Primary prevention
Primary prevention hinges on lifestyle and risk-factor modification.[28] The American Heart Association (AHA) ‘Essential 8’ serves as an educational tool for the prevention of all forms of cardiovascular disease in the general population. The 8 strategies are as follows: ‘eat better, be more active, quit tobacco, get healthy sleep, manage weight, control cholesterol, manage blood sugar, and manage blood pressure.’ AHA: Life's essential 8 Opens in new window
The American Heart Association recommends a blood pressure (BP) target of <130/80 mmHg for adults with an estimated 10-year risk of atherosclerotic cardiovascular disease (CVD) of >10%; and <140/90 mmHg for those at lower risk.[42] Lowering BP is associated with a 30% to 40% reduction in stroke risk.[43] Carotid endarterectomy is recommended for significant stenosis.[22] The use of anticoagulation in patients with atrial fibrillation with elevated scores on risk stratification tools such as CHADS2-Vasc or mechanical valves is recommended. Guidelines on antiplatelet use vary based on patients' age and bleeding risk. American College of Cardiology/American Heart Association (ACC/AHA) guidelines state that low-dose aspirin might be considered for primary prevention of atherosclerotic CVD in adults ages 40-70 years who are at higher risk of atherosclerotic CVD but not at increased bleeding risk.[44] The US Preventive Services Task Force (USPSTF) recommends that the decision to initiate low-dose aspirin use for the primary prevention of CVD in adults ages 40-59 years who have a 10% or greater 10-year CVD risk should be an individual one.[45] Evidence indicates that the net benefit of aspirin use in this group is small. Those who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit.[45] The risk-benefit ratio differs in older patients.[46] The AHA states that low-dose aspirin should not be given routinely for primary prevention of atherosclerotic CVD to adults over 70 years, or to adults of any age who are at increased bleeding risk.[44] The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults ages 60 years or older.[45]
The table that follows summarizes recommendations on the primary prevention of ischemic stroke and transient ischemic attack (TIA) taken from the American Heart Association/American Stroke Association guideline for the primary prevention of stroke.[28]
Recommendations on screening are described in the guideline, but note that they are not outlined in the table. Use a risk prediction instrument that estimates risk for atherosclerotic CVD broadly rather than cerebrovascular disease alone, such as the Pooled Cohort Equations (ASCVD Risk Estimator Plus). [ ASCVD Risk Estimator Plus Opens in new window ]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult with hypertension
Stage 1 hypertension; systolic blood pressure (SBP) of 130-139 mmHg or diastolic blood pressure (DBP) of 80-89 mmHg. Stage 2 hypertension; SBP ≥140 mmHg or DBP ≥90 mmHg.
All
Intervention
Optimal management of hypertension
Optimize hypertensive control with nonpharmacologic interventions (lifestyle improvements) with or without pharmacologic treatment; treatment is individualized based on the stage of hypertension as well as according to cardiovascular risk.
Pharmacologic treatment with antihypertensive is recommended:
In all adults with stage 2 hypertension
In those with stage 1 hypertension at higher risk for atherosclerotic CVD
The following drugs are recommended as initial antihypertensive drug therapies to prevent stroke:
Thiazide and thiazide-like diuretics
Calcium-channel blockers
ACE inhibitors
Angiotensin-II receptor antagonists
Goal
Reduced risk of ischemic stroke and TIA
For those requiring pharmacologic treatment, a treatment target of <130/80 mmHg is recommended to prevent stroke.
In most adults with hypertension, a treatment regimen incorporating ≥2 antihypertensive medications is indicated to achieve the BP control necessary to prevent stroke.
Age ≥60 years; with uncontrolled BP (SBP ≥140mmHg if taking antihypertensive medication or ≥160 mmHg if not)
Intervention
Consider use of a salt substitute
Salt substitution (with 75% sodium chloride and 25% potassium chloride) compared with the use of regular salt (100% sodium chloride) is reasonable to reduce stroke risk.
Use caution for people taking a potassium-sparing diuretic or potassium supplement and for those with known kidney disease, owing to a potential risk of hyperkalemia in this group.
Goal
Reduced risk of ischemic stroke and TIA
Adult with cigarette smoking or with other type of tobacco and/or nicotine use
All
Intervention
Treatment for smoking cessation
For people who are active cigarette smokers or users of other tobacco products, offer assistance with cessation.
