AHA/ASA 2021 Guideline for the Prevention of Secondary Stroke

The American Heart Association/American Stroke Association (AHA/ASA) issued its most recent guideline for the prevention of stroke in patients with previous stroke and transient ischemic attack (TIA). The last guideline was published in 2014. The overall message of the 2021 update is that the risk of second stroke can be reduced with prevention efforts based on the cause of the first stroke. Identifying the cause or causes of the first stroke is key to developing strategies to prevent additional strokes, and it is essential for clinicians to collaboratively develop care plans with patients, incorporating patients’ wishes, goals, and concerns. The guideline features a new recommendation for healthcare professionals to perform diagnostic evaluations to determine the cause of the first stroke or TIA within 48 hours of symptom onset.

For patients who have survived a stroke or TIA, the secondary prevention guidelines recommend these three actions:

  • Managing their vascular risk factors, especially hypertension as well as type 2 diabetes, cholesterol and triglyceride levels, and not smoking.
  • Limiting salt intake and/or following a Mediterranean diet, which typically includes plenty of fruits, vegetables, bread and other grains, potatoes, beans, nuts, and seeds, and uses olive oil as a primary fat source; dairy products, eggs, fish, and poultry are consumed in low to moderate amounts (as opposed to red meat).
  • If capable of physical activity, engaging in moderate-intensity aerobic activity for at least 10 minutes four times a week or vigorous-intensity aerobic activity at least 30 minutes twice a week.

For healthcare professionals, the treatment recommendations highlight:

  • Using multidisciplinary teams to personalize care for patients and employing shared decision-making with patients to develop care plans that incorporate the patient’s wishes, goals, and concerns.
  • Screening for and diagnosing atrial fibrillation and starting blood-thinning medications to reduce recurrent events.
  • Prescribing antithrombotic therapy, including antiplatelet medications or anti coagulant medications, for nearly all patients without contraindications. However, the guidelines caution that the combination of antiplatelets and anticoagulation is typically not recommended for preventing second strokes. Dual antiplatelet therapy, taking aspirin along with a second medication to prevent blood clotting, is recommended short term only for patients with early arriving minor stroke and high-risk TIA or severe symptomatic stenosis.
  • Carotid endarterectomy or, in select cases, the use of a stent in the carotid artery for patients with narrowing arteries in the neck.

The guidelines state that aggressive management of risk factors and short-term dual antiplatelet therapy are preferred for patients with severe intracranial stenosis. In some cases, it is now reasonable to consider percutaneously closing a patent foramen ovale.