Definitive Diagnostic Evaluation of the Child With Arterial Ischemic Stroke and Approaches to Secondary Stroke Prevention

Introduction: Aspirin is one of the most commonly used medications for cardiovascular disease and stroke prevention. Many older patients who present with a first or recurrent stroke are already on aspirin monotherapy, yet little evidence is available to guide antithrombotic strategies for these patients. Method: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we described discharge antithrombotic treatment pattern among Medicare beneficiaries without atrial fibrillation who were discharged alive for acute ischemic stroke from 1734 hospitals in the United States between October 2012 and December 2017. Results: Of 261,634 ischemic stroke survivors, 100,016 (38.2%) were on prior aspirin monotherapy (median age 78 years; 53% women; 79.4% initial stroke and 20.6% recurrent stroke). The most common discharge antithrombotics (Figure) were 81 mg aspirin monotherapy (20.9%), 325 mg aspirin monotherapy (18.2%), clopidogrel monotherapy (17.8%), and dual antiplatelet therapy (DAPT) of 81 mg aspirin and clopidogrel (17.1%). Combined, aspirin monotherapy, clopidogrel monotherapy, and DAPT accounted for 86.8% of discharge antithrombotics. The rest of 13.2% were discharged on either aspirin/dipyridamole, warfarin or non-vitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotics at all. Among patients with documented stroke etiology (TOAST criteria), 81 mg aspirin monotherapy (21.2-24.0%) was the most commonly prescribed antithrombotic for secondary stroke prevention. The only exception was those with large-artery atherosclerosis, in which, 25.3% received DAPT of 81 mg aspirin and clopidogrel at discharge. Conclusion: Substantial variations exist in discharge antithrombotic therapy for secondary stroke prevention in ischemic stroke with prior aspirin failure. Future research is needed to identify best management strategies to care for this complex but common clinical scenario.

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Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.159 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ying Xian ◽

Peter Shrader ◽

Eric Smith ◽

Gregg C Fonarow ◽

Deepak L Bhatt ◽

...

Keyword(s):

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Stroke Prevention ◽

Patient Characteristics ◽

Minor Stroke ◽

Secondary Stroke Prevention ◽

Class Iii ◽

Prescription Patterns ◽

Class Iib ◽

Over Time

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit >> risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p<0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p<0.001) and those with NIHSS>3 (18.7%, 22.8%, 28.3%, and 28.3%, p<0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS>3, where the risk-benefit ratio of DAPT remains to be established.

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Abstract WMP112: Cilostazol versus Aspirin for Secondary Stroke Prevention: Systematic Review and Meta-Analysis

Stroke ◽

10.1161/str.51.suppl_1.wmp112 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Michelle P Lin ◽

Kevin M Barrett ◽

James F Meschia ◽

Benjamin H Eidelman ◽

Josephine F Huang ◽

...

Keyword(s):

Systematic Review ◽

Clinical Trials ◽

Ischemic Stroke ◽

Random Effects ◽

Intracranial Hemorrhage ◽

Stroke Prevention ◽

Lower Risk ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Secondary Stroke Prevention