Direct questioning helps classify individuals as never, past, or current smokers. Identify whether a patient is ready to quit, which is a cue to offer treatment options for smoking cessation. Ask also about other forms of tobacco, electronic nicotine delivery systems such as electronic cigarettes (e-cigarettes), and environmental tobacco smoke exposure.
For people who are active cigarette smokers, smoking cessation pharmacotherapy delivered along with behavioral counseling is recommended in preference to behavioral counseling alone.
Advise people that the long-term health benefits of using e-cigarettes in place of nicotine replacement therapy to facilitate cigarette smoking cessation are not well established.
See Smoking cessation.
Goal
Smoking, tobacco, and nicotine cessation and avoidance of environmental exposure; reduced risk of ischemic stroke and TIA
Adult with substance use problem or disorder
People who use recreational drugs (e.g., cannabis, synthetic cannabinoids, cocaine, heroin, methamphetamine), misuse alcohol or prescription medications (e.g., stimulants and opioids), or with a substance use disorder.
All
Intervention
Counseling to stop or appropriate substance use disorder treatment
Offer referral for counseling or substance use disorder treatment (e.g., pharmacologic, behavioral or multimodal) as appropriate to the nature of the substance use problem or disorder.
Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have evidence of efficacy in reducing heavy drinking and illicit substance use in the short-term.
Pharmacologic treatment is an evidence-supported approach for some types of substance use disorder, including alcohol use disorder and opioid use disorder.
See Alcohol use disorder.
See Opioid use disorder.
Goal
Cessation of substance use
Cessation of substance use is recommended; observational data shows an increased risk of stroke in those with a substance use disorder, however evidence directly linking reduced use with reduction in stroke risk is lacking.
Adult with physical inactivity
All
Intervention
Counseling on recommended activity levels
Recommend that people reach physical activity targets (see goal column).
Advise people to avoid excessive time spent in sedentary behavior (characterized by low-energy expenditure while sitting, reclining, or lying while awake).
Evidence-based methods to promote physical activity include:
repeated individual counseling (minimum, 3–5 sessions), and
group meetings based on models of behavior change that typically involve goal setting, monitoring, problem-solving, and feedback.
When physicians cannot provide intensive counseling themselves, brief counseling followed by referral to an exercise coach may be effective.
Goal
Reduced risk of ischemic stroke and TIA
The aim is to achieve each week:
At least 150 minutes of moderate-intensity physical activity
At least 75 minutes of vigorous-intensity activity
Or an equivalent combination
Adult with suboptimal dietary quality
All
Intervention
Advise a Mediterranean dietary pattern
Advise people that the Mediterranean diet has been shown to reduce the risk of stroke, especially when supplemented with nuts and olive oil.
Goal
Reduced risk of ischemic stroke and TIA
Adult with class II obesity or greater
Body mass index (BMI) 35-39.9 kg/m² or greater
All
Intervention
Consider a bariatric surgical procedure
Consider a bariatric surgical procedure (e.g., gastric bypass surgery or sleeve gastrectomy) to prompt weight loss to reduce the risk of cardiovascular events, including stroke.
Pharmacologic treatment for obesity may also be considered in select patients.
See Obesity in adults.
Goal
Weight loss and reduced risk of ischemic stroke, TIA, and other types of atherosclerotic CVD
Adult with obstructive sleep apnea (OSA)
All
Intervention
Consider continuous positive airway pressure (CPAP)
Consider offering CPAP to people with OSA to reduce the risk of stroke.
OSA is a direct risk factor for stroke, and also increases stroke risk through its indirect effects on hypertension. There is some observational evidence to suggest that CPAP might reduce stroke risk in people with OSA.
Goal
Reduced risk of ischemic stroke and TIA
Adult with periodontal disease
All
Intervention
Promotion of good oral hygiene and regular dental care
Poor periodontal health and peridontitis are strongly associated with increased stroke risk.
Advise all people to maintain good oral hygiene and to have regular visits with a dental health professional.
Goal
Reduced risk of ischemic stroke and TIA
Adult with diabetes
Defined as: hemoglobin (Hb)A1c ≥6.5 %; or fasting plasma glucose ≥126 mg/dL; or 2-hour plasma glucose from oral glucose tolerance test ≥200 mg/dL
With high cardiovascular risk or established CVD and HbA1c ≥7%
Intervention
Consider a glucagon-like peptide-1 (GLP-1) receptor agonist
Randomized controlled trials have shown that GLP-1 receptor agonists reduce stroke risk.
