The average annual rate of stroke recurrence is at an all-time low (3%-4%) as a result of advances in stroke prevention research. The American Heart Association/American Stroke Association publishes revised guidelines every 2-3 years to arm providers with the latest recommendations on secondary stroke prevention. Below is a summary of some of the more pertinent revised 2014 recommendations on secondary stroke prevention.
Hypertension
Blood pressure (BP) therapy should be initiated in post stroke/transient ischemic attack (TIA) patients who are noted to have a persistent BP ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic. Patients already on antihypertensive therapy who have suffered a stroke/TIA should optimize therapy to drive BP to less than 140/90.
Dyslipidemia
Statins therapy with a highly potent statin is recommended in patients with a stroke/TIA history presumed to be of atherosclerotic origin regardless of baseline low-density lipoprotein cholesterol (LDL-C) and regardless of other cardiovascular comorbid conditions.
Diabetes mellitus
Patients with a TIA/stroke history should probably be screened for diabetes mellitus. The hemoglobin A1c screening tool may be the most revealing in the immediate postevent period.
Obesity/Physical activity/Nutrition
Stroke/TIA patients should be screened for obesity and nutritional issues. The usefulness of weight loss after TIA or stroke is uncertain. Both Mediterranean and low-sodium (< 2.4 g/day) diets should be recommended.
Sleep apnea
Patients who have suffered a stroke or TIA might be screened for sleep apnea in light of the high prevalence of sleep apnea among stroke patients.
Carotid artery disease/Vertebral artery disease/Intracranial atherosclerosis
Patients who have had a stroke or TIA in the past 6 months and who have ipsilateral severe (>70%) carotid artery stenosis should be referred for carotid endarterectomy (CEA). If a patient has less severe stenosis (50%-69%), CEA may be indicated depending on a number of factors, such as age, sex, and comorbidities. When revascularization is indicated, it should be performed within 2 weeks of the index event.
Carotid angioplasty and stenting (CAS) can be considered versus CEA, with decision depending on patients age, procedural risks, and carotid anatomy.
In the poststroke setting of 50%-99% stenosis of a major intracranial artery, aspirin in a daily dose of 325 mg is recommended. In the poststroke setting of severe intracranial stenosis, the combination of aspirin 325 mg daily and clopidogrel 75 mg daily for 90 days “may be reasonable.”
Atrial fibrillation and Anticoagulation
Prolonged rhythm monitoring (30 days) for atrial fibrillation (AF) is reasonable in patients who have experienced a stroke or TIA without an apparent cause.
Dabigatran, apixaban, and vitamin K antagonists (VKA) are the preferred anticoagulation agents to prevent recurrent stroke in nonvalvular AF. Rivaroxaban is another reasonable alternative.
The use of antiplatelet agents with oral anticoagulation is not routinely indicated but is reasonable in patients with an additional history of clinically apparent coronary artery disease (CAD). Aspirin alone is recommended in patients intolerant of oral anticoagulation. The addition of clopidogrel to aspirin therapy may be considered. Oral anticoagulation can be initiated 14 days after a stroke/TIA caused by AF. Longer waiting time periods may be needed in the setting of stroke events linked with a higher risk for hemorrhagic conversion, such as larger strokes or in patients with uncontrolled hypertension.
Mechanical closure of the left atrial appendage is of uncertain benefit.
MI/Thrombus/Cardiomyopathy
Stroke/TIA events that occur in the setting of a myocardial infarction (MI) complicated by a thrombus in the left atrium or ventricle warrant > 3 months of anticoagulation. VKA therapy may be considered for 3 months in post-MI patients who have experienced a stroke/TIA and are found to have apical wall–motion abnormalities without thrombus on imaging. In patients with a stroke and a cardiomyopathy with ejection fraction < 35%, without apparent thrombus, it is unclear whether anticoagulation or antiplatelet therapy has better outcomes, and the choice of approach can be individualized.
Antiplatelet agents
The use of an antiplatelet agent is recommended to decrease the risk of recurrent stroke. Aspirin (50 mg–325 mg daily ) monotherapy or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is recommended. Clopidogrel 75 mg daily as monotherapy is also an option. The combination of aspirin and clopidogrel can be considered beginning within a day of a minor stroke or TIA and should be used for 90 days. The use of clopidogrel and aspirin together long term is not recommended due to increased hemorrhagic risk.
Patent foramen ovale
In patients with a patent foramen ovale (PFO), it is unclear whether anticoagulation or aspirin is more effective at preventing stroke recurrence. Available evidence does not support PFO closure when there is not evidence for concomitant DVT.
Hypercoagulation
The utility of screening for factor V Leiden, protein C deficiency, antiphospholipid antibodies, or other thrombophilic states is unclear. Anticoagulation can be considered if a coagulation abnormality is found, and if anticoagulation is not used then antiplatelet therapy is recommended.
Bottom line
Maintaining a healthy stroke-free lifestyle after a stroke/TIA requires rapid identification of stroke risk factors. The 2014 American Heart Association/American Stroke Association secondary stroke recommendations including the use of antiplatelet agents, anticoagulation for patients with atrial fibrillation, control of hypertension and hypercholesterolemia, and other risk factors are important evidence-based approaches to decrease the risk of recurrent stroke.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Mathew is a third-year resident in the family medicine residency program at Abington Memorial Hospital.