Introduction: Cilostazol has promise as an alternative to aspirin for secondary stroke prevention given its vasodilatory and anti-inflammatory properties in addition to platelet aggregation inhibition. We conducted a systematic review and meta-analysis to estimate the comparative effectiveness and safety of cilostazol compared to aspirin for stroke prevention in patients with previous stroke or TIA. Hypothesis: Cilostazol is more effective than aspirin in preventing recurrent ischemic stroke with lower risk of intracranial hemorrhage and bleeding. Methods: We searched PubMed and the Cochrane Central Register of Controlled Trials from inception to 2019. Randomized clinical trials that compared cilostazol vs aspirin and reported the endpoints of ischemic stroke, intracranial hemorrhage and bleeding were included. A random-effects estimate was computed based on Mantel-Haenszel methods. The pooled estimates with 95% confidence intervals were compared between cilostazol and aspirin and displayed as forest plots (Figure). Results: The search identified 5 randomized clinical trials comparing cilostazol vs aspirin for secondary stroke prevention that enrolled 7,240 patients from primarily Asian countries (3,615 received cilostazol and 3,625 received aspirin). The pooled results from the random-effects model showed that cilostazol was associated with significantly lower risk of recurrent ischemic stroke (Hazard ratio [HR] 0.70; 95%CI, 0.54-0.89), intracranial hemorrhage (HR 0.41; 95%CI, 0.25-0.65) and bleeding (HR 0.71; 95%CI, 0.55-0.91). See forest plots. Conclusion: This meta-analysis suggests cilostazol is more effective than aspirin in the prevention of recurrent ischemic stroke with lower risk of intracranial hemorrhage and bleeding. Confirmatory randomized trials of cilostazol for secondary stroke prevention to be performed in more generalizable populations are needed.

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Residual Risk and Its Risk Factors for Ischemic Stroke with Adherence to Guideline-Based Secondary Stroke Prevention

Journal of Stroke ◽

10.5853/jos.2020.03391 ◽

2021 ◽

Vol 23 (1) ◽

pp. 51-60

Author(s):

Yuesong Pan ◽

Zixiao Li ◽

Jiejie Li ◽

Aoming Jin ◽

Jinxi Lin ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Secondary Prevention ◽

Acute Ischemic Stroke ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Antihypertensive Agents ◽

Residual Risk ◽

Stroke Recurrence ◽

Secondary Stroke Prevention

Background and Purpose Despite administration of evidence-based therapies, residual risk of stroke recurrence persists. This study aimed to evaluate the residual risk of recurrent stroke in acute ischemic stroke or transient ischemic attack (TIA) with adherence to guideline-based secondary stroke prevention and identify the risk factors of the residual risk.Methods Patients with acute ischemic stroke or TIA within 7 hours were enrolled from 169 hospitals in Third China National Stroke Registry (CNSR-III) in China. Adherence to guideline-based secondary stroke prevention was defined as persistently receiving all of the five secondary prevention medications (antithrombotic, antidiabetic and antihypertensive agents, statin and anticoagulants) during hospitalization, at discharge, at 3, 6, and 12 months if eligible. The primary outcome was a new stroke at 12 months.Results Among 9,022 included patients (median age 63.0 years and 31.7% female), 3,146 (34.9%) were identified as adherence to guideline-based secondary prevention. Of all, 864 (9.6%) patients had recurrent stroke at 12 months, and the residual risk in patients with adherence to guidelinebased secondary prevention was 8.3%. Compared with those without adherence, patients with adherence to guideline-based secondary prevention had lower rate of recurrent stroke (hazard ratio, 0.85; 95% confidence interval, 0.74 to 0.99; P=0.04) at 12 months. Female, history of stroke, interleukin-6 ≥5.63 ng/L, and relevant intracranial artery stenosis were independent risk factors of the residual risk.Conclusions There was still a substantial residual risk of 12-month recurrent stroke even in patients with persistent adherence to guideline-based secondary stroke prevention. Future research should focus on efforts to reduce the residual risk.

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Effectiveness of Antiviral Therapy in the Secondary Prevention of the Ischemic Stroke on the Background of Viral Infection Manifestation

Ukraïnsʹkij žurnal medicini bìologìï ta sportu ◽

10.26693/jmbs05.06.188 ◽

2020 ◽

Vol 5 (6) ◽

pp. 188-194

Author(s):