Direct evidence of the effect of other diabetes drugs on stroke risk reduction is lacking.
Goal
Reduced risk of ischemic stroke and TIA
Adult; with indication for lipid-lowering therapy
For example, ages 20-75 years with low density lipoprotein cholesterol (LDL-C) >190 mg/dl (>4.9 mmol/L); or 10-year atherosclerotic CVD risk ≥20%; or 10-year atherosclerotic CVD risk ≥7.5% to <20% plus ≥1 risk enhancers
All
Intervention
Statin treatment
Treatment with a statin is recommended.
Explain to patients that treatment with a statin is associated with an overall reduction in risk of stroke in those at high cardiovascular risk; include this information within patient discussions related to the overall benefit of statins for lowering their risk of vascular events.
See Hypercholesterolemia.
Goal
Reduced risk of ischemic stroke, TIA, and other types of atherosclerotic CVD
Adult with a recent myocardial infarction (MI)
Without contraindication to high-intensity statin therapy
Intervention
Consider low-dose colchicine
Consider adding low-dose colchicine to intensive statin treatment for those with a history of recent MI.
Colchicine is an anti-inflammatory medication that has been tested in a number of CVD trials, with promising results.
Goal
Reduced risk of ischemic stroke, TIA, and adverse cardiovascular outcomes
Adult with autoimmune condition
With a high-risk antiphospholipid (aPL) profile
Intervention
Prophylactic low-dose aspirin
Prophylactic low-dose aspirin is recommended for those without a history of stroke and with no clinical indication for anticoagulation who have any one of the following:
Triple-positive aPL testing (lupus anticoagulant, anticardiolipin antibody, anti-β2 glycoprotein 1)
Double-positive aPL testing (any combination)
Isolated lupus anticoagulant
Isolated persistently positive anticardiolipin antibody at medium to high titer
This recommendation includes people with systemic lupus erythematosus (SLE) and without a clinical indication for anticoagulation (i.e., history of thrombosis or pregnancy complications).
Goal
Reduced risk of ischemic stroke and TIA
With systemic lupus erythematosus (SLE); with a low-risk aPL profile
Intervention
Consider prophylactic low-dose aspirin
For those without a clinical indication for anticoagulation (i.e., history of pregnancy complications or thrombosis), consider offering low-dose prophylactic aspirin.
A low-risk aPL profile is defined as:
isolated anticardiolipin antibody, or
anti-β2 glycoprotein 1 antibody at low to medium titer, particularly if transiently positive.
Less evidence exists on the use of aspirin in this group, although a reduced risk of arterial and venous thrombosis has been suggested with aspirin, based on data from 2 cohort studies.
Goal
Reduced risk of ischemic stroke and TIA
With antiphospholipid syndrome (APS); with prior unprovoked venous thrombosis
Intervention
Lifelong anticoagulation; vitamin K antagonist preferred
Lifelong anticoagulation is recommended owing to a high risk of recurrence of thrombosis.
It is reasonable to choose a vitamin K antagonist (usually warfarin) in this group in preference to aspirin or direct oral anticoagulants (DOACs), providing there are no contraindications.
Consider using a DOAC in patients not able to achieve a target international normalized ratio (INR) despite good adherence to a vitamin K antagonist (e.g., allergy or intolerance), although there is limited evidence on their safety or effectiveness in people with APS.
Goal
Reduced risk of thrombosis including ischemic stroke and TIA
A target INR of 2-3 is recommended if a vitamin K antagonist is used.
With APS; with a history of obstetric APS only
Intervention
Consider prophylactic low-dose aspirin
Consider prophylactic treatment with low-dose aspirin for nonpregnant adults with a history of obstetric APS after thorough risk/benefit evaluation.
Factors to consider as part of the decision making process include:
aPL profile;
coexistent traditional cardiovascular risk factors; or
intolerance or contraindication to aspirin
Goal
Reduced risk of ischemic stroke and TIA
With rheumatoid arthritis (RA)
Intervention
Consider statin treatment (if not already started)
Statin treatment may be reasonable in this group.
Some evidence supports a potential beneficial impact of statins on RA disease activity, attributable to their anti-inflammatory and immunomodulatory properties.
See Rheumatoid arthritis.
