AHA/ASA Clinical Practice Guideline Addresses Prevention of Secondary Stroke

May 24, 2021—The American Heart Association (AHA)/American Stroke Association (ASA)’s “2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack” was published by Dawn O. Kleindorfer, MD, et al in Stroke.

According to a press release from the AHA and ASA, the guideline recommends health care professionals perform diagnostic evaluations to determine the cause of the first stroke or transient ischemic attack (TIA) within 48 hours of symptom onset. The guideline includes a section outlining treatment recommendations based on the cause of the initial stroke/TIA.

As summarized by AHA/ASA in the press release, the updated treatment recommendations for health care professionals highlighted in the guideline include:

• Using multidisciplinary care teams to personalize care for patients and employing shared decision-making with the patient to develop care plans that incorporate a patient’s wishes, goals, and concerns
• Screening for and diagnosing atrial fibrillation and starting blood-thinning medications to reduce recurrent events
• Prescribing antithrombotic therapy, including antiplatelet medications or anticoagulant medications, for nearly all patients who don’t have contraindications; however, the combination of antiplatelets and anticoagulation is typically not recommended for preventing second strokes, and dual antiplatelet therapy (DAPT) is recommended short term, only for specific patients (those with early arriving minor stroke and high-risk TIA or severe symptomatic stenosis)
• Carotid endarterectomy should be considered for patients with narrowing arteries in the neck
• Aggressive medical management of risk factors and short-term DAPT are preferred for patients with severe intracranial stenosis thought to cause the stroke or TIA
• In some patients, it is now reasonable to consider percutaneously closing a patent foramen ovale

For patients who have survived a stroke or TIA, the secondary prevention guidelines recommend:

• Managing their vascular risk factors, especially high blood pressure, as well as type 2 diabetes, cholesterol, triglyceride levels, and not smoking
• Limiting salt intake and/or following a Mediterranean diet
• If they are capable of physical activity, engaging in moderate-intensity aerobic activity for at least 10 minutes four times a week or vigorous-intensity aerobic activity for at least 20 minutes twice a week

“It is critically important to understand the best ways to prevent another stroke once someone has had a stroke or a TIA,” commented Dr. Kleindorfer in the AHA/ASA announcement. “If we can pinpoint the cause of the first stroke or TIA, we can tailor strategies to prevent a second stroke.” Dr. Kleindorfer serves as Chair of the guideline writing group.

Amytis Towfighi, MD, Vice-Chair of the guideline writing group, added, “In fact, approximately 80% of strokes can be prevented by controlling blood pressure, eating a healthy diet, engaging in regular physical activity, not smoking, and maintaining a healthy weight.”

The AHA/ASA announcement advised that the guideline is accompanied by a systematic review article by Devin L. Brown, MD, et al, published simultaneously in Stroke. “Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention” is a meta-analysis of three short-duration clinical trials on DAPT. The paper concludes DAPT may be appropriate for select patients.

As noted by AHA/ASA, the review investigators stated, “Additional research is needed to determine the optimal timing of starting treatment relative to the clinical event; the optimal duration of DAPT to maximize the risk-benefit ratio; whether additional populations excluded from POINT and CHANCE [two of the trials examined], such as those with major stroke, may also benefit from early DAPT; and whether certain genetic profiles eliminate the benefit of early DAPT.”

Dr. Kleindorfer added, “The secondary prevention of stroke guideline is one of the ASA’s ‘flagship’ guidelines, last updated in 2014. There are also a number of changes to the writing and formatting of this guideline to make it easier for professionals to understand and locate information more quickly, ultimately greatly improving patient care and preventing more strokes in our patients.”