N. Turchina ◽

◽

T. Cherenko

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Viral Infection ◽

Antiviral Therapy ◽

Recurrence Rate ◽

Stroke Prevention ◽

World Literature ◽

Antiviral Drugs ◽

Secondary Stroke Prevention ◽

Vascular Events

Recurrent stroke remains the key health issue in the world. A higher three-year recurrence rate of stroke in patients with persistence of the genome of herpes viruses, and with presence in the blood of the genome of at least 2 types of viruses was identified. These investigations demonstrate the importance of further research into the role of antiviral therapy in improving the rehabilitation and secondary prevention of stroke in patients with persistent viral infection The purpose of the study was to evaluate the effectiveness of antiviral therapy in the secondary ischemic stroke prevention on the viral infection manifestation background. Material and methods. The study included 105 patients with moderate to severe ischemic stroke with a viral manifestation confirmed by the detection of herpes virus’s DNA (HSV1, HSV2, EBV, CMV, HHV6) and Flu RNA. Patients who were additionally prescribed antiviral drugs on the background of traditional therapy were in the main group (n = 35). Patients who received only traditional, recommended by the modern stroke treatment guidelines, therapy and secondary stroke prevention measures were included in the comparison group (n = 70). Results and discussion. We found that the effectiveness of the proposed preventive treatment depended on the viral load of the patient. In the presence of three or more types of viruses, the proposed therapy provided a significantly lower ischemic stroke recurrence rate, compared to the patients who did not receive antiviral therapy 11.1% vs. 49.8%, p = 0.042. Prevention of recurrent ischemic stroke, which should have started as soon as possible after the development of the first stroke or transient ischemic attack occurrence, F. Rincon and R. L. Sacco (2008) consider the most relevant in this group of patients. Herewith, as emphasized by D. G. Hackam and J. D. Spence (2007), comprehensive prevention has reduced the risk of recurrent ischemic stroke by almost 80%, thus preventing 4 out of 5 possible disorders. However, both native and world literature still has a lack of systematic data of the problem of antiviral therapy using in patients with acute disorders of cerebral circulation, although it has been proven that infectious and inflammatory complications are an important pathogenetic factor of its unfavorable and severe outcome. M. S. Elkind et al. (2016) consider that antiviral drugs such as acyclovir may play an appropriate role in the prevention of recurrent ischemic stroke in children if their causal relation is confirmed. Conclusion. The use of acyclovir in complex rehabilitation therapy and secondary stroke prevention in patients with viral infection manifestation provided an increase in the average score of Bartel index after 1 year, p = 0.017. In the case of antiviral therapy using in the complex prevention of recurrent vascular events in patients with viral infection manifestation, the three-year recurrence rate of stroke is lower (p = 0.042)

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Antithrombotic Prescription at Discharge in Medicare Patients with Ischemic Stroke/Transient Ischemic Attack: Results from the National Stroke Project

Stroke ◽

10.1161/str.32.suppl_1.376-d ◽

2001 ◽

Vol 32 (suppl_1) ◽

pp. 376-377

Author(s):

Timothy F Kresowik ◽

David S Nilasena ◽

Anton F Piskac ◽

Rebecca A Hemann ◽

Marian A Brenton ◽

...

