Ischemic strokes account for 87% of acute strokes, and 12% of patients with acute ischemic stroke have recurrence within 5 years. After an acute ischemic stroke is identified, several tools can be used to help detect the likely cause. Controlling cardiovascular risk factors with antihypertensive therapy (with a goal of 130/80 mm Hg), statin therapy, blood glucose control, healthy diet, regular exercise, avoidance of substance use, treatment of obstructive sleep apnea, if present, and care based on the cause of stroke reduces the risk of recurrence. Antithrombotic therapy with anticoagulants is recommended for embolic stroke due to atrial fibrillation; antiplatelet therapy is more commonly used for the treatment of nonembolic stroke. Procedural management for those with carotid stenosis or closure of patent foramen ovale may be indicated. Additional evaluation, such as long-term cardiac monitoring to identify initially undetected atrial fibrillation, may be required if the cause of stroke is unclear.
In the United States, 9.4 million adults (3.3%) report having had a stroke of any kind, and 87% of acute strokes are ischemic.1,2 Stroke is the fifth-leading cause of death and a leading cause of disability; it is also associated with substantial health care costs.3,4 Approximately 12% of individuals whose index (initial) stroke was an acute ischemic stroke will experience another stroke within 5 years.5
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| During and immediately after an index stroke, efforts should be made to assign a stroke subtype to inform secondary prevention measures using a framework such as TOAST to characterize stroke etiology (eg, large artery atherosclerosis, cardioembolic, lacunar [small artery occlusion], other determined source, embolic stroke of undetermined source, nonembolic stroke of undetermined source [cryptogenic]).2,7,8 | C | Guideline and prospective trials on clinical efficacy |
| Blood pressure should be treated to a target of 130/80 mm Hg in most patients (140/90 mm Hg in patients with large artery atherosclerosis) using thiazide diuretics, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers, with consideration of calcium channel blockers if additional therapy is warranted.2,30,36–38 | A | Meta-analysis of RCTs |
| Statins should be used as first-line therapy for lowering low-density lipoprotein cholesterol to less than 70 mg/dL (1.81 mmol/L), with adjuncts used as needed.39–42 | A | RCTs and meta-analyses |
| Lifestyle factors including adherence to the Mediterranean or DASH diet, at least 10 minutes of moderate physical activity four times per week, and treatment of obstructive sleep apnea, if present, should be recommended to reduce stroke recurrence.2,52,53,57,58 | C | Smaller heterogeneous trials, expert opinion, and guidelines |
| In patients with minor stroke or those at high risk of transient ischemic attack, dual antiplatelet therapy should be started within 72 hours and taken for 21 to 30 days, whereas patients with acute ischemic stroke due to large artery atherosclerosis should be treated for 90 days.2,52,60–70,72,73 | A | RCTs with consistent results, meta-analysis, and guidelines |
DASH = Dietary Approach to Stop Hypertension; RCT = randomized controlled trial; TOAST = Trial of Org 10172 in Acute Ischemic Stroke.
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.
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