Goal
Reduced risk of adverse cardiovascular events, including ischemic stroke and TIA
Adult with established, stable coronary artery disease; age <70 years and without chronic kidney disease
All
Intervention
Consider aspirin plus ticagrelor
For patients with established coronary artery disease, the use of ticagrelor in addition to background therapy with aspirin can modestly reduce risk of ischemic stroke.
This treatment is suitable only for those at low bleeding risk, as guided by an assessment of the individualized risk:benefit ratio; use of both aspirin and ticagrelor can increase the risk for bleeding events.
Note that in the absence of established coronary artery disease, the use of aspirin to prevent a first stroke is not well established.
For people age ≥70 years with at least one additional cardiovascular risk factor, use of aspirin is not beneficial to prevent a first stroke, and may be associated with harm (from bleeding).
In patients with chronic kidney disease, the use of aspirin is not effective to prevent a first stroke, and may be associated with harm (from bleeding).
Goal
Reduced risk of ischemic stroke and TIA
Use of ticagrelor may be beneficial beyond 12 months, and for a period of up to 3 years, to reduce the rate of ischemic stroke.
With nonvalvular atrial fibrillation (AF) of any duration
With an annual stroke risk ≥2% (generally a CHA₂DS₂-VASc score of ≥2 in men or ≥3 in women)
Intervention
Consider oral anticoagulation (as guided by the individualized risk assessment for stroke)
Anticoagulation is generally recommended in this group.
However, risk of stroke varies among populations with the same risk score, so consider other factors related to stroke risk as part of the individualized risk assessment. An assessment of bleeding risk is key.
In individuals with nonvalvular AF, use a validated clinical risk score such as the CHA₂DS₂-VASc tool to guide decisions on prescription of oral anticoagulation to reduce risk for stroke. [ Atrial fibrillation CHADS(2) score for stroke risk Opens in new window ]
It is recommended that decisions on anticoagulation are individualized in the context of shared decision making.
Goal
Use of anticoagulation for stroke risk reduction is warranted when the benefit outweighs the harms
With heart failure with reduced ejection fraction; without AF or left ventricular thrombus
All
Intervention
Individualized treatment; note that anticoagulation is not indicated to prevent stroke
In patients with left ventricular systolic dysfunction (ejection fraction ≤35%-40%) and no evidence of AF or left ventricular thrombus, anticoagulation is not indicated to prevent stroke and is associated with a higher bleeding risk.
Goal
Minimization of medication-related harm (from bleeding)
Woman considering contraception
All
Intervention
Individualized contraceptive choice; for those considering combined hormonal contraception, use a lower dose of ethinyl estradiol
Evaluate risk of stroke according to individualized patient factors as well as according to the type of contraception under consideration. Risk of stroke may vary substantially between different types of hormonal contraception.
It should be noted that the overall rate of stroke in women using hormonal contraception is lower than the rate of stroke in women from pregnancy.
See Contraception.
Goal
Reduced risk of ischemic stroke and TIA
With specific stroke risk factors
Intervention
Shared decision making to determine contraceptive choice; progestin-only contraception or nonhormonal contraception may be preferred
Specific stroke risk factors include:
Age >35 years
Tobacco use
Hypertension
Migraine with aura
For those with any of the above, shared decision making is recommended to determine the best contraceptive choice.
Contraceptive choice is affected by many medical and personal factors for the patient. Shared decision making is recommended to weigh the benefits and risks of those choices.
Take into account the effectiveness of each contraceptive option and the risk of stroke associated with pregnancy. Thoughtful discussion of absolute risk is recommended.
For those with risk factors for stroke, progestin-only or nonhormonal contraception is reasonable.
For specific advice for women with migraine with aura needing contraception see next group (‘Adult with migraine [with or without aura]’).
See Contraception.
Goal
To balance the risk of stroke from contraception and the risk of stroke with pregnancy
Adult with migraine (with or without aura)
All
Intervention
Evaluation and modification of vascular risk factors
Pay particular attention to risk factor screening and modification in people with migraine.
An association between migraine, particularly migraine with aura, and stroke risk has been consistently identified within observational studies.
Vascular risk factors are common in this population, even at younger ages, and contribute towards excess stroke risk.
Goal
Reduced risk of ischemic stroke and TIA
Woman with migraine with aura; contraception needed
Intervention
Recommend progestin-only or nonhormonal contraception
Advise patients with migraine with aura to avoid combined oral contraception. Use of combined hormonal contraception in those with migraine with aura is associated with increased risk for ischemic stroke.
