ESO卒中指南英文版

TheEuropeanStrokeOrganization

-ESO-ExecutiveCommitteeand

WritingCommitteeGuidelinesforManagementofIschaemicStroke2021MISSIONOFESOToreducetheincidenceandburdenofstrokebychangingthewaystrokeisviewedandtreatedinEuropeESOGuidelines2021Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagement

ofComplicationsRehabilitationESOWritingCommitteeChair:WernerHacke,Heidelberg,GermanyCo-Chairs:Marie-GermaineBousser,Paris,FranceGaryFord,Newcastle,UKESOWritingCommitteeEducation,ReferralandEmergencyroomCo-Chairs:MichaelBrainin,Krems,Austria;JoséFerro,Lisbon,PortugalMembers:CharlotteCordonnier,Lille,France;HeinrichP.Mattle,Bern,Switzerland;KeithMuir,Glasgow,UK;PeterD.Schellinger,Erlangen,GermanyStrokeUnitsCo-Chairs:Hans-ChristophDiener,Essen,Germany;PeterLanghorne,Glasgow,UKMembers:AntonyDavalos,Barcelona,Spain;GaryFord,Newcastle,UK;VeronikaSkvortsova,Moscow,RussiaESOWritingCommitteeImagingandDiagnosticsCo-Chairs:MichaelHennerici,Mannheim,Germany;MarkkuKaste,Helsinki,FinlandMembers:HughS.Markus,London,UK;E.BerndRingelstein,Münster,Germany;RüdigervonKummer,Dresden,Germany;JoannaWardlaw,Edinburgh,UKPreventionCo-Chairs:PhilBath,Nottingham,UK;DidierLeys,Lille,FranceMembers:álvaroCervera,Barcelona,Spain;LászlóCsiba,Debrecen,Hungary;JanLodder,Maastricht,TheNetherlands;NilsGunnarWahlgren,StockholmESOWritingCommitteeGeneralTreatmentCo-Chairs:ChristophDiener,Essen,Germany;PeterLanghorne,Glasgow,UKMembers:AntonyDavalos,Barcelona,Spain;GaryFord,Newcastle,UK;VeronikaSkvortsova,Moscow,RussiaAcuteTreatmentandTreatmentofComplicationsCo-Chairs:AngelChamorro,Barcelona,Spain;

