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The American Heart Association/American Stroke Association have updated the guidelines for secondary prevention in patients with stroke or transient ischemic attack (TIA).

Last updated in 2011, the document -- penned by a writing group chaired by , of Yale University -- includes new sections on nutrition and sleep apnea and revisions of several other sections, including those dealing with hypertension, dyslipidemia, diabetes, carotid stenosis, and atrial fibrillation.

In addition, "recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy," the authors wrote in the guideline, which was published online in .

The guidance on secondary prevention for patients with stroke or TIA is updated every few years to keep pace with the most current research into maintaining a low risk of recurrent events, which currently stands at 3% to 4% per year.

"This represents a historic low," Kernan told 麻豆传媒. "However, it's low because of very careful attention to science-based interventions for secondary prevention. These scientific developments in the area of secondary prevention are very rapidly accumulating; therefore, the guidelines need to be rapidly updated approximately every 3 to 4 years."

To make it easy for healthcare professionals to know what's new in the document, the authors included a table detailing the major additions and revisions.

Hypertension leads the list of major risk factors, and clarifications were made to that section regarding when to initiate or resume antihypertensive therapy in these patients. Blood pressure-lowering therapy should be started in previously untreated patients with a blood pressure of 140/90 mm Hg or higher after the first several days following an ischemic stroke or TIA, according to the authors.

The dyslipidemia section also was revised to be consistent with the cholesterol guideline that was part of the suite of prevention guidelines released by the American College of Cardiology and American Heart Association last fall. Recommendations regarding the use of niacin or gemfibrozil were removed.

Greater emphasis was placed in the updated guidelines on lifestyle factors, including diet, exercise, and weight management.

The importance of what people put into their bodies was underscored with a new nutrition section, which included the following recommendations:

• It is reasonable to conduct a nutritional assessment to look for signs of overnutrition or undernutrition; those with signs of undernutrition should be referred for nutritional counseling.
• The use of routine supplementation with a single vitamin or vitamin combinations is not recommended.
• It is reasonable to recommend reduction of sodium intake to less than 2.4 grams per day, or even lower to less than 1.5 grams per day.
• It also is reasonable to recommend adherence to a Mediterranean-type diet that includes vegetables, fruits, whole grains, low-fat dairy, poultry, fish, legumes, olive oil, and nuts, and limits sweets and red meats.

The authors made major revisions to the sections on carotid stenosis, atrial fibrillation, and prosthetic heart valves "in a manner that is consistent with recently published American Heart Association and American College of Chest Physicians (ACCP) guidelines."

In terms of carotid stenosis, there is a new recommendation stating that it is reasonable to consider age when choosing between carotid artery stenting or carotid endarterectomy based on data showing that surgery might be better than stenting for patients older than about 70, but that the two approaches have similar benefits in younger patients.

The authors also made extensive changes to the section on intracranial atherosclerosis, with two new class III recommendations:

• Angioplasty or stenting is not recommended for patients with a stroke or TIA related to moderate stenosis (50% to 69%) of a major intracranial artery.
• The Wingspan stent system is not recommended as an initial treatment for patients with an event related to severe stenosis (70% to 99%) of a major intracranial artery.

Another change from the 2011 guidance is a greater appreciation for the impact of clinically silent brain infarctions, which can be detected on brain imaging and "are associated with typical risk factors for ischemic stroke, increased risk for future ischemic stroke, and unrecognized neurological signs in the absence of symptoms," the authors wrote.

"Clinicians who diagnose silent infarction routinely ask whether this diagnosis warrants implementation of secondary prevention measures," they wrote. "The writing committee, therefore, identified silent infarction as an important and emerging issue in secondary stroke prevention."

Some of the other changes found in the document include the following:

• A recommendation stating that all patients should probably be screened for diabetes with tests of fasting plasma glucose, glycated hemoglobin (HbA1c), or oral glucose tolerance.
• An expansion of the section on diabetes to include information on pre-diabetes.
• A recommendation to screen all patients for obesity using body mass index.
• A recommendation stating that a sleep study might be considered to detect sleep apnea because of the high prevalence of the disorder in patients with stroke or TIA.
• A recommendation that 30-day monitoring for atrial fibrillation in patients who had a stroke of unknown cause is reasonable within 6 months of the event.
• Addition of new class I recommendations for the use of apixaban (Eliquis) and dabigatran (Pradaxa) to prevent recurrent strokes in patients with nonvalvular atrial fibrillation as alternatives to warfarin. Rivaroxaban (Xarelto) received a class II recommendation.
• A stronger recommendation against the use of closure of a patent foramen ovale with a transcatheter device in patients with a cryptogenic ischemic stroke or TIA and a lack of evidence for deep venous thrombosis.
• Removal of the section on Fabry disease because of the "rarity and specialized nature of this condition."

The guidance was endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The American Academy of Neurology "affirms the value of this guideline as an educational tool for neurologists."

From the American Heart Association:

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