New AHA/ASA guidelines for prevention of recurrent stroke in stroke survivors

Kernan WN, Ovbiagele B, Black HR, et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease
STR.0000000000000024  Published online May 1, 2014, doi: 10.1161/​STR.0000000000000024

The American Heart Association/American Stroke Association (AHA/ASA) have issued an update of the guideline for the prevention of stroke in patients with stroke and transient ischaemic attack (TIA). The update aims to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischaemic stroke or TIA, each time indicating the strength of the recommendation and the level of evidence.

Based on the latest evidence, guidance is provided on control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Important revisions since the last statement include a section on sleep apnea and aortic arch atherosclerosis, since these appear to be prevalent risk factors for recurrent stroke. Pre-diabetes is now also discussed. Lifestyle and obesity are given emphasis as potential targets for risk reduction, and also nutrition is discussed. The writing group furthermore emphasises the importance of treating hypertension, if systolic blood pressure (BP) is >140 mmHg or diastolic BP >90 mmHg.

The document considers the importance of identifying clinically silent brain infarction, since these events are associated with typical risk factors for ischaemic stroke and in increased risk for future ischaemic stroke, and should be a starting point for secondary prevention.

Specific circumstances in which stroke prevention is needed are addressed, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinaemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy.

Use of antithrombotic and anticoagulation therapy after an intracranial haemorrhage is addressed, and a section is dedicated to practical implementation of the guidelines.

Find the new AHA/ASA guideline online