II. Indications

  1. Post-stroke antithrombotic therapy
  2. Atrial Fibrillation
    1. See Atrial Fibrillation Anticoagulation

III. Management: Short term prevention after Ischemic Stroke

  1. Aspirin (first choice)
    1. Dose 81 to 325 mg daily indefinately
    2. CVA reduction of 1% with Aspirin by IST trial
    3. Effective in acute CVA therapy as well as prevention
  2. Aspirin and Clopidogrel (first 3 weeks)
    1. Indicated immediately following mild ischemic Cerebrovascular Accident (CVA) or Transient Ischemic Attack (TIA)
    2. Protocol
      1. Combination protocol for 3 weeks
        1. Aspirin 81 mg daily and
        2. Clopidogrel 75 mg daily
      2. After 3 weeks
        1. Discontinue Clopidogrel
        2. Continue Aspirin indefinately as above
    3. Efficacy
      1. Decreases risk of recurrent TIA or CVA in short term (NNT 29 compared with Aspirin alone)
      2. Not effective long-term (and should not be used for this due to increased bleeding risk) - see below
    4. References
      1. Wang (2013) N Engl J Med 369(1):11-9 [PubMed]
  3. Low dose non-bolus Heparin (use is variable)
    1. Efficacy
      1. No evidence of benefit in CVA evolution
      2. Less Hemorrhage than ASA by IST trial
      3. CVA reduction 1-2%
      4. Not indicated in most cases (risk without benefit)
        1. Stead (2004) Ann Emerg Med 44:540-2 [PubMed]
    2. Dosing: Goal is PTT approximately twice normal
      1. Dose: 12 u/kg/h (NO bolus, by actual weight)
    3. Indications
      1. Cardioembolic CVA
      2. Aortic arch atheroma
    4. Contraindications
      1. CT Head shows bleeding
      2. Endocarditis on native valve thromboembolic CVA
  4. Antihypertensives
    1. See below regarding precautions (do not lower BP on first day) and management strategies
    2. See CVA Blood Pressure Control for acute control
    3. ACE Inhibitor with a Diuretic (e.g. Lisinopril/hctz)
      1. Start immediately after hyperacute period
      2. Significantly reduces recurrent CVA risk
        1. (2001) Lancet 358:1033-41 [PubMed]
  5. Avoid potentially harmful interventions
    1. Heparin drip (Regular dose): Do Not Use
      1. No significant benefit by IST trial
      2. Risk of Hemorrhage (especially with bolus)
    2. Low Molecular Weight Heparin
      1. Dose dependent CVA reduction by Hong Kong Study
      2. No benefit and high Hemorrhage risk by TOAST study
    3. Emergent Anticoagulation not indicated
      1. Recurrent stroke in first 14 days is only 0.06%
      2. Can start in first 48 hours after CVA
      3. Bolus therapy is not indicated
    4. Do not lower Blood Pressure aggressively on first day
      1. See CVA Blood Pressure Control
    5. Ibuprofen
      1. Inactivates Aspirin positive effect
      2. Unclear if other NSAIDs also reduce Aspirin benefit

IV. Management: Long term prevention (Primary and Secondary Prevention)

  1. Evaluate for reversible and modifiable disease
    1. See Transient Ischemic Attack
    2. Carotid Endarterectomy
      1. See Carotid Stenosis for indications
      2. Typically carotid endarterectomy is recommended for Carotid Stenosis >70%
      3. Indications depend on patient perioperative risk, comorbidity, age and symptoms
    3. Evaluate for arrhythmia (e.g. Atrial Fibrillation)
    4. Treat Coronary Artery Disease
    5. Optimize Diabetes Mellitus control
      1. Maintain Blood Pressure <130/80 (most important)
      2. Maintain Fasting Glucose <126 mg/dl (Hemoglobin A1C <7)
    6. Manage Major Depression (up to 20% of patients after stroke)
      1. Screen for and treat comorbid Major Depression
      2. Reduces mortality after Ischemic Stroke
      3. Consider Selective Serotonin Reuptake Inhibitor
      4. Jorge (2003) Am J Psychiatry 160:1823-9 [PubMed]
  2. Antiplatelet agents after CVA or TIA
    1. See Anticoagulation in Atrial Fibrillation
    2. First-Line options
      1. Background: Agent comparison
        1. Aspirin alone offers 18-22% Relative Risk Reduction of subsequent stroke or TIA
        2. Aggrenox or Plavix each offer a 37% Relative Risk Reduction of subsequent stroke or TIA
      2. Aspirin 81 to 325 mg daily
        1. Use concurrently with PPI if history of GI Bleeding on Aspirin
      3. Clopidogrel (Plavix) 75 mg daily
        1. Indicated if Aspirin intolerant or high risk
        2. Equivalent to Aggrenox in cerebrovascular event risk reduction
        3. Slightly lower risk of GI Bleeding than with Aggrenox
      4. Aspirin 50 mg with Dipyridamole 400 mg (Aggrenox)
        1. Consider over Aspirin in highest risk patients (TIA or CVA on Aspirin)
        2. Better efficacy over Aspirin alone (and similar to reduction with Plavix)
        3. Minimal increased risk of bleeding
        4. Poorly tolerated (stopped due to Headache in 25%) and twice daily
        5. Expensive! ($320 versus Aspirin $1 or Clopidogrel $10 per month)
        6. References
          1. Diener (1996) J Neurol Sci 143:1-13 [PubMed]
          2. Halkes (2006) Lancet 367:1665-73 [PubMed]
    3. Avoid Warfarin (Coumadin) after nonembolic stroke
      1. No advantage over Aspirin to prevent recurrent CVA
      2. Warfarin is indicated in thromboembolic stroke
      3. Mohr (2001) N Engl J Med 345:1444-51 [PubMed]
    4. Avoid combination of Aspirin and Clopidogrel longterm (aside from 3 week acute course)
      1. Bleeding risk outweighed small vascular benefit
        1. Diener (2004) Lancet 364:331-7 [PubMed]
      2. However consider for first 3 weeks following mild CVA or TIA
        1. See above (under short-term)
  3. Other measures
    1. Tobacco Cessation
      1. Single most effective measure in CVA Prevention
      2. Risk of CVA is 50% higher in smokers
      3. Shinton (1999) BMJ 298:789-94 [PubMed]
    2. Control Hyperlipidemia
      1. Statin Drugs are preferred (e.g. Simvastatin, Atorvastatin)
      2. Goal LDL Cholesterol <70-100 mg/dl
    3. Control Hypertension to Blood Pressure <130/80 (after initial 24 hours)
      1. Systolic Blood Pressure as a predictor of subsequent stroke (hazard ratios)
        1. Maximum systolic Blood Pressure: Hazard Ratio 15
        2. High variability in systolic Blood Pressure: Hazard Ratio 6
        3. Rothwell (2010) Lancet 375(9718): 895-905 [PubMed]
      2. Interventions
        1. See DASH Diet
        2. Hydrochlorothiazide (first line)
        3. ACE Inhibitors (in combination with Diuretic)
        4. Calcium Channel Blockers may lower Blood Pressure lability
    4. Alcohol only in moderation
    5. Maintain regular Exercise >30 minutes, >3 days/week
      1. High intensity Exercise is associated with a 64% CVA Relative Risk Reduction
      2. Lee (2003) Stroke 34(10): 2475-81 [PubMed]
    6. Fish intake (1-4 servings per month)
      1. Lowered Ischemic Stroke risk by 40%
      2. He (2002) JAMA 288:3130-6 [PubMed]
    7. Mediterranean Diet
      1. Fung (2009) Circulation 119(8): 1093-1100 [PubMed]
    8. Weight loss
      1. Increased waist to hip ratio (Apple Obesity) is associated with an increased CVA risk (OR 1.65)
  4. Ineffective measures
    1. Homocysteine modification with Vitamins not effective
      1. Toole (2004) JAMA 291:565-75 [PubMed]

VI.

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Stroke prevention (C1277289)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 367285008, 367056007, 135875009
English cva prevention, preventions stroke, prevention stroke, prevention strokes, stroke prevention, CVA prevention, Stroke prevention (procedure), Stroke prevention
Spanish prevención de la apoplejía, prevención del ACV, prevención del accidente cerebrovascular (procedimiento), prevención del accidente cerebrovascular, prevención del ictus