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Stroke Prevention ◽

Antiplatelet Agents ◽

Secondary Stroke Prevention ◽

Antithrombotic Agents ◽

Patterns Of Use ◽

Medicare Patients ◽

Ischemic Attack ◽

Univariate Analyses

P205 Background: Antiplatelet agents have been shown to be effective for secondary stroke prevention in patients with ischemic stroke (IS) or transient ischemic attack (TIA). As part of HCFA’s National Stroke Project, we examined patterns of use of antithrombotic agents for inpatients with IS or TIA. Methods: Findings were based on abstracted data from a sample of Medicare inpatient medical records (discharge dates 4/98 - 3/99). All U.S. states, the District of Columbia and Puerto Rico were sampled using a systematic random approach. Each record had a principal diagnosis of one of the following ICD-9-CM codes: 362.34, 433.xx, 434.xx, 435.0, 435.1, 435.3, 435.8, 435.9 or 436. The main outcome measure was the frequency of eligible patients with a prescription or a plan for antithrombotic therapy at discharge. Antithrombotics were aspirin, clopidogrel, dipyridamole, ticlopidine and warfarin. Results: Of the 36,650 cases reviewed, 25,659 met the criteria for inclusion in the indicator. A large percentage of excluded cases (53.1%) were removed due to a history or current finding of hemorrhage. Nationwide, 20,947 (unadjusted rate 81.6%) patients were prescribed an antithrombotic at discharge or had a plan for starting an antithrombotic after discharge. The state-specific rates ranged from 72.0% to 90.1%. Univariate analyses showed this therapy was prescribed less frequently (p<0.001) for adults 85 years and over (rate=77.8%, OR=0.74, 95% CI=0.69–0.80), women (rate=80.4%, OR=0.83, 95% CI=0.78–0.89) and African-Americans (rate=77.6%, OR=0.76, 95% CI=0.68–0.85). Asians were found to have been prescribed this therapy more frequently than other races (p<0.02, rate=87.2%, OR=1.54 95% CI=1.10–2.16). Among those IS/TIA patients who also had atrial fibrillation (AF), 57.1% received warfarin. Conclusions: Antithrombotic agents are not prescribed for almost one-fifth of eligible Medicare inpatients with IS/TIA. For those with IS/TIA and AF, a large proportion are not treated with warfarin. These results show important opportunities for improvement in secondary stroke prevention for Medicare patients.

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Role of CYP2C19 alleles in the management of recurrent ischemic stroke

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000584 ◽

2018 ◽

Vol 9 (2) ◽

pp. 140-144

Author(s):

Michael J. Lyerly ◽

Kelly Bartlett ◽

Karen C. Albright

Keyword(s):

Ischemic Stroke ◽

Stroke Prevention ◽

Drug Exposure ◽

Antiplatelet Agent ◽

Platelet Inhibition ◽

Secondary Stroke Prevention ◽

Nucleotide Polymorphisms ◽

Loss Of Function ◽

Single Nucleotide

Purpose of reviewCYP2C19 is the primary enzyme involved in the activation of clopidogrel, an antiplatelet agent used for secondary stroke prevention. An individual's CYP2C19 alleles are used to understand their CYP2C19-clopidogrel metabolizer phenotype. Single nucleotide polymorphisms of the CYP2C19 gene result in altered metabolism of this prodrug.Recent findingsThree ischemic stroke cases were treated with clopidogrel. Despite confirming adequate drug exposure, medication adherence, and ruling out drug-drug interactions, all had recurrent ischemic stroke. Each case had a CYP2C19 *2/*17 genotype, categorizing them as intermediate clopidogrel metabolizers. Even with the gain-of-function allele, the loss-of-function allele resulted in lack of prodrug activation, leading to decreased efficacy in platelet inhibition.SummaryThese cases illustrate the importance of a thoughtful approach to secondary stroke prevention and demonstrate the utility of pharmacogenomic testing in clopidogrel hyporesponders. Recognition of the importance of CYP2C19 genotyping has the potential to enable better selection of appropriate secondary prevention strategies.

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Antiplatelet Therapy for Secondary Stroke Prevention in Patients with Ischemic Stroke or Transient Ischemic Attack

Cardiovascular Prevention and Pharmacotherapy ◽

10.36011/cpp.2021.3.e10 ◽

2021 ◽

Vol 3 ◽

Author(s):

Kyung-Yul Lee

Keyword(s):

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Transient Ischemic Attack ◽

Stroke Prevention ◽

Secondary Stroke Prevention ◽

Ischemic Attack

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Factors Affecting Non-Adherence to Secondary Stroke Prevention Therapy in Ischemic Stroke Patients

JURNAL MANAJEMEN DAN PELAYANAN FARMASI (Journal of Management and Pharmacy Practice) ◽

10.22146/jmpf.34434 ◽

2018 ◽

Vol 8 (2) ◽

pp. 90

Author(s):

