AHA/ASA richtlijn update ischemische stroke

The latest ischemic stroke guidelines from the American Heart Association and American Stroke Association (AHA/ASA) include advice on antithrombotic treatment in specific subgroups and managing patients with the metabolic syndrome.
 

The guidelines stress the importance of hypertension as a stroke risk factor, and offer the new recommendation that the choice of antihypertensive agents should be individualized, partly according to patient characteristics that may help guide drug prescribing, such as renal impairment, cardiac disease, and diabetes.
 

The writing committee, led by Karen Furie (Massachusetts General Hospital, Boston, USA), notes in the journal Stroke that the metabolic syndrome is present in nearly a quarter of US adults.

But they say: "Considerable controversy surrounds the metabolic syndrome, largely because of uncertainty regarding its etiology and clinical usefulness." For this reason, they simply recommend lifestyle advice and treatment of individual components of the metabolic syndrome in line with established guidelines.
 

New recommendations for patients with atherosclerotic stroke include optimal medical therapy for those with carotid or vertebral artery stenosis, and use of aspirin rather than warfarin in patients with severe intracranial stenosis.
 

The guidelines contain two new recommendations for patients with atrial fibrillation - that the combination of clopidogrel plus aspirin carries a high bleeding risk and should be avoided in patients in whom warfarin is contraindicated due to hemorrhagic concerns, and that bridging therapy with a low molecular weight heparin is "reasonable" in patients requiring temporary interruption of oral anticoagulation.
 

Furie et al also cover treatment of patients with specific comorbid conditions. In this section of the guidelines, they note that the relative benefits of antiplatelet versus oral anticoagulant treatment are not established in patients with arterial dissection or patent foramen ovale.
 

Finally, the committee explores antithrombotic strategies in patients with intracranial hemorrhage (ICH), describing this as "one of the most difficult problems that clinicians face."
 

The guidelines offer two new recommendations in this area: firstly, that protamine sulfate should be used to reverse heparin-associated ICH, and secondly, that antiplatelet treatment be considered for patients with a "comparatively lower" risk for ischemic stroke and a high risk for amyloid angiopathy or with very poor neurologic function.
 

If patients are at very high thromboembolic risk and restart of warfarin is deemed necessary, then the committee suggests it may be reasonable to do this 7-10 days after ICH.