Secondary Stroke Prevention Clinical Practice Guidelines (AHA/ASA, 2021)

American Heart Association/American Stroke Association

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

June 01, 2021

Updated guidelines on the secondary prevention of stroke (in patients with stroke and transient ischemic attack [TIA]) were published in May 2021 by the American Heart Association/American Stroke Association in Stroke.[1,2] Among the recommendations is that, whenever possible, diagnostic tests to determine the cause of a first stroke or TIA should be completed within 48 hours after symptomatic onset.

Top 10 Key Messages

The ischemic stroke/TIA subtype guides prevention strategies. Therefore, the AHA/ASA has grouped their advice by etiologic subtype in a new section with recommendations for post-ischemic stroke diagnostic workup—to define the ischemic stroke etiology (when possible), and to identify treatment targets to reduce the risk of recurrent ischemic stroke.

A key strategy for secondary stroke prevention is multidisciplinary management of, and personalized treatment goals for, vascular risk factors, particularly hypertension, diabetes, lipid levels, and smoking cessation.

Lifestyle factors such as limiting salt intake and/or following a heart-healthy Mediterranean diet are also advised, as well as, when possible, engaging in at least 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.

Patient lifestyle and behavioral modifications (eg, diet, exercise, medication compliance) require not only the receipt of clinical advice or brochures but also participation in programs that use theoretical models of behavior change, proven techniques, and multidisciplinary support.

Prescribe antithrombotic therapy, including antiplatelets or anticoagulants, in the absence of contraindications. The combination of antiplatelets and anticoagulation is typically not indicated for secondary stroke prevention, and dual antiplatelet therapy (DAT) (taking aspirin plus a second agent to prevent blood clotting) is recommended in the short term and only for specific patients: those with early arriving minor stroke and high-risk TIA or severe symptomatic intracranial stenosis.

Screen for atrial fibrillation (AF), and initiate anticoagulation in the absence of contraindications to reduce recurrent events. If no other cause of stroke can be identified, heart rhythm monitoring for occult AF is often recommended.

Consider carotid endarterectomy or carotid artery stenting for select patients with stenosis of the carotid arteries, such as those with severe stenosis ipsilateral to a nondisabling stroke or TIA who are candidates for intervention.

Aggressive medical management of risk factors and short-term DAT are preferred as first-line therapy for preventing recurrence in patients with severe intracranial stenosis believed to be the cause of first ischemic stroke or TIA, rather than angioplasty and stenting.

It is reasonable to consider percutaneous closure of patent foramen ovale in selected patients: those with younger age who have nonlacunar stroke or no other cause at any age.

No benefit has been found for empirical treatment with anticoagulants or ticagrelor in patients with embolic stroke of uncertain source.

For more information, please go to Stroke Prevention and Ischemic Stroke.

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