Stroke Stroke is available at www.ahajournals.org/journal/str AHA/ASA GUIDELINE 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 Reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Endorsed by the Society of Vascular and Interventional Neurology The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Dawn O. Kleindorfer, MD, FAHA, Chair; Amytis Towfighi, MD, FAHA, Vice Chair; Seemant Chaturvedi, MD, FAHA; Kevin M. Cockroft, MD, MSc, FAHA; Jose Gutierrez, MD, MPH; Debbie Lombardi-Hill, BS, FAHA; Hooman Kamel, MD; Walter N. Kernan, MD*; Steven J. Kittner, MD, MPH, FAHA; Enrique C. Leira, MD, MS, FAHA; Olive Lennon, PhD; James F. Meschia, MD, FAHA; Thanh N. Nguyen, MD, FAHA; Peter M. Pollak, MD; Pasquale Santangeli, MD, PhD; Anjail Z. Sharrief, MD, MPH, FAHA; Sidney C. Smith Jr, MD, FAHA; Tanya N. Turan, MD, MS, FAHA ; Linda S. Williams, MD, FAHA Key Words: AHA Scientific Statements ischemic attack, transient secondary prevention stroke TOP 10 TAKE-HOME MESSAGES FOR THE SECONDARY STROKE PREVENTION GUIDELINE 1. Specific recommendations for prevention strate- gies often depend on the ischemic stroke/tran- sient ischemic attack subtype. Therefore, new in this guideline is a section describing recommen- dations for the diagnostic workup after ischemic stroke, to define ischemic stroke etiology (when possible), and to identify targets for treatment in order to reduce the risk of recurrent ischemic stroke. Recommendations are now grouped by etiologic subtype. 2. Management of vascular risk factors remains extremely important in secondary stroke preven- tion, including (but not limited to) diabetes, smok- ing cessation, lipids, and especially hypertension. Intensive medical management, often performed by multidisciplinary teams, is usually best, with goals of therapy tailored to the individual patient. 3. Lifestyle factors, including healthy diet and physi- cal activity, are important for preventing a second stroke. Low-salt and Mediterranean diets are rec- ommended for stroke risk reduction. Patients with stroke are especially at risk for sedentary and prolonged sitting behaviors, and they should be encouraged to perform physical activity in a super- vised and safe manner. 4. Changing patient behaviors such as diet, exercise, and medication compliance requires more than just simple advice or a brochure from their physician. Programs that use theoretical models of behavior change, proven techniques, and multidisciplinary support are needed. 5. Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all patients without contraindications. With very few exceptions, the combination of antiplatelets and anticoagulation is typically not indicated for sec- ondary stroke prevention. Dual antiplatelet therapy is not recommended long term, and short term, dual *AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guidelines Liaison. AAN Representative. AHA Stroke Council Scientific Statement Oversight Committee Members, see page e436. 2021 American Heart Association, Inc. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer antiplatelet therapy is recommended only in very specific patients, including those with early arriv- ing minor stroke and high-risk transient ischemic attack or severe symptomatic intracranial stenosis. 6. Atrial fibrillation remains a common and high- risk condition for second ischemic stroke. Anticoagulation is usually recommended if the patient has no contraindications. Heart rhythm monitoring for occult atrial fibrillation is usu- ally recommended if no other cause of stroke is discovered. 7. Extracranial carotid artery disease is an important and treatable cause of stroke. Patients with severe stenosis ipsilateral to a nondisabling stroke or transient ischemic attack who are candidates for intervention should have the stenosis fixed, likely relatively early after their ischemic stroke. The choice between carotid endarterectomy and carotid artery stenting should be driven by specific patient comor- bidities and features of their vascular anatomy. 8. Patients with severe intracranial stenosis in the vascular territory of ischemic stroke or transient ischemic attack should not receive angioplasty and stenting as a first-line therapy for preventing recur- rence. Aggressive medical management of risk factors and short-term dual antiplatelet therapy are preferred. 9. There have been several studies evaluating sec- ondary stroke prevention of patent foramen ovale closure since the previous guideline in 2014. It is now considered reasonable to percutaneously close patent foramen ovale in patients who meet each of the following criteria: age 18 60 years, nonlacunar stroke, no other identified cause, and high risk patent foramen ovale features. 10. Patients with embolic stroke of uncertain source should not be treated empirically with anticoagu- lants or ticagrelor because it was found to be of no benefit. PREAMBLE Since 1990, the American Heart Association (AHA)/ American Stroke Association (ASA)* have translated sci- entific evidence into clinical practice guidelines with rec- ommendations to improve cerebrovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cerebrovascular care. The AHA/ ASA sponsor the development and publication of clinical practice guidelines without commercial support, and mem- bers volunteer their time to the writing and review efforts. Clinical practice guidelines for stroke provide rec- ommendations applicable to patients with or at risk of developing cerebrovascular disease. The focus is on medical practice in the United States, but many aspects are relevant to patients throughout the world. Although it must be acknowledged that guidelines may be used to inform regulatory or payer decisions, the core intent is to improve quality of care and to align with patients inter- ests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment; furthermore, the recommendations set forth should be considered in the context of individual patient values, preferences, and associated conditions. The AHA/ASA strive to ensure that guideline writing groups contain requisite expertise and are representative of the broader medical community by selecting experts from a broad array of backgrounds, representing differ- ent sexes, races, ethnicities, intellectual perspectives, geographic regions, and scopes of clinical practice and by inviting organizations and professional societies with related interests and expertise to participate as endors- ers. The AHA/ASA have rigorous policies and methods for development of guidelines that limit bias and prevent improper influence. The complete policy on relationships with industry and other entities can be found at https:// professional.heart.org/-/media/phd-files/guidelines-and- statements/policies-devolopment/aha-asa-disclosure- rwi-policy-5118.pdf?la=en. Beginning in 2017, numerous modifications to the guidelines have been implemented to make guidelines shorter and to enhance user friendliness. Guidelines are written and presented in a modular knowledge chunk format, in which each chunk includes a table of recom- mendations, a brief synopsis, recommendation-specific supportive text, and, when appropriate, flow diagrams or additional tables. Hyperlinked references are provided for each modular knowledge chunk to facilitate quick access and review. Other modifications to the guidelines include the addition of Knowledge Gaps and Future Research segments in some sections and a web guideline supple- ment (Data Supplement) for useful but noncritical tables and figures. Sepideh Amin-Hanjani, MD, FAHA Immediate Past Chair, AHA Stroke Council Scientific Statement Oversight Committee Joseph P. Broderick, MD, FAHA Chair, AHA Stroke Council Scientific Statement Oversight Committee Each year, 795000 individuals in the United States experience a stroke, of which 87% (690000) are isch- emic and 185000 are recurrent.1 individuals experience a transient ischemic attack (TIA) The risk of recurrent stroke or TIA is high but can be mitigated with appropriate secondary stroke *The American Stroke Association is a division of the American Heart Association. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer prevention. In fact, cohort studies have shown a reduc- tion in recurrent stroke and TIA rates in recent years as secondary stroke prevention strategies have improved.3,4 A meta-analysis of randomized controlled trials (RCTs) of secondary stroke prevention therapies published from 1960 to 2009 showed a reduction in annual stroke recurrence from 8.7% in the 1960s to 5.0% in the 2000s, with the reduction driven largely by improved blood pressure (BP) control and use of antiplatelet ther- The changes may have been influenced by changes in diagnostic criteria and differing sensitivities of diag- nostic tests over the years. The overwhelming majority of strokes can be pre- vented through BP control, a healthy diet, regular physi- cal activity, and smoking cessation. In fact, 5 factors BP, diet, physical inactivity, smoking, and abdominal obe- sity accounted for 82% and 90% of the population- attributable risk (PAR) for ischemic and hemorrhagic stroke in the INTERSTROKE study (Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries).5a Similarly, the Global Burden of Disease Study showed that 90.5% (95% uncertainty interval, 88.5 92.2) of the global burden of stroke was attributable to modifiable risk factors.6 A modeling study showed that targeting multiple risk factors has additive benefits for secondary prevention; specifically, aspirin, statin, and antihypertensive medi- cations, combined with diet modification and exercise, can result in an 80% cumulative risk reduction in recur- rent vascular events.7 Although the benefits of a healthy lifestyle and vascular risk factor control are well docu- risk factors remain poorly controlled among 1.1. Methodology and Evidence Review This guideline provides a comprehensive yet succinct compilation of practical guidance for the secondary prevention of ischemic stroke or TIA (ie, prevention of ischemic stroke or TIA in individuals with a history of stroke or TIA). We aim to promote optimal dissemina- tion of information by using concise language and for- matting. The recommendations listed in this guideline are, whenever possible, evidence based and supported by an extensive evidence review. A search for literature derived from research involving human subjects, pub- lished in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases rel- evant to this guideline was conducted between July 2019 and February 2020. Additional trials published between February and June 2020 that affected the guideline recommendations were also included. For specific search terms used, please see the Data Sup- plement, which also contains the final evidence tables that summarize the evidence used by the guideline writ- ing group to formulate recommendations. References selected and published in the present document are representative and not all inclusive. An independent Evidence Review Committee was commissioned to perform a formal systematic review of a critical clinical question (Table 1) related to secondary stroke prevention, the results of which were considered by the writing group for incorporation into the present guideline. Concurrently with this process, writing group members evaluated study data relevant to the rest of the guideline. The results of these evidence reviews were evaluated by the writing group for incorporation into the present guideline. Each topic area was assigned a primary author and a primary, and sometimes secondary, reviewer. Author assignments were based on the areas of expertise of the members of the writing group members and their lack of any relationships with industry related to the sec- tion material. All recommendations were fully reviewed and discussed among the full committee to allow diverse perspectives and considerations for this guideline. Rec- ommendations were then voted on to reach consensus. The systematic review has been published in conjunc- tion with this guideline and includes its respective data 1.2. Organization of the Writing Group The writing group consisted of neurologists, neurological surgeons, cardiologists, internists, and a lay/patient rep- resentative. The writing group included representatives from the AHA/ASA and the American Academy of Neu- rology. Appendix 1 lists writing group members relevant relationships with industry and other entities. For the pur- poses of full transparency, the writing group members comprehensive disclosure information is available online. 1.3. Document Review and Approval This document was reviewed by the AHA s Stroke Coun- cil Scientific Statement Oversight Committee; the AHA s Science Advisory and Coordinating Committee; the AHA s Executive Committee; reviewers from the Ameri- can Academy of Neurology, from the Society of Vascu- lar and Interventional Neurology, and from the American Association of Neurological Surgeons and Congress of Neurological Surgeons; as well as by 55 individual con- tent reviewers. The individual reviewers relationships with industry information is available in Appendix 2. This document was approved for publication by the governing bodies of the ASA and the AHA. It was reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons and Congress of Neurological Surgeons, was endorsed by the Society of Vascular and Interventional Neurology, and the American Academy of Neurology affirmed the value of the guideline. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer 1.4. Scope of the Guideline The aim of the present guideline is to provide clinicians with evidence-based recommendations for the preven- tion of future stroke among survivors of ischemic stroke or TIA. It should be noted that this guideline does not cover the following topics, which have been addressed elsewhere: Acute management decisions (covered in the 2019 Update to the 2018 Guidelines for the Early Management of Patients With Acute Ischemic ), Intracerebral hemorrhage (ICH; covered in the Guidelines for the Management of Spontaneous ), Primary prevention (covered in the Guidelines for the Primary Prevention of Stroke 18 and 2019 American College of Cardiology/ American Heart Association Guideline on the Primary Prevention of Cardiovascular ), Special considerations for stroke prevention in women (covered in the Guidelines for the Prevention of Stroke in Women 20 ), and Cerebral venous sinus thrombosis (covered in Diagnosis and Management of Cerebral Venous ). In general, with very few exceptions, the literature sup- ports the concept that patients with TIA and those with ischemic stroke should be treated the same in terms of secondary prevention. This guideline is divided into 4 sections: Diagnostic Evaluation for Secondary Stroke Prevention 2. Vascular Risk Factor Management 3. Management by Etiology Systems of Care for Secondary Ischemic Stroke Prevention. The structure and scope of this guideline differ from those of the 2014 Guidelines for the prevention of stroke in patients with stroke and TIA9 in several ways. First, the current guideline reflects numerous innova- tions and modifications that were incorporated into the AHA clinical practice guideline format. Introduced in 2017, modifications to AHA guidelines included making the text shorter and more user friendly; focusing guide- lines on recommendations and patient management flow diagrams and less on extensive text and back- ground information; formatting guidelines so that they can be easily updated with guideline focused updates; and including chunks of information after each rec- Second, the Diagnostic Evaluation and Systems of Care for Secondary Prevention sections are new. The Diagnostic Evaluation for Secondary Stroke Prevention section focuses on the evidence base for laboratory and imaging studies for guiding secondary stroke prevention decisions. Often these tests are com- pleted in the inpatient setting. The Systems of Care for Secondary Prevention section contains 3 subsections: (1) Health Systems Based Interventions for Secondary Stroke Prevention, (2) Interventions Aimed at Chang- ing Patient Behavior, and (3) Health Equity. The Health Equity subsection is a refocus of the 2014 guideline s section guiding management of high-risk populations. Third, this guideline does not include a separate section on metabolic syndrome because there are no unique recommendations for metabolic syndrome aside from managing each of the individual components of the syn- drome. Fourth, the section on alcohol use was expanded to include the use of other substances. Finally, several additional conditions were included in the Management by Etiology section: congenital heart disease, cardiac tumors, moyamoya disease, migraine, malignancy, vas- culitis, other genetic disorders, carotid web, fibromus- cular dysplasia, dolichoectasia, and embolic stroke of undetermined source (ESUS). In developing the 2021 secondary stroke prevention guideline, the writing group reviewed prior published AHA/ASA guidelines and scientific statements. Table 2 contains a list of these other guidelines and statements deemed pertinent to this writing effort and is intended for use as a reader resource, thus reducing the need to repeat existing guideline recommendations. 