Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

Duc Dang PhucStroke department Hospital 103

Hanoi 2015

References1. AHA/ASA, Guidelines for the Prevention of Stroke in Patients With Stroke

and Transient Ischemic Attack, Stroke. 2014;45:2160-2236

2. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary, J A C C V O L . 6 4 , N O . 2 1 , 2 0 1 4

3. ACC/AHA Guideline on the Assessment of Cardiovascular Risk, Circulation, Print ISSN: 0009-7322.

4. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013;36(suppl 1):S11–S66

5. ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J.2013;34:2159–2219

6. AHA/ACC/TOS guideline for the management of overweight and obesity in adults. Circulation. doi:10.1161/01

Applying Classification of Recommendations and Level of Evidence

Class Explaination

I Benefit >>> Risk

IIa Benefit >> Risk

IIb Benefit ≥ Risk

III Benefit < Risk

Level Explaination

A Multiple RCT or meta – analyses

B A RCT or nonrandomized studies

C Only consensus

Risk Factor Control for All Patients WithTIA or Ischemic Stroke

MODIFIABLE:HypertensionDyslipidemiaGlucose disordersObesityPhysical inactivityNutritionCarotid diseaseIntracranial atherosclerosisAF…

UNMODIFIABLE:RaceAgeSexGenetic…

Hypertension

- Define: ≥140/90 mmHg

- Prevalence: ≈70% among ischemic stroke

Hypertension

3 RCTs:BP lowering is associated with a 30% - 40% stroke risk reduction

HypertensionAHA’s “Guidelines for the Early Management of Patients With Acute Ischemic Stroke.” -2013“…restarting antihypertensive therapy is reasonable after the first 24 hours for patients who have preexisting hypertension and who are neurologically stable.”

Hypertension Recommendations

- Goals for target BP: < 140/90mmHg (IIa,B)

- Several lifestyle modifications have been associated with BP reductions and are a reasonable part of a comprehensive antihypertensive therapy (IIa,C).

Dyslipidemia

The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study:

RRR 2,1% (11.2% / 13.1%)

LDL-C level of <70 mg/dL was related to a 28% reduction in risk of stroke

Dyslipidemia Recommendations

- Recommend statin therapy to reduce risk of stroke among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin (I, B/C)

- Patients should be managed according to the 2013 ACC/AHA cholesterol guidelines (I, A)

Dyslipidemia Recommendations

The “ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” - 2013

4 “statin benefit groups”:1) Clinical ASCVD2) LDL-C ≥190 mg/dL3) DM aged 40 to 75 years with LDL-C 70-189mg/dL4) Estimated 10-year ASCVD risk ≥7.5%

2013 ACC/AHA Cardiovascular Risk Guideline

Disorders of Glucose Metabolism and DM

Classification:

Type 1 DM

Type 2 DM

Pre-DM

Disorders of Glucose Metabolism and DM

Normal Pre-DM DM

IFG IGT

G (B) < 100mg/dL (5.6mmol/l)

100-125mg/dL (6.9mmol/l)

>125

G tolerance < 140mg/dL (7.8mmol/l)

140-199mg/dL(7.8-11.0mmol/l)

>199

HbA1c <5.7% 5.7-6.4% > 6.4%

Epidemiology of DM-11.3% of adults:

† aged 20 to 44 years: 3.7% † ≥65 years: 26.9%

-Increase the risk of stroke: aRR 1.5 - 3.7

Recommendations

After a TIA or ischemic stroke, all patients should be screened for DM

Use of existing guidelines from the ADA for glycemic control recommended for patients with an ischemic stroke or TIA who also have DM or pre-DM (I,B)

Overweight and Obesity

Weight status (CDC)

BMI Weight Status

≤18.5 Underweight

18.5 – 24.9 Normal or Healthy Weight

25.0 – 29.9 Overweight

≥30.0 Obese

1kg/m2 increase in BMI = 5% increase in risk for stroke.

Obesity RecommendationsAll patients with TIA or stroke should be screened for obesity with measurement of BMI (I, C)

The usefulness of weight loss among patients with a recent TIA or isch-emic stroke and obesity is uncertain (IIb; C)

Symptomatic Extracranial Carotid Atherosclerosis

Carotid Endarterectomy (CEA)3 RCTs: (VACS, NASCET, and ECST): CEA plus medical therapy is better than medical therapy alone for symptomatic patients with a high-grade (>70% angiographic stenosis) atherosclerotic carotid stenosisCarotid Angioplasty and Stenting (CAS)Less invasiveDecrease patient discomfortShorter recuperation period

Recommendations

For patients with a TIA or ischemic stroke:

-Carotid artery stenosis 70%–99% by noninvasive imaging or 50-69% by DSA: CEA

- Stenosis < 50%: CEA and CAS are not recommended

- Time: within 2 weeks

Recommendations

-CAS: + Older than ≈70 years+ Anatomic or medical conditions are present that greatly increase the risk for surgery

- Recommend optimal medical therapy, which should include:

†antiplatelet therapy†statin therapy†risk factor modification

Intracranial Atherosclerosis

Recommendations

- Moderate stenosis (50%–69%): angioplasty or stenting is not recommended

- Severe stenosis (70%–99%): CAS – need more ivestigations

Intracranial AtherosclerosisRecommendations

-Aspirin 325 mg/d is recommended in preference to warfarin- Severe stenosis (70%–99%), the addition of clopidogrel 75 mg/d to aspirin for 90 days might be reasonable (IIb; B)- No evidence:

†clopidogrel†combination of aspirin and dipyridamole †cilostazol

Atrial Fibrillation

In the US, AF caused >70,000 ischemic strokes

each year (10%–12% of all ischemic strokes)

The risk of stroke among people with AF

CHADS2

Condition Points

 C   Congestive heart failure 1

 H  Hypertension 1

 A  Age ≥75 years 1

 D  Diabetes mellitus 1

 S2  Prior Stroke or TIA  2

Annual Stroke Risk

CHADS2  Risk %

0 1.9

1 2.8

2 4.0

3 5.9

4 8.5

5 12.5

6 18.2

CHA2DS2-VASc

Condition Points

 C   Congestive heart failure 1

 H  Hypertension 1

 A2  Age ≥75 years 2

 D  Diabetes Mellitus 1

 S2  Prior Stroke or TIA  2

 V  Vascular disease 1

 A  Age 65–74 years 1

 Sc  Sex: female 1

Score Risk %0 01 1.32 2.23 3.24 4.05 6.76 9.87 9.68 12.59 15.2

AF Recommendations- Anticoagulation drugs:

†VKA therapy (I,A)†Apixaban (I;A)†Dabigatran (I;B)†Rivaroxaban (IIa; B)

- Target INR: 2.5 (2.0–3.0) (I,A)

- For patients can not take anticoagulants: aspirin (I,A).

- Start treatment: within 14 days after the onset

Antiplatelet Agent Recommendations

- First choice: †aspirin (50–325 mg/d) (I,A) †aspirin 25 mg + dipyridamole 200 mg bid (I,B)

- Alternative drugs: Clopidogrel 75mg

- The combination of aspirin and clopidogrel might be considered (IIb,B)

Hyperhomocysteinemia Recommendations

- In adults with a recent ischemic stroke or TIA who are known to

have mild to moderate hyperhomocysteinemia, supplementation

with folate, vitamin B , and vitamin B safely reduces levels of

homocysteine but has not been shown to prevent stroke (III,B)

Thanks for your attention!