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

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Furie et al Prevention of Stroke in Patients With Stroke and TIA 2335-year absolute reduction in risk of major cardiovascularevents was 3.5% (HR, 0.80; 95% CI, 0.69 to 0.92; P0.002).Statin therapy was generally well tolerated, with a mildlyincreased rate of elevated liver enzymes and elevation ofcreatine kinase but no cases of liver failure nor significantexcess in cases of myopathy, myalgia, or rhabdomyolysis. 55There was a higher incidence of hemorrhagic stroke in theatorvastatin treatment arm (n55 [2.3%] for active treatmentversus n33 [1.4%] for placebo; HR, 1.66; 95% CI, 1.08 to2.55) but no difference in the incidence of fatal hemorrhagicstroke between the groups (17 in the atorvastatin group and18 in the placebo group). 55The SPARCL results may understate the magnitude of thetrue treatment effect in fully compliant patients because ofhigh rates of discontinuation of assigned therapy and crossoversto open-label, nonstudy statin therapy in the placebogroup. A prespecified on-treatment analysis of 4162 patientsrevealed an 18% relative reduction in risk of stroke in theatorvastatin treatment group versus controls (HR, 0.82; 95%CI, 0.69 to 0.98; P0.03). 56On the basis of SPARCL, the number needed to treat(NNT) to prevent a first recurrent stroke over 1 year is 258;to prevent 1 nonfatal MI, the NNT is 288. Despite theexclusion of subjects with CHD from the trial, the reductionof various CHD events surpassed that of stroke events,suggesting that asymptomatic CHD is often a comorbidcondition in stroke patients even in the absence of a medicalhistory of CHD. SPARCL assessed the benefits and risksassociated with achieving a degree of LDL-C lowering andnational guideline–recommended nominal targets. Patientswith 50% reduction in LDL-C had a 35% reduction incombined risk of nonfatal and fatal stroke. Although ischemicstrokes were reduced by 37% (HR, 0.63; 95% CI, 0.49 to0.81), there was no increase in hemorrhagic stroke (HR, 1.02;95% CI, 0.60 to 1.75). Achieving an LDL-C level of 70mg/dL was associated with a 28% reduction in risk of stroke(HR, 0.72; 95% CI, 0.59 to 0.89; P0.0018) without anincrease in risk of hemorrhagic stroke (HR, 1.28; 95% CI,0.78 to 2.09; P0.3358), but again the confidence intervalsaround the latter point estimate were wide. 57 A post hocanalysis of the small number of ICHs in SPARCL (n55 foractive treatment versus n33 for placebo) found an increasedrisk of hemorrhagic stroke associated with hemorrhagic stroke asthe entry event (HR, 5.65; 95% CI, 2.82 to 11.30, P0.001),male sex (HR, 1.79, 95% CI, 1.13 to 2.84, P0.01), age(10-year increments; HR, 1.42; 95% CI, 1.16 to 1.74, P0.001),and having stage 2 (JNC 7) hypertension at the last study visit(HR, 6.19; 95% CI, 1.47 to 26.11, P0.01). 58The National Cholesterol Education Program (NCEP) ExpertPanel on Detection, Evaluation, and Treatment of HighCholesterol in Adults (Adult Treatment Panel III [ATP III]) isthe most comprehensive guide for management of dyslipidemiain persons with or at risk for vascular disease, includingstroke. 59,60 The NCEP recommends LDL-C lowering as theprimary lipid target. Therapeutic lifestyle modification emphasizesa reduction in saturated fat and cholesterol intake,weight reduction to achieve ideal body weight, and a boost inphysical activity. LDL-C goals and cutpoints for implementingtherapeutic lifestyle change and drug therapy are based on3 categories of risk: CHD and CHD risk equivalents (the lattercategory includes diabetes and symptomatic carotid artery disease),2 cardiovascular risk factors stratified by 10-year risk of10% to 20% for CHD and 10% for CHD according to theFramingham risk score, and 0 to 1 cardiovascular risk factor. 59When there is a history of CHD and CHD risk equivalents, thetarget LDL-C goal is 100 mg/dL. Drug therapy options andmanagement of other dyslipidemias are addressed in the NCEPguideline. LDL-C lowering results in a reduction of totalmortality, coronary mortality, major coronary events, coronaryprocedures, and stroke in persons with CHD. 59Other medications used to treat dyslipidemia include niacin,fibrates, and cholesterol absorption inhibitors. Theseagents can be used by stroke or TIA patients who cannottolerate statins, but data demonstrating their efficacy forprevention of stroke recurrence are sparse. Niacin has beenassociated with a reduction in cerebrovascular events, 61whereas gemfibrozil reduced the rate of unadjudicated totalstrokes among men with coronary artery disease and lowlevels of HDL-C (40 mg/dL) in the Veterans Affairs HDLIntervention Trial (VA-HIT), but the latter result lost significancewhen adjudicated events alone were analyzed. 62Recommendations1. Statin therapy with intensive lipid-lowering effects isrecommended to reduce risk of stroke and cardiovascularevents among patients with ischemic strokeor TIA who have evidence of atherosclerosis, anLDL-C level >100 mg/dL, and who are withoutknown CHD (Class I; Level of Evidence B).2. For patients with atherosclerotic ischemic stroke orTIA and without known CHD, it is reasonable to targeta reduction of at least 50% in LDL-C or a target LDL-Clevel of