BoNorrving,Lund,SwedenMembers:ValericaCaso,Perugia,Italy;Jean-LouisMas,Paris,France;VictorObach,Barcelona,Spain;PeterA.Ringleb,Heidelberg,Germany;LarsThomassen,Bergen,NorwayESOWritingCommitteeRehabilitationCo-Chairs:KennedyLees,Glasgow,UK;DaniloToni,Rome,ItalyMembers:StefanoPaolucci,Rome,Italy;JuhaniSivenius,Kuopio,Finland;KatharinaStibrantSunnerhagen,G?teborg,Sweden;MarionF.Walker,Nottingham,UK;Substantialassistance:YvonneTeuschl,IsabelHenriques,TerenceQuinnDefinitionsofLevelsofEvidenceLevelAEstablishedasuseful/predictiveornotuseful/predictiveforadiagnosticmeasureorestablishedaseffective,ineffectiveorharmfulforatherapeuticintervention;requiresatleastoneconvincingClassIstudyoratleasttwoconsistent,convincingClassIIstudies.LevelBEstablishedasuseful/predictiveornotuseful/predictiveforadiagnosticmeasureorestablishedaseffective,ineffectiveorharmfulforatherapeuticintervention;requiresatleastoneconvincingClassIIstudyoroverwhelmingClassIIIevidence.LevelCEstablishedasuseful/predictiveornotuseful/predictiveforadiagnosticmeasureorestablishedaseffective,ineffectiveorharmfulforatherapeuticintervention;requiresatleasttwoClassIIIstudies.GoodClinicalPractice(GCP)Recommendedbestpracticebasedontheexperienceoftheguidelinedevelopmentgroup.UsuallybasedonClassIVevidenceindicatinglargeclinicaluncertainty,suchGCPpointscanbeusefulforhealthworkers.ClassificationofEvidenceEvidenceclassificationschemeforatherapeuticinterventionClassIAnadequatelypowered,prospective,randomized,controlledclinicaltrialwithmaskedoutcomeassessmentinarepresentativepopulationoranadequatelypoweredsystematicreviewofprospectiverandomizedcontrolledclinicaltrialswithmaskedoutcomeassessmentinrepresentativepopulations.ClassIIProspectivematched-groupcohortstudyinarepresentativepopulationwithmaskedoutcomeassessmentorarandomized,controlledtrialinarepresentativepopulationthatlacksonecriterionforclassIevidence.ClassIIIAllothercontrolledtrials(includingwell-definednaturalhistorycontrolsorpatientsservingasowncontrols)inarepresentativepopulation,whereoutcomeassessmentisindependentofpatienttreatment.ClassIVEvidencefromuncontrolledstudies,caseseries,casereports,orexpertopinion.ClassificationofEvidenceEvidenceclassificationschemeforadiagnosticmeasureClassIAprospectivestudyinabroadspectrumofpersonswiththesuspectedcondition,usinga‘goldstandard’forcasedefinition,wherethetestisappliedinablindedevaluation,andenablingtheassessmentofappropriatetestsofdiagnosticaccuracy.ClassIIAprospectivestudyofanarrowspectrumofpersonswiththesuspectedcondition,orawell-designedretrospectivestudyofabroadspectrumofpersonswithanestablishedcondition(by‘goldstandard’)comparedtoabroadspectrumofcontrols,wheretestisappliedinablindedevaluation,andenablingtheassessmentofappropriatetestsofdiagnosticaccuracy.ClassIIIEvidenceprovidedbyaretrospectivestudywhereeitherpersonswiththeestablishedconditionorcontrolsareofanarrowspectrum,andwheretestisappliedinablindedevaluation.ClassIVEvidencefromuncontrolledstudies,caseseries,casereports,orexpertopinion.ESOGuidelines2021Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationStrokeasanEmergencyBackgroundStrokeisthemostimportantcauseofmorbidityandlongtermdisabilityinEurope1DemographicchangesarelikelytoresultinanincreaseinbothincidenceandprevalenceStrokeisalsothesecondmostcommoncauseofdementia,themostfrequentcauseofepilepsyintheelderly,andafrequentcauseofdepression2,31:LopezADetal.Lancet(2006)367:1747-17572:RothwellPMetal.Lancet(2005)366:1773-17833:O'BrienJTetal.LancetNeurol(2003)2:89-98StrokeasanEmergencyBackgroundStrokeisamedicalandoccasionallyasurgicalemergencyThemajorityofischaemicstrokepatientsdonotreachthehospitalquicklyenoughThedelaybetweenstrokeonsetandhospitaladmissionis;reducediftheEmergencyMedicalSystems(EMS)areusedincreasedifdoctorsoutsidethehospitalareconsultedfirstStrokeasanEmergencyEmergencycareinacutestrokedependsonafour-stepchain:Rapidrecognitionof,andreactionto,strokesignsandsymptomsImmediateEMScontactandpriorityEMSdispatchPrioritytransportwithnotificationofthereceivinghospitalImmediateemergencyroomtriage,clinical,laboratoryandimagingevaluation,accuratediagnosis,andadministrationofappropriatetreatmentsatthereceivinghospital.StrokeasanEmergencyDelaysduringacutestrokemanagementhavebeenidentifiedatthreedifferentlevels1atthepopulationlevel,duetofailuretorecognizethesymptomsofstrokeandcontactemergencyservicesattheleveloftheemergencyservicesandemergencyphysicians,duetoafailuretoprioritizetransportofstrokepatientsatthehospitallevel,duetodelaysinneuroimagingandinefficientin-hospitalcare1:KwanJetal.AgeAgeing(2004)33:116-121EducationRecommendationsEducationalprogrammestoincreaseawarenessofstrokeatthepopulationlevelarerecommended(ClassII,

