October 30, 2019
Update Published to AHA/ASA Guidelines for Early Acute Ischemic Stroke Management
October 30, 2019—Online in Stroke, William J. Powers, MD, et al published the American Heart Association/American Stroke Association (AHA/ASA) 2019 update for early management of acute ischemic stroke (AIS).
According to the AHA/ASA, this guideline update provides up-to-date comprehensive recommendations for the management and treatment of people with acute arterial ischemic stroke. This guideline updates the 2018 acute ischemic guideline and adds several new recommendations.
The AHA/ASA summarized the key points of the update.
1. Each year, approximately 795,000 people experience stroke; approximately 690,000 are new AISs, and approximately 140,000 deaths can be attributed to stroke per year.
2. This guideline updates the 2018 AIS guideline with content based on recent clinical trials and clarifies previous recommendations.
3. The guideline is comprehensive, addressing AIS management from acute symptom onset in the prehospital phase through 2 weeks postacute stroke.
4. Prehospital procedures need to be developed to identify and rapidly triage and transport intravenous (IV) fibrinolytic-ineligible patients with a high likelihood of large vessel occlusion and potential eligibility for thrombectomy to the nearest health care facility that can perform these procedures.
5. Stroke systems of care should be developed to assure that fibrinolytic-eligible patients and mechanical thrombectomy-eligible patients receive treatment as fast as possible.
6. Dysphagia screening is effective in discovering patients at potentially high risk of aspiration.
7. IV aspirin should not be given within 90 minutes after the start of IV alteplase.
8. In patients with noncardioembolic ischemic stroke, treatment with triple antiplatelet therapy (aspirin, clopidogrel, dipyridamole) for secondary prevention should not be administered.
9. Standard IV alteplase dosing (0.9 mg/kg for > 1 hour, with a 10% bolus for 1 minute) can be beneficial in patients who wake up (within 4.5 hours) with AIS symptoms, or in patients who have an unclear time of onset (> 4.5 hours) of stroke symptoms from last known well time and who have a diffusion-weighted imaging lesion smaller than one-third of the middle cerebral artery territory and no visible signal change on fluid-attenuated inversion recovery imaging.
10. Tenecteplase may be considered instead of IV alteplase for patients who are eligible to undergo mechanical thrombectomy.
11. Smoking recommendations with a high level of evidence are discussed in this guideline, including high-intensity interventions to target smoking cessation and nicotine replacement.
12. Comprehensive recommendations from the multisociety 2018 cholesterol guidelines are included in this guideline for management of hyperlipidemia in stroke patients.
13. This guideline includes comprehensive recommendations on brain imaging for acute imaging and in-hospital evaluation.
14. Effective treatment for AIS must be instituted urgently and measures to prevent recurrent stroke should be started as soon as possible while in hospital.