“2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack”: Links And Excerpts

In this post, I link to and excerpt from 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Stroke. 2021 Jul;52(7):e364-e467

All that follows is from the above resource.

TOP 10 Take-Home Messages for the Secondary Stroke Prevention Guideline

  1. Specific recommendations for prevention strategies often depend on the ischemic stroke/transient ischemic attack subtype. Therefore, new in this guideline is a section describing recommendations for the diagnostic workup after ischemic stroke, to define ischemic stroke etiology (when possible), and to identify targets for treatment in order to reduce the risk of recurrent ischemic stroke. Recommendations are now grouped by etiologic subtype.

  2. Management of vascular risk factors remains extremely important in secondary stroke prevention, including (but not limited to) diabetes, smoking cessation, lipids, and especially hypertension. Intensive medical management, often performed by multidisciplinary teams, is usually best, with goals of therapy tailored to the individual patient.

  3. Lifestyle factors, including healthy diet and physical activity, are important for preventing a second stroke. Low-salt and Mediterranean diets are recommended for stroke risk reduction. Patients with stroke are especially at risk for sedentary and prolonged sitting behaviors, and they should be encouraged to perform physical activity in a supervised and safe manner.

  4. Changing patient behaviors such as diet, exercise, and medication compliance requires more than just simple advice or a brochure from their physician. Programs that use theoretical models of behavior change, proven techniques, and multidisciplinary support are needed.

  5. Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all patients without contraindications. With very few exceptions, the combination of antiplatelets and anticoagulation is typically not indicated for secondary stroke prevention. Dual antiplatelet therapy is not recommended long term, and short term, dual antiplatelet therapy is recommended only in very specific patients, including those with early arriving minor stroke and high-risk transient ischemic attack or severe symptomatic intracranial stenosis.

  6. Atrial fibrillation remains a common and high-risk condition for second ischemic stroke. Anticoagulation is usually recommended if the patient has no contraindications. Heart rhythm monitoring for occult atrial fibrillation is usually recommended if no other cause of stroke is discovered.

  7. Extracranial carotid artery disease is an important and treatable cause of stroke. Patients with severe stenosis ipsilateral to a nondisabling stroke or transient ischemic attack who are candidates for intervention should have the stenosis fixed, likely relatively early after their ischemic stroke. The choice between carotid endarterectomy and carotid artery stenting should be driven by specific patient comorbidities and features of their vascular anatomy.

  8. Patients with severe intracranial stenosis in the vascular territory of ischemic stroke or transient ischemic attack should not receive angioplasty and stenting as a first-line therapy for preventing recurrence. Aggressive medical management of risk factors and short-term dual antiplatelet therapy are preferred.

  9. There have been several studies evaluating secondary stroke prevention of patent foramen ovale closure since the previous guideline in 2014. It is now considered reasonable to percutaneously close patent foramen ovale in patients who meet each of the following criteria: age 18–60 years, nonlacunar stroke, no other identified cause, and high risk patent foramen ovale features.

  10. Patients with embolic stroke of uncertain source should not be treated empirically with anticoagulants or ticagrelor because it was found to be of no benefit.


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1.4. Scope of the Guideline

The aim of the present guideline is to provide clinicians with evidence-based recommendations for the prevention of future stroke among survivors of ischemic stroke or TIA. It should be noted that this guideline does not cover the following topics, which have been addressed elsewhere:

  • Acute management decisions (covered in the “2019 Update to the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke”16),

  • Intracerebral hemorrhage (ICH; covered in the “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage”17),

  • Primary prevention (covered in the “Guidelines for the Primary Prevention of Stroke”18 and “2019 American College of Cardiology/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease”19),

  • Special considerations for stroke prevention in women (covered in the “Guidelines for the Prevention of Stroke in Women”20), and

  • Cerebral venous sinus thrombosis (covered in “Diagnosis and Management of Cerebral Venous Thrombosis”22).

In general, with very few exceptions, the literature supports the concept that patients with TIA and those with ischemic stroke should be treated the same in terms of secondary prevention.

This guideline is divided into 4 sections:

  1. Diagnostic Evaluation for Secondary Stroke Prevention

  2. Vascular Risk Factor Management

  3. Management by Etiology

  4. Systems of Care for Secondary Ischemic Stroke Prevention.

The structure and scope of this guideline differ from those of the 2014 Guidelines for the prevention of stroke in patients with stroke and TIA9 in several ways. First, the current guideline reflects numerous innovations and modifications that were incorporated into the AHA clinical practice guideline format. Introduced in 2017, modifications to AHA guidelines included making the text shorter and more user friendly; focusing guidelines on recommendations and patient management flow diagrams and less on extensive text and background information; formatting guidelines so that they can be easily updated with guideline focused updates; and including “chunks” of information after each recommendation.23 Second, the Diagnostic Evaluation and Systems of Care for Secondary Prevention sections are new. The Diagnostic Evaluation for Secondary Stroke Prevention section focuses on the evidence base for laboratory and imaging studies for guiding secondary stroke prevention decisions. Often these tests are completed in the inpatient setting. The Systems of Care for Secondary Prevention section contains 3 subsections: (1) Health Systems–Based Interventions for Secondary Stroke Prevention, (2) Interventions Aimed at Changing Patient Behavior, and (3) Health Equity. The Health Equity subsection is a refocus of the 2014 guideline’s section guiding management of high-risk populations. Third, this guideline does not include a separate section on metabolic syndrome because there are no unique recommendations for metabolic syndrome aside from managing each of the individual components of the syndrome. Fourth, the section on alcohol use was expanded to include the use of other substances. Finally, several additional conditions were included in the Management by Etiology section: congenital heart disease, cardiac tumors, moyamoya disease, migraine, malignancy, vasculitis, other genetic disorders, carotid web, fibromuscular dysplasia, dolichoectasia, and embolic stroke of undetermined source (ESUS).

In developing the 2021 secondary stroke prevention guideline, the writing group reviewed prior published AHA/ASA guidelines and scientific statements. Table 2 contains a list of these other guidelines and statements deemed pertinent to this writing effort and is intended for use as a reader resource, thus reducing the need to repeat existing guideline recommendations.

Table 2. Associated AHA/ASA Guidelines and Statements
Title Organization Publication year
AHA/ASA guidelines
 Guidelines for Carotid Endarterectomy24 AHA/ASA 1998
 Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease25 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS 2011
 Guideline on Lifestyle Management to Reduce Cardiovascular Risk26 AHA/ACC 2013
 Guideline for the Management of Overweight and Obesity in Adults27 AHA/ACC/TOS 2013
 Guideline for the Management of Patients With Atrial Fibrillation28 AHA/ACC/HRS 2014
 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage17 AHA/ASA 2014
 Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack9 AHA/ASA 2014
 Guidelines for the Prevention of Stroke in Women20 AHA/ASA 2014
 Guidelines for the Primary Prevention of Stroke18 AHA/ASA 2014
 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults29 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 2017
 Guideline for the Management of Adults With Congenital Heart Disease30 AHA/ACC 2018
 Guideline on the Management of Blood Cholesterol31 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA 2018
 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke16 AHA/ASA 2019
 Guideline on the Primary Prevention of Cardiovascular Disease19 ACC/AHA 2019
 Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation32 AHA/ACC/HRS 2019
 Guideline for the Management of Patients With Valvular Heart Disease33 ACC/AHA 2020
AHA/ASA statements
 Diagnosis and Management of Cerebral Venous Thrombosis22 AHA/ASA 2011
 Cervical Arterial Dissections and Association With Cervical Manipulative Therapy21 AHA/ASA 2014
 Physical Activity and Exercise Recommendations for Stroke Survivors34 AHA/ASA 2014
 Spontaneous Coronary Artery Dissection: Current State of the Science34a AHA/ASA 2018
AHA/ASA presidential advisory
 Defining Optimal Brain Health in Adults35 AHA/ASA 2017

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AANN, American Association of Neuroscience Nurses; AANS, American Association of Neurological Surgeons; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; ACPM, American College of Preventive Medicine; ACR, American College of Radiology; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; ASA, American Stroke Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASNR, American Society of Neuroradiology; ASPC, American Society for Preventive Cardiology; CNS, Congress of Neurological Surgeons; HRS, Heart Rhythm Society; NLA, National Lipid Association; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; SAIP, Society of Atherosclerosis Imaging and Prevention; SCAI, Society for Cardiovascular Angiography and Interventions; SIR, Society of Interventional Radiology; SNIS, Society of NeuroInterventional Surgery; SVM, Society for Vascular Medicine; SVS, Society for Vascular Surgery; and TOS, The Obesity Society.

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