In addition to today’s resource, please see and review the outstanding summary article from the American Family Physician, Secondary Prevention of Ischemic Stroke: Updated Guidelines From AHA/ASA [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Am Fam Physician. 2022;105(1):99-102
Today, I review, 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. doi: 10.1161/STR.0000000000000375. Epub 2021 May 24.
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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.1. INTRODUCTION
Each year, ≈795 000 individuals in the United States experience a stroke, of which 87% (690 000) are ischemic and 185 000 are recurrent.1 Approximately 240 000 individuals experience a transient ischemic attack (TIA) each year.2 The risk of recurrent stroke or TIA is high but can be mitigated with appropriate secondary stroke prevention. In fact, cohort studies have shown a reduction in recurrent stroke and TIA rates in recent years as secondary stroke prevention strategies have improved.3,4 A meta-analysis of randomized controlled trials (RCTs) of secondary stroke prevention therapies published from 1960 to 2009 showed a reduction in annual stroke recurrence from 8.7% in the 1960s to 5.0% in the 2000s, with the reduction driven largely by improved blood pressure (BP) control and use of antiplatelet therapy.5 The changes may have been influenced by changes in diagnostic criteria and differing sensitivities of diagnostic tests over the years.The overwhelming majority of strokes can be prevented through BP control, a healthy diet, regular physical activity, and smoking cessation. In fact, 5 factors—BP, diet, physical inactivity, smoking, and abdominal obesity—accounted for 82% and 90% of the population-attributable risk (PAR) for ischemic and hemorrhagic stroke in the INTERSTROKE study (Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries).5a Similarly, the Global Burden of Disease Study showed that 90.5% (95% uncertainty interval, 88.5–92.2) of the global burden of stroke was attributable to modifiable risk factors.6 A modeling study showed that targeting multiple risk factors has additive benefits for secondary prevention; specifically, aspirin, statin, and antihypertensive medications, combined with diet modification and exercise, can result in an 80% cumulative risk reduction in recurrent vascular events.7 Although the benefits of a healthy lifestyle and vascular risk factor control are well documented,8,9 risk factors remain poorly controlled among stroke survivors.10–141.4. 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),• 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 Prevention2. Vascular Risk Factor Management3. Management by Etiology4. 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.23Second, 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).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 AH 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.1.5. Class of Recommendation and Level of Evidence
Recommendations are designated both a Class of Recommendation (COR) and a Level of Evidence (LOE). The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 3).Table 3. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*1.6. Abbreviations
Abbreviation Meaning/Phrase ACC American College of Cardiology ACS acute coronary syndrome ACTIVE W Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events AF atrial fibrillation AHA American Heart Association AHI apnea-hypopnea index ARCH Aortic Arch Related Cerebral Hazard Trial ARISTOTLE Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ASA American Stroke Association ASAP Addressing Sleep Apnea Post Stroke/TIA ASTRO-APS Apixaban for Secondary Prevention of Thromboembolism Among Patients With Antiphospholipid Syndrome ASCVD atherosclerotic cardiovascular disease BMI body mass index BP blood pressure BUST-Stroke Breaking Up Sitting Time After Stroke CADISS Cervical Artery Dissection in Stroke Study CARDIA Coronary Artery Risk Development in Young Adults CAP Continued Access Registry CAPRIE Clopidogrel Versus Aspirin in Patients at Risk of Ischaemic Events CAS carotid artery stenting CATHARSIS Cilostazol-Aspirin Therapy Against Recurrent Stroke With Intracranial Artery Stenosis CEA carotid endarterectomy CHANCE Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events CICAS Chinese Intracranial Atherosclerosis CLAIR Clopidogrel Plus Aspirin for Infarction