Guidelines issued on preventing stroke in patients with previous stroke and transient ischemic attack

The American Heart Association (AHA) and the American Stroke Association have released new guidelines on preventing stroke in patients who have survived an ischemic stroke or transient ischemic attack (TIA).

The current guidelines are an update of the 2011 version and are intended for clinicians who manage secondary prevention in this population. The new guidelines have added sections on sleep apnea, aortic arch atherosclerosis, and nutrition, and the section on diabetes mellitus has been expanded to include prediabetes. In addition, substantial revisions were made to the sections on carotid stenosis, atrial fibrillation, prosthetic heart valves, pregnancy, and intracranial atherosclerosis, while a section on Fabry disease was removed. More emphasis is given to lifestyle and obesity as targets for risk reduction. The recommendations and levels of evidence were classified according to AHA and American College of Cardiology methods.

Some of the new recommendations are as follows:

• All patients with TIA or stroke should be screened for obesity with measurement of body mass index (Class I recommendation; Level of Evidence C).
• For patients who are able and willing to initiate increased physical activity, referral to a comprehensive, behaviorally oriented program is probably recommended (Class IIa recommendation; Level of Evidence C).
• Patients with a history of ischemic stroke or TIA and signs of undernutrition should be referred for individualized nutritional counseling (Class I recommendation; Level of Evidence B).
• A sleep study might be considered for patients with an ischemic stroke or TIA on the basis of the very high prevalence of sleep apnea in this population and the strength of the evidence that the treatment of sleep apnea improves outcomes in the general population (Class IIb recommendation; Level of Evidence B).
• Rivaroxaban is reasonable for the prevention of recurrent stroke in patients with nonvalvular atrial fibrillation (Class IIa recommendation; Level of Evidence B).
• For most patients with a stroke or TIA in the setting of atrial fibrillation, it is reasonable to initiate oral anticoagulation within 14 days after the onset of neurological symptoms (Class IIa recommendation; Level of Evidence B).
• The combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 90 days (Class IIb recommendation; Level of Evidence B).

The guidelines were published online by Stroke on May 1. An executive summary is also available.