Identifying the cause of a first stroke, whether it is blocked blood vessels or a transient ischemic attack (TIA), and then developing multidisciplinary strategies to mitigate those causes are key steps for preventing future strokes, according to new clinical practice guidelines published in Stroke.

A new recommendation for health care professionals in the American Heart Association (AHA)/American Stroke Association (ASA) 2021 guidelines is to perform diagnostic evaluations within 48 hours of symptom onset of a first stroke or TIA to determine the cause or causes. The guideline includes cause-based treatment recommendations.

Because approximately 87% of strokes in the United States are ischemic, the guidelines include a new section detailing recommendations for performing a diagnostic workup after ischemic stroke, determining the etiology of ischemic stroke when possible, and identifying treatment targets to reduce the risk for recurrence.

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Managing vascular risk factors of patients with a history of stroke is important. Prevention should include quitting smoking and managing type 2 diabetes, lipids, and especially hypertension. The recommendations include consuming a Mediterranean diet and/or a diet low in sodium, getting regular physical activity, and avoiding prolonged sitting.

Programs employing theoretical behavioral models, proven techniques for change, and multidisciplinary support are needed. Multidisciplinary teams should provide intensive personalized patient care and shared decision-making.

Patients should be screened for atrial fibrillation, a common condition that puts patients at high risk for stroke. Patients diagnosed with atrial fibrillation should be started on blood-thinners to reduce recurrent stroke events.

Antithrombotic therapy, including antiplatelet medications or anticoagulant medications, should be prescribed for nearly all stroke survivors who do not have contraindications. Combining antiplatelet and anticoagulation medications, however, is not typically recommended for second stroke prevention, and dual antiplatelet therapy should be only a short-term solution for patients with high-risk TIA and early arriving minor stroke or severe symptomatic intracranial stenosis.

An important treatable cause of stroke is extracranial carotid artery disease. The guidelines suggest that patients who are appropriate candidates should have the stenosis fixed relatively early after their ischemic stroke. Clinicians should consider carotid endarterectomy, surgical blockage removal, or in select cases, a stent placed in the carotid artery. These choices should be driven by comorbidities and features of the patient’s vascular anatomy.

Angioplasty and stenting are not recommended as first-line therapies for patients with severe intracranial stenosis in the vascular territory of the TIA or ischemic stroke. Aggressive medical management of stroke risk factors and short-term dual antiplatelet therapy are preferable.

Since the previous guideline in 2014, several studies have assessed secondary stroke prevention of patent foramen ovale closure. It is currently considered reasonable to percutaneously close patent foramen ovale in younger patients with nonlacunar stroke or patients of any age with strokes of no other cause.

Patients diagnosed with embolic stroke of uncertain source should not be empirically treated with ticagrelor or anticoagulants, as they were found to be of no benefit.

 “Although this document provides guidance based on a review of the literature, it is essential for clinicians to collaboratively develop care plans with patients, incorporating patients’ wishes, goals, and concerns,” the study authors stated.

Disclosure: Some guideline authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: a guideline from the American Heart Association/American Stroke Association. Stroke. Published online May 24, 2021. doi:10.1161/STR.0000000000000375

This article originally appeared on The Cardiology Advisor