2021 Guideline for the Secondary Prevention of Stroke

The 2021 secondary stroke prevention guideline from the American Heart Association/American Stroke Association: 1. Recommendations for the diagnostic workup to define ischemic stroke etiology. 2. Management of vascular risk factors remains extremely important, including (but not limited to) diabetes, smoking cessation, lipids, and especially hypertension. 3. Lifestyle factors: Low-salt and Mediterranean diets are recommended. Physical activity in a supervised and safe manner should be encouraged. 4. Programs that use theoretical models of behavior change, proven techniques, and multidisciplinary support are needed. 5. Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all patients without contraindications. With very few exceptions, the combination of antiplatelets and anticoagulation is typically not indicated for secondary stroke prevention. Dual antiplatelet therapy is not recommended long term, and short term, dual antiplatelet therapy is recommended only in very specific patients, including those with early arriving minor stroke and high-risk transient ischemic attack or severe symptomatic intracranial stenosis. 6. Anticoagulation is usually recommended for atrial fibrillation patient if no contraindications. Heart rhythm monitoring for occult atrial fibrillation is usually recommended if no other cause of stroke is discovered. 7. Patients with severe extracranial carotid artery stenosis ipsilateral to a nondisabling stroke or transient ischemic attack who are candidates for intervention should have the stenosis fixed, likely relatively early after their ischemic stroke. 8. Aggressive medical management of risk factors and short-term dual antiplatelet therapy are preferred for patients with severe intracranial stenosis in the vascular territory of ischemic stroke or transient ischemic attack, but not angioplasty and stenting. 9. It is considered reasonable to close patent foramen ovale percutaneously in patients with younger age with nonlacunar stroke or no other cause at any age. 10. Patients with embolic stroke of uncertain source should not be treated empirically with anticoagulants or ticagrelor. Source: https://www.ahajournals.org/