234 Stroke January 2011Table 4.Recommendations for Modifiable Behavioral Risk FactorsRisk FactorCigarette smokingAlcohol consumptionRecommendationsHealthcare providers should strongly advise every patient with stroke or TIA who has smoked in the pastyear to quit (Class I; Level of Evidence C).It is reasonable to avoid environmental (passive) tobacco smoke (Class IIa; Level of Evidence C).Counseling, nicotine products, and oral smoking cessation medications are effective for helping smokers toquit (Class I; Level of Evidence A).Patients with ischemic stroke or TIA who are heavy drinkers should eliminate or reduce their consumption ofalcohol (Class I; Level of Evidence C).Light to moderate levels of alcohol consumption (no more than 2 drinks per day for men and 1 drink per dayfor nonpregnant women) may be reasonable; nondrinkers should not be counseled to start drinking (ClassIIb; Level of Evidence B).Physical activity For patients with ischemic stroke or TIA who are capable of engaging in physical activity, at least 30minutes of moderate-intensity physical exercise, typically defined as vigorous activity sufficient to break asweat or noticeably raise heart rate, 1 to 3 times a week (eg, walking briskly, using an exercise bicycle)may be considered to reduce risk factors and comorbid conditions that increase the likelihood of recurrentstroke (Class IIb; Level of Evidence C).For those individuals with a disability following ischemic stroke, supervision by a healthcare professional,such as a physical therapist or cardiac rehabilitation professional, at least on initiation of an exerciseregimen, may be considered (Class IIb; Level of Evidence C).Metabolic syndrome At this time, the utility of screening patients for the metabolic syndrome after stroke has not beenestablished (Class IIb; Level of Evidence C). (New recommendation)For patients who are screened and classified as having the metabolic syndrome, management should includecounseling for lifestyle modification (diet, exercise, and weight loss) for vascular risk reduction (Class I;Level of Evidence C). (New recommendation)Preventive care for patients with the metabolic syndrome should include appropriate treatment for individualcomponents of the syndrome that are also stroke risk factors, particularly dyslipidemia and hypertension(Class I; Level of Evidence A). (New recommendation)*See Tables 1 and 2 for explanation of class and level of evidence.Class/Level ofEvidence*Class I; Level CClass IIa; Level CClass I; Level AClass I; Level CClass IIb; Level BClass IIb; Level CClass IIb; Level CClass IIb; Level CClass I; Level CClass I; Level ARecommendations1. Healthcare providers should strongly advise everypatient with stroke or TIA who has smoked in thepast year to quit (Class I; Level of Evidence C).2. It is reasonable to avoid environmental (passive)tobacco smoke (Class IIa; Level of Evidence C).3. Counseling, nicotine products, and oral smokingcessation medications are effective for helping smokersquit (Class I; Level of Evidence A) (Table 4).E. Alcohol ConsumptionThere is strong evidence that chronic alcoholism and heavydrinking are risk factors for all stroke subtypes. 82–86 Studieshave demonstrated an association between alcohol and ischemicstroke, ranging from a definite independent effect to noeffect. Most studies have suggested a J-shaped associationbetween alcohol and ischemic stroke, with a protective effectfrom light or moderate consumption and an elevated risk ofstroke with heavy consumption of alcohol. 82,83,87–96The majority of the data on the risk of alcohol are relatedto primary prevention, which is discussed extensively in theAHA/ASA guideline statement on primary prevention ofischemic stroke. 13Few studies have evaluated the association between alcoholconsumption and recurrent stroke. Stroke recurrence was significantlyincreased among ischemic stroke patients with priorheavy alcohol use in the Northern Manhattan cohort. 89 Nostudies have demonstrated that reduction of alcohol intakedecreases risk of recurrent stroke. The mechanism for reducedrisk of ischemic stroke with light to moderate alcohol consumptionmay be related to an increase in HDL, 97,98 a decrease inplatelet aggregation, 99,100 and a lower concentration of plasmafibrinogen. 101,102 The mechanism of risk in heavy alcohol usersincludes alcohol-induced hypertension, hypercoagulable state,reduced cerebral blood flow, and AF or cardioembolism due tocardiomyopathy. 83,89,103 In addition, alcohol consumption has beenassociated with insulin resistance and the metabolic syndrome. 104It is well established that alcohol can cause dependenceand that alcoholism is a major public health problem. Whenadvising a patient about behaviors to reduce risk of recurrentstroke, clinicians should consider the interrelationship betweenother risk factors and alcohol consumption. Nondrinkersshould not be counseled to start drinking. A primary goalfor secondary stroke prevention is to eliminate or reducealcohol consumption in heavy drinkers through establishedscreening and counseling methods as outlined in the USPreventive Services Task Force Update 2004. 105Recommendations1. Patients with ischemic stroke or TIA who are heavydrinkers should eliminate or reduce their consumptionof alcohol (Class I; Level of Evidence C).2. Light to moderate levels of alcohol consumption (nomore than 2 drinks per day for men and 1 drink perday for women who are not pregnant) may be reasonable;nondrinkers should not be counseled to startdrinking (Class IIb; Level of Evidence B) (Table 4).Downloaded from stroke.ahajournals.org by on March 8, 2011
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