LevelB)Educationalprogrammestoincreasestrokeawarenessamongprofessionals(paramedics,emergencyphysicians)arerecommended(ClassII,LevelB)ReferralRecommendations(1/2)ImmediateEMScontactandpriorityEMSdispatcharerecommended(ClassII,LevelB)Prioritytransportwithadvancenotificationofthereceivinghospitalisrecommended(ClassIII,LevelB)Suspectedstrokevictimsshouldbetransportedwithoutdelaytothenearestmedicalcentrewithastrokeunitthatcanprovideultra-earlytreatment(ClassIII,LevelB)PatientswithsuspectedTIAshouldbereferredwithoutdelaytoaTIAclinicorastrokeunit(ClassIII,LevelB)ReferralRecommendations(2/2)DispatchersandambulancepersonnelshouldbetrainedtorecognisestrokeusingsimpleinstrumentssuchastheFace-Arm-Speech-Test(ClassIV,GCP)Immediateemergencyroomtriage,clinical,laboratoryandimagingevaluation,accuratediagnosis,therapeuticdecisionandadministrationofappropriatetreatmentsarerecommended(ClassIII,LevelB)Inremoteorruralareashelicoptertransferandtelemedicineshouldbeconsideredtoimproveaccesstotreatment(ClassIII,LevelC)EmergencyManagementThetimewindowfortreatmentofpatientswithacutestrokeisnarrowAcuteemergencymanagementofstrokerequiresparallelprocessesoperatingatdifferentlevelsofpatientmanagementAcuteassessmentofneurologicalandvitalfunctionsparallelsthetreatmentofacutelylife-threateningconditionsTimeisthemostimportantfactorEmergencyManagementTheinitialexaminationshouldincludeObservationofbreathingandpulmonaryfunctionandconcomitantheartdiseaseAssessmentofbloodpressureandheartrateDeterminationofarterialoxygensaturationBloodsamplesforclinicalchemistry,coagulationandhaematologystudiesObservationofearlysignsofdysphagiaTargetedneurologicalexaminationCarefulmedicalhistoryfocussingonriskfactorsforarteriosclerosisandcardiacdiseaseAncillaryDiagnosticTestsInallpatientsBrainImaging:CTorMRIECGLaboratoryTestsCompletebloodcountandplateletcount,

prothrombintimeorINR,PTTSerumelectrolytes,bloodglucoseCRPorsedimentationrateHepaticandrenalchemicalanalysisAncillaryDiagnosticTestsInselectedpatientsDuplex/DopplerultrasoundMRAorCTADiffusionandperfusionMRorperfusionCTEchocardiography,ChestX-rayPulseoximetryandarterialbloodgasanalysisLumbarpunctureEEGToxicologyscreenEmergencyManagementRecommendationsOrganizationofpre-hospitalandin-hospitalpathwaysandsystemsforacutestrokepatientsisrecommended(ClassIII,LevelC)Allpatientsshouldreceivebrainimaging,ECG,andlaboratorytests.Additionaldiagnosticexaminationsarenecessaryinselectedpatients(ClassIV,GCP)ESOGuidelines2021Content:Education,ReferralandEmergencyroomStrokeUnit

ImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationStrokeUnitAstrokeunitIsadedicatedandgeographicallydefinedpartofahospitalthattakescareofstrokepatientsHasspecialisedstaffwithcoordinatedmultidisciplinaryexpertapproachtotreatmentandcareComprisescoredisciplines:medical,nursing,physiotherapy,occupationaltherapy,speechandlanguagetherapy,socialwork11:LanghornePetal.AgeAgeing(2002)31:365-371StrokeUnitTypicalcomponentsofstrokeunitsincludeAssessmentMedicalassessmentanddiagnosis,earlyassessmentofnursingandtherapyneedsEarlymanagementpoliciesEarlymobilisation,preventionofcomplications,treatmentofhypoxia,hyperglycaemia,pyrexiaanddehydrationOngoingrehabilitationpoliciesCoordinatedmultidisciplinaryteamcareEarlyassessmentsofneedsafterdischargeStrokeUnitTreatmentatastrokeunitcomparedtotreatmentinageneralward1reducesmortality(absoluteriskreductionof3%)reducesdependency(5%)reducesneedforinstitutionalcare(2%)Alltypesofpatients,irrespectiveofgender,age,strokesubtypeandstrokeseverity,appeartobenefitfromtreatmentinstrokeunits1

