Recurrent Ischemic Stroke: Strategies for Prevention

 

Am Fam Physician. 2017 Oct 1;96(7):436-440.

  Patient Information: See related handout on stroke prevention.

Recurrent strokes make up almost 25% of the nearly 800,000 strokes that occur annually in the United States. Risk factors for ischemic stroke include hypertension, diabetes mellitus, hyperlipidemia, sleep apnea, and obesity. Lifestyle modifications, including tobacco cessation, decreased alcohol use, and increased physical activity, are also important in the management of patients with a history of stroke or transient ischemic attack. Antiplatelet therapy is recommended to reduce the risk of recurrent ischemic stroke. The selection of antiplatelet therapy should be based on timing, safety, effectiveness, cost, patient characteristics, and patient preference. Aspirin is recommended as initial treatment to prevent recurrent ischemic stroke. Clopidogrel is recommended as an alternative monotherapy and in patients allergic to aspirin. The combination of clopidogrel and aspirin is not recommended for long-term use (more than two to three years) because of increased bleeding risk. Aspirin/dipyridamole is at least as effective as aspirin alone, but it is not as well tolerated. Warfarin should not be used for prevention of recurrent ischemic stroke.

Stroke is the fifth-leading cause of death in the United States.1 The total cost of direct stroke-related medical care is projected to rise from $71.6 billion in 2012 to $184.1 billion by 2030.1 Out of the 795,000 strokes each year in the United States, 691,000 are ischemic, and 185,000 are recurrent events.1 The American Heart Association (AHA) and the American Stroke Association (ASA) define a transient ischemic attack (TIA) as a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.2 They define an ischemic stroke as brain, spinal cord, or retinal cell death due to ischemia based on neuropathology, neuroimaging, or clinical evidence of permanent injury.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Antihypertensive therapy should be initiated in untreated patients with a recurrent ischemic stroke or TIA who have systolic blood pressure of more than 140 mm Hg or diastolic blood pressure of more than 90 mm Hg several days after the event.

B

57

All patients with ischemic stroke or TIA should be screened for diabetes mellitus using fasting plasma glucose measurement, A1C measurement, or an oral glucose tolerance test.

C

5

High-intensity statin therapy should be initiated to reduce risk of stroke and cardiovascular events in patients with ischemic stroke or TIA presumed to be of atherosclerotic origin.

C

5

Patients with an established history of stroke or TIA and any symptoms of obstructive sleep apnea should undergo polysomnography.

C

5

Patients who have had a stroke or TIA should be strongly encouraged to quit smoking and avoid secondhand smoke.

C

5

Patients with a history of stroke or TIA who are capable of physical activity should be encouraged to participate in at least 120 to 150 minutes per week of moderate- to vigorous-intensity aerobic exercise.

C

5

In patients with previous stroke or TIA, antiplatelet therapy should be used to reduce the risk of a recurrent event.

A

5, 28


TIA = transient ischemic attack.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Antihypertensive therapy should be initiated in untreated patients with a recurrent ischemic stroke or TIA who have systolic blood pressure of more than 140 mm Hg or diastolic blood pressure of more than 90 mm Hg several days after the event.

B

57

All patients with ischemic stroke or TIA should be screened for diabetes mellitus using fasting plasma glucose measurement, A1C measurement, or an oral glucose tolerance test.

C

5

High-intensity statin therapy should be initiated to reduce risk of stroke and cardiovascular events in patients with ischemic stroke or TIA presumed to be of atherosclerotic origin.

C

5

Patients with an established history of stroke or TIA and any symptoms of obstructive sleep apnea should undergo polysomnography.

C

5

Patients who have had a stroke or TIA should be strongly encouraged to quit smoking and avoid secondhand smoke.

C

5

Patients with a history of stroke or TIA who are capable of physical activity should be encouraged to participate in at least 120 to 150 minutes per week of moderate- to vigorous-intensity aerobic exercise.

C

5

In patients with previous stroke or TIA, antiplatelet therapy should be used to reduce the risk of a recurrent event.

A

5, 28


TIA = transient ischemic attack.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patie

The Authors

show all author info

RUPAL OZA, MD, is a clinical assistant professor in the Department of Family Medicine at The Ohio State University Wexner Medical Center in Columbus....

KRISTEN RUNDELL, MD, is a visiting associate professor in the Department of Family Medicine at The Ohio State University Wexner Medical Center.

MIRIAM GARCELLANO, DO, is a clinical assistant professor in the Department of Family Medicine at The Ohio State University Wexner Medical Center.

Author disclosure: No relevant financial affiliations.

Address correspondence to Rupal Oza, MD, The Ohio State University, 543 Taylor Ave., 2nd Fl., Columbus, OH 43203 (e-mail: rupal.oza@osumc.edu). Reprints are not available from the authors

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