卒中和短暫性腦缺血發(fā)作患者的卒中預(yù)防

ClinicalUpdateADAPTEDFROM:

卒中和短暫性腦缺血發(fā)作患者的卒中預(yù)防Table1.

ApplyingClassofRecommendationandLevelofEvidencetoClinicalStrategies,Interventions,Treatments,orDiagnosticTestinginPatientCareCLASS(STRENGTH)OFRECOMMENDATIONCLASS1(STRONG)Benefit>>>RiskSuggestedphrasesforwritingrecommendations:IsrecommendedIsindicated/useful/effective/beneficialShouldbeperformed/administered/otherComparative-EffectivenessPhrases?:Treatment/strategyAisrecommended/indicatedinpreferencetotreatmentBTreatmentAshouldbechosenovertreatmentBCLASS2a(MODERATE)Benefit>>RiskSuggestedphrasesforwritingrecommendations:IsreasonableCanbeuseful/effective/beneficialComparative-EffectivenessPhrases?:Treatment/strategyAisprobablyrecommended/indicatedinpreferencetotreatmentBItisreasonabletochoosetreatmentAovertreatmentBCLASS2b(Weak)Benefit≥RiskSuggestedphrasesforwritingrecommendations:May/mightbereasonableMay/mightbeconsideredUsefulness/effectivenessisunknown/unclear/uncertainornotwell-establishedCLASS3:NoBenefit(MODERATE)Benefit=RiskSuggestedphrasesforwritingrecommendations:IsnotrecommendedIsnotindicated/useful/effective/beneficialShouldnotbeperformed/administered/otherCLASS3:Harm(STRONG)Risk>BenefitSuggestedphrasesforwritingrecommendations:PotentiallyharmfulCausesharmAssociatedwithexcessmorbidity/mortalityShouldnotbeperformed/administered/otherLEVEL(QUALITY)OFEVIDENCE?LEVELAHigh-qualityevidence?frommorethan1RCTMeta-analysesofhigh-qualityRCTsOneormoreRCTscorroboratedbyhigh-qualityregistrystudiesLEVELB-R(Randomized)Moderate-qualityevidence?from1ormoreRCTsMeta-analysesofmoderate-qualityRCTsLEVELB-NR(Nonrandomized)Moderate-qualityevidence?from1ormorewell-designed,well-executednonrandomizedstudies,observationalstudies,orregistrystudiesMeta-analysesofsuchstudiesLEVELC-LD(LimitedData)RandomizedornonrandomizedobservationalorregistrystudieswithlimitationsofdesignorexecutionMeta-analysesofsuchstudiesPhysiologicalormechanisticstudiesinhumansubjectsLEVELC-EO(ExpertOpinion)Consensusofexpertopinionbasedonclinicalexperience.CORandLOEaredeterminedindependently(anyCORmaybepairedwithanyLOE).ArecommendationwithLOECdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedinguidelinesdonotlendthemselvestoclinicaltrials.AlthoughRCTsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.*Theoutcomeorresultoftheinterventionshouldbespecified(animprovedclinicaloutcomeorincreaseddiagnosticaccuracyorincrementalprognosticinformation).

?Forcomparative-effectivenessrecommendation(COR1and2a;LOEAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisonsofthetreatmentsorstrategiesbeingevaluated.?Themethodofassessingqualityisevolving,includingtheapplicationofstandardized,widely-used,andpreferablyvalidatedevidencegradingtools;andforsystematicreviews,theincorporationofanEvidenceReviewCommittee.CORindicatesClassofRecommendation;EO,expertopinion;LD,limiteddata;LOE,LevelofEvidence;NR,nonrandomized;R,randomized;andRCT,randomizedcontrolledtrial.2Introduction&ScopeAnnualIschemicStrokeandTIAIncidencePillarsofPreventionBloodPressureControlDietPhysicalActivitySmokingCessationGuidingPrinciple:SecondarypreventionforStrokeandTIApatientsisidentical!Abbreviation:TIAindicatestransientischemicattack.TotalStrokes:~795KRecurrentStroke185KIschemicStrokes690K(87%)3TIA~240KFigure1.ConceptualRepresentationofIschemicStrokeSubtypes