No increased risk of stroke has been identified in individuals with migraine using progestin-only forms of contraception.
Goal
Avoid increased risk of ischemic stroke and TIA associated with combined oral contraception
Adult with endometriosis
All
Intervention
Individualized management of vascular risk factors
Asking about a history of endometriosis can be useful in evaluating stroke risk.
Young people in particular may benefit from enhanced attention to cardiovascular risk assessment and prevention strategies, although evidence is limited.
Among those with endometriosis, studies have shown a consistent increased risk of stroke (as well as other cardiovascular risk factors, e.g. hypertension and hypercholesterolemia).
Goal
Reduced risk of ischemic stroke and TIA
Adult with asymptomatic carotid artery stenosis (>70%)
All
Intervention
Intensive pharmacologic management and risk factor modification
All people should receive optimal medical management for carotid artery stenosis as well as risk factor modification; medical management is evolving, and choice of treatment is guided by both multidisciplinary decision making and shared decision making between patient and clinical team.
Evidence supports the use of statin therapy for risk factor reduction in this population.
Goal
Reduced risk of ischemic stroke and TIA
At high risk of stroke despite optimal medical management
Intervention
Consider carotid revascularization
A subset of patients will remain at high risk of stroke despite optimal medical treatment; consensus is lacking as to the best course of management for these patients.
Consider whether carotid revascularization is appropriate, depending on the individualized risks versus benefit analysis, including perioperative risk.
Choice of treatment is therefore guided by multidisciplinary decision making as well as shared decision making between patient and clinical team.
Goal
Reduced risk of ischemic stroke and TIA
Adult with asymptomatic cerebral small vessel disease (SVD), including silent cerebral infarcts
All
Intervention
Careful attention to risk factor modification; consider low-dose statin
Assessment and management of modifiable risk factors is particularly important for this population; e.g. hypertension, tobacco use, dyslipidemia and diabetes.
Consider low-dose statin therapy even for those who do not have an indication.
Goal
Reduced risk of ischemic stroke and TIA
Adult with genetic stroke syndrome
The role of genetics in stroke pathogenesis is increasingly recognized. Monogenetic conditions are the most well understood. These include Fabry disease, CADASIL, HHT, and type IV collagen (COL4A1/2) mutations, among others.
All
Intervention
Individualized approach to stroke risk modification
Although each individual genetic condition is rare, stroke risk in some can be modified with prophylactic therapy.
For patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), counseling and treatment of modifiable risk factors (e.g., smoking cessation, treatment of hypertension and other vascular risk factors) is particularly important.
Variable expression inherent in many genetic disorders makes uniform recommendations for stroke prevention challenging.
Goal
Reduced risk of ischemic stroke and TIA
With hereditary hemorrhagic telangiectasia (HHT); with pulmonary arteriovenous malformation (PAVM) identified
Intervention
Multidisciplinary evaluation to manage stroke risk
It is recommended that a multidisciplinary team with expertise in HHT weigh up the risks and benefits of intervention for patients with PAVMs.
As a minimum, this consists of specialists in:
Pulmonology
Interventional radiology
Neurology/neurosurgery
PAVMs are present in nearly half of patients with HHT and are associated with embolic complications, including ischemic stroke and brain abscesses.
Goal
Reduced risk of ischemic stroke and TIA
Adult with previous specific adverse pregnancy outcomes (APOs)
Includes: hypertensive disorder of pregnancy, preterm birth, gestational diabetes, recurrent pregnancy loss, small for gestational age infant, placental abruption, miscarriage or stillbirth.
All
Intervention
Individualized management of vascular risk factors
It is recommended that obstetrician-gynecologists and other primary care clinicians screen parous women for a history of APOs, and discuss the increased risk of stroke with these patients, who are often unaware of their risk.
Mounting data support that those who experience APOs have increased risk and earlier onset of cerebrovascular disease.
These discussions may also help patients make informed decisions about future pregnancies.
Pay particular attention to modifiable vascular risk factors. Even young adults with a history of APOs have an increased risk of developing chronic hypertension as soon as 2 years after the index pregnancy; early diagnosis and treatment is key. Women who have experienced preeclampsia and gestational hypertension are at particularly high risk of chronic hypertension and stroke later in life.