1:StrokeUnitTrialists'CollaborationCochraneRev(2007)StrokeServicesandStrokeUnitsRecommendationsAllstrokepatientsshouldbetreatedinastrokeunit

(ClassI,LevelA)Healthcaresystemsmustensurethatacutestrokepatientscanaccesshightechnologymedicalandsurgicalstrokecarewhenrequired(ClassIII,LevelB)Thedevelopmentofclinicalnetworks,includingtelemedicine,isrecommendedtoexpandtheaccesstohightechnologyspecialiststrokecare(ClassII,LevelB)ESOGuidelines2021Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationEmergencyDiagnosticTestsDifferentiatebetweendifferenttypesofstrokeAssesstheunderlyingcauseofbrainischaemiaAssessprognosisProvideabasisforphysiologicalmonitoringofthestrokepatientIdentifyconcurrentdiseasesorcomplicationsassociatedwithstrokeRuleoutotherbraindiseasesEmergencyDiagnosticTestsCranialComputedTomography(CT)ImmediateplainCTscanningdistinguishesreliablybetweenhaemorrhagicandischaemicstrokeDetectssignsofischaemiaasearlyas2hafterstrokeonset1Helpstoidentifyotherneurologicaldiseases(e.g.neoplasms)Mostcost-effectivestrategyforimagingacutestrokepatients21:vonKummerRetal.Radiology(2001)219:95-1002:WardlawJetal.Stroke(2004)35:2477-2483EmergencyDiagnosticTestsMagneticResonanceImaging(MRI)Diffusion-weightedMRI(DWI)ismoresensitivefordetectionofearlyischaemicchangesthanCTDWIcanbenegativeinpatientswithdefinitestroke1IdentifiesischaemiclesionsintheposteriorfossareliablyDetectsevensmallintracerebralhaemorrhagesreliablyonT2*sequencesMRIisparticularlyimportantinacutestrokepatientswithunusualpresentations

1:AyHetal.CerebrovascDis(2002)14:177-186EmergencyDiagnosticTestsMismatchConceptMismatchbetweentissueabnormalonDWIandtissuewithreducedperfusionmayreflecttissueatriskoffurtherischaemicdamage1Thereisdisagreementonhowtobestidentifyirreversibleischaemicbraininjuryandtodefinecriticallyimpairedbloodflow2

Thereisnoclearevidencethatpatientswithparticularperfusionpatternsaremoreorlesslikelytobenefitfromthrombolysis3

1:JansenOetal.Lancet(1999)353:2036-20372:KaneIetal.Stroke(2007)38:3158-31643:AlbersGWetal.AnnNeurol(2006)60:508-517EmergencyDiagnosticTestsUltrasoundstudiesCerebrovascularultrasoundisfastandnon-invasiveandcanbeadministeredusingportablemachines.Itisthereforeapplicabletopatientsunabletoco-operatewithMRAorCTA1CombinationsofultrasoundimagingtechniquesandMRAcanproduceexcellentresultsthatareequaltoDigitalsubtractionangiography(DSA)21:Allend?rferJetal.LancetNeurology(2005)5:835-8402:NederkoornPetal.Stroke(2003)34:1324-1332EmergencyDiagnosticTestsImaginginTIA-patientsUpto10%recurrenceriskinthefirst48hours1Simpleclinicalscoringsystemscanbeusedtoidentifypatientsatparticularlyhighrisk1