Zakky Cholisoh ◽

Hidayah Karuniawati ◽

Tanti Azizah ◽

Zaenab Zaenab ◽

Laila Nur Hekmah

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Stroke Prevention ◽

Recurrent Stroke ◽

Antihypertensive Agents ◽

Heart Association ◽

Secondary Stroke Prevention ◽

Stroke Patients ◽

Factors Affecting ◽

Prevention Therapy

Stroke is cardiovascular disease that causes the world's highest disability and is the most prevalence disease after heart disease and cancer. Stroke is caused by circulatory disorders with 80% of the sufferers are diagnosed with ischemic stroke and 20% of them are diagnosed with hemorrhagic stroke. Patients who survive from the first stroke have high risk to have recurrent stroke. American Heart Association/American Stroke Association and Perhimpunan Dokter Spesialis Syaraf Indonesia recommend secondary stroke prevention therapy including antiplatelet/anticoagulant, antihypertensive agents, and antidislipidemia to minimalize the risk of recurrent stroke. Secondary stroke prevention therapy is only the first step. Patients need to be adhere to those therapies. The non-adherence will increase the risk of recurrent stroke. The study aimed to determine factors which causing the non-adherence to secondary prevention therapy in patients with ischemic stroke. This was a case control study with concecutive sampling method by interviewing patients who met the inclusion criterias i.e., had been diagnosed and were inpatients due to ischemic stroke, but in the time of interview patients were outpatients, patients were able to communicate and agree to participate in the study.Data was analized by bivariate / chi square test and multivariate logistic regression test. During the study period, 184 respondents met the inclusion criterias. Factors affecting non-adherence in the use of secondary prevention therapy were No one reminded to take medicine p = 0.03; OR 4.51, denial of the disease p = 0,036 OR 214, and tired of taking medicine p = 0,045 OR 1,97.

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Abstract TP375: Using Characteristics of Secondary Ischemic Stroke Events to Improve Stroke Education Initiatives

Stroke ◽

10.1161/str.51.suppl_1.tp375 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Amanda Dirickson ◽

Suzanne Stone

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Stroke Prevention ◽

Small Vessel Disease ◽

Secondary Stroke Prevention ◽

Stroke Treatment ◽

Vessel Disease ◽

Acute Stroke Treatment ◽

Stroke Education ◽

Toast Classification

Purpose: While it is common practice for nursing to perform the duty of stroke education,it is not common to use secondary stroke event data to determine what aspect of stroke education should be emphasized for the greatest impact on secondary stroke prevention. The purpose of this descriptive study is to exam the characteristics of secondary stroke events using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria so future educational initiatives can be customized to the needs of the local high risk population. Methods: The team collected data characteristics on all ischemic stroke admissions with previous admitting diagnosis of acute ischemic stroke. The strokes were further characterized using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification to determine any emerging patterns of both risk factors and etiological types. Conclusions: A total of n=51 admissions were previous adult stroke survivors, (M=30, F=21). Pre-morbid risk factors were as follows: hypertension=78%, type 2 diabetes=39%, hyperlipidemia =54%, smoking=8%, atrial fibrillation=24%. TOAST classification results: Large Vessel Atherosclerosis=14%, Cardioembolic =17%, Small Vessel Disease=3%, Other Known Cause=2%, Cryptogenic=15%. Summary: The results reveal a striking pattern of the presence of premorbid hypertension. While the TOAST classification did not have a single dominant type, but nearly equal distribution of large vessel atherosclerosis, cardioembolic, and small vessel disease etiologies. Not surprising, the decline in stroke mortality is felt to be due to improved blood pressure control, but in discharge stroke education, hypertension is not necessarily emphasized over other perhaps less impactful risk factors. Yet, the most recent acute ischemic stroke clinical guidelines gave providers a first-time recommendation to start or restart antihypertensive therapy in stable patients with BP > 140/90. Nursing has enough encouragement to take the lead on hypertension prevention education in appropriate stable patients ready for discharge. The next goal will be to develop a multimedia educational effort in patient stroke education on hypertension as a risk factor for secondary stroke prevention in this Comprehensive Stroke Center.

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