Más contenido relacionado


Stroke prevention (secondary).pptx

  1. Secondary prevention of stroke: What, when and how long? Stroke Foundation: PRABAHO
  2. Lifestyle modification Mediterranean type diet Daily sodium intake of less than 1.5g is ideal Atleast 10min of moderate intensity aerobic activity 4 times per week or atleast 20min of vigorous aerobic activity twice a week Smoking cessation Moderation of alcohol consumption
  3. Hypertension Target BP 130/80mmHg or less Start treatment if BP more than 130/80mmHg in patients without h/o hypertension
  4. Diabetes mellitus Target HbA1c 7% or less GLP1 receptor agonist and SGLT2 inhibitor reduces risk of stroke when added to metformin and lifestyle modification
  5. Dyslipidemia  Target LDL 70mg/dl or less  High intensity statin therapy is beneficial  Add ezetimibe if target not reached  Add PCSK9 inhibitor if LDL more than 70mg/dl despite statin+ezetimibe and patient has another major ASCVD or multiple high risk conditions
  6.  Icosapentethyl 2g BD for patients with triglyceride 135- 499mg/dl and LDL 41-100mg/dl on moderate-high intenisty statin therapy with HbA1c less than 10%, no h/o pancreatitis, AF, or severe heart failure  Identify and manage severe hypertriglyceridemia (TG level 500mg/dl or more) with very low fat diet, omega3 fatty acids, fibrates, and avoidance of refined carbohydrate and alcohol
  7. Antiplatelets  Aspirin 50-325mg/day or clopidogrel 75mg/day for non- cardioembolic stroke  Aspirin+Clopidogrel for minor (NIHSS 3 or less) non- cardioembolic stroke, high risk TIA (ABCD2 score 4 or more) or intracranial atheroslerosis. Should be initiated within 7 days (ideally within 24 hours) and continued for 21 days in case of minor stroke or high risk TIA. In case of ICAD, it should be initiated within 30 days and continued upto 90 days.
  8.  Aspirin+Ticagrelor for non-cardioembolic stroke with NIHSS 5 or less, TIA with ABCD2 score 6 or more, or symptomatic intra/extracranial stenosis more than 30%. Should be initiated within 24 hours and continued for 30 days.  Cilostazol 200mg/day may be added to aspirin or clopidogrel for stroke/TIA due to 50-99% stenosis of major intracranial artery  Single antiplatelet should be continued after completion of dual antiplatelet therapy
  9. Anticoagulants Indicated in stroke patients having Atrial fibrillation or flutter Mechanical heart valve or assist device LA/LV thrombus (for 3 months) Anterior AMI with EF less than 50% (for 3 months) Congenital cyanotic heart disease Extracranial carotid/vertebral dissection Antiphospholipid syndrome
  10. Special situations
  11. Apixaban and warfarin can be used for secondary prevention of stroke in ESRD patients with AF Anticoagulants should be continued even in patients with high HASBLED score (3 or more) but needs close monitoring at more frequent intervals
  12. In patients with AF and LASO, OAC only is preferred over OAC+Antiplatelets if there is complete occlusion of the carotid artery In patients with AF and LASO, OAC + Antiplatelets may be beneficial compared to OAC alone if there is moderate to severe stenosis of the carotid artery
  13. In patients with stroke and AF who underwent recent carotid artery stenting, NOAC + P2Y12 inhibitor is preferred over triple therapy or DAPT or OAC alone In patients with lacunar stroke and AF, OAC alone may not be sufficient to prevent small vessel stroke. NOAC plus antiplatelets may be required along with lifestyle modification and control of diabetes and hypertension
  14. In patients with stroke and SDH, resumption of antithrombotic therapy may be attempted within 2-14 days after SDH. Resume early if thrombotic risk high and bleeding risk low. Resume late if thrombotic risk low and bleeding risk high. In stroke patients with low EF (less than 30%) who are in sinus rhythm, anticoagulation reduces stroke risk at the expense of bleeding risk
  15. Surgical/Endovascular Intervention  Carotid endarterectomy for TIA or nondisabling stroke within 6 months and ipsilateral 70-99% (50-69% in selected cases) extracranial carotid stenosis  Carotid stenting if surgical risk is high  Procedure should be done ideally within 2 weeks of the event (CEA preferred over CAS if within 1 week)
  16. LA appendage closure in ischemic stroke/TIA with nonvalvular AF if there is contraindication for lifelong anticoagulation. Surgery in ischemic stroke/TIA and native left-sided valve endocarditis with mobile vegetations more than 10mm in length. PFO closure in 18-60 years old patients with nonlacunar ischemic stroke of undetermined cause and high risk anatomic features of PFO
  17. Resection of left-sided cardiac tumor in patients with stroke/TIA Endovascular intervention in patients with ischemic stroke/TIA due to extracranial carotid/vertebral artery dissection if recurrent events despite antithrombotics Carotid stenting/endarterectomy in patients with carotid web or fibromuscular dysplasia and ischemic stroke on the same side refractory to medical management