what could a patient do to prevent recurrence of stroke
Recurrent Ischemic Stroke: Strategies for Prevention
Am Fam Doc. 2017 Oct 1;96(7):436-440.
Patient Information: Come across related handout on stroke prevention.
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Article Sections
- Abstract
- Hazard Factors for Recurrent Stroke
- Antithrombotic Therapy
- References
Recurrent strokes make upward almost 25% of the nearly 800,000 strokes that occur annually in the United States. Risk factors for ischemic stroke include hypertension, diabetes mellitus, hyperlipidemia, slumber apnea, and obesity. Lifestyle modifications, including tobacco cessation, decreased alcohol use, and increased concrete activity, are also important in the management of patients with a history of stroke or transient ischemic attack. Antiplatelet therapy is recommended to reduce the risk of recurrent ischemic stroke. The selection of antiplatelet therapy should be based on timing, safety, effectiveness, price, patient characteristics, and patient preference. Aspirin is recommended equally initial handling to prevent recurrent ischemic stroke. Clopidogrel is recommended equally an alternative monotherapy and in patients allergic to aspirin. The combination of clopidogrel and aspirin is non recommended for long-term employ (more than two to three years) considering of increased haemorrhage risk. Aspirin/dipyridamole is at least equally effective as aspirin alone, but information technology is not also tolerated. Warfarin should not be used for prevention of recurrent ischemic stroke.
Stroke is the fifth-leading cause of decease in the United States.1 The full cost of directly stroke-related medical care is projected to ascent from $71.six billion in 2012 to $184.1 billion by 2030.ane Out of the 795,000 strokes each year in the United States, 691,000 are ischemic, and 185,000 are recurrent events.1 The American Heart Association (AHA) and the American Stroke Clan (ASA) define a transient ischemic assault (TIA) equally a transient episode of neurologic dysfunction caused by focal brain, spinal string, or retinal ischemia without acute infarction.2 They define an ischemic stroke as encephalon, spinal cord, or retinal cell death due to ischemia based on neuropathology, neuroimaging, or clinical testify of permanent injury.three
SORT: Central RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Antihypertensive therapy should exist initiated in untreated patients with a recurrent ischemic stroke or TIA who have systolic blood pressure of more than than 140 mm Hg or diastolic claret pressure of more than xc mm Hg several days after the event. | B | 5–vii |
| All patients with ischemic stroke or TIA should be screened for diabetes mellitus using fasting plasma glucose measurement, A1C measurement, or an oral glucose tolerance exam. | C | five |
| High-intensity statin therapy should exist initiated to reduce run a risk of stroke and cardiovascular events in patients with ischemic stroke or TIA presumed to be of atherosclerotic origin. | C | five |
| Patients with an established history of stroke or TIA and whatsoever symptoms of obstructive sleep apnea should undergo polysomnography. | C | 5 |
| Patients who have had a stroke or TIA should be strongly encouraged to quit smoking and avoid secondhand smoke. | C | 5 |
| Patients with a history of stroke or TIA who are capable of concrete activity should be encouraged to participate in at least 120 to 150 minutes per week of moderate- to vigorous-intensity aerobic exercise. | C | 5 |
| In patients with previous stroke or TIA, antiplatelet therapy should be used to reduce the take chances of a recurrent event. | A | five, 28 |
Near one-half of patients who survive an ischemic stroke or TIA are at increased risk of recurrent stroke within a few days or weeks of the initial event, with the greatest take a chance during the first week.4 Patients who have a TIA have a 10-year stroke risk of 19% and a combined x-year take a chance of stroke, myocardial infarction, and vascular decease of 43%.1 Recurrent events atomic number 82 to prolonged hospitalization, worsened functional upshot, and increased mortality.
This article discusses current recommendations for chance factor management and antithrombotic therapy for the prevention of recurrent ischemic stroke based on the AHA/ASA guidelines, with a focus on not-cardioembolic stroke management. Preventing a TIA and preventing an ischemic stroke are as important, and the electric current AHA/ASA guidelines apply to both.5
Risk Factors for Recurrent Stroke
- Abstract
- Gamble Factors for Recurrent Stroke
- Antithrombotic Therapy
- References
HYPERTENSION
Hypertension is a major risk cistron for ischemic stroke, and its treatment can drastically reduce the take a chance of recurrent ischemic stroke.five Ii major trials—PATS (Mail service-stroke Antihypertensive Treatment Written report), which studied a diuretic, and PROGRESS (Perindopril Protection Confronting Recurrent Stroke Written report), which studied an angiotensin-converting enzyme inhibitor alone or in combination with a diuretic—demonstrated that lowering blood pressure level was associated with marked reduction in recurrent stroke risk.6,7
The AHA/ASA guidelines recommend lifestyle interventions, such every bit weight loss, a Mediterranean-fashion diet, reduced sodium intake, regular aerobic physical action, and limited booze consumption, to lower claret pressure.5,eight The guidelines also recommend initiating blood pressure therapy in untreated patients with a recurrent ischemic stroke or TIA who have systolic blood pressure of more 140 mm Hg or diastolic blood pressure of more than 90 mm Hg several days later the event; the do good of starting therapy in patients with lower blood force per unit area is unclear.5 Treatment should be individualized, with a recommended blood force per unit area goal of less than 140 mm Hg systolic or 90 mm Hg diastolic, and the mechanism of action and the patient's medical history (e.chiliad., history of diabetes mellitus, renal disease, or cardiovascular affliction) should be considered. For patients with previous lacunar stroke, the recommended goal is a systolic blood pressure of less than 130 mm Hg.v Current evidence suggests using thiazide diuretics alone or in combination with an angiotensin-converting enzyme inhibitor.5–vii
DIABETES
The AHA/ASA recommends screening all patients with a TIA or ischemic stroke for diabetes using a fasting plasma glucose measurement, A1C measurement, or oral glucose tolerance test and and then following American Diabetes Association guidelines for glycemic control.five There are no trials that look at specific therapies for the secondary prevention of stroke and TIA in patients with diabetes.
