

Diabetes. We should use a vascular-active agent, typically either a GLP-1 or SGLT2 inhibitor. However, with stroke, GLP-1s and the TZD pioglitazone have data showing that they decrease the risk for recurrent stroke, but the SGLT2s do not have such data.

Antiplatelet agents. For patients with recent minor (NIHSS score ≤ 3) noncardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥ 4), dual-acting antiplatelet therapy (DAPT; aspirin plus clopidogrel) should be initiated early in patients whose stroke was not related to AF (ideally within 12-24 hours of symptom onset) and continued for 21-90 days, followed by single antiplatelet therapy. Long-term use of DAPT should be avoided because it increases the risk for hemorrhagic complications.

Specific recommendations are made for AF. The most important is that in patients with TIA in the setting of nonvalvular AF, it is reasonable to initiate anticoagulation immediately after the index event when AF is found. For patients with stroke at high risk for hemorrhagic conversion — those with large strokes in the setting of AF — it is reasonable to delay initiation of oral anticoagulation beyond 14 days to reduce the risk for hemorrhagic conversion. If patients do not have mitral stenosis or a mechanical valve, a DOAC is recommended over warfarin.

Some specific recommendations are made for different areas, so I refer you to the full guidelines for those. These are incredibly important guidelines for something we see often.

I'm Dr Neil Skolnik, and this is Medscape.

Neil Skolnik, MD, is a professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and associate director of the Family Medicine Residency Program at Abington – Jefferson Health. He has published over 350 articles, essays, poems, and op-eds in the medical and nonmedical literature, as well as four medical textbooks and a book of short stories. In addition, he is the host of the American Diabetes Association's monthly Diabetes Core Update podcast. Follow him or direct-message on Twitter: @NeilSkolnik

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