Reduction CLOSE Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence CNS central nervous system COMMANDER HF A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction or Stroke in Participants With Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure COMPASS Cardiovascular Outcomes for People Using Anticoagulation Strategies COR Class of Recommendation COSS Carotid Occlusion Surgery Study CPAP continuous positive airway pressure CREST Carotid Revascularization Endarterectomy versus Stenting Trial CSPS Cilostazol for Prevention of Secondary Stroke CT computed tomography CTA computed tomographic angiography CVD cardiovascular disease DAPT dual antiplatelet therapy DASH Dietary Approaches to Stop Hypertension DCCT Diabetes Control and Complication Trial DESERVE Discharge Educational Strategies for Reduction of Vascular Events DHA docosahexaenoic acid DiRECT Diabetes Remission Clinical Trial DOAC direct-acting oral anticoagulant ECST European Carotid Surgery Trial EF ejection fraction ENGAGE AF-TIMI 48 Global Study to Assess the Safety and Effectiveness of Edoxaban (DU-176b) vs Standard Practice of Dosing With Warfarin in Patients With Atrial Fibrillation EPA eicosapentaenoic acid EPIC-CVD European Prospective Investigation into Cancer and Nutrition-CVD case-cohort study ESH-CHL-SHOT European Society of Hypertension and Chinese Hypertension League Stroke in Hypertension Optimal Treatment Trial ESPRIT European/Australasian Stroke Prevention in Reversible Ischaemia Trial ESPS2 Second European Stroke Prevention Study ESUS embolic stroke of undetermined source ExStroke Physical Exercise After Acute Ischaemic Stroke FASTEST Efficacy and Safety of a TIA/Stroke Electronic Support Tool FMD fibromuscular dysplasia FOURIER Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk GELIA German Experience With Low Intensity Anticoagulation GLP-1 glucagon-like protein 1 HbA1c hemoglobin A1c HR hazard ratio ICA internal carotid artery ICARUSS Integrated Care for the Reduction of Secondary Stroke ICAS intracranial atherosclerotic stenosis ICH intracerebral hemorrhage IE infective endocarditis IMPROVE-IT Improved Reduction of Outcomes: Vytorin Efficacy International Trial INR international normalized ratio INSPiRE-TMS Intensified Secondary Prevention Intending a Reduction of Recurrent Events in TIA and Minor Stroke Patients IPE icosapent ethyl IRIS Insulin Resistance Intervention After Stroke JAM Japan Adult Moyamoya JELIS Japan EPA Lipid Intervention Study LDL low-density lipoprotein LDL-C low-density lipoprotein cholesterol LOE Level of Evidence LV left ventricular LVAD left ventricular assist devices MACE major adverse cardiovascular event MD mean difference MI myocardial infarction MIST Motivational Interviewing in Stroke MRA magnetic resonance angiography MRI magnetic resonance imaging NAILED Stroke Nurse Based Age Independent Intervention to Limit Evolution of Disease After Stroke NASCET North American Symptomatic Carotid Endarterectomy Trial NAVIGATE ESUS Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source NIHSS National Institutes of Health Stroke Scale ODYSSEY OUTCOMES Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab OMEMI Omega-3 Fatty Acids in Elderly Patients With Acute Myocardial Infarction OR odds ratio OSA obstructive sleep apnea OXVASC Oxford Vascular Study PAR population-attributable risk PAST-BP Prevention After Stroke–Blood Pressure PCSK9 proprotein convertase subtilisin/kexin type 9 PFO patent foramen ovale PODCAST Prevention of Decline in Cognition after Stroke Trial POINT Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke PRAISE Prevent Recurrence of All Inner-City Strokes Through Education PREDIMED Prevención con Dieta Mediterránea PREVAIL Prospective Randomised Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy PREVENTION Preventing Recurrent Vascular Events in Patients With Stroke or Transient Ischemic Attack PRoFESS Prevention Regimen for Effectively Avoiding Second Strokes PROTECT AF Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation PTAS percutaneous transluminal angioplasty and stenting RCT randomized controlled trial RE-ALIGN Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients After Heart Valve Replacement RE-LY Randomized Evaluation of Long-Term Anticoagulant Therapy REDUCE-IT Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial REGARDS Reasons for Geographic and Racial Differences in Stroke Study