Upto50%ofpatientswithTIAshaveacuteischaemiclesionsonDWI.Thesepatientsareatincreasedriskofearlyrecurrentdisablingstroke2ThereiscurrentlynoevidencethatDWIprovidesbetterstrokepredictionthanclinicalriskscores31:RothwellPetal.LancetNeurol(2005)5:323-3312:CouttsSetal.AnnNeurol(2005)57:848-8543:RedgraveJetal.Stroke(2007)38:1482-1488EmergencyDiagnosticTestsElectrocardiogram(ECG)Cardiacabnormalitiesarecommoninacutestrokepatients1Arrhythmiasmayinducestroke,strokemaycausearrhythmiasHoltermonitoringissuperiortoroutineECGforthedetectionofatrialfibrillation(AF)2ItisunclearwhethercontinuousECGrecordingatthebedsideisequivalenttoHoltermonitoringforthedetectionofAF1:ChristensenHetal.NeurolSci(2005)234:99–1032:GunalpMetal.AdvTher(2006)23:854-60EmergencyDiagnosticTestsEchocardiography(TTE/TOE)Echocardiographycandetectmanypotentialcausesofstroke1Itisparticularlyrequiredinpatientswithhistoryofcardiacdisease,ECGpathologies,suspectedsourceofembolism,suspectedaorticdisease,suspectedparadoxicalembolismTransoesophagealechocardiography(TOE)mightbesuperiortotransthoracicechocardiography(TTE)forthedetectionofpotentialcardiacsourcesofembolism21:LerakisSetal.AmJMedSci(2005)329:310-62:deBruijnSFetal.Stroke(2006)37:2531-4EmergencyDiagnosticTestsLaboratorytestsHaematology(RBC,WBC,plateletcount)BasicclottingparametersElectrolytesRenalandhepaticchemistryBloodGlucoseCRP,sedimentationrateDiagnosticImagingRecommendationsInpatientswithsuspectedTIAorstroke,urgentcranialCT(ClassI),oralternativelyMRI(ClassII),isrecommended(LevelA)IfMRIisused,theinclusionofdiffusionweightedimaging(DWI)andT2*-weightedgradientechosequencesisrecommended(ClassII,LevelA)InpatientswithTIA,minorstroke,orearlyspontaneousrecoveryimmediatediagnosticwork-up,includingurgentvascularimaging(ultrasound,CT-angiography,orMRangiography)isrecommended(ClassI,LevelA)OtherDiagnosticsRecommendations(1/2)InpatientswithacutestrokeandTIA,earlyevaluationofphysiologicalparameters,routinebloodtests,andelectrocardiography(ECG)isrecommended(ClassI,LevelA)AllacutestrokeandTIApatientsshouldhavea12-channelECG.ContinuousECGrecordingisrecommendedforischaemicstrokeandTIApatients(ClassI,LevelA)

OtherDiagnosticsRecommendations(2/2)ForstrokeandTIApatientsseenaftertheacutephase,24-hourHolterECGmonitoringshouldbeperformedwhenarrhythmiasaresuspectedandnoothercausesofstrokearefound

(ClassI,LevelA)ForallstrokeandTIApatients,asequenceofbloodtestsisrecommendedEchocardiographyisrecommendedinselectedpatients(ClassIII,LevelB)ESOGuidelines2021Content:Education,ReferralandEmergencyroomStrokeUnitImagingandDiagnosticsPreventionGeneralTreatmentAcuteTreatmentManagementofComplicationsRehabilitationPrimaryPreventionContentManagementofvascularriskfactorsAntithrombotictherapyCarotidsurgeryandangioplastyVascularRiskFactorsConditionsandlifestylecharacteristicsidentifiedasariskfactorsforstrokeHighbloodpressure HighCholesterolAtrialfibrillation Hyper-homocysteinaemiaDiabetesmellitus Smoking Carotidarterydisease HeavyalcoholuseMyocardialinfarction Physicalinactivity ObesityHighbloodpressure(BP)BackgroundHighbloodpressure(>120/80mmHg)isthemostimportantandprevalentmodifiableriskfactorforstrokeSignificantreductionofstrokeincidencewithadecreaseinBP1NoclassofantihypertensiveisclearlysuperiorLIFE:lorsatanissuperiortoatenolol2ALLHAT:chlorthalidoneismoreeffectivethanamlodipineandlisinopril31:NealBetal.Lancet(2000)356:1955-642:DahlofBetal.Lancet(2002)359:995-1003.3:ManciaGetal.EurHeartJ(2007)28:1462-536BackgroundIndependentriskfactorforischaemicstrokeImprovingglucosecontrolmaynotreducestroke1BPinpatientswithdiabetesshouldbe<130/80mmHg2Statintreatmentreducestheriskofmajorvascularevents,includingstroke3ElevatedbloodglucoseintheearlyphaseofstrokeisassociatedwithdeathandpoorrecoveryDiabetesmellitus1:TurnerRCetal.JAMA(1999)281:2005-122:ManciaGJ:HypertensSuppl(2007)25:S7-123:SeverPSetal.DiabetesCare(2005)28:1151-7BackgroundStatintreatmentreducestheincidenceofstrokefrom3.4%to2.7%1Nosignificanteffectforpreventionoffatalstroke1HeartProtectionStudyfoundanexcessofmyopathyofoneper10,000patientsperannum2

