“However, the combination of antiplatelets and anticoagulation is typically not recommended for preventing second strokes, and dual antiplatelet therapy, taking aspirin along with a second medicine to prevent blood clotting, is recommended short-term, only for specific patients: those with early arriving minor stroke and high-risk TIA or severe symptomatic stenosis,” explained the writing group for the updated guidelines issued by the American Heart Association/American Stroke Association.
Stroke or a transient ischemic attack (TIA) signals are known to signal higher risk for stroke in the future, and the new guideline emphasizes that identifying the cause of the initial event can better guide specific prevention strategies for additional strokes. The document was published in the journal Stroke.
The authors point out that the overwhelming majority of strokes in the United States, 87%, are ischemic. While a TIA occurs when an artery is blocked for a short amount of time and doesn’t usually cause permanent brain injury, when blood flow is blocked, either by clots or plaques, ischemic stroke can lead to serious disability or even death, according to the report.
The guideline panel notes that recurrent stroke rates have dropped substantially in the United States from 8.7% in the 1960s to 5% in the 2000s, as prevention strategies have improved. Yet, it points out that many risk factors for a second stroke remain poorly managed among stroke survivors.
The “2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack” recommends that diagnostic evaluations to determine the cause of the first stroke or TIA be performed within 48 hours of symptom onset.
Once that is ascertained, the guideline includes a section outlining treatment recommendations based on the cause of the initial stroke/TIA. Possible underlying causes include blockages in large arteries in the neck or brain, small arteries in the brain which are damaged from high blood pressure or diabetes, irregular heart rhythms and many other potential causes.
“It is critically important to understand the best ways to prevent another stroke once someone has had a stroke or a TIA,” explained Dawn O. Kleindorfer, MD, chair of the guideline writing group, and professor and chair of the department of neurology at the University of Michigan School of Medicine in Ann Arbor. “If we can pinpoint the cause of the first stroke or TIA, we can tailor strategies to prevent a second stroke.”
Secondary prevention guidelines recommend that patients who have survived a stroke or TIA manage their vascular risk factors, especially high blood pressure, but also type 2 diabetes, cholesterol, and triglyceride levels. They also are urged to quit smoking, limit salt intake, and follow a Mediterranean diet.
In addition to antithrombotic therapy, updated treatment recommendations for clinicians include:
• Using multidisciplinary care teams to personalize care for patients and employing shared decision-making with the patient to develop care plans that incorporate a patient’s wishes, goals, and concerns.
• Screening for and diagnosing atrial fibrillation and starting blood-thinning medications to reduce recurrent events.
• Carotid endarterectomy, surgical removal of a blockage or, in some cases, the use of a stent in the carotid artery, should be considered for patients with narrowing arteries in the neck.
• Aggressive medical management of risk factors and short-term dual antiplatelet therapy are preferred for patients with severe intracranial stenosis suspected of causing the stroke or TIA.
• Percutaneous closure, a less invasive, catheter-based surgical procedure, might be considered in a patent foramen ovale, a small and relatively common heart defect.
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