1.5. Class of Recommendation and Level of Evidence Recommendations are designated both a Class of Rec- ommendation (COR) and a Level of Evidence (LOE). The COR indicates the strength of recommendation, encom- passing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the quality of scien- tific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 3). Numerous studies have evaluated strategies for stroke prevention in individuals without a history of stroke/TIA (ie, primary prevention studies) or included individuals with a history of stroke/TIA mixed into the pools of patients studied in smaller numbers. After care- fully reviewing the literature and discussing with AHA methodologists, the writing group decided that many of these prevention strategies were important to include Table 1. Evidence Review Committee Question Question No. Question Section No. 1 In patients with an ischemic stroke or TIA, what are the benefits and risks of DAPT compared to single antiplatelet therapy within 5 y for prevention of recurrent stroke? DAPT indicates dual antiplatelet therapy; and TIA, transient ischemic attack. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer in any guideline on the prevention of recurrent stroke. There is often no reason to think that the mechanism of stroke prevention and benefits would be different in pri- mary versus secondary prevention, although not studied within a purely secondary stroke prevention trial. There- fore, this writing group occasionally includes recommen- dations with evidence based in the primary prevention of atherosclerotic cardiovascular disease (ASCVD), athero- sclerosis, or combined end points of cardiac disease and stroke in this guideline. To acknowledge that some studies were not performed in a purely ischemic stroke population, the LOE was down- graded. In this way, the writing group agreed that this would provide the best and most complete recommendations to the clinician about important strategies for secondary stroke prevention. Principles guiding inclusion and extrapo- lation of the results of these studies were as follows: 1. The quality of the trial/trials was acceptable. (Ideally, stroke or TIA occurrence or recurrence was a prespecified end point, with clear protocols for assessing stroke end points.) 2. From a physiological perspective, the primary pre- vention strategy used in the study will likely be effective for secondary prevention. 3. Patients with ischemic stroke were included in the population studied when possible. Table 2. Associated AHA/ASA Guidelines and Statements Title Organization Publication year AHA/ASA guidelines Guidelines for Carotid Endarterectomy24 Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease25 ASA/ACCF/AHA/AANN/ AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/ SVM/SVS Guideline on Lifestyle Management to Reduce Cardiovascular Risk26 Guideline for the Management of Overweight and Obesity in Adults27 Guideline for the Management of Patients With Atrial Fibrillation28 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage17 Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack9 Guidelines for the Prevention of Stroke in Women20 Guidelines for the Primary Prevention of Stroke18 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults29 ACC/AHA/AAPA/ABC/ ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the Management of Adults With Congenital Heart Disease30 Guideline on the Management of Blood Cholesterol31 AHA/ACC/AACVPR/AAPA/ ABC/ACPM/ADA/AGS/ APhA/ASPC/NLA/PCNA Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke16 Guideline on the Primary Prevention of Cardiovascular Disease19 Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation32 Guideline for the Management of Patients With Valvular Heart Disease33 AHA/ASA statements Diagnosis and Management of Cerebral Venous Thrombosis22 Cervical Arterial Dissections and Association With Cervical Manipulative Therapy21 Physical Activity and Exercise Recommendations for Stroke Survivors34 Spontaneous Coronary Artery Dissection: Current State of the Science34a AHA/ASA presidential advisory Defining Optimal Brain Health in Adults35 AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AANN, American Association of Neuroscience Nurses; AANS, American Association of Neurological Surgeons; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiol- ogy; ACCF, American College of Cardiology Foundation; ACPM, American College of Preventive Medicine; ACR, American College of Radiology; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; ASA, American Stroke Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASNR, American Society of Neuroradiology; ASPC, American Society for Preventive Cardiology; CNS, Congress of Neurological Surgeons; HRS, Heart Rhythm Society; NLA, National Lipid Association; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; SAIP, Society of Atherosclerosis Imaging and Prevention; SCAI, Society for Cardiovascular Angiography and Interventions; SIR, Society of Interventional Radiology; SNIS, Society of NeuroInterventional Surgery; SVM, Society for Vascular Medicine; SVS, Society for Vascular Surgery; and TOS, The Obesity Society. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer Abbreviation Meaning/Phrase ACC American College of Cardiology ACS acute coronary syndrome ACTIVE W Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events AF atrial fibrillation AHA American Heart Association AHI apnea-hypopnea index ARCH Aortic Arch Related Cerebral Hazard Trial ARISTOTLE Apixaban for Reduction in Stroke and Other Thrombo- embolic Events in Atrial Fibrillation ASA American Stroke Association ASAP Addressing Sleep Apnea Post Stroke/TIA ASTRO-APS Apixaban for Secondary Prevention of Thromboembo- lism Among Patients With Antiphospholipid Syndrome ASCVD atherosclerotic cardiovascular disease BMI body mass index BP blood pressure BUST-Stroke Breaking Up Sitting Time After Stroke CADISS Cervical Artery Dissection in Stroke Study CARDIA Coronary Artery Risk Development in Young Adults CAP Continued Access Registry CAPRIE Clopidogrel Versus Aspirin in Patients at Risk of Ischaemic Events CAS carotid artery stenting CATHARSIS Cilostazol-Aspirin Therapy Against Recurrent Stroke With Intracranial Artery Stenosis CEA carotid endarterectomy CHANCE Clopidogrel in High-Risk Patients With Acute Non- Disabling Cerebrovascular Events CICAS Chinese Intracranial Atherosclerosis CLAIR Clopidogrel Plus Aspirin for Infarction Reduction CLOSE Patent Foramen Ovale Closure or Anticoagulants Ver- sus Antiplatelet Therapy to Prevent Stroke Recurrence CNS central nervous system COMMANDER HF A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction or Stroke in Participants With Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure COMPASS Cardiovascular Outcomes for People Using Anticoagu- lation Strategies COR Class of Recommendation COSS Carotid Occlusion Surgery Study CPAP continuous positive airway pressure CREST Carotid Revascularization Endarterectomy versus Stenting Trial CSPS Cilostazol for Prevention of Secondary Stroke CT computed tomography CTA computed tomographic angiography CVD cardiovascular disease DAPT dual antiplatelet therapy DASH Dietary Approaches to Stop Hypertension DCCT Diabetes Control and Complication Trial DESERVE Discharge Educational Strategies for Reduction of Vascular Events DHA docosahexaenoic acid DiRECT Diabetes Remission Clinical Trial DOAC direct-acting oral anticoagulant ECST European Carotid Surgery Trial EF ejection fraction ENGAGE Global Study to Assess the Safety and Effective- ness of Edoxaban (DU-176b) vs Standard Practice of Dosing With Warfarin in Patients With Atrial Fibrillation EPA eicosapentaenoic acid EPIC-CVD European Prospective Investigation into Cancer and Nutrition-CVD case-cohort study ESH-CHL-SHOT European Society of