HYPERLIPIDEMIA
The 2013 American College of Cardiology/AHA Guideline on the Treatment of Claret Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults focuses on patient hazard instead of specific cholesterol targets.ix Patients with recurrent stroke or TIA presumed to be of atherosclerotic origin, regardless of low-density lipoprotein cholesterol level, should receive high-intensity statin therapy such as atorvastatin (Lipitor), 40 mg or more than, or rosuvastatin (Crestor), 20 mg.5,10,11 This recommendation is based on a meta-analysis of statins vs. placebo that showed that statins reduced the risk of cerebrovascular disease in persons with or without cerebrovascular affliction,12 and on the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial, which demonstrated a lower hazard of recurrent stroke later a contempo stroke or TIA.13 Benefits in patients older than 75 years, including all-crusade bloodshed and primary prevention, have not been established. Because of unclear benefits and possible adverse furnishings and drug-drug interactions, at that place is doubtfulness regarding statin use after 75 years of age.fourteen
Obesity has not been established as a adventure factor for recurrent stroke, fifty-fifty though it is associated with vascular take a chance factors, such as diabetes, hypertension, and hyperlipidemia, and there is a 5% increased risk of first stroke for every 1 kg per thousand2 increase in body mass alphabetize over xx kg per gii.x,15 Recent studies indicate that obese patients with stroke accept a somewhat lower gamble of having another major vascular event (i.e., stroke, myocardial infarction, or vascular expiry) than nonobese patients.sixteen,17 Therefore, the role of weight loss recommendations in obese patients with stroke is uncertain based on the bachelor data.eighteen
OBSTRUCTIVE Slumber APNEA
Polysomnography is recommended for patients with an established history of stroke or TIA and any symptoms of obstructive sleep apnea.5,19 Among patients with previous stroke or TIA, 50% to 75% have sleep apnea, which is oft undiagnosed.5,20 Sleep apnea symptoms may include daytime sleepiness, loud snoring, witnessed animate interruptions, or awakenings because of gasping or choking.19
TOBACCO USE
Cigarette smoking is an independent take a chance gene for kickoff ischemic stroke5,21 and increases the risk of silent brain infarction.22 Exposure to environmental or passive secondhand smoke may also contribute to the risk of stroke.5 Although data are limited, one study showed an increased risk of recurrent stroke in older smokers.23 Patients who have had a stroke or TIA should exist strongly encouraged to quit smoking and avoid secondhand smoke.5
ALCOHOL Utilise
Heavy booze utilize (more than two drinks per day) and binge drinking (more than iv drinks in one sitting) may increase the risk of recurrent stroke.24 Heavy drinkers with a history of stroke or TIA should eliminate or reduce their booze consumption. One or two drinks per day for men and one drink per day for nonpregnant women may exist reasonable for prevention of recurrent stroke.five Non-drinkers who accept had a stroke should not commencement drinking.
Concrete ACTIVITY
Regular physical activity improves stroke risk factors and may too reduce stroke risk itself.5 There are currently ii ongoing trials to help analyze the role of concrete action in the prevention of recurrent stroke.25,26 Patients with a history of stroke or TIA should be encouraged to participate in at least 120 to 150 minutes of aerobic physical activity per week, involving moderate-intensity exercise (e.g., brisk walking) or vigorous-intensity exercise (e.thou., jogging).five Barriers to concrete activeness in patients with stroke may include motor weakness, contradistinct proprioception and residual, and impaired noesis.22 Structured concrete therapy or cardiac rehabilitation should exist considered for those with practice barriers.5
Antithrombotic Therapy
- Abstract
- Risk Factors for Recurrent Stroke
- Antithrombotic Therapy
- References
The AHA/ASA guidelines recommend the apply of anti-platelet agents to reduce the risk of a recurrent event.five Three options are canonical by the U.S. Food and Drug Assistants: aspirin, clopidogrel (Plavix), and aspirin/dipyridamole (Aggrenox).5 The relative risk reduction from antiplatelet therapy for recurrent ischemic stroke is approximately 22%, with a number needed to treat of 28 over 2.5 years.27 The selection of antiplatelet therapy should be based on timing, rubber, effectiveness, cost, patient characteristics, and patient preference (Tabular array 1).28
Tabular array 1.
Comparing of Antithrombotic Agents for the Prevention of Recurrent Ischemic Stroke
| Agent | Safety (percentage of cases) | Tolerability | Effectiveness | Average monthly price* |
|---|---|---|---|---|
| Aspirin | Intracranial hemorrhage (0.49%), major bleeding (0.8%), GI bleeding (3%), possible aspirin allergy | GI upset (17.six%) | Stroke, death: NNT = 22 (vs. placebo) | $1 to $2 |
| Stroke, myocardial infarction, vascular death: NNT = 28 (vs. placebo) | ||||
| Clopidogrel (Plavix) | Intracranial hemorrhage (0.35%), life-threatening bleeding (1%), GI bleeding (2%) | GI upset (15%), diarrhea (4.5%), rash (six%) | Stroke, myocardial infarction, vascular death: NNT = 196 (vs. aspirin) | $145 ($215) |
| Aspirin plus clopidogrel | Major bleeding (two%), life-threatening bleeding (3%), possible aspirin allergy | GI upset, diarrhea, rash | No difference in effectiveness vs. aspirin | See to a higher place |
| Aspirin/dipyridamole (Aggrenox) | Intracranial hemorrhage (0.viii%), extracranial hemorrhage (1.seven%), possible aspirin allergy | Headache (26%), GI upset | Death from all vascular causes, nonfatal stroke: NNT = 33 (vs. aspirin) | $400 ($550) |
ASPIRIN
Aspirin, 50 to 325 mg daily, is recommended for initial therapy to preclude recurrent ischemic stroke. The benefit is similar for any dose, merely the agin effect profiles vary greatly.27,29–33 The major adverse reaction is gastrointestinal bleeding, which increases with increased daily dosing.29,30 Patients taking 325 mg or less daily have a 0.4% annual run a risk of gastrointestinal bleeding.32–35 For patients who take a recurrent stroke during aspirin therapy, in that location is no clear prove that increasing the dose of aspirin decreases the hazard of some other issue.5 Aspirin is the nearly cost-effective therapy option.
CLOPIDOGREL
Clopidogrel monotherapy, 75 mg daily, is recommended for secondary prevention of stroke and tin also be used in patients who are allergic to aspirin.5 Comparison studies show that patients taking clopidogrel monotherapy, aspirin monotherapy, or aspirin/dipyridamole have like rates of recurrent stroke and TIA.5 Clopidogrel is considered to be as safe every bit aspirin with fewer haemorrhage episodes.36
The effectiveness of clopidogrel may be decreased when used with a proton pump inhibitor considering of possible cytochrome P450 2C19 interactions. For patients with concomitant gastroesophageal reflux disease, a histamine H2 blocker or pantoprazole (Protonix) should be used instead of omeprazole (Prilosec) because of its decreased furnishings at CYP2C19.34,36,37
ASPIRIN PLUS CLOPIDOGREL
The Run a risk (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial demonstrated that starting aspirin plus clopidogrel within 24 hours of a minor ischemic stroke or TIA and standing it for up to 21 days may prevent recurrent stroke.38 The aspirin plus clopidogrel combination is not recommended for long-term use (more than two to 3 years) because bleeding chance increases.5 Two trials comparing aspirin plus clopidogrel with each therapy alone did not prove an comeback in recurrent stroke or TIA rates, and the combination increased bleeding events.35,39
ASPIRIN/DIPYRIDAMOLE
Aspirin/dipyridamole, 25 mg/200 mg twice daily, is indicated for initial therapy after TIA or ischemic stroke for recurrent stroke prevention.5,40,41 In ane trial, aspirin/dipyridamole demonstrated a 33% relative risk reduction vs. placebo for stroke or death, with a number needed to treat of 11.twoscore In a 2nd trial, aspirin/dipyridamole demonstrated a 23% relative hazard reduction vs. aspirin monotherapy for stroke.41 When the trials were compared, the combination was at least equally effective as aspirin alone for secondary stroke prevention, but it was non as well tolerated as aspirin monotherapy.5
WARFARIN
Vitamin Chiliad antagonists such as warfarin (Coumadin) are no improve than other antiplatelet therapies with increased bleeding risk, and they are non recommended for prevention of recurrent ischemic stroke.42–44
Data Sources: We searched PubMed, Cochrane Database of Systematic Reviews, U.Due south. Preventive Services Job Strength, and UpToDate. The search included meta-analyses, randomized controlled trials, clinical trials, guidelines, and reviews. The cardinal terms strokes and recurrent were searched with the other primal terms diet, salt reduction, Nuance nutrition, exercise, weight loss, smoking, obstructive sleep apnea, meditation, alcohol use, and supplements. Search dates: September ane, 2016, to January 8, 2017.
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