NodatasupportstatintreatmentinpatientswithLDL-cholesterol<150mg/dl(3.9mmol/l)HighCholesterol1:AmarencoPetal.:Stroke(2004)35:2902-29092:HPSGroup:Lancet(2002)360:7-22.BackgroundIndependentriskfactorforischaemicstrokeinmenandwomen2-3foldincreasedriskcomparedtonon-smokers1Spousalcigarettesmokingmaybeassociatedwithanincreasedstrokerisk250%riskreductionby2yearsafterstoppingsmoking3CigaretteSmoking1:ShintonRetal.:BMJ(1989)298:789-94.2:QureshiAetal.:Stroke(2005)36:74-763:ColditzGAetal.:NEnglJMed(1988)318:937-41.BackgroundIncreasedriskforbothischaemic(RR1.69)andhaemorrhagicstroke(RR2.18)withheavyalcoholconsumption(>60g/day)1BPelevationmightbeareasonableexplanation3Lightalcoholconsumption(<12g/day)associatedwithreducedischaemic(RR0.80)andhaemorrhagicstroke1Redwineconsumptioncarriesthelowestrisk2

AlcoholConsumption1:ReynoldsKetal.:JAMA(2003)289:579-882:MukamalKetal.:AnnInternMed(2005)142:11-193:BazzanoLAetal.:AnnNeurol(2007)Background

Regularexercise(atleast3x30min/week)isassociatedwithadecreasedriskofstrokePhysicallyactiveindividualshavealowerriskofstrokeordeaththanthosewithlowactivity(RR0.73)1

Thisismediated,inpart,throughbeneficialeffectsonbodyweight,bloodpressure,serumcholesterol,andglucosetolerance2PhysicalActivity1:LeeCetal.:Stroke(2003)34:2475-24812:DeplanqueDetal.:Neurology(2006)67:1403-1410)BodyWeight,Diet,NutritionBackgroundHighbodymassindex(BMI≥25)increasesriskofstrokeinmenandwomen1Abdominaladiposityisariskfactorforstrokeinmenbutnotwomen2Arandomizedtrialinwomenfoundnoeffectofdietaryinterventionstoreducetheincidenceofstroke3Tocopherolandbetacarotenesupplementationdonotreducetheriskofstroke.VitaminEmightincreasemortalitywhenusedathigh-dose(≥400IU/d)1:KurthTetal.:Circulation(2005)111:1992-19982:HuGetal.:ArchInternMed(2007)167:1420-14273:HowardBetal.:JAMA(2006)295:655-666BackgroundStrokeratesriserapidlyinwomenafterthemenopause

Hormonereplacementtherapyinpostmenopausalwomenisassociatedwithan44%increasedriskofstroke1

HormoneReplacementTherapy1:GabrielSetal.:CochraneReview(2005)CD002229RiskFactorManagementRecommendations(1/4)Bloodpressureshouldbecheckedregularly.Highbloodpressureshouldbemanagedwithlifestylemodificationandindividualizedpharmacological

therapy(ClassI,LevelA)aimingatnormallevelsof120/80mmHg(ClassIV,GCP)RiskFactorManagementRecommendations(2/4)Bloodglucoseshouldbecