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Transcript of AHA/ASA Guideline - PAC 4 2006.pdf · PDF fileIschemic stroke is classified into various...

  • Guidelines for Prevention of Stroke in Patients WithIschemic Stroke or Transient Ischemic Attack

    A Statement for Healthcare Professionals From the American HeartAssociation/American Stroke Association Council on Stroke

    Co-Sponsored by the Council on Cardiovascular Radiologyand Intervention

    The American Academy of Neurology affirms the value of this guideline.

    Ralph L. Sacco, MD, MS, FAHA, FAAN, Chair; Robert Adams, MD, FAHA, Vice Chair;Greg Albers, MD; Mark J. Alberts, MD, FAHA; Oscar Benavente, MD;

    Karen Furie, MD, MPH, FAHA; Larry B. Goldstein, MD, FAHA, FAAN;Philip Gorelick, MD, MPH, FAHA, FAAN; Jonathan Halperin, MD, FAHA;

    Robert Harbaugh, MD, FACS, FAHA; S. Claiborne Johnston, MD, PhD; Irene Katzan, MD, FAHA;Margaret Kelly-Hayes, RN, EdD, FAHA; Edgar J. Kenton, MD, FAHA, FAAN; Michael Marks, MD;

    Lee H. Schwamm, MD, FAHA; Thomas Tomsick, MD, FAHA

    AbstractThe aim of this new statement is to provide comprehensive and timely evidence-based recommendations on theprevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-basedrecommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease,antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Furtherrecommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances,including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease;cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use ofpostmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for theimplementation of guidelines and their use in high-risk populations. (Stroke. 2006;37:577-617.)

    Key Words: AHA Scientific Statements ischemia ischemia attack, transient stroke

    Survivors of a transient ischemic attack (TIA) or strokehave an increased risk of another stroke, which is amajor source of increased mortality and morbidity.Among the estimated 700 000 people with stroke in theUnited States each year, 200 000 of them are among personswith a recurrent stroke. The number of people with TIA,and therefore at risk for stroke, is estimated to be muchgreater. Epidemiological studies have helped to identifythe risk and determinants of recurrent stroke, and clinicaltrials have provided the data to generate evidence-basedrecommendations to reduce this risk. Prior statements from

    the American Heart Association (AHA) have dealt withprimary1 and secondary stroke prevention.2,3 Because moststrokes are cerebral infarcts, these recommendations focusprimarily on the prevention of stroke among the ischemicstroke or TIA group. Other statements from the AHA havedealt with acute ischemic stroke,4 subarachnoid hemor-rhage (SAH),5 and intracerebral hemorrhage (ICH).6 Rec-ommendations follow the AHA and the American Collegeof Cardiology (ACC) methods of classifying the level ofcertainty of the treatment effect and the class of evidence(see Table 1).7

    The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outsiderelationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are requiredto complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

    This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 16, 2005. A singlereprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX75231-4596. Ask for reprint No. 71-0339. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000or more copies, call 410-528-4121, fax 410-528-4264, or e-mail kramsay@lww.com. To make photocopies for personal or educational use, call theCopyright Clearance Center, 978-750-8400.

    Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,visit http://www.americanheart.org/presenter.jhtml?identifier3023366.

    American Heart Association, Inc.

    Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000199147.30016.74


    AHA/ASA Guideline

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  • The aim of this new statement is to provide comprehensiveand timely evidence-based recommendations on the preven-tion of ischemic stroke among survivors of ischemic stroke orTIA. A writing committee chair and vice chair were desig-nated by the Stroke Council Manuscript Oversight Commit-tee. A writing committee roster was developed and approvedby the Stroke Council with representatives from neurology,cardiology, radiology, surgery, nursing, and health servicesresearch. The committee met in person and had a number ofteleconferences to develop the outline and text of the recom-mendations. The writing group conducted a comprehensivereview of the relevant literature. Although the complete list ofkeywords is beyond the scope of this section, the committeereviewed all compiled reports from computerized searchesand conducted additional searching by hand. Searches werelimited to English language sources and to human subjects.Literature citations were generally restricted to publishedmanuscripts appearing in journals listed in Index Medicusand reflected literature published as of December 31, 2004.Because of the scope and importance of certain ongoingclinical trials and other emerging information, publishedabstracts were cited when they were the only publishedinformation available. The references selected for this documentare exclusively for peer-reviewed papers that are representativebut not all inclusive. All members of the committee had frequentopportunities to review drafts of the document, comment inwriting or during teleconference discussions, and reach consen-sus with the final recommendations.

    Although prevention of stroke is the primary outcome ofinterest, many of the grades for the recommendations werechosen to reflect the existing evidence on the reduction of allvascular outcomes after stroke, including stroke, myocardialinfarction (MI), and vascular death. We have organized ourrecommendations in this statement to aid the clinician whohas arrived at a potential explanation of the cause of theischemic stroke in an individual patient and is embarking ontherapy to reduce the risk of a recurrent event and othervascular outcomes. Our intention is to have these statementsupdated every 3 years, with additional interval updates asneeded, to reflect the changing state of knowledge on theapproaches to prevention of a recurrent stroke.

    Definition of TIA and IschemicStroke Subtypes

    The distinction between TIA and ischemic stroke has becomeless important in recent years because many of the preventive

    approaches are applicable to both groups. They share patho-genetic mechanisms; prognosis may vary, depending on theirseverity and cause; and definitions are dependent on thetiming and degree of the diagnostic evaluation. By conven-tional clinical definitions, if the neurological symptomscontinue for 24 hours, a person has been diagnosed withstroke; otherwise, a focal neurological deficit lasting 24hours has been defined as a TIA. With the more widespreaduse of modern brain imaging, many patients with symptomslasting 24 hours are found to have an infarction. The mostrecent definition of stroke for clinical trials has requiredeither symptoms lasting 24 hours or imaging of an acuteclinically relevant brain lesion in patients with rapidly van-ishing symptoms. The proposed new definition of TIA is abrief episode of neurological dysfunction caused by a focaldisturbance of brain or retinal ischemia, with clinical symp-toms typically lasting less than 1 hour, and without evidenceof infarction.8 TIAs are an important determinant of stroke,with 90-day risks of stroke reported as high as 10.5% and thegreatest stroke risk apparent in the first week.9,10

    Ischemic stroke is classified into various categories accord-ing to the presumed mechanism of the focal brain injury andthe type and localization of the vascular lesion. The classiccategories have been defined as large-artery atheroscleroticinfarction, which may be extracranial or intracranial; embo-lism from a cardiac source; small-vessel disease; otherdetermined cause such as dissection, hypercoagulable states,or sickle cell disease; and infarcts of undetermined cause.11

    The certainty of the classification of the ischemic strokemechanism is far from ideal and reflects the inadequacy ortiming of the diagnostic workup in some cases to visualize theoccluded artery or to localize the source of the embolism.Recommendations for the timing and type of diagnosticworkup for TIA and stroke patients are beyond the scope ofthis guideline statement.

    I. Risk Factor Control for All Patients WithTIA or Ischemic Stroke

    A. HypertensionIt is estimated that 50 000 000 Americans have hyperten-sion.12 There is a continuous association between both sys-tolic and diastolic blood pressures (BPs) and the risk ofischemic stroke.13,14 Meta-analyses of randomized controlledtrials confirm an approximate 30% to 40% stroke risk

    TABLE 1. Definition of Classes and Levels of Evidence Used in AHA Recommendations

    Class I Conditions for which there is evidence for and/or general agreement that the procedure or treatment isuseful and effective

    Class II Conditi