New guidelines address how to prevent a second stroke, TIA

Stroke Journal Report01/25/2006
New guidelines address how to prevent a second stroke, TIA
American Heart Association Scientific Statement:
DALLAS, Jan 25 – The greatest threat a stroke or transient ischemic attack (TIA) survivor faces is another stroke.
That’s the conclusion of the American Heart Association/American Stroke Association in its “Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack.”
Published in Stroke: Journal of the American Heart Association, these guidelines are the association’s most comprehensive recommendations for preventing recurrent strokes and “mini-strokes.”
Almost a third of the estimated 700,000 strokes that occur each year in the United States are recurrent strokes, said Ralph L. Sacco, M.D., M.S. The risk of another stroke among stroke and TIA survivors is as high as 40 percent within five years.
“Due to the aging U.S. population and other changing sociodemographics, the number of new and recurrent strokes is projected to increase to nearly 1 million annually by the year 2050,” said Sacco, chair of the American Stroke Association’s Stroke Advisory Board and of the associations’ Secondary Stroke Prevention Guidelines Committee.
“The most frequent event that threatens a stroke survivor's quality of life is another stroke, which can cause further disability or death,” he said.
New Guidelines Represent Major Changes in Stroke Treatment
These guidelines make a significant shift from earlier guidelines by strongly suggesting that stroke and transient ischemic attack TIA known as “mini-stroke” be treated interchangeably, Sacco said. TIA is a temporary disturbance in the brain that causes stroke-like symptoms without causing permanent injury.
“Both conditions increase the risk of a subsequent stroke and both require similar diagnostic work-ups and treatment,” said Sacco, who is associate chairman of neurology and professor of neurology and epidemiology at Columbia University Medical Center in New York. He is also director of the Stroke and Critical Care Division at New York-Presbyterian Hospital/Columbia in New York.
“Other documents have split the two conditions out, but we are treating TIA just as seriously as a stroke. For the last few years, we’ve been trying to get both the public and healthcare professionals to treat TIA as aggressively as stroke.”
The writing committee reviewed medical literature on recurrent stroke including analysis of the results of several recently completed large clinical trials.
The document addresses modifiable risk factors (eliminating smoking, limiting alcohol, reducing obesity and encouraging physical activity); medical options (using anticoagulants and antiplatelet agents); and interventional recommendations (carotid artery surgery or angioplasty).
Risk of Stroke Among Special Populations
Other important updates include sections addressing special populations such as pregnant women, menopausal women and ethnic minorities.
“There is a strong recommendation against the use of hormone replacement therapy (HRT) based on all the new evidence,” Sacco said, underscoring the importance of large, randomized trials and evidence-based recommendations.
Based on observational studies, HRT was once widely thought to hold promise as a way to prevent cardiovascular disease. However, the Women’s Health Initiative (WHI), which examined the role of hormonal therapy for the primary prevention of cardiovascular disease and stroke among postmenopausal women, was stopped early because of an increase in vascular events, he said.
The last secondary prevention guidelines came out prior to those findings.
The elderly, Mexican Americans and African Americans, as well as members of lower socioeconomic groups, are at high risk of recurrent stroke. They may also face barriers to care, he said.
“We recognize that stroke is on the rise and that as our population ages and becomes more diverse the predicted number of strokes is expected to increase.
Co-authors include: Robert Adams, M.D., FAHA, vice-chair; Greg Albers, M.D.; Mark J. Alberts, M.D., FAHA; Oscar Benavente, M.D.; Karen Furie, M.D., MPH, FAHA; Larry B. Goldstein, M.D., FAHA, FAAN; Philip Gorelick, M.D., MPH, FAHA, FAAN; Jonathan Halperin, M.D., FAHA; Robert Harbaugh, M.D., FACS, FAHA; S. Claiborne Johnston, M.D., Ph.D.; Irene Katzan, M.D., FAHA; Margaret Kelly-Hayes, RN, EdD, FAHA; Edgar J. Kenton, M.D., FAHA, FAAN; Michael Marks, M.D.; Lee H. Schwamm, M.D., FAHA; and Thomas Tomsick, M.D., FAHA