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New Strategy Developed for Preventing Second Strokes

In a shift from earlier guidelines, new stroke prevention guidelines are urging all doctors to
Ralph Sacco

Ralph Sacco

treat transient ischemic attacks (TIAs, or “mini-strokes”) as dangerous as full-blown strokes when considering treatments to prevent future strokes.

"The greatest threat a TIA patient or a stroke survivor faces is another stroke,"says Ralph Sacco, M.D., professor of neurology, who chaired the Secondary Stroke Prevention Guidelines Committee of the American Heart Association and American Stroke Association.

"TIA is to stroke as angina is to a heart attack – it’s a warning but also a great opportunity to step in, fix the problem, and prevent a disabling or fatal stroke in the future. Everything we do to prevent heart attacks, we should do to prevent strokes," Dr. Sacco says.

Almost a third of the 700,000 strokes that occur in the United States each year are second strokes or are preceded by a TIA. About 200,000 to 500,000 TIAs occur each year.

Although stroke experts have recognized the dangers of TIAs for a number of years, these attacks were initially considered benign because the symptoms, which are identical to those of a stroke, usually disappear in less than one hour and do not cause permanent injury.

The belief that TIAs are benign has persisted among many clinicians and the public, Dr. Sacco says. More and more research, however, shows that TIAs increase the risk of a stroke, particularly in the early days after the attack. About 10 percent of patients have a stroke within 90 days of a TIA; half of those come in the first 24 hours after the TIA.

“If a patient comes in and receives a TIA diagnosis, they sometimes won’t get an appointment with a neurologist until five weeks later. That could be too late,” Dr. Sacco says. “TIAs should be treated just as urgently and just as aggressively as strokes.”

The new evidence-based guidelines are the first to combine stroke prevention recommendations for both TIA and stroke patients in the same document. The guidelines also include recommendations for different kinds of strokes and TIAs. Until now many of these recommendations were in separate documents.

Key recommendations in the new guidelines include antihypertensive treatment for all TIA and stroke patients, more rigorous control of lipids and glucose in diabetic patients, and surgery to remove plaque in the carotid artery if the blockage is severe.

“These are guidelines that can be easily used by a practicing clinician,” Dr. Sacco says. “What we’re saying is ‘here’s a stroke or TIA patient in front of you, here’s how you prevent another stroke.’”

The guidelines were prepared by the American Heart Association/American Stroke Association Council on Stroke; co-sponsored by the Council on Cardiovascular Radiology and Interven-tion; and affirmed by the American Academy of Neurology.

—Susan Conova