CryptogenicStrokeNon-LacunarStrokeIschemicStrokeStrokeIntracerebralHemorrhageSubarachnoidHemorrhageIschemicStrokeLacunar(Majorityduetosmallvesseldisease)Non-LacunarCardioembolicCryptogenicLargeArteryOtherESUSNON-ESUS4Abbreviations:ESUSindicatesembolicstrokeofundeterminedsource;andnon-ESUS,non-embolicstrokeofundeterminedsource.SharedDecision-Making&AdherenceSharedDecisionMakingKeycomponentofpatient-centeredcareProcessinwhichcliniciansdescribeoptions,risks,benefitsandassistspatientsinevaluatingoptionsCollaborativelydevelopcareplanswithpatients,incorporatingpatients’wishes,goals,andconcernsAssessingBarrierstoAdherenceAssessandaddressbarrierstoadherencetomedicationsandlifestyleInrecurrentstroke,vitaltoassesswhethertakingprescribedmedicationsExploreand,ifpossible,addressfactorsthatcontributedtonon-adherence,priortoassumingmedicationswereineffective5Diagnostics:TestandImplicationsforStrokePreventionECGScreenforatrialfibrillation/flutterDetectsadditionalarrhythmiasAssessesformyocardialinfarctionCTorMRIBrainImagingConfirmsischemiccauseofsymptomsMayneedrepeatimagingafterthrombolysisortoconfirmdiagnosisCervicalCarotidImagingUtilizedtoscreenforstenosis,dissection,etc.Typesofdiagnostictestingapproachesincludecarotidultrasound,CTA,andMRAultrasonography,CTA),ormagneticCTangiography(CTA),ormagneticresonanceangiography(MRA)isrecommendedtoscreenforstenosis.4arotidultrasonography,CTangiography(CTA),ormagneticresonanceangiography(MRA)isrecommendedtoscreenforstenosis.4onstIntracranialArterialImagingIdentifiesstenosis,dissection,etc.BloodTestingInformstherapyandidentifiesriskfactorsformodificationCanincludetestingforcryptogenicstrokesifneededEchocardiography

IdentifiespossiblecardioaorticsourcesofortranscardiacpathwaysforcerebralembolismTransthoracicechocardiographyispreferredoverTEEforthedetectionofleftventricular(LV)thrombus,butTEEissuperiortotransthoracicechocardiogramindetectingleftatrialthrombus,aorticatheroma,prostheticvalveabnormalities,nativevalveabnormalities,atrialseptalabnormalities,andcardiactumorsRhythmMonitoringMobilecardiacoutpatienttelemetry,implantablelooprecorder,orotherapproach,isreasonabletodetectintermittentatrialfibrillationAbbreviations:CT,indicatescomputedtomography;;CTA,computerizedtomographyangiography;MRA,magneticresonanceangiography;MRI,magneticresonanceimaging;andTEE,transesophagealechocardiography.6Figure2.AlgorithmforEvaluatingPatientswithClinicalDiagnosisofStrokeforOptimizingPreventionofRecurrentIschemicStrokeYESNO7Abbreviations:CTindicatescomputedtomography;CTA,computedtomographyangiogram;ECG,electrocardiogram;MRA,magneticresonanceangiography;MRI,magneticresonanceimaging;SOE,sourceofembolism;TEE,transesophagealecho;TIA;transientischemicattack:andUS,ultrasound.?Whenapatienthasatransientneurologicaldeficitclinicallycharacteristicoftransientischemicattack,thepatientshouldbeevaluatedinthesamemannerasapatientwhohasanischemicstrokewithacorrespondingcerebralinfarctonimaging.Showsischemic

stroke?ManageaccordinglyECGandbasiclaboratorytests*(Class1)YESNOCTorMRIshowsischemic

strokemimicConsiderdelayedreimagingwithCTorMRIifnotdoneinitially(Class2a)ManageaccordinglyAnterior

circulation

infarctNon-invasivecervicalcarotidimaging[CTA,MRA,orUS](Class1)EchocardiographytoevaluateforcardiacSOE(Class2a)Non-invasiveintracranialandextracranialimagingofvertebrobasilararterialsystem(Class2a)CauseidentifiedBasedonage,medicalcomorbiditiesandclinicalsyndrome,consider:Long-termcardiacrhythmmonitoring(Class2a)Testforgeneticstrokesyndrome(Class2a)Testforinfectiousvasculitis(Class2a)TEE,CardiacCTorCardiacMRI(Class2b)EvaluateforotherrarecausesofstrokeCTorMRI(Class1)YESNOYESNONon-invasiveintracranialarterialimaging(Class2a)Mediterraneantypediet(inpreferencetolow-fatdiet)(Class2a)MediterraneanDiet(Summarized)Highmonounsaturated/saturatedfatratio

(useofoliveoilasmaincookingingredientand/orconsumptionofothertraditionalfoodshighinmonounsaturatedfatssuchastreenuts)Highintakeofplant‐basedfoods,includingfruits,vegetablesandlegumesHighconsumptionofwholegrainsandcerealsIncreasedconsumptionoffishLowconsumptionofmeatandmeatproductsDiscouragesredandprocessedmeatsLowtomoderateredwineconsumptionModerateconsumptionofmilkanddairyproductsDiscouragessodadrinks,pastries,sweets,commercialbakeryproductsandspreadfatsVascularRiskFactorManagement:NutritionReducedriskofrecurrentstroke+hypertension

(ifnotcurrentlyrestrictingdietarysodium)InpatientswithstrokeorTIAandhypertensionwhoarenotcurrentlyrestrictingtheirdietarysodiumintake,itisreasonabletorecommendthatindividualsreducetheirsodiumintakebyatleast1g/dsodium(2.5grams/daysalt)toreducetheriskofcardiovasculardisease(CVD)events(includingstroke)(Class2a)Reducedriskofcardiovasculardiseaseevents(includingstroke)Strokeortransientischemicattack8VascularRiskFactorManagement:PhysicalActivityCORPATIENTPOPULATIONRECOMMENDATIONSIMPACT1CapableofphysicalactivityModerateintensityaerobicactivityforaminimumof10minutes4timesaweekORVigorousintensityaerobicactivityforaminimumof20minutes2timesaweekLowerriskofrecurrentstrokeandcompositecardiovascularendpointofrecurrentstroke,myocardialinfarction,orvasculardeath2aAbletoincreasephysicalactivityEngageinexerciseclassthatincludescounselingtochangephysicalactivitybehaviorReducescardiometabolicriskfactorsandincreasesleisuretimephysicalactivityparticipation2aImpairedabilitytoexerciseSupervisionofexerciseprogrambyhealthcareprofessional(ex.physicaltherapist,cardiacrehabilitationprofessional)inadditiontoroutinerehabilitationBeneficialforsecondarystrokeprevention2bSitforlongperiodsofuninterruptedtimeBreakupsedentarytimewithintervalsasshortas3minutesofstandingORlightexerciseevery30minutesImprovescardiovascularhealth9VascularRiskFactorManagement:

SmokingCessationandSubstanceUse10*Nicotinereplacement,bupropion,vareniclineTobaccoCurrentsmokerEnvironmental(passive)exposureCounselstopsmoking±drugtherapy*(orreduceuseifunableto)(Class1)Avoidexposure(Class1)ReducesriskofrecurrentstrokeAlcoholIfconsumption:Men:>2alcoholicdrinksperdayWomen:>1alcoholicdrinkperdayCounseleliminateorreduceconsumptionofalcoholtoreducestrokerisk(Class1)?i.e.,amphetamines,amphetaminederivatives,cocaine,orkhatStimulantuseStimulantuse?or

patientswithinfectiveendocarditis

(withintravenousdruguse)Counselbehaviorishealthriskandtostopuse(Class1)SubstanceuseSubstanceusedisorders

(drugsand/oralcohol)Specializedservicestohelpmanagedependency(Class1)VascularRiskFactorManagement:Hypertension11StrokeortransientischemicattackHistoryof

hypertension?InpatientswithhypertensionwhoexperienceastrokeorTIA,treatmentwithathiazidediuretic,angiotensin-convertingenzymeinhibitor,orangiotensinIIreceptorblockersisusefulforloweringBPandreducingrecurrentstrokerisk(Class1)InpatientswithhypertensionwhoexperienceastrokeorTIA,individualizeddrugregimensthattakeintoaccountpatientcomorbidities,agentpharmacologicalclass,andpatientpreferencearerecommendedtomaximizedrugefficacy(Class1)InpatientswithhypertensionwhoexperienceastrokeorTIA,anofficeBPgoalof<130/80mmHgisrecommendedformostpatientstoreducetheriskofrecurrenteventsandvascularstroke(Class1)

InpatientswithnohistoryofhypertensionwhoexperienceastrokeorTIAandhaveanaverageofficeBPof≥130/80mmHg,antihypertensivemedicationtreatmentcanbebeneficialtoreducetheriskofrecurrentstroke,ICH,andothervascularevents(Class2a)YESNOAbbreviations:BPindicatesbloodpressure;ICH;intracranialhemorrhage;mm/Hg;millimetersofmercury;andTIA,transientischemicattack.VascularRiskFactorManagement:

HyperlipidemiaandHypertriglyceridemiaHYPERLIPIDEMIACORRECOMMENDATIONS1Inpatientswithischemicstrokewithnoknowncoronaryheartdisease,nomajorcardiacsourcesofembolism,andLDLcholesterol(LDL-C)>100mg/dL,atorvastatin80mgdailyisindicatedtoreduceriskofstrokerecurrence1InpatientswithischemicstrokeorTIAandatheroscleroticdisease(intracranial,carotid,aortic,orcoronary),lipid-loweringtherapywithastatinandalsoezetimibe,ifneeded,toagoalLDL-Cof<70mg/dLisrecommendedtoreducetheriskofmajorcardiovascularevents2aInpatientswithischemicstrokewhoareveryhighrisk(definedasstrokeplusanothermajorASCVDorstrokeplusmultiplehigh-riskconditions),aretakingmaximallytoleratedstatinandezetimibetherapyandstillhaveanLDL-C>70mg/dL,itisreasonabletotreatwithPCSK9inhibitortherapytopreventASCVDevents*StrokeplusanothermajorASCVDorstrokeplusmultiplehigh-riskconditions1MonitoringInpatientswithstrokeorTIAandhyperlipidemia,patients’adherencetochangesinlifestyleandtheeffectsofLDL-Cloweringmedicationshouldbeassessedbymeasurementoffastinglipidsandappropriatesafetyindicators4-12weeksafterstatininitiationordoseadjustmentandevery3-12monthsthereafter,basedonneedtoassessadherenceofsafetyAbbreviations:AFindicatesatrialfibrillation;ASCVD,atheroscleroticcardiovasculardisease;HbA1c,glycatedhemoglobinA1c;LDL-C,low-densitylipoproteincholesterol;PCSK9,proproteinconvertasesubtilisin/kexintype9;andTIA,transientischemicattack.12VascularRiskFactorManagement:

HyperlipidemiaandHypertriglyceridemiaHYPERTRIGLYCERIDEMIACORRECOMMENDATIONS2aInpatientswithischemicstrokeorTIA,withfastingtriglycerides135to499mg/dLandLDL-Cof41to100mg/dL,onmoderate-orhigh-intensitystatintherapy,withHbA1c<10%,andwithnohistoryofpancreatitis,AF,orsevereheartfailure,treatmentwithicosapentethyl(IPE)2gtwiceadayisreasonabletoreduceriskofrecurrentstroke.2aInpatientswithseverehypertriglyceridemia(ie,fastingtriglycerides≥500mg/dL[≥5.7mmol/L]),itisreasonabletoidentifyandaddresscausesofhypertriglyceridemiaand,iftriglyceridesarepersistentlyelevatedorincreasing,tofurtherreducetriglyceridesinordertolowertheriskofASCVDeventsbyimplementationofaverylow-fatdiet,avoidanceofrefinedcarbohydratesandalcohol,consumptionofomega-3fattyacids,and,ifnecessarytopreventacutepancreatitis,fibratetherapy.Abbreviations:AFindicatesatrialfibrillation;ASCVD,atheroscleroticcardiovasculardisease;HbA1c,glycatedhemoglobinA1c;LDL-C,low-densitylipoproteincholesterol;andTIA,transientischemicattack.13VascularRiskFactorManagement:GlucoseDIABETES&ISCHEMICSTROKEORTIACORRECOMMENDATIONS1Goalforglycemiccontrolindividualizedbasedonriskforadverseevents,patientcharacteristics,andpreferences.1Formostpatients,especiallyif<65yearsoldwithoutlife-limitingcomorbidillness,achievingagoalofHbA1c≤7%toreduceriskofmicrovascularcomplications.1Treatmentofdiabetesshouldincludeglucose-loweringagentswithprovencardiovascularbenefittoreducetheriskforfuturemajoradversecardiovascularevents(i.e.,stroke,MI,cardiovasculardeath).1Multidimensionalcareisindicatedtoachieveglycemicgoalsandimprovestrokeriskfactors:LifestylecounselingMedicalnutritionaltherapyDiabetesself-managementeducationSupportMedication2bUsefulnessofachievingintenseglucosecontrol(i.e.,HbA1c≤7%)beyondacutephaseofischemiceventforpreventionofrecurrentstrokeisunknown.PRE-DIABETES&ISCHEMICSTROKEORTIACORRECOMMENDATIONS2aLifestyleoptimization(i.e.,healthydiet,regularphysicalactivity,andsmokingcessation)canbebeneficialtopreventprogressiontodiabetes.2bIfbodymassindex≥35kg/m2,aged<60yearsold,orwomenwithahistoryofgestationaldiabetes,metforminmaybebeneficialtocontrolbloodsugarandpreventprogressiontodiabetes.Abbreviations:HbA1cindicatesglycatedhemoglobinA1c;MI,myocardialinfarction;andTIA,transientischemicattack.14VascularRiskFactorManagement:GlucoseISCHEMICSTROKEORTIA&UNKNOWNIFDIABETESCORRECOMMENDATIONS2aReasonabletoscreenforprediabetes/diabetesusingHbA1c.≤6MONTHSAFTERISCHEMICSTROKEORTIAWITHINSULINRESISTANCE,HBA1C<7%,ANDWITHOUTHEARTFAILUREORBLADDERCANCERCORRECOMMENDATIONS2bPioglitazonemaybeconsideredtopreventrecurrentstroke.Abbreviations:HbA1cindicatesglycatedhemoglobinA1c;andTIA,transientischemicattack.15VascularRiskFactorManagement:

ObesityandObstructiveSleepApneaOBESITYCORPATIENTPOPULATIONRECOMMENDATIONS1IschemicstrokeorTIAandoverweightorobeseWeightlosstoimproveASCVDriskfactorprofile1IschemicstrokeorTIAandobeseToachievesustainedweightloss,referraltointensive,multicomponent,behaviorallifestyle-modificationprogram1IschemicstrokeorASCVDCalculatebodymassindexattimeoftheeventandannuallythereaftertoscreenforandclassifyobesityOBSTRUCTIVESLEEPAPNEACORPATIENTPOPULATIONRECOMMENDATIONS2aIschemicstrokeorTIAandOSATreatmentwithpositiveairwaypressure(i.e.,continuouspositiveairwaypressure)canbebeneficialforimprovedsleepapnea,bloodpressure,sleepiness,andotherapnea-relatedoutcomes2bIschemicstrokeorTIAEvaluationforOSAmaybeconsideredfordiagnosingsleepapneaAbbreviations:ASCVDindicatesatheroscleroticcardiovasculardisease;OSA,obstructivesleepapnea;andTIA,transientischemicattack.16ManagementofIntracranialLargeArteryAtherosclerosis17Abbreviations:TIAindicatestransientischemicattack.CORRECOMMENDATIONSAntithromboticTherapy11.InpatientswithastrokeorTIAcausedby50%to99%stenosisofamajorintracranialartery,aspirin325mg/disrecommendedinpreferencetowarfarintoreducetheriskofrecurrentischemicstrokeandvasculardeath.2a2.InpatientswithrecentstrokeorTIA(within30days)attributabletoseverestenosis(70%–99%)ofamajorintracranialartery,theadditionofclopidogrel75mg/dtoaspirinforupto90daysisreasonabletofurtherreducerecurrentstrokerisk.2b3.Inpatientswithrecent(within24hours)minorstrokeorhigh-riskTIAandconcomitantipsilateral>30%stenosisofamajorintracranialartery,theadditionofticagrelor90mgtwiceadaytoaspirinforupto30daysmightbeconsideredtofurtherreducerecurrentstrokerisk.2b4.InpatientswithstrokeorTIAattributableto50%to99%stenosisofamajorintracranialartery,theadditionofcilostazol200mg/daytoaspirinorclopidogrelmightbeconsideredtoreducerecurrentstrokerisk.2b5.InpatientswithstrokeorTIAattributableto50%to99%stenosisofamajorintracranialartery,theusefulnessofclopidogrelalone,thecombinationofaspirinanddipyridamole,ticagreloralone,orcilostazolaloneforsecondarystrokepreventionisnotwellestablished.ManagementofExtracranialLargeArteryAtherosclerosis18CORRECOMMENDATIONS11.InpatientswithaTIAornondisablingischemicstrokewithinthepast6monthsandipsilateralsevere(70%–99%)carotidarterystenosis,carotidendarterectomy(CEA)isrecommendedtoreducetheriskoffuturestroke,providedthatperioperativemorbidityandmortalityriskisestimatedtobe<6%.12.InpatientswithischemicstrokeorTIAandsymptomaticextracranialcarotidstenosiswhoarescheduledforcarotidarterystenting(CAS)orCEA,proceduresshouldbeperformedbyoperatorswithestablishedperiproceduralstrokeandmortalityratesof<6%toreducetheriskofsurgicaladverseevents.13.InpatientswithcarotidarterystenosisandaTIAorstroke,intensivemedicaltherapy,withantiplatelettherapy,lipid-loweringtherapy,andtreatmentofhypertension,isrecommendedtoreducestrokerisk.14.InpatientswithrecentTIAorischemicstrokeandipsilateralmoderate(50%–69%)carotidstenosisasdocumentedbycatheter-basedimagingornoninvasiveimaging,CEAisrecommendedtoreducetheriskoffuturestroke,dependingonpatient-specificfactorssuchasage,sex,andcomorbidities,iftheperioperativemorbidityandmortalityriskisestimatedtobe<6%.2a5.Inpatients≥70yearsofagewithstrokeorTIAinwhomcarotidrevascularizationisbeingconsidered,itisreasonabletoselectCEAoverCAStoreducetheperiproceduralstrokerate.2a6.Inpatientsinwhomrevascularizationisplannedwithin1weekoftheindexstroke,itisreasonabletochooseCEAoverCAStoreducetheperiproceduralstrokerate.Abbreviations:CASindicatescarotidarterystenting;CEA,carotidendarterectomy;andTIA,transientischemicattack.19Abbreviations:CASindicatescarotidarterystenting;CEA,carotidendarterectomy;andTIA,transientischemicattack.Continued…..ManagementofExtracranialLargeArteryAtherosclerosisCORRECOMMENDATIONS2a7.InpatientswithTIAornondisablingstroke,whenrevascularizationisindicated,itisreasonabletoperformtheprocedurewithin2weeksoftheindexeventratherthandelaysurgerytoincreasethelikelihoodofstrokefreeoutcome.2a8.Inpatientswithsymptomaticseverestenosis(≥70%)inwhomanatomicormedicalconditionsarepresentthatincreasetheriskforsurgery(suchasradiation-inducedstenosisorrestenosisafterCEA)itisreasonabletochooseCAStoreducetheperiproceduralcomplicationrate.2b9.Insymptomaticpatientsataverageorlowriskofcomplicationsassociatedwithendovascularintervention,whentheinternalcarotidarterystenosisis≥70%bynoninvasiveimagingor>50%bycatheter-basedimagingandtheanticipatedrateofperiproceduralstrokeordeathis>6%,CASmaybeconsideredasanalternativetoCEAforstrokeprevention,particularlyinpatientswithsignificantcardiovascularcomorbiditiespredisposingtocardiovascularcomplicationswithendarterectomy.2b10.InpatientswitharecentstrokeorTIA(past6months),theusefulnessoftranscarotidarteryrevascularization(TCAR)forpreventionofrecurrentstrokeandTIAisuncertain.3:NoBenefit11.InpatientswithrecentTIAorischemicstrokeandwhenthedegreeofstenosisis<50%,revascularizationwithCEAorCAStoreducetheriskoffuturestrokeisnotrecommended.3:NoBenefit12.Inpatientswitharecent(within120days)TIAorischemicstrokeipsilateraltoatheroscleroticstenosisorocclusionofthemiddlecerebralorcarotidartery,extracranialintracranialbypasssurgeryisnotrecommended.OverallStrokeRiskReductionStrategiesForSymptomaticExtracranialVertebralAtherosclerosisIntensivemedicaltherapyAnti-platelettherapyHighintensitystatinBloodpressurecontrolPhysicalactivity(Class1)ForSymptomaticAorticArchAtherosclerosisForSymptomaticIntracranialAtherosclerosisForSymptomaticExtracranialAtherosclerosis20Recommendations21SymptomaticMoyamoyaDiseaseSurgicalrevascularizationwithdirectorindirectextracranialtointracranialbypasscanbebeneficialtopreventrecurrentischemicstrokeorTIA(Class2a)Anti-platelettherapymaybereasonabletopreventrecurrentischemicstrokeorTIA(Class2b)Abbreviations:TIAindicatestransientischemicattack.SmallVesselStrokeTheusefulnessofcilostazolforsecondarystrokepreventionisuncertain(Class2b)IschemicStrokeDuetoCerebralSmallVesselDisease22TimingofAnticoagulationafterStrokeorTIADAY0IschemicstrokeorTIADAY0-2TIAand

non-valvularatrialfibrillation(Class2a)DAY2–DAY14Strokeandatrialfibrillation(lowriskforhemorrhagicconversion)(Class2b)DAY14ANDONStrokeandatrialfibrillation(HIGHriskforhemorrhagicconversion*)(Class2a)*Largecerebralinfarcts(NIHSS>15,lesionsinvolvingcompletearterialterritoryormorethanonearterialterritory),evidenceofhemorrhageonneuroimaging,orotherfeatureswhichplacepatientatincreasedriskofhemorrhagicconversionfollowingacutestroke.Abbreviation:

TIAindicatestransientischemicattack.23ConsiderIntensifyingWarfarin§(Class2b)RecurrentStroke/TIA?Moderate-SevereMSorMechanicalValve*AllOtherVHDConditionsWarfarin(Class1)DOAC(Class1)Non-RheumaticMVD?AVD?Antiplatelet

(Class1)MV/AVBioprosthesisMechanicalMV/AVWarfarin(Class1)AssessValveFunction,RuleOutNon-ValvularCauses,AssessBleedingRiskFigure3.AntithromboticRegimeninIschemicStrokeorTIAandDifferentValvularHeartDiseaseConditions24?*DefinitionofValvularAF?IncludesMACandMVP?RheumaticandNon-RheumaticAVD§IncreasethetargetINRby0.5dependingonbleedingrisk.Abbreviations:Abxindicatesantibiotics;AF,atrialfibrillation;AV,aorticvalve;AVD,aorticvalvedisease;DOAC,directoralanticoagulant;MAC,mitralannularcalcification;MS,mitralstenosis;MV,mitralvalve;MVD,mitralvalvedisease;MVP,mitralvalveprolapse;TIA,transientischemicattack;VHD,andvalvularheartdisease.

ValvularHeartDiseaseandIschemicStrokeorTIAsAtrialFibrillationSinusRhythmInfectiveEndocarditisIntracranial

Hemorrhageor

MajorIschemic

StrokeDelaySurgery(Class2b)EarlySurgery(Class2b)EarlySurgery(Class2a)MobileVegetation>10mmRecurrentEmbolicStrokeDespiteAbxtherapyYESNOSecondaryStrokePreventionwithProstheticHeartValvesBioprostheticMV/AVStrokeorTIABEFOREvalveplacement(andnootherreasonfo