What are the guidelines for secondary prevention of Cerebrovascular Accident (CVA)?

Guidelines for Secondary Prevention of Cerebrovascular Accident (CVA)

Secondary prevention of stroke requires a comprehensive approach targeting modifiable risk factors, with treatment strategies tailored to the specific stroke etiology.

Risk Factor Management

Blood Pressure Control

• All patients after stroke or TIA should receive blood pressure lowering therapy, regardless of baseline blood pressure, unless contraindicated by symptomatic hypotension 1
• Target BP: <130/80 mmHg 1
• Initiate therapy before discharge or within first week after stroke/TIA 1
• For patients with severe intracranial stenosis, maintaining systolic BP below 140 mmHg is recommended 1

Lipid Management

• High-intensity statin therapy is recommended for all stroke patients 1, 2
• Atorvastatin has been shown to reduce stroke risk by 48% and MI risk by 42% 2
• Benefits are seen regardless of baseline lipid levels

Diabetes Management

• Monitor glucose in all stroke patients 1
• Manage glucose intolerance or diabetes according to national diabetes guidelines 1

Lifestyle Modifications

• Smoking cessation: Consider nicotine replacement therapy, bupropion, nortriptyline, or behavioral therapy 1
• Diet: Low in fat (especially saturated fat) and sodium, high in fruits and vegetables; Mediterranean diet recommended 1
• Physical activity: Regular exercise is recommended; patients should be encouraged to perform physical activity in a supervised and safe manner 1
• Alcohol: Avoid excessive consumption 1

Antithrombotic Therapy Based on Stroke Etiology

Non-Cardioembolic Stroke/TIA

Antiplatelet Therapy

• Long-term antiplatelet therapy should be prescribed to all patients with ischemic stroke or TIA who are not prescribed anticoagulation therapy 1
• Options include:
  1. First-line: Low-dose aspirin plus extended-release dipyridamole 1
  2. Alternatives: Aspirin alone or clopidogrel alone for those who don't tolerate combination therapy 1
  3. Avoid: Long-term combination of aspirin plus clopidogrel is not recommended unless there is acute coronary disease or recent coronary stent 1

Special Situations for Dual Antiplatelet Therapy (Short-Term)

• Recent minor stroke or high-risk TIA: Addition of clopidogrel to aspirin for up to 90 days is reasonable for patients with severe stenosis (70%-99%) of a major intracranial artery 1
• Early minor stroke with >30% intracranial stenosis: Addition of ticagrelor to aspirin for up to 30 days might be considered 1
• Short-duration DAPT (≤1 month) started during early acute phase shows greater reduction in recurrent strokes with less bleeding risk compared to longer DAPT 3

Cardioembolic Stroke (Atrial Fibrillation)

• Anticoagulation therapy should be used in all patients with ischemic stroke or TIA who have atrial fibrillation, cardioembolic stroke from valvular heart disease, or recent myocardial infarction, unless contraindicated 1
• Warfarin (target INR 2.0-3.0) is effective in reducing recurrent stroke in patients with atrial fibrillation 4, 5
• Anticoagulation is superior to antiplatelet therapy for stroke prevention in patients with NRAF and recent stroke/TIA 5
• Decision to start anticoagulation should be made before discharge 1
• In TIA patients, confirm absence of intracranial hemorrhage with CT/MRI before starting anticoagulation 1

Management of Specific Stroke Subtypes

Large Artery Atherosclerosis

Extracranial Carotid Disease

• Carotid endarterectomy (CEA) recommendations:
  • For 70-99% stenosis: CEA should be performed if surgery can be done by specialist with low perioperative risk 1
  • For 50-69% stenosis: CEA should be considered in select patients 1
  • For asymptomatic 60-99% stenosis: CEA may be considered in highly select patients 1
  • Timing: Ideally within 2 weeks of event 1
  • Should only be performed at centers where outcomes are routinely audited 1
  • Not recommended for <50% symptomatic or <60% asymptomatic stenosis 1

Intracranial Stenosis

• For 50-99% stenosis of major intracranial artery:
  • Aspirin 325 mg/day is preferred over warfarin 1
  • Maintain SBP <140 mmHg, use high-intensity statin therapy, and encourage physical activity 1
  • Angioplasty/stenting is not recommended as initial treatment, even for patients on antithrombotic therapy at time of stroke/TIA 1
  • Extracranial-intracranial bypass surgery is not recommended 1

Prevention of Complications

Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE)

• Early mobilization and adequate hydration 1
• Antiplatelet therapy for ischemic stroke patients 1
• For high-risk patients, consider:
  • Low molecular weight heparin or heparin in prophylactic doses 1
  • Thigh-length antithrombotic stockings 1

Pressure Care

• Risk assessment for all immobilized patients 1
• Provide pressure-relieving mattress for high-risk patients 1

Pyrexia

• Use antipyretic therapy (paracetamol and/or physical cooling measures) when fever occurs 1

Monitoring and Follow-up

• Follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved 1
• Systematic strategies to improve BP control should include home BP monitoring, team-based care, and telehealth strategies 1

Common Pitfalls and Caveats

• Avoid long-term dual antiplatelet therapy due to increased bleeding risk without additional benefit 1
• Avoid combination of antiplatelet and anticoagulation therapy except in specific situations 1
• For patients who develop intracranial hemorrhage while on antithrombotics, discontinue all anticoagulants and antiplatelets for at least 1-2 weeks 1
• Restarting antithrombotic therapy after ICH depends on risk assessment of thromboembolism vs. recurrent ICH 1

Remember that secondary prevention strategies often depend on the specific stroke subtype, so proper diagnostic workup to determine stroke etiology is essential for targeted treatment.