Goal
Reduced risk of ischemic stroke and TIA
Woman with menopause
Considering oral estrogen-based therapy for management of menopausal symptoms
Intervention
Careful risk factor assessment and evaluation
In women age ≥60 years, more than 10 years after natural menopause, or at elevated risk for CVD or stroke, oral estrogen-containing hormonal treatment to manage vasomotor symptoms of menopause is associated with an excess risk of stroke. It is recommended that clinicians use shared decision making when selecting hormonal therapy, and weigh this risk against clinical benefits in those at excess stroke risk.
It is important to note that topical estrogen treatments are not associated with stroke risk.
See Menopause.
Goal
Reduced risk of ischemic stroke and TIA
With premature ovarian failure or early menopause
Intervention
Individualized management of vascular risk factors
Premature ovarian failure is defined as menopause before age 40 years. Early menopause is defined as menopause before age 45 years.
Evaluation and modification of vascular risk factors are recommended in these groups owing to an increased risk of stroke.
In particular, earlier changes in lipids and bloop pressure (BP) have been noted compared to those with later onset of menopause; monitoring and treatment of lipids and BP (as well as other CVD risk factors) is recommended during menopausal transition.
The ACC/AHA 2018 guideline on cholesterol management included premature menopause as a risk-enhancing factor to be considered in cholesterol management decisions.
Premature ovarian failure and early menopause may be due to primary ovarian insufficiency, or secondary to medical treatment (medical or surgical); the type of menopause does not appear to modify the association with stroke.
Data are lacking on whether hormone replacement therapy, at least until the average age of menopause, may modify this risk.
Goal
Reduced risk of ischemic stroke and TIA
Transgender woman or gender diverse person taking estrogens for gender affirmation
All
Intervention
Individualized management of vascular risk factors
It is recommended that clinicians evaluate and address risk factors in transfeminine people using gender-affirming hormone therapy (e.g., tobacco use, hypertension) owing to a potential increased risk of stroke in this population.
Transgender and gender diverse people experience disparate access to and outcomes within health care, including stroke.
Goal
Reduced risk of ischemic stroke and TIA
Man with hypogonadism; with appropriate indication for testosterone therapy
All
Intervention
Advise that initiation or continuation of testosterone therapy is reasonable
In men ages 45-80 years with confirmed hypogonadism who are considering testosterone therapy, initiation or continuation of testosterone replacement therapy is reasonable and does not increase the risk of stroke.
The potential increased risk of stroke in men with confirmed hypogonadism using exogenous testosterone has been debated for several years; however, patients may be reassured that recent data suggest that initiation or continuation of transdermal testosterone in people with appropriate indications does not increase the risk of stroke.
See: Hypogonadism in men.
Goal
Favorable balance of risk versus benefits of treatment with testosterone
Secondary prevention
In addition to lifestyle and dietary changes, most patients with ischemic stroke or transient ischemic attack (TIA) and atherosclerotic disease (intracranial, carotid, aortic, or coronary) should be treated with a statin, with or without ezetimibe, to a goal low-density lipoprotein cholesterol (LDL-cholesterol) of <70 mg/dL (<1.81 mmol/L) to reduce the risk of major cardiovascular events.[21][23] The BMJ: PCSK9 inhibitors and ezetimibe for the reduction of cardiovascular events: a clinical practice guideline with risk-stratified recommendations Opens in new window
Glucose control (consistent with established guidelines for care of all diabetic patients) is advocated in patients with TIA who have diabetes.
Patients with previously treated hypertension should be restarted on antihypertensive treatment after the first few days of the index event.[42] Patients not previously treated for hypertension who experience a TIA and have an established blood pressure (BP) ≥140/90 mmHg should be prescribed antihypertensive treatment a few days after the index event.[42]
American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend an office BP goal of <130/80 mmHg for most patients to reduce the risk of recurrent stroke and vascular events.[21] The American Academy of Neurology recommends a long-term BP target of <140/90 mmHg in patients with symptomatic intracranial atherosclerotic arterial stenosis.[23]
Drug regimens should be individualized to take into account patient comorbidities, agent pharmacological class, and patient preference.[21][23][42]
Patients with TIA who drink >2 alcoholic drinks a day (men) or >1 alcoholic drink a day (women) should be counseled to eliminate or reduce their consumption of alcohol to reduce stroke risk.[21]
Patients with TIA who smoke are strongly advised to stop smoking. Counseling with or without drug therapy (e.g., nicotine replacement, bupropion, or varenicline) is recommended to assist in stopping smoking to reduce risk of recurrent stroke.[21] Avoidance of environmental (passive) tobacco smoke is also recommended.[21]
In patients who are overweight or obese, weight loss is recommended.[21] In patients who are obese, referral to an intensive, multicomponent, behavioral lifestyle-modification program is recommended to achieve sustained weight loss.[21]
Low- to moderate-intensity aerobic activity, muscle-strengthening exercise, and a less sedentary lifestyle is advocated.
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]
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For patients with noncardioembolic ischemic stroke or TIA, guidelines from the AHA/ASA recommend aspirin, clopidogrel, or aspirin/dipyridamole for secondary prevention of ischemic stroke.[21] In patients with high-risk TIA (ABCD2 score ≥4), guidelines from the AHA/ASA recommend that dual antiplatelet therapy should be initiated early (ideally within 12-24 hours of symptom onset and at least within 7 days of onset) and continued for 21 to 90 days, followed by single antiplatelet therapy, to reduce the risk of recurrent ischemic stroke.[21][48] Loading doses are recommended for dual antiplatelet therapy but not for monotherapy.[86][87][88]
The dual antiplatelet therapy regimen of ticagrelor plus aspirin is approved by the Food and Drug Administration (FDA) in the US to reduce the risk for stroke in patients with acute ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score of ≤5 or high-risk TIA. The choice of adding ticagrelor or clopidogrel to aspirin should be based on patient factors (e.g., adherence to treatment, dose frequency).[21] In Europe, an application to the European Medicines Agency (EMA) to change the marketing authorization of ticagrelor to include the prevention of stroke in adults who have had a mild to moderate ischemic stroke or high-risk TIA was withdrawn in December 2021. Based on trial data and the company's response to their questions, the EMA expressed concern that the benefits of short-term treatment with ticagrelor plus aspirin in preventing stroke in these patients did not clearly outweigh the risks of fatal and nonfatal bleeding. The THALES trial of 11,016 patients (none of whom received thrombolysis or thrombectomy or required anticoagulation) demonstrated that compared with aspirin alone, dual treatment with ticagrelor plus aspirin reduced the risk of disabling stroke or death within 30 days (4.0% vs. 4.7%).[87] Severe bleeding was more frequent with ticagrelor plus aspirin than with aspirin alone (0.5% vs. 0.1%), including in those with intracranial hemorrhage (0.4% vs. 0.1%). For people with recent stroke with NIHSS score of <5, ticagrelor plus aspirin for 30 days was more effective in preventing recurrent ischemic stroke than aspirin alone.[87]
Anticoagulation therapy is superior to antiplatelet therapy for prevention of cardioembolic strokes and should be started within the first 2 weeks. In patients with nonvalvular atrial fibrillation and stroke or TIA, oral anticoagulation (e.g., apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of recurrent stroke, regardless of whether the atrial fibrillation pattern is paroxysmal, persistent, or permanent.[21] Direct-acting oral anticoagulants (DOACs), such as apixaban, dabigatran, edoxaban, or rivaroxaban, are recommended over a vitamin K antagonist, e.g., warfarin, in patients with stroke or TIA and atrial fibrillation who do not have moderate to severe mitral stenosis or a mechanical heart valve.[21] Large randomized trials have shown DOACs to clinically reduce the risk of thrombotic stroke with less bleeding risk compared with vitamin K antagonists.[21][101][102] DOACs have the significant advantage of fast onset, predictable dosing requirements, and eliminating the need for monitoring.[103] Disadvantages include higher drug cost and inability to reliably monitor anticoagulant effect using prothrombin time (PT), international normalized ratio (INR), or partial thromboplastin time (PTT). Patients with valvular atrial fibrillation (i.e., moderate to severe mitral stenosis or mechanical heart valves) should be treated with warfarin. Range INR for patients on warfarin should be 2.0 to 3.0.[21] Mitral mechanical prosthetic valves require a higher INR goal of 3.0.[21] Antiplatelet therapy continues to be recommended over warfarin in patients with ischemic stroke or TIA and native aortic or nonrheumatic mitral valve disease (e.g., mitral annular calcification or mitral valve prolapse) who do not have atrial fibrillation or another indication for anticoagulation.[21] Dabigatran is contraindicated in people with mechanical heart valves. Apixaban, edoxaban, and rivaroxaban have not been studied in patients with prosthetic heart valves and are not recommended in these patients.
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