AHA/ASA Guideline Guidelines for the Prevention of Stroke in ...

252 Stroke January 2011Table 10.ContinuedRisk FactorPostmenopausalhormone replacementtherapyUse of anticoagulationafter intracranialhemorrhageSpecial approaches toimplementingguidelines and theiruse in high-riskpopulationsRecommendationsFor women who have had ischemic stroke or TIA, postmenopausal hormone therapy (with estrogen with orwithout a progestin) is not recommended (Class III; Level of Evidence A).For patients who develop ICH, SAH, or SDH, it is reasonable to discontinue all anticoagulants and antiplateletsduring the acute period for at least 1 to 2 weeks and reverse any warfarin effect with fresh frozen plasmaor prothrombin complex concentrate and vitamin K immediately (Class IIa; Level of Evidence B).Protamine sulfate should be used to reverse heparin-associated ICH, with the dose depending on the timefrom cessation of heparin (Class I; Level of Evidence B). (New recommendation)The decision to restart antithrombotic therapy after ICH related to antithrombotic therapy depends on the riskof subsequent arterial or venous thromboembolism, risk of recurrent ICH, and overall status of the patient.For patients with a comparatively lower risk of cerebral infarction (eg, AF without prior ischemic stroke)and a higher risk of amyloid angiopathy (eg, elderly patients with lobar ICH) or with very poor overallneurological function, an antiplatelet agent may be considered for prevention of ischemic stroke. In patientswith a very high risk of thromboembolism in whom restarting warfarin is considered, it may be reasonableto restart warfarin at 7 to 10 days after onset of the original ICH (Class IIb; Level of Evidence B). (Newrecommendation)For patients with hemorrhagic cerebral infarction, it may be reasonable to continue anticoagulation, dependingon the specific clinical scenario and underlying indication for anticoagulant therapy (Class IIb; Level ofEvidence C).It can be beneficial to embed strategies for implementation within the process of guideline development anddistribution to improve utilization of the recommendations (Class IIa; Level of Evidence B). (Newrecommendation)Intervention strategies can be useful to address economic and geographic barriers to achieving compliancewith guidelines and to emphasize the need for improved access to care for the aged, underserved, andhigh-risk ethnic populations (Class IIa; Level of Evidence B). (New recommendation)Class/Level ofEvidence*Class III; Level AClass IIa; Level BClass I; Level BClass IIb; Level BClass IIb; Level CClass IIa; Level BClass IIa; Level BAPL indicates antiphospholipid; CVT, cerebral venous thrombosis; DVT, deep vein thrombosis; SCD, sickle cell disease; SDH, subdural hematoma; and UFH,unfractionated heparin.*See Tables 1 and 2 for explanation of class and level of evidence.size or presence of atrial septal aneurysm. No differences(HR, 1.17; P0.65) were seen in outcome in patients withcryptogenic stroke and PFO between those treated withaspirin (2-year event rates, 13.2%) versus warfarin (16.5%).Although these data are from a randomized clinical trial, thissubstudy was not designed specifically to test the superiorityof one medical treatment in this subset. 356In contrast, the European PFO-ASA study reported by Maset al 357 in 2002 reported recurrence rates of stroke on 4-yearfollow-up of 581 stroke patients with stroke of unknowncause. The patients were 18 to 55 years of age, and all weretreated with 300 mg of aspirin. The rate of recurrence was2.3% (0.3 to 4.3) in those with PFO alone, 15.2% (1.8 to 28.6)in patients with PFO and atrial septal aneurysm, and 4.2%(1.8 to 6.6) in patients with neither cardiac finding. Theimportance of PFO with or without atrial septal aneurysm andits optimal treatment remain in question. 357 Three largeprospective studies have examined the risk of first stroke withPFO and cast doubt on the strength of the relationshipbetween PFO and stroke risk. 13,252,352,354More recently, Handke et al 358 examined 503 consecutivepatients with stroke, including 227 patients with cryptogenicstroke and 276 patients with stroke of known cause. TEE wasperformed after stroke classification. PFO was detected moreoften in cryptogenic stroke for both younger patients (43.9%versus 14%; OR, 4.7; 95% CI, 1.89 to 11.68; P0.001) andolder patients (28.3% versus 11.9%; OR, 2.92; 95% CI, 1.70to 5.01; P0.001). An atrial septal aneurysm was presentwith a PFO in 13.4% versus 2.0% of younger patients(cryptogenic versus known; OR, 7.36; 95% CI, 1.01 to 326)and in older patients (15.2% versus 4.4%; OR, 3.88; 95% CI,1.78 to 8.49; P0.001). 358 The Prospective Spanish Multicenter(CODICIA) Study examined 486 patients with cryptogenicstoke and quantified the magnitude of right-to-leftshunt using contrast transcranial Doppler ultrasonography.Massive right-to-left shunt was detected in 200 patients(41%). Stroke recurrence was low (5.8%) and was notassociated with the degree of the shunt. 359Given these data, overall, the importance of PFO with orwithout atrial septal aneurysm for a first stroke or recurrentcryptogenic stroke remains in question. No randomizedcontrolled clinical trials comparing different medical therapies,medical versus surgical closure, or medical versustranscatheter closure have been reported, although severalstudies are ongoing. Nonrandomized comparisons of variousclosure techniques with medical therapy have generallyshown reasonable complication rates and recurrence riskwith closure at or below those reported with medicaltherapy. 360–370 One study suggested a particular benefit inpatients with 1 stroke at baseline. 370In summary, these studies provide new information onoptions for closure of PFO and generally indicate thatshort-term complications with these procedures are rare andfor the most part minor. Unfortunately, long-term follow-upis lacking. Event rates over 1 to 2 years after transcatheterclosure ranged from 0% to 3.4%. Studies in which closureDownloaded from stroke.ahajournals.org by on March 8, 2011