Population: Patients with DM.
Organization
AHA/ASA 2011
Prevention Recommendations
–HbA1c goal is <6.5%.
–Blood pressure goal is <130/80 mmHg.
–Statin therapy.
–Consider ACE inhibitor or ARB therapy for further stroke risk reduction.
Practice Pearls
• Sixfold increase in stroke in patients with DM. Short-term glycemic control does not lower macrovascular events.
• Strokes and nonfatal strokes are reduced in diabetic patients by lower BP targets (<130/80 mmHg). In the absence of harm, this benefit appears to justify the lower BP goal.
Source
–Stroke. 2011;42:517-584.
Population: Patients with asymptomatic carotid artery stenosis (CAS).
Organizations
USPSTF 2014, AHA/ASA 2014
Prevention Recommendations
–No indication for general screening for CAS with ultrasonography.
–Screen for other stroke risk factors and treat aggressively.
–ASA and statin unless contraindicated.
–Prophylactic carotid endarterectomy (CEA) for patients with high-grade (≥70%) CAS by ultrasonography when performed by surgeons with low (<3%) morbidity/mortality rates may be useful in selected cases depending on life expectancy, age, sex, and comorbidities.
–However, recent studies have demonstrated that “best” medical therapy results in a stroke rate <1%.
Practice Pearl
• The number needed to treat (NNT) in published trials to prevent 1 stroke in 1 y in this asymptomatic group varies from 84 up to 2000. (J Am Coll Cardiol. 2011;57(8):e16-e94)
Sources
–USPSTF. Carotid Artery Stenosis. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
–Neurology. 2011;77:751-758.
–Neurology. 2011;77:744-750.
–Stroke. 2011;42:517-584.
–Stroke. 2014;45:3754-3832.
Population: Patients with symptomatic CAS.
Organizations
ASA/ACCF/AHA/AANN/AANS/ACR/CNS 2011
Prevention Recommendations
–Optimal timing for CEA is within 2 wk posttransient ischemic attack.
–CEA plus medical therapy is effective within 6 mo of symptom onset with ≥70% CAS.
–Intense medical therapy alone is indicated if the occlusion is <50%.
–Intensive medical therapy plus CEA may be considered with obstruction 50%–69%.
–Limit surgery to male patients with a low perioperative stroke/death rate (<6%) and should have a life expectancy of at least 5 y.
Practice Pearls
• Treat asymptomatic CAS aggressively.
• Individualize surgical intervention, guided by comparing comorbid medical conditions and life expectancy to the surgical morbidity and mortality.
• Atherosclerotic intracranial stenosis: Use ASA in preference to warfarin.
• Warfarin—significantly higher rates of adverse events with no benefit over ASA. (N Engl J Med. 2005;352(13):1305-1316)
• Qualitative findings (embolic signals and plaque ulceration) may identify patients who would benefit from asymptomatic CEA.
Sources
–J Am Coll Cardiol. 2011;57(8):1002-1038.
–Neurology. 2005;65(6):794-801.
–Arch Intern Med. 2011;171(20):1794-1795.
–Stroke. 2011;42:227-276, 517-584.
Population: Patients with cryptogenic CVA.
Organizations
ASA/ACCF/AHA/AANN/AANS/ACR/CNS 2011
Prevention Recommendations
–Carotid artery stenting is associated with increased nonfatal stroke frequency but this is offset by decreased risk of MI post-CEA.
–Treat patients who have had cryptogenic CVA with patent foramen ovale (PFO) with ASA 81 mg/d.
Practice Pearls
• Consider referral to tertiary center for enrollment in randomized trial to determine optimal Rx.
• Closure I trial demonstrated no benefit at 2 y of PFO closure device over medical therapy.
• In 2013, the PC Trial also failed to demonstrate significant benefit in reducing recurrent embolic events in patients undergoing PFO closure compared to medical therapy, at 4 y follow-up.
Sources
–J Am Coll Cardiol. 2011;57(8):1002-1044.
–J Am Coll Cardiol. 2009;53(21):2014-2018.
–N Engl J Med. 2012;366:991-999.
–N Engl J Med. 2013;368:1083-1091.
Population: Patients with sickle cell disease.
Organizations
ASA/ACCF/AHA/AANN/AANS/ACR/CNS 2011
Prevention Recommendations
–Transfusion therapy (target reduction of hemoglobin S from a baseline of ≥90% to <30%) is effective for reducing stroke risk in those children at elevated stroke risk.
–Begin screening with transcranial Doppler (TCD) at age 2 y.
–Use transfusion therapy for patients at high-stroke risk per TCD (high cerebral blood flow velocity ≥200 cm/s).
–Frequency of screening not determined.
Sources
–J Am Coll Cardiol. 2011;57(8):1002-1044.
–ASH Education Book. 2013;2013(1):439-446.
Population: Women interested in primary prevention of stroke.
Organization
ACC/ASA 2014
Prevention Recommendations
–Higher lifetime risk, third leading cause of death in women, 53.5% of new recurrent strokes occur in women.
–Sex-specific risk factors: pregnancy, preeclampsia, gestational diabetes, oral contraceptive (OC) use, postmenopausal hormone use, changes in hormonal status.
–Risk factors with a stronger prevalence in women: migraine with aura, atrial fibrillation (AF), diabetes, hypertension, depression, psychosocial stress.
Source
–Circulation. 2011;123:1243-1262.
Population: Women who use oral contraceptives or postmenopausal hormone therapy.
Organization
ACC/ASA 2014
Prevention Recommendations
–Stroke risk with low-dose OC users is about 1.4–2 times that of non-OC users.
–Measure BP prior to initiation of hormonal contraception therapy.
–Routine screening for prothrombotic mutations prior to initiation of hormonal contraception is not useful.
–Among OC users, aggressive therapy of stroke risk factors may be reasonable.
–Hormone therapy (conjugated equine estrogen with or without medroxyprogesterone) should not be used for primary or secondary prevention of stroke in postmenopausal women.
–Selective estrogen receptor modulators, such as raloxifene, tamoxifen, or tibolone, should not be used for primary prevention of stroke.
Source
–Stroke. 2014;45:1545-1588.