The 2014 update to the American Heart Association’s “Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack” is available here. These guideline documents are very long and detailed, which is good when you want to delve deep into the evidence base on a particular topic. When reading to familiarize yourself with the overall set of recommendations (eg., if you’re a junior resident) then I suggest reading the paragraphs in bold face type. These are the bottom line recommendations, such as:
Extracranial Vertebrobasilar Disease Recommendations
1. Routine preventive therapy with emphasis on antithrombotic therapy, lipid lowering, BP control, and lifestyle optimization is recommended for all patients with recently symptomatic extracranial vertebral artery stenosis (Class I; Level of Evidence C).
2. Endovascular stenting of patients with extracranial vertebral stenosis may be considered when patients are having symptoms despite optimal medical treatment (Class IIb; Level of Evidence C).
3. Open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, may be considered when patients are having symptoms despite optimal medical treatment (Class IIb; Level of Evidence C).
(Page 25). If you’re already familiar with the guidelines and are reading to keep abreast of the latest updates, (senior residents and up) table 1 has everything you need. A few highlights:
- Lipid guidelines have been revised to comport with the 2013 ACC/AHA cholesterol guideline, in particular the recommendation to start high-intensity statin therapy even in patients whose LDL is < 100 mg/dL.
- It is suggested that sleep studies and CPAP, if appropriate, be considered for stroke patients.
- The level of evidence supporting carotid stenting as an alternative to endarterectomy has been lowered from level I to level IIa on the basis of a recent Cochrane Review.
- The effect of age on the benefits of stenting versus endarterectomy are noted (i.e., for those aged < 70 years, stenting may indeed be equivalent to endarterectomy, but for those older, it may be associated with worse outcome).
- Adding clopidogrel to aspirin for 90 days (as was done in the SAMMPRIS trial) “may be reasonable” for stroke/TIA patients with high-grade intracranial atherosclerosis.
- Adding clopidogrel to aspirin, starting within 24 hours and continuing for 90 days (as was done in the CHANCE trial) “might be considered”. (Note that at our institution, we’re participating in the POINT study, a randomized trial of such intervention.