AHA Updates Guidelines for Secondary Stroke Prevention, Risk Factor Mitigation

Dawn O. Kleindorfer, MD, FAHA

The American Heart Association/American Stroke Association (AHA/ASA) has published updated 2021 guidelines for the prevention of secondary stroke in patients with stroke and transient ischemic attack (TIA).¹

The guidelines focus on improving diagnostics, managing vascular risk factors and lifestyle factors, altering patient behaviors, recommending antithrombotic therapy, monitoring atrial fibrillation (AF), extracranial carotid artery disease, severe intracranial stenosis, and embolic stroke of uncertain source, and the determinant use of patent foramen ovale closure.

“It is critically important to understand the best ways to prevent another stroke once someone has had a stroke or a TIA,” first author Dawn O. Kleindorfer, MD, FAHA, chair of the guideline writing group, and professor and chair, department of neurology, University of Michigan School of Medicine, said in a statement.² “If we can pinpoint the cause of the first stroke or TIA, we can tailor strategies to prevent a second stroke.”

The authors consisted of neurologists, neurological surgeons, cardiologists, internists, and a lay/patient representative, and included representatives from the AHA/ASA and the American Academy of Neurology. They compiled evidence-based recommendations that were supported by an extensive evidence review whenever possible. A commissioned independent Evidence Review Committee also performed formal systematic reviews of any critical clinical questions.

READ MORE: Hypertension Is Significantly Undertreated in Those With History of Stroke

Kleindorfer and colleagues identified areas of secondary stroke prevention to be improved, as having a stroke or TIA greatly increases chances of having a future stroke. They stressed that identifying the cause of the first stroke is key to developing strategies to prevent additional stroke. Much of the new guidelines focus on managing blood pressure levels, reducing or quitting smoking, eating a healthy diet, and regular physical activity to reduce secondary stroke risk, as well as managing conditions such as Type 2 diabetes and high cholesterol. 

“In fact, approximately 80% of strokes can be prevented by controlling blood pressure, eating a healthy diet, engaging in regular physical activity, not smoking and maintaining a healthy weight,” said co-author Amytis Towfighi, MD, FAHA, vice-chair, guideline writing group, and director, neurological services, Los Angeles County Department of Health Services.

Recommendations for a healthy diet include limiting salt intake and/or following a Mediterranean diet. For physical activity, the authors prescribe engaging in moderate-intensity aerobic activity for at least 10 minutes four times a week or vigorous-intensity aerobic activity for at least 20 minutes twice a week if patients are capable. Additionally, people who experience a stroke or TIA should be screened and potentially treated for AF (FIGURE).

New to the 2021 guidelines is a recommendation for health care professionals to perform diagnostic evaluations to determine the cause of the first stroke or TIA within 48 hours of symptom onset and treating any conditions or managing risk factors accordingly. Conditions may include blockages in large arteries in the neck or brain, damaged small arteries in the brain from high blood pressure or diabetes, AF or other potential causes.

“The secondary prevention of stroke guideline is one of the American Stroke Association’s ’flagship’ guidelines, last updated in 2014,” Kleindorfer added. “There are also a number of changes to the writing and formatting of this guideline to make it easier for professionals to understand and locate information more quickly, ultimately greatly improving patient care and preventing more strokes in our patients.”

REFERENCES

1. Kleindorfer DA, Towfighi A, Chaturvedi S, et al. 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. Stroke. Published online May 24, 2021 doi: 0.1161/STR.0000000000000375
2. Risk of second stroke can be reduced with prevention efforts based on cause of first stroke: American Heart Association/American Stroke Association clinical practice guideline. News release. AHA/ASA. Published online May 24, 2021. https://newsroom.heart.org/news/risk-of-second-stroke-can-be-reduced-with-prevention-efforts-based-on-cause-of-first-stroke?preview=1cd4