Hypertension and Chinese Hypertension League Stroke in Hypertension Optimal Treatment Trial ESPRIT European/Australasian Stroke Prevention in Reversible Ischaemia Trial ESPS2 Second European Stroke Prevention Study ESUS embolic stroke of undetermined source ExStroke Physical Exercise After Acute Ischaemic Stroke FASTEST Efficacy and Safety of a TIA/Stroke Electronic Support Tool FMD fibromuscular dysplasia FOURIER Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk GELIA German Experience With Low Intensity Anticoagulation HR hazard ratio ICA internal carotid artery ICARUSS Integrated Care for the Reduction of Secondary Stroke ICAS intracranial atherosclerotic stenosis ICH intracerebral hemorrhage IE infective endocarditis IMPROVE-IT Improved Reduction of Outcomes: Vytorin Efficacy International Trial INR international normalized ratio INSPiRE-TMS Intensified Secondary Prevention Intending a Reduction of Recurrent Events in TIA and Minor Stroke Patients IPE icosapent ethyl IRIS Insulin Resistance Intervention After Stroke JAM Japan Adult Moyamoya JELIS Japan EPA Lipid Intervention Study LDL low-density lipoprotein LDL-C low-density lipoprotein cholesterol LOE Level of Evidence LV left ventricular LVAD left ventricular assist devices MACE major adverse cardiovascular event MD mean difference MI myocardial infarction MIST Motivational Interviewing in Stroke MRA magnetic resonance angiography MRI magnetic resonance imaging NAILED Stroke Nurse Based Age Independent Intervention to Limit Evolution of Disease After Stroke Abbreviation Meaning/Phrase CLINICAL STATEMENTS AND GUIDELINES Kleindorfer NASCET North American Symptomatic Carotid Endarterectomy Trial NAVIGATE ESUS Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source NIHSS National Institutes of Health Stroke Scale ODYSSEY OUTCOMES Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab OMEMI Omega-3 Fatty Acids in Elderly Patients With Acute Myocardial Infarction OR odds ratio OSA obstructive sleep apnea OXVASC Oxford Vascular Study PAR population-attributable risk PAST-BP Prevention After Stroke Blood Pressure PCSK9 proprotein convertase subtilisin/kexin type 9 PFO patent foramen ovale PODCAST Prevention of Decline in Cognition after Stroke Trial POINT Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke PRAISE Prevent Recurrence of All Inner-City Strokes Through Education PREDIMED Prevenci n con Dieta Mediterr nea PREVAIL Prospective Randomised Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy PREVENTION Preventing Recurrent Vascular Events in Patients With Stroke or Transient Ischemic Attack PRoFESS Prevention Regimen for Effectively Avoiding Second Strokes PROTECT AF Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation PTAS percutaneous transluminal angioplasty and stenting RCT randomized controlled trial RE-ALIGN Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients After Heart Valve Replacement RE-LY Randomized Evaluation of Long-Term Anticoagulant Therapy REDUCE-IT Reduction of Cardiovascular Events With Icosapent Ethyl Intervention Trial REGARDS Reasons for Geographic and Racial Differences in Stroke Study RESPECT Randomized Evaluation of Recurrent Stroke Compar- ing PFO Closure to Established Current Standard of Care Treatment RESPECT ESUS Dabigatran Etexilate for Secondary Stroke Preven- tion in Patients With Embolic Stroke of Undetermined Source RISE-UP Recovery in Stroke Using PAP ROCKET AF Rivaroxaban Once Daily Oral Direct Factor Xa Inhibi- tion Compared With Vitamin K Antagonism for Preven- tion of Stroke and Embolism Trial in Atrial Fibrillation RR relative risk SAMMPRIS Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis SAPPHIRE Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy SAPT single antiplatelet therapy SAVE Sleep Apnea Cardiovascular Endpoints SBP systolic blood pressure SCD sickle cell disease SIT Silent Cerebral Infarct Transfusion multi-center clinical trial Sleep SMART Sleep for Stroke Management and Recovery Trial SMART Second Manifestations of Arterial Disease SOCRATES Soluble Guanylate Cyclase Stimulator in Heart Failure Studies SPAF Stroke Prevention in Atrial Fibrillation Study SPARCL Stroke Prevention by Aggressive Reduction in Choles- terol Levels SPS3 Secondary Prevention of Small Subcortical Strokes STANDFIRM Shared Team Approach Between Nurses and Doctors for Improved Risk Factor Management for Stroke Patients STOP Stroke Prevention Trial in Sickle Cell Anemia SUCCEED Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities SUSTAIN Systemic Use of Stroke Averting Interventions STRENGTH Outcomes Study to Assess Statin Residual Risk Reduction With Epanova in High CV Risk Patients With Hypertriglyceridemia SWiTCH Stroke With Transfusions Changing to Hydroxyurea TARDIS Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke TCAR transcarotid artery revascularization TCD transcranial Doppler TEE transesophageal echocardiography THALES Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death TIA transient ischemic attack TOSS Trial of Cilostazol in Symptomatic Intracranial Arterial Stenosis TST Treat Stroke to Target TWiTCH TCD With Transfusions Changing to Hydroxyurea UKPDS United Kingdom Prospective Diabetes Study VAST Vertebral Artery Stenting Trial VHD valvular heart disease VISP Vitamin Intervention for Stroke Prevention VISSIT Vitesse Intracranial Stent Study for Ischemic Stroke Therapy VIST Vertebral Artery Ischemic Stenting Trial VISTA Virtual International Stroke Trials Archive VITATOPS Vitamins to Prevent Stroke VKA vitamin K antagonist VLDL very-low-density lipoprotein VZV varicella zoster virus WARCEF Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction WARSS Warfarin-Aspirin Recurrent Stroke Study WASID Warfarin-Aspirin Symptomatic Intracranial Disease WEAVE Wingspan Stent System Post Market Surveillance Abbreviation Meaning/Phrase Abbreviation Meaning/Phrase CLINICAL STATEMENTS AND GUIDELINES Kleindorfer 2. GENERAL CONCEPTS Figure 1 illustrates the writing group s conceptual repre- sentation of ischemic stroke subtypes. Lacunar stroke: Lacunar syndrome, with normal com- puted tomography (CT)/magnetic resonance imaging (MRI) or subcortical stroke measuring <1.5 cm in diam- eter on CT or MRI. Most, although not all, of lacunar strokes are due to small vessel disease. Stroke attributable to small vessel disease: Subcorti- cal stroke measuring <1.5 cm in diameter on CT or MRI without evidence of a concomitant cortical infarct. Cardioembolic stroke: Stroke attributable to arte- rial occlusion from an embolus that presumably arose in the heart. Clinical and brain imaging find- ings are similar to those described in large artery atherosclerosis. Evidence of a previous TIA or stroke in >1 vascular territory supports a clinical diagnosis of cardioembolic stroke. Cryptogenic stroke: An imaging-confirmed stroke with unknown source despite thorough diagnostic assess- ment (including, at a minimum, arterial imaging, echo- cardiography, extended rhythm monitoring, and key laboratory studies such as a lipid profile and hemoglobin A1c [HbA1c]). Stroke caused by large artery atherosclerosis: Ischemic stroke in the vascular distribution of a major intracranial or extracranial artery with >50% stenosis or occlusion on vascular imaging. Clinical findings include those of Table 3. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* CLINICAL STATEMENTS AND GUIDELINES Kleindorfer cerebral cortical involvement or brainstem or cerebellar dysfunction. Cortical and cerebellar lesions and brain- stem or subcortical lesions >1.5 cm are considered potentially caused by large artery atherosclerosis. Diag- nostic studies should exclude potential sources of car- dioembolic embolism. ESUS: A stroke that appears nonlacunar on neu- roimaging without an obvious source after a minimum standard evaluation (including arterial imaging, echocar- diography, extended rhythm monitoring, and key labora- tory studies such as a lipid profile and HbA1c) to rule out known stroke etiologies such as cardioembolic sources and atherosclerosis proximal to the stroke.39 A diagnosis of ESUS implies that the stroke is embolic in origin, given the nonlacunar location; however, the source of the embolus is unknown, despite a minimal standard evaluation. Although cryptogenic stroke simi- larly implies that the cause of the origin is unknown, the stroke is not necessarily embolic. Individuals with ESUS have cryptogenic stroke, but the converse is not always the case. 2.2. Shared Decision-Making Shared decision-making is a key component of patient-centered care. It is a process in which clini- cians describe options, provide information on risks and benefits, assist patients in evaluating those options based on their personal goals and concerns, and facili- tate deliberation and decision-making. Although this document provides guidance based on a review of the literature, it is essential for clinicians to collabora- tively develop care plans with patients, incorporating patients wishes, goals, and concerns. Treatment should always be tailored to patients individ- ual situations. Therefore, as a rule, we did not include the statement unless contraindicated in the recommenda- tions. It is implicit that if a recommendation is contra- indicated in a patient s circumstance, it should not be implemented. Figure 1. Conceptual representation of ischemic stroke subtypes. Percentages are approximate and are informed by Kolominsky-Rabas et al36 and Gardener et al.37 Precise percentages will depend on extent of testing and patient populations. Ischemic stroke subtype definitions are informed by the TOAST (Trial of Org 10172 in Acute Stroke Treatment) unless otherwise indicated. ESUS indicates embolic stroke of undetermined source. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer A key component of secondary stroke prevention is assessing and addressing barriers to adherence to medi- cations and a healthy lifestyle. If a patient has a recurrent stroke while on secondary stroke prevention medica- tions, it is vital to assess whether they were taking the medications that they were prescribed and, if possible, to explore and address factors that contributed to non- adherence before assuming that the medications were ineffective. 2.5. Antithrombotic Dosing Unless stated otherwise in the recommendations herein, the international normalized ratio (INR) goal for warfarin is 2.0 to 3.0 and the dose of aspirin is 81 to 325 mg. 2.6. Application Across Populations Unless otherwise indicated, the recommendations in this guideline apply across race/ethnicity, sex, and age groups. Special considerations to address health equity are delineated in section 6.3, Health Equity. 3. DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION Recommendations for Diagnostic Evaluation Referenced studies that support recommendations are summarized in online Data Supplements 1 and 2. COR LOE Recommendations In patients suspected of having a stroke or TIA, an ECG is recommended to screen for atrial fibrillation (AF) and atrial flutter and to assess for other concomitant cardiac condi- In patients with ischemic stroke or TIA, a diag- nostic evaluation is recommended for gaining insights into the etiology of and planning opti- mal strategies for preventing recurrent stroke, with testing completed or underway within 48 hours of onset of stroke symptoms.42 45 In patients with symptomatic anterior circulation cerebral infarction or TIA who are candidates for revascularization, noninva- sive cervical carotid imaging with carotid ultrasonography, CT angiography (CTA), or magnetic resonance angiography (MRA) is recommended to screen for stenosis.46 50 In patients suspected of having a stroke or TIA, CT or MRI of the brain is recommended to confirm the diagnosis of symptomatic ischemic cerebral vascular disease.51 53 In patients with a confirmed diagnosis of symptomatic ischemic cerebrovascular disease, blood tests, including complete blood count, prothrombin time, partial throm- boplastin time, glucose, HbA1c, creatinine, and fasting or nonfasting lipid profile, are recommended to gain insight into risk factors for stroke and to inform therapeutic In patients with cryptogenic stroke, echocar- diography with or without contrast is reason- able to evaluate for possible cardiac sources of or transcardiac pathways for cerebral In patients with cryptogenic stroke who do not have a contraindication to anticoagula- tion, long-term rhythm monitoring with mobile cardiac outpatient telemetry, implantable loop recorder, or other approach is reasonable to detect intermittent AF.58 60 In patients suspected of having ischemic stroke, if CT or MRI does not demonstrate symptomatic cerebral infarct, follow-up CT or MRI of the brain is reasonable to confirm In patients suspected of having had a TIA, if the initial head imaging (CT or MRI) does not demonstrate a symptomatic cerebral infarct, follow-up MRI is reasonable to predict risk of early stroke and to support the In patients with cryptogenic stroke, tests for inherited or acquired hypercoagulable state, bloodstream or cerebral spinal fluid infections, infections that can cause central nervous system (CNS) vasculitis (eg, HIV and syphilis), drug use (eg, cocaine and amphetamines), and markers of systemic inflammation and genetic tests for inherited diseases associated with stroke are reason- able to perform as clinically indicated to identify contributors to or relevant risk factors In patients with ischemic stroke or TIA, noninvasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system with MRA or CTA can be effective to identify atheroscle- rotic disease, dissection, moyamoya, or other etiologically relevant vasculopathies.73 75 In patients with ischemic stroke and a treatment plan that includes anticoagulant therapy, CT or MRI of the brain before therapy is started may be considered to assess for hemorrhagic transformation and final size of infarction.76 In patients with ESUS, transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable to identify possible cardioaortic sources of or transcardiac pathways for cerebral In patients with ischemic stroke or TIA in whom patent foramen ovale (PFO) closure would be contemplated, TCD (transcranial Doppler) with embolus detection might be reasonable to screen for right-to-left Synopsis Patients presenting with signs and symptoms of acute stroke will undergo an evaluation tailored to ensure that, when appropriate, they receive reperfusion therapy (Fig- ure 2). Imaging recommendations based on acute treatment Recommendations for Diagnostic Evaluation (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES Kleindorfer considerations overlap with, but are not identical to, imaging recommendations based on secondary stroke prevention considerations. Recommendations presented in this guide- linefocusonevaluationsdoneforthepurposesofconfirming the diagnosis of stroke and characterizing its pathomecha- nism by identifying potential sources of cardioembolism, thromboembolism from large artery atherosclerosis, dissec- tion, or other disease processes such as hypercoagulability. Confirmation of stroke diagnosis may require follow-up head imaging because of poor sensitivity of noncontrast CT for small or hyperacute infarcts. Some conditions associated with stroke and with specific therapies are common (eg, AF), whereas others are relatively rare (eg, endocarditis). The variable yield of testing means that treating physicians need to exercise judgment on the likelihood that a test will alter management in a given clinical situation. Figure 2. Algorithm for evaluating patients with a clinical diagnosis of stroke for the purposes of optimizing prevention of recurrent ischemic stroke. Colors correspond to Class of Recommendation in Table 3. CT indicates computed tomography; CTA, computed tomography angiogram; ECG, electrocardiogram; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; PFO, patent foramen ovale; SOE, source of embolism; TCD, transcranial Doppler; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; and US, ultrasound. *Basic laboratory tests include complete blood count, troponin, prothrombin time, partial thromboplastin time, glucose, hemoglobin A1c , creatinine, and fasting or nonfasting lipid profile. When a patient has a transient neurological deficit clinically characteristic of transient ischemic attack, the patient should be evaluated in the same manner as a patient who has an ischemic stroke with a corresponding cerebral infarct on imaging. TTE, TEE, TCD, cardiac MRI, or cardiac CT. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer Recommendation-Specific Supportive Text 1. An ECG is a simple, noninvasive means of diag- nosing AF in patients with acute stroke. A meta- analysis through 2014 found that the proportion of patients diagnosed with poststroke AF in the emergency department by electrocardiography An ECG can also detect pertinent comorbidities that may have thera- peutic implications. About 3% of patients present- ing with acute stroke also have acute myocardial 2. Effective secondary prevention requires timely evalua- tion of stroke mechanism, with the intent of identifying modifiable risk factors. The risk of recurrent stroke in the short term and long term varies by stroke mech- The risk of stroke within 90 days after a first stroke is 5%, but the risk can vary greatly from >10% to <1%, depending in part on mechanism.42 Symptomatic carotid stenosis and AF are important to diagnose in a timely fashion to allow implementation of specific treatments with proven efficacy. 3. Because patients with symptomatic high-grade cervical carotid stenosis are candidates for revas- cularization, it is appropriate to screen for stenosis in any patient who may have such stenosis. Initial testing for carotid stenosis should be done with a noninvasive test such as CTA, MRA, or ultrasonog- raphy rather than digital subtraction angiography, with case series finding a risk of stroke ranging Experienced stroke cen- ters typically have a risk of stroke attributable to digital subtraction angiography of <0.5%. For patients at high risk of carotid artery stenosis who can undergo surgery without delay, immediate CTA is the most cost-effective strategy.84 Using consensus interpretation criteria, carotid ultra- sonography has a sensitivity of 38.8%, specific- ity of 91.6%, and accuracy of 87.1% for 70% With the use of a 70% cutoff value for carotid stenosis, CTA and digital subtrac- tion angiography were in agreement in 78 of 81 vessels (95% CI, 90 99) in a series of patients with stroke or TIA.48 Compared with digital sub- traction angiography, a meta-analysis of studies performed in 2008 found the overall sensitivity of time-of-flight MRA for the detection of 70% to 99% internal carotid artery (ICA) stenoses to be 91.2% with a specificity of 88.3%, whereas the sensitivity of contrast-enhanced MRA was 94.6% with a specificity of 91.9%.49 4. An accurate diagnosis of ischemic stroke or TIA is essential for justifying and optimizing stroke preven- tion. Many patients will have had brain imaging in the acute setting to exclude stroke mimics and to include stroke chameleons (stroke initially thought to be an alternative diagnosis). About 15% to 25% of patients thought to have stroke on clinical grounds will be given an alternative diagnosis with the help of About 13% of patients with stroke or TIA thought to have a nonstroke diagnosis for their neurological symptoms will be given the diag- nosis of stroke with the help of brain imaging.52,53 A prospective, multicenter multinational study showed that, in patients with recent minor focal nonmotor, nonspeech neurological deficits, diffusion-weighted MRI detected acute infarction in 13.5% and that this finding had prognostic relevance because detection of infarction was associated with a >6-fold increase in the risk of recurrent stroke at 1 year.85 5. As reported in this guideline, control of hyperten- sion (Section 4.2), blood glucose (Section 4.4), and lipids (Section 4.3) have been proven effective for reducing the risk of ischemic stroke; thus, assess- ment of whether the patient is at therapeutic goal for these metabolic parameters helps to optimize therapy. Fasting is not routinely required for lipid testing because the lipid profile components under fasting and nonfasting conditions differ in non- clinically significant degrees (the exception being patients with nonfasting triglycerides of >440 mg/dL, who should have fasting levels drawn).86 HbA1c determination can detect new cases of type 2 diabetes (T2D) in 11.5% of patients pre- senting with acute ischemic stroke and prediabe- tes in 36.2%.54 Abnormal blood testing can help to stratify risk so that physicians can concentrate efforts of prevention on those at highest risk. In patients with lacunar infarction, chronic kidney dis- ease is associated with a 50% increase in risk of Testing prothrombin time and activated partial thromboplastin time screens for diverse clotting and bleeding disorders that are relevant to active management of patients with acute stroke. An isolated prolonged activated par- tial thromboplastin time can be seen with heparin use, lupus anticoagulant, or clotting factor deficien- All of these states or exposures are relevant to long-term management of patients with stroke. Liver failure, malnutrition, malabsorption, myelopro- liferative diseases, and disseminated intravascular coagulation can cause acquired factor deficiencies and would have relevance in managing patients 6. Many diseases with specific indications for specific treatment such as patent foramen ovale (PFO), papillary fibroelastoma, myxoma, endocarditis, and intracardiac thrombi are diagnosed by echocardiog- Transthoracic echocardiography is preferred over TEE for the detection of left ventricular (LV) thrombus, but TEE is superior to transthoracic echo- cardiogram in detecting left atrial thrombus, aortic atheroma, prosthetic valve abnormalities, native CLINICAL STATEMENTS AND GUIDELINES Kleindorfer valve abnormalities, atrial septal abnormalities, and A systematic review that included 65 studies concluded that transthoracic echocar- diography in the second harmonic is cost-effective relative to TEE.56 TEE findings will change manage- ment in 1 in 7 patients with ESUS.57 7. Randomized trials show that longer heart monitoring in patients with cryptogenic stroke results in higher detection rates for AF. A randomized study of an insertable cardiac monitor versus conventional follow- up in patients with cryptogenic stroke found that by 6 months AF had been detected in 8.9% of patients in the insertable cardiac monitor group versus 1.4% of patients in the control group (95% CI, 1.9 21.7; A randomized study of patients 55 years of age who had had a cryptogenic ischemic stroke or TIA within the previous 6 months found AF lasting 30 seconds in 16.1% in the interven- tion group monitored with a 30-day event triggered recorder compared with 3.2% in the control group who had standard monitoring, including 24-hour Repeated Holter electrocardiographic monitoring in patients 60 years of age with recent stroke signifi- cantly increases the likelihood of AF detection over Improvement in patient outcomes with long-term rhythm monitoring has not been established. 8. A systematic review in 2012 found no evidence that multimodal MRI when used purely for diagnostic purposes improves outcomes, although there was limited evidence that it can change management.61 The use of MRI for in-hospital stroke evaluation grew dramatically from 1999 to 2008, varying widely The growth was likely related to wide- spread appreciation of the diagnostic yield of follow- up brain imaging with MRI within 1 to 2 days. About one-quarter of acute stroke cases with an initially negative head CT will have an MRI with evidence of An emergency depart- ment series of 252 patients presenting with atypical stroke symptoms and a negative CT found that 29 patients (11.5%) had acute ischemic stroke on MRI For posterior circulation strokes in particular, a follow-up MRI may be appro- priate to confirm a diagnosis even when the initial MRI is negative.64 MRI with diffusion-weighted imag- ing is also particularly helpful in evaluating patients with low-risk TIA and mild neurological symptoms.85 Confirming the diagnosis of acute ischemic stroke with brain imaging may help with patient education and prognostication, which in turn may promote adherence to a prescribed prevention regimen.65 9. About one-third of patients with stroke symptoms for <24 hours have a diffusion-weighted imaging A cost-effectiveness analysis of the use of MRI in patients with TIA reported in 2014 concluded that MRI was generally not cost- effective, although there might be utility to MRI in this population if the imaging is done >1 week after onset of symptoms and with a blood-sensitive sequence, if the clinical team is considering unusual causes of symptoms, or if symptoms are related to ipsilateral high-grade stenosis.69 Predictive scores that incorporate MRI findings (eg, ABCD2 -I and -I) are better able to discriminate high risk of early stroke from low risk of early stroke than predictive scores that do not incorporate MRI find- ings (eg, ABCD2 ) when MRI is done within 7 days of onset of symptoms.67 10. Stroke can be the initial manifestation of a host of systemic conditions that either are treatable by themselves or must be identified to avoid misdi- rected ineffective or harmful therapies. The pretest probability of finding a diagnostically meaningful abnormality for many of these tests will depend on clinical suspicion informed by demographic variables (eg, age), medical history, physical find- ings, and results of basic testing. For example, the yield of testing for a hypercoagulable state is low for patients >50 years of age.90 Patients present- ing with stroke will have echocardiographically con- firmed infectious endocarditis in 1.7% of cases, and an initial C-reactive protein of at least 10 mg/L dramatically increased the likelihood of infectious endocarditis (odds ratio [OR], 22).70 Use of cocaine within the prior 24 hours increases the risk of stroke in young adults by >6-fold.71 Toxicology testing for cocaine and other drugs of abuse should be done at the time of presentation.91,92 When diagnostic algo- rithms were used, monogenic causes of stroke were 11. Identification of symptomatic intracranial athero- sclerotic disease supports treatment to aggressive antiatherosclerotic targets and is often seen as an indication for dual antiplatelet therapy (DAPT). have been shown to reli- ably exclude high-grade intracranial atherosclerotic stenosis (ICAS) when digital subtraction catheter angiography was used as the reference test. Early identification of symptomatic extracranial vertebro- basilar stenosis identifies patients at high risk of 12. Hemorrhagic transformation is often seen as a con- traindication to early (<2 weeks of stroke onset) oral anticoagulation, although no randomized trial has been done that directly addresses the question. A multicenter, prospective international study of con- secutive patients with acute ischemic stroke and AF that included a second CT 24 to 72 hours after stroke onset found that the presence of hemorrhagic trans- formation led to an average delay in anticoagulation CLINICAL STATEMENTS AND GUIDELINES Kleindorfer of 12 days and that this delay was not associated with a significant rise in the rate of recurrent stroke.76 Large infarcts, for example, the entire territory of either the middle, anterior, or posterior cerebral artery, had nearly twice the risk of hemorrhagic transforma- tion as smaller infarcts in this series.76 13. TEE, cardiac CT, and cardiac MRI will provide actionable information in a minority of patients with acute stroke. In a prospective study of 61 patients with ESUS who underwent investigation with TEE (mean age, 44 12 years; 49% men), TEE revealed additional findings in 52% (95% CI, 40 65) of the study population, and findings changed manage- ment (initiation of anticoagulation therapy, admin- istration of intravenous antibiotic therapy, and PFO In a meta-analysis of 3562 patients with acute isch- emic stroke, the pooled rate of anticoagulation therapy attributed to abnormal TEE findings was In a single-center ret- rospective study of 1458 patients with suspected cardioembolic stroke, findings on TEE significantly changed management in 16.7%.77 Smaller series have found that the addition of TEE to a standard stroke workup identified an indication for antico- Cardiac CT has a modest sensitivity (72%) and high speci- ficity (95%) for detecting potential embolic source in patients with cryptogenic stroke in whom TEE is used as the gold standard.78 A single-center study of consecutive patients with cryptogenic stroke who underwent both TEE and cardiac MRI found that cardiac MRI reduced the percentage of patients with cryptogenic stroke by only slightly >1%.79 14. TCD compares favorably with TEE for detecting right-to-left shunting, which is usually the result of PFO, now a potential target for device closure. A pooled analysis of the OXVASC (Oxford Vascular Study) data with data from 2 previous smaller studies of bubble-TCD in patients 50 years of age found an association between right-to-left shunting and cryp- togenic TIA or nondisabling stroke (OR, 2.35 [95% A pooled analysis of a systematic literature review found that TCD had a sensitivity of (95% CI, 85.5 96.1) compared with TEE (gold stan- dard) for detection of right-to-left shunting.57 Knowledge Gaps and Future Research Randomized trials have provided compelling evidence of specific therapies for specific subsets of patients with ischemic stroke, for example, anticoagulation in the subset of patients with AF and low risk of hemorrhage. Diagnosing these mechanistically related risk factors is an important part of the early evaluation of stroke to opti- mize prevention of recurrent stroke. New risk factors for stroke are being discovered through observational stud- ies, but several knowledge gaps exist relating to the rela- tive importance of testing to identify uncommon or rare conditions associated and potentially causally linked with recurrent stroke. The less prevalent a comorbid condition is among patients with stroke, the more challenging it is to execute successfully a well-powered clinical trial to provide high levels of evidence justifying the diagnostic testing. There are several clinical conditions associated with ischemic stroke for which trial evidence would be helpful to guide therapy: To better prevent cardioembolism, it would be helpful to have trials that clarify optimal duration of heart rhythm monitoring, determine the clinical significance of brief episodes of AF, and define the precise role of cardiac CT/MRI and microembolus detection with TCD. In terms of large artery disease, much is known about atherosclerotic stenosis, but far less is known about the importance of detecting microemboli with TCD or identifying characteristics of unstable plaque such as intraplaque hemorrhage. Further research is also needed to clarify the clinical significance of detecting nonatherosclerotic condi- tions, including carotid dissection, fibromuscular dys- plasia, and carotid webs. Other uncommon causes of stroke such as CNS vasculitis and Susac syndrome suffer from a lack of well-designed clinical trials to guide therapies. 4. VASCULAR RISK FACTOR MANAGEMENT Recommendations for Nutrition Referenced studies that support recommendations are summarized in online Data Supplements 3 and 4. COR LOE Recommendations In patients with stroke and TIA, it is reason- able to counsel individuals to follow a Mediterranean-type diet, typically with empha- sis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce risk of In patients with stroke or TIA and hypertension who are not currently restricting their dietary sodium intake, it is reasonable to recommend that individuals reduce their sodium intake by at least 1g/d sodium (2.5 g/d salt) to reduce the risk of cardiovascular disease (CVD) events (including stroke).97,98 Synopsis Limited evidence supports dietary interventions to reduce recurrent stroke,96 with recommendations CLINICAL STATEMENTS AND GUIDELINES Kleindorfer drawn from high-risk CVD and coronary heart disease populations, or dietary effects on stroke risk factors, for example, BP and cholesterol.98 Epidemiological diet and nutrition studies identify protective effects for stroke from regular consumption of fish,99 high consumption of fruit and vegetables100,101 and following the Mediterranean diet96 and the DASH (Dietary Approaches to Stop Hypertension) diet,103 reflected in the AHA/American College of Cardiology (ACC) guideline on lifestyle management to reduce PAR for stroke for the lowest versus the highest tertile of the modified Alternative Healthy Eating Index is 18.8% (99% CI, 11.2 29.7).5a In the United States, the REGARDS cohort study (Rea- sons for Geographic and Racial Differences in Stroke Study) identified higher adherence to the Southern diet (high in added fats, fried food, eggs, processed meats, and sugar-sweetened beverages) was associated with a 39% increased risk of stroke (hazard ratio [HR], 1.39 Sodium and potassium con- sumption, unlike many vitamins and minerals in foods, can be adjusted without altering overall dietary pat- Both high potassium consumption106 and low are associated with lower stroke rates. No evidence supports potassium-based inter- ventions for CVD reduction26 ; no dietary interventions of increased potassium consumption alone in stroke survivors were identified. Overnutrition is addressed in Section 4.5, Obesity. Recommendation-Specific Supportive Text 1. The interventional arms of the PREDIMED trial (Prevenci n con Dieta Mediterr nea), compris- ing the Mediterranean diet with either supple- mental extravirgin olive oil or tree nuts (Table 4) compared with a low-fat diet,95 provide evidence of a reduction in stroke events in individuals with high cardiovascular risk (HR, 0.60 [95% CI, The primary end point (MI, stroke. or cardiovas- cular death) identified adjusted HRs of 0.72 (95% CI, 0.54 0.95) for the Mediterranean diet with olive oil supplementation and 0.69 (95% CI, 0.53 0.91) with nut supplementation compared with the control diet. Evidence in secondary pre- vention is drawn from the Lyon Diet Heart trial of the Mediterranean diet with supplemental canola compared with a usual post-MI prudent diet, producing low-quality evidence of reduced CVD mortality and total mortality (adjusted HR, 0.21 0.92], respectively) in a coronary heart One study in first stroke and matched control cases108 shows each unit (1 of 55) in MedDietScore is associated with a 17% lower likelihood of ischemic stroke in participants without hypercholesterolemia (95% CI, 0.72 0.96) and 10% lower likelihood in par- ticipants with hypercholesterolemia (95% CI, 0.81 0.99). 2. A meta-analysis of 13 prospective studies and follow-up, 3.5 19 years) identified that higher levels of habitual salt intake are associated with greater stroke risk (relative risk [RR], 1.23 [95% A Japanese population-based study identified that in men the highest compared with the lowest tertile of sodium intake recorded was significantly positively associated with death resulting from ischemic stroke (adjusted HR, 3.22 Meta-analysis in those with established CVD identified through long- term follow-up of participants in 5 salt-reducing reported a reduction of 1 g/d sodium (2.5 g/d salt) is associated with a 20% reduction in further cardiovascular events (RR, 0.80 [95% CI, identified that for a typical US diet in the 1990s (the con- trol diet), a reduction in sodium intake from 3.3 to 2.4 g/d reduced systolic BP (SBP) by 2.1 mmHg (P<0.001), and further reducing sodium intake from 2.4 to 1.5 g/d yielded additional reductions of 4.6 mmHg (P<0.001). The DASH diet was associated with a significantly lower SBP at each sodium level than the control diet. Table 4. Dietary Details of Typical Mediterranean-Type Diets Mediterranean diet (summarized) DASH diet (summarized) High monounsaturated/saturated fat ratio (use of olive oil as main cooking ingredient and/or consumption of other traditional foods high in mono- unsaturated fats such as tree nuts) Limited saturated fat and cholesterol and emphasized nut consumption High intake of plant based foods, including fruits, vegetables, and legumes Emphasizes fruit, vegetables, and legumes consumption High consumption of whole grains and cereals Emphasizes whole grains Increased consumption of fish Low consumption of meat and meat products Discourages red and processed meats Limits red and processed meats Low to moderate red wine con- sumption Moderate consumption of milk and dairy products Emphasizes fat-free/low-fat dairy Discourages soda drinks, pastries, sweets, commercial bakery prod- ucts, and spread fats Limits sweets, added sugars, salt, and sugar-sweetened beverages. DASH indicates Dietary Approaches to Stop Hypertension. Summarized Mediterranean Diet95,96 ; summarized DASH diet.103 CLINICAL STATEMENTS AND GUIDELINES Kleindorfer 4.1.2. Physical Activity Recommendations for Physical Activity Referenced studies that support recommendations are summarized in online Data Supplements 5 and 6. COR LOE Recommendations In patients with stroke or TIA who are capable of physical activity, engaging in at least moderate- intensity aerobic activity for a minimum of 10 min- utes 4 times a week or vigorous-intensity aerobic activity for a minimum of 20 minutes twice a week is indicated to lower the risk of recurrent stroke and the composite cardiovascular end point of recurrent stroke, MI, or vascular death.110 In patients with stroke or TIA who are able and willing to increase physical activity, engaging in an exercise class that includes counseling to change physical activity behavior can be beneficial for reducing cardiometabolic risk fac- tors and increasing leisure time physical activity In patients with deficits after stroke that impair their ability to exercise, supervision of an exercise program by a health care professional such as a physical therapist or cardiac reha- bilitation professional, in addition to routine rehabilitation, can be beneficial for secondary stroke prevention. In individuals with stroke or TIA who sit for long periods of uninterrupted time during the day, it may be reasonable to recommend breaking up sedentary time with intervals as short as 3 minutes of standing or light exer- cise every 30 minutes for their cardiovascular Synopsis Regular physical activity reduces stroke risk116 118 ; posi- tively affects stroke risk factors, for example, BP, cho- ; and can improve endothelial function and reduce platelet aggregation, fibrinogen lev- and onset stroke severity.123 Physical inactiv- ity (eg, sitting >4 h/d) as a cardiovascular risk behavior124 is attenuated by increased bouts of moderate- to vigor- ous-intensity physical activity.125 Low levels of physical activity are observed in acute,126 subacute, and chronic phases of stroke, with >78% of recorded time catego- rized as sedentary.127 When able, stroke survivors should aim to achieve population-based recommendations (40-minute sessions, 3 to 4 times per week of moderate- to vigorous-intensity aerobic activity),26 and when this is not possible, their physical activity goals need to be cus- tomized to their exercise tolerance, stage of recovery, environment, available social support, physical activity preferences, and specific impairments, activity limitations, and participation restrictions as identified by the AHA/ ASA guideline for physical activity and exercise.34 Exercise interventions positively affect disability, aerobic fitness, mobility (walking speed), and functional balance indices after stroke.128 Efficacy of exercise inter- ventions compared with usual care was established by a meta-analysis for risk factors after stroke, including BP, cholesterol, glucose levels, and weight.112,113 Physical activity interventions are often delivered in multimodal, lifestyle-based programs. These are addressed in Section 6.2, Interventions Aimed at Changing Patient Behavior. Recommendation-Specific Supportive Text 1. Planned analysis of participants in the medical management arm (n=227) of the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial at the 3-year follow-up identified 49 primary end point events (stroke, MI, and vascular death), including 32 ischemic strokes. For the com- posite end point at 3 years, participants who were not in target for physical activity levels, defined as a Physician-Based Assessment and Counselling for Exercise score of 4, had a significantly higher odds of stroke, MI, and vascular death than those who did achieve this target (OR, 5.4 [95% CI, 2.4 12.1]). The Physician-Based Assessment and Counselling for Exercise score of 4 equates to 10-minute bouts of moderate physical activity (sufficient to break a sweat or to noticeably raise heart rate, eg, walking briskly, using an exercise bicycle) up to 4 times a week or 20-minute bouts of vigorous activity (eg, jogging) up to twice a week. For the end point of ischemic stroke, physical activity was the only risk factor associated with lower stroke events; those who were out of target for defined physical activ- ity levels had an OR of 6.7 (95% CI, 2.5 18.1) for recurrent stroke compared with those who achieved the targets. Multivariable analysis controlling for low-density lipoprotein (LDL), non high-density lipoprotein, and SBP identified that greater physi- cal activity on the Physician-Based Assessment and Counselling for Exercise scale was independently associated with 40% lower risk of stroke, MI, or vas- cular death at 3 years (OR, 0.6 [95% CI, 0.4 0.8]). 2. Physical activity is a complex behavior. 