Revised guidelines for the prevention of future stroke for survivors of a stroke or transient ischemic attack (TIA) align with other guidelines and provide additional sections based on new insights on risk factors.

The American Heart Association/American Stroke Association published an updated set of recommendations online May 1 in Stroke that incorporate the latest evidence and strategies for reducing the risk of secondary stroke. The authors, led by Walter N. Kernan, MD, of Yale School of Medicine in New Haven, Conn., wrote that the 3 percent to 4 percent annual rate of a future stroke in the U.S. “represents a historical low that is the result of important discoveries in prevention science.” By updating the guidelines they intend to drive the rate even lower.   

Guideline writers added new sections on sleep apnea and aortic arch atherosclerosis, calling them prevalent risk factors for recurrent stroke; included prediabetes in the section on diabetes mellitus; rewrote sections on intracranial atherosclerosis and pregnancy; revised sections on carotid stenosis, atrial fibrillation and prosthetic heart valves; integrated data on silent infarction into relevant sections; and deleted a section on Fabry disease.

Many sections underwent revisions to be consistent with other recently published guidelines. They provide recommendations on obesity and nutrition, including reduced sodium intake and a Mediterranean diet. They also address the use of new oral anticoagulants.

Among new recommendations for treatments deemed to have no benefit or possible harm, the authors did not recommend:

• Angioplasty or stenting in patients with a stroke or TIA that was attributed to moderate stenosis of a major intracranial artery (Class III B);
• Stenting with a Wingspan stent as an initial treatment in patients whose stroke or TIA was attributed to severe stenosis of a major intracranial artery (Class III B);
• Stenting with the Wingspan stent as an initial treatment in patients whose stroke or TIA was attributed to severe stenosis of a major intracranial artery (Class III B);
• Surgical endarterectomy of aortic arch plaque as secondary stroke prevention (Class III C);
• Routine, long-term follow-up imaging of the extracranial cartotid circulation by ultrasongraphy (Class III B);
• Routine screening for hyperhomocysteinemia in patients with a recent stroke or TIA (Class III C); and
• Routine testing for antiphospholipid antibodies in patients with no signs of the syndrome and who have an alternate explanation for their stroke of TIA (Class III C).

The guidelines were endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.