What are the immediate and secondary prevention strategies for managing patients at risk of or who have experienced a CVA (Cerebrovascular Accident) infarct?

Immediate and Secondary Prevention Strategies for CVA (Cerebrovascular Accident) Infarct

For patients who have experienced a cerebrovascular accident (CVA) infarct, immediate antiplatelet therapy with aspirin 75-325 mg daily should be initiated within 24-48 hours of stroke onset, followed by dual antiplatelet therapy for 21-90 days in high-risk patients, and then long-term single antiplatelet therapy for secondary prevention. 1, 2

Immediate Management of Acute Ischemic Stroke

Initial Assessment and Treatment

• Patients with suspected stroke should be rapidly transferred to a stroke unit or center with neurosurgical expertise 1
• Cardiac monitoring for at least the first 24 hours to screen for atrial fibrillation and other arrhythmias 1
• Blood pressure management:
  • Maintain BP below 180/105 mmHg for at least 24 hours after acute reperfusion treatment 1
  • For patients with intracerebral hemorrhage presenting within 6 hours, lower SBP to target of 140 mmHg (avoiding SBP <110 mmHg) 1

Antiplatelet Therapy

• Administer aspirin 75-325 mg within 24-48 hours after stroke onset 1
• For patients treated with IV thrombolysis, delay aspirin administration until >24 hours 1
• For patients with minor ischemic stroke or high-risk TIA, consider dual antiplatelet therapy with clopidogrel plus aspirin for 21-90 days to reduce risk of recurrent stroke 2, 3

Prevention of Complications

• Gradual early mobilization 1
• For patients with limited mobility: use thigh-high intermittent pneumatic compression devices 1
• Monitor body temperature and treat fever (>38°C) 1
• Antiseizure medications only for documented secondary seizures 1
• Assess swallowing before allowing oral intake to prevent aspiration 1
• Subcutaneous anticoagulants for immobilized patients to prevent deep vein thrombosis 1

Secondary Prevention Strategies

Antiplatelet/Anticoagulant Therapy

1. For non-cardioembolic stroke (atherothrombotic, lacunar, or cryptogenic):

   • Initial dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel for 21-90 days 2, 3
   • Followed by long-term single antiplatelet therapy with one of the following options 1, 2:
     • Aspirin 75-162 mg daily
     • Clopidogrel 75 mg daily
     • Combination of aspirin plus extended-release dipyridamole (25 mg and 200 mg twice daily)

2. For cardioembolic stroke (e.g., atrial fibrillation):

   • Oral anticoagulation with warfarin (target INR 2.0-3.0) or direct oral anticoagulants 1, 4
   • For patients with mechanical heart valves: warfarin with target INR 2.5-3.5 2

Blood Pressure Management

• Target BP <130/80 mmHg for most patients 2
• For intracranial stenosis, maintain systolic BP <140 mmHg 2
• ACE inhibitors are recommended for all patients with left ventricular ejection fraction <40% and those with hypertension, diabetes, or chronic kidney disease 1

Lipid Management

• High-intensity statin therapy for all stroke patients regardless of baseline lipid levels 2
• Target LDL-C <70 mg/dL for very high-risk patients 1

Diabetes Management

• Monitor glucose levels in all stroke patients 2
• For patients with diabetes, individualize the intensity of blood sugar-lowering interventions based on risk of hypoglycemia 1
• Consider metformin as first-line pharmacotherapy if not contraindicated 1

Lifestyle Modifications

• Physical activity: 30-60 minutes of moderate-intensity aerobic activity on most days 1
• Weight management: target BMI 18.5-24.9 kg/m² 1
• Smoking cessation through counseling, nicotine products, and oral medications 2
• Diet: At least 5 daily servings of fruits and vegetables; low in fat and sodium 2
• Alcohol: Limit to ≤2 drinks/day for men, ≤1 drink/day for women, or eliminate if heavy drinker 2

Management of Carotid Stenosis

• Carotid endarterectomy (CEA) recommended for patients with 70-99% stenosis 2
• May be considered for select patients with 50-69% stenosis 2

Special Considerations and Pitfalls

Medication Adherence

• Poor adherence is a major issue: approximately 50% of patients stop taking antihypertensive medications, more than 50% stop statins, and 75% stop aspirin within 1 year 1
• Use strategies to improve adherence such as teaching self-management skills or motivational interviewing 2

Bleeding Risk with Antithrombotic Therapy

• Dual antiplatelet therapy increases bleeding risk compared to single antiplatelet therapy 3
• For patients requiring warfarin plus antiplatelet therapy (e.g., those with atrial fibrillation and recent stent), monitor closely for bleeding 1
• If intracranial hemorrhage occurs while on antithrombotics, discontinue all anticoagulants and antiplatelets for at least 1-2 weeks 2

Vascular Cognitive Impairment

• Monitor for cognitive decline in stroke patients 1
• Consider cholinesterase inhibitors for patients with vascular or mixed dementia 1
• Continue guideline-based antithrombotic therapy for secondary stroke prevention 1

By following these evidence-based strategies for immediate management and secondary prevention, the risk of recurrent stroke and other vascular events can be significantly reduced, improving long-term outcomes for patients who have experienced a CVA infarct.