RESPECT Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment RESPECT ESUS Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source RISE-UP Recovery in Stroke Using PAP ROCKET AF Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation RR relative risk SAMMPRIS Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis SAPPHIRE Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy SAPT single antiplatelet therapy SAVE Sleep Apnea Cardiovascular Endpoints SBP systolic blood pressure SCD sickle cell disease SIT Silent Cerebral Infarct Transfusion multi-center clinical trial Sleep SMART Sleep for Stroke Management and Recovery Trial SMART Second Manifestations of Arterial Disease SOCRATES Soluble Guanylate Cyclase Stimulator in Heart Failure Studies SPAF Stroke Prevention in Atrial Fibrillation Study SPARCL Stroke Prevention by Aggressive Reduction in Cholesterol Levels SPS3 Secondary Prevention of Small Subcortical Strokes STANDFIRM Shared Team Approach Between Nurses and Doctors for Improved Risk Factor Management for Stroke Patients STOP Stroke Prevention Trial in Sickle Cell Anemia SUCCEED Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities SUSTAIN Systemic Use of Stroke Averting Interventions STRENGTH Outcomes Study to Assess Statin Residual Risk Reduction With Epanova in High CV Risk Patients With Hypertriglyceridemia SWiTCH Stroke With Transfusions Changing to Hydroxyurea TARDIS Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke T2D type 2 diabetes TCAR transcarotid artery revascularization TCD transcranial Doppler TEE transesophageal echocardiography THALES Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death TIA transient ischemic attack TOSS Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis TST Treat Stroke to Target TWiTCH TCD With Transfusions Changing to Hydroxyurea UKPDS United Kingdom Prospective Diabetes Study VAST Vertebral Artery Stenting Trial VHD valvular heart disease VISP Vitamin Intervention for Stroke Prevention VISSIT Vitesse Intracranial Stent Study for Ischemic Stroke Therapy VIST Vertebral Artery Ischemic Stenting Trial VISTA Virtual International Stroke Trials Archive VITATOPS Vitamins to Prevent Stroke VKA vitamin K antagonist VLDL very-low-density lipoprotein VZV varicella zoster virus WARCEF Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction WARSS Warfarin-Aspirin Recurrent Stroke Study WASID Warfarin-Aspirin Symptomatic Intracranial Disease WEAVE Wingspan Stent System Post Market Surveillance 2. General Concepts
2.1. Definitions
Figure 1 illustrates the writing group’s conceptual representation of ischemic stroke subtypes.Figure 1. Conceptual representation of ischemic stroke subtypes. Percentages are approximate and are informed by Kolominsky-Rabas et al36 and Gardener et al.37 Precise percentages will depend on extent of testing and patient populations. Ischemic stroke subtype definitions are informed by the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification scheme38 unless otherwise indicated. ESUS indicates embolic stroke of undetermined source.Lacunar stroke: Lacunar syndrome, with normal computed tomography (CT)/magnetic resonance imaging (MRI) or subcortical stroke measuring <1.5 cm in diameter on CT or MRI. Most, although not all, of lacunar strokes are due to small vessel disease.Stroke attributable to small vessel disease: Subcortical stroke measuring <1.5 cm in diameter on CT or MRI without evidence of a concomitant cortical infarct.Cardioembolic stroke: Stroke attributable to arterial occlusion from an embolus that presumably arose in the heart. Clinical and brain imaging findings are similar to those described in large artery atherosclerosis. Evidence of a previous TIA or stroke in >1 vascular territory supports a clinical diagnosis of cardioembolic stroke.Cryptogenic stroke: An imaging-confirmed stroke with unknown source despite thorough diagnostic assessment (including, at a minimum, arterial imaging, echocardiography, extended rhythm monitoring, and key laboratory studies such as a lipid profile and hemoglobin A1c [HbA1c]).Stroke caused by large artery atherosclerosis: Ischemic stroke in the vascular distribution of a major intracranial or extracranial artery with >50% stenosis or occlusion on vascular imaging. Clinical findings include those of cerebral cortical involvement or brainstem or cerebellar dysfunction. Cortical and cerebellar lesions and brainstem or subcortical lesions >1.5 cm are considered potentially caused by large artery atherosclerosis. Diagnostic studies should exclude potential sources of cardioembolic embolism.ESUS: A stroke that appears nonlacunar on neuroimaging without an obvious source after a minimum standard evaluation (including arterial imaging, echocardiography, extended rhythm monitoring, and key laboratory studies such as a lipid profile and HbA1c) to rule out known stroke etiologies such as cardioembolic sources and atherosclerosis proximal to the stroke.39A diagnosis of ESUS implies that the stroke is embolic in origin, given the nonlacunar location; however, the source of the embolus is unknown, despite a minimal standard evaluation. Although cryptogenic stroke similarly implies that the cause of the origin is unknown, the stroke is not necessarily embolic. Individuals with ESUS have cryptogenic stroke, but the converse is not always the case.2.2. Shared Decision-Making
Shared decision-making is a key component of patient-centered care.2.3. Contraindications
Treatment should always be tailored to patients’ individual situations. Therefore, as a rule, we did not include the statement “unless contraindicated” in the recommendations. It is implicit that if a recommendation is contraindicated in a patient’s circumstance, it should not be implemented.2.4. Adherence
A key component of secondary stroke prevention is assessing and addressing barriers to adherence to medications and a healthy lifestyle. If a patient has a recurrent stroke while on secondary stroke prevention medications, it is vital to assess whether they were taking the medications that they were prescribed and, if possible, to explore and address factors that contributed to nonadherence before assuming that the medications were ineffective.2.5. Antithrombotic Dosing
Unless stated otherwise in the recommendations herein, the international normalized ratio (INR) goal for warfarin is 2.0 to 3.0 and the dose of aspirin is 81 to 325 mg.2.6. Application Across Populations
Unless otherwise indicated, the recommendations in this guideline apply across race/ethnicity, sex, and age groups. Special considerations to address health equity are delineated in section 6.3, Health Equity.3. Diagnostic Evaluation for Secondary Stroke Prevention
Synopsis
Patients presenting with signs and symptoms of acute stroke will undergo an evaluation tailored to ensure that, when appropriate, they receive reperfusion therapy (Figure 2). Imaging recommendations based on acute treatment considerations overlap with, but are not identical to, imaging recommendations based on secondary stroke prevention considerations. Recommendations presented in this guideline focusFigure 2. Algorithm for evaluating patients with a clinical diagnosis of stroke for the purposes of optimizing prevention of recurrent ischemic stroke. Colors correspond to Class of Recommendation in Table 3. CT indicates computed tomography; CTA, computed tomography angiogram; ECG, electrocardiogram; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; PFO, patent foramen ovale; SOE, source of embolism; TCD, transcranial Doppler; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; and US, ultrasound. *Basic laboratory tests include complete blood count, troponin, prothrombin time, partial thromboplastin time, glucose, hemoglobin A1c, creatinine, and fasting or nonfasting lipid profile. †When a patient has a transient neurological deficit clinically characteristic of transient ischemic attack, the patient should be evaluated in the same manner as a patient who has an ischemic stroke with a corresponding cerebral infarct on imaging. ‡TTE, TEE, TCD, cardiac MRI, or cardiac CT.on evaluations done for the purposes of confirming the diagnosis of stroke and characterizing its pathomechanism by identifying potential sources of cardioembolism, thromboembolism from large artery atherosclerosis, dissection, or other disease processes such as hypercoagulability. Confirmation of stroke diagnosis may require follow-up head imaging because of poor sensitivity of noncontrast CT for small or hyperacute infarcts. Some conditions associated with stroke and with specific therapies are common (eg, AF), whereas others are relatively rare (eg, endocarditis). The variable yield of testing means that treating physicians need to exercise judgment on the likelihood that a test will alter management in a given clinical situation.
