|
| Clinician's quick guide for management
after TIA or Stroke |
Risk of stroke after TIA
 | 1st month: 4-8%. 1st year: 12%. 5 years: 24-29% |
| Long-term stroke recurrence rates range
from 4% to 14% annually. |
| There may be differences in recurrence
rates by stroke subtype.
 | Lacunar infarction may have the
lowest recurrence rate |
| Atherothrombotic infarction the
highest |
|
|
| Risk
Factor |
Treatment
Goal |
Recommendations |
| Hypertension |
SBP
<140 mm Hg and DBP <90 mm Hg; SBP <135 mm Hg and DBP <85
mm Hg if target organ damage is present |
Lifestyle
modification and antihypertensive medications |
| Smoking |
Cessation |
Provide
counseling, nicotine replacement, and formal programs |
| Diabetes
mellitus |
Glucose
<126 mg/dL (6.99 mmol/L) |
Diet, oral
hypoglycemics, insulin |
| Lipids |
LDL
<100 mg/dL (2.59 mmol/L) HDL >35 mg/dL (0.91 mmol/L) TC
<200 mg/dL (5.18 mmol/L) TG <200 mg/dL (2.26 mmol/L) |
AHA Step
II diet:  30% fat,
<7% saturated fat, <200 mg/d cholesterol. If target goal not
achieved, add drug therapy (eg, statin agent) if LDL >130 mg/dL
(3.37 mmol/L) and consider drug therapy if LDL 100–130 mg/dL
(2.59–3.37 mmol/L) |
| Alcohol |
Moderate
consumption (< or = 2
drinks/d) |
|
| Physical
activity |
30–60
minutes of activity at least 3–4 times/wk |
Moderate
exercise (eg, brisk walking, jogging, cycling, or other aerobic
activity) Medically supervised programs for high-risk patients (eg,
cardiac disease) |
| Weight |
< 120%
of ideal body weight for height. Check
ideal weight. |
Diet and
exercise |
| SBP
indicates systolic blood pressure; DBP, diastolic blood pressure;
AHA, American Heart Association; HDL, high-density lipoproteins; TC,
total cholesterol; and TG, triglycerides |
|
| Ischemic
Stroke Subtype |
Recommendations |
| Atherosclerotic
carotid disease |
|
>70%
stenosis |
Carotid
endarterectomy of definite benefit if done with acceptable
morbidity and mortality. Antiplatelet
agents |
| 50–69%
stenosis |
Carotid
endarterectomy of potential benefit depending on risk factors
Antiplatelet
agents |
| <50%
stenosis |
Carotid
endarterectomy of no benefit. Use Antiplatelet
agents |
| Intracranial artery
stenosis |
| 50 to 99% stenosis of an intracranial artery (carotid; anterior, middle, or posterior cerebral; vertebral; or basilar) |
Patients with TIA or stroke in the territory of the stenotic artery qualified for inclusion in the study. 88
treated with warfarin and 63 treated with aspirin. The rates of major vascular events were 18.1 per 100 patient-years of follow-up in the aspirin group compared with 8.4 per 100 patient-years of follow-up in the warfarin group.
(The Warfarin Aspirin Symptomatic Intracranial Disease Study.
Neurology. 1995 Aug;45(8):1488-93.) |
| Cardiac
embolism |
| Definite
source: |
Oral
anticoagulation (unless contraindicated): |
| Nonvalvular
atrial fibrillation |
INR
2–3 (target 2.5) lifelong therapy |
| Left
ventricular thrombus, recent Myocardial
infarction |
INR
2–3 (target 2.5) 6-month therapy |
| Prosthetic
Valvular heart disease |
INR
3–4 (target 3.5) lifelong therapy |
| Possible
cardiac source |
Antiplatelet
agents (oral anticoagulation undergoing evaluation) |
| Other
infarct subtypes including small-vessel lacunar disease and
cryptogenic stroke |
Antiplatelet
agents |
|
| |
Source,
study population & design |
Relative
risk reduction |
| Stroke |
Stroke/MI/Vascular
death |
| ASA: Acceptable dose 30-1300 mg per day |
|
Antiplatelet
Trialists meta-analysis. All high risk patients: ASA vs Placebo |
31% |
27% |
| Algre & van
Gijn mini meta analysis: stroke & TIA pateints, aspirin vs
placebo |
|
16% |
| Aggrenox: 25 asa/200 dipyridamole bid |
|
ESPS2: Stroke or
TIA. Aggrenox bid vs asa 25 mg bid |
23% |
|
| Plavix: 75 mg qd |
|
CAPRIE: recent
stroke, MI, peripheral vascular disease. Plavix vs 325 mg asa |
about the same with
aspirin |
7.6% |
|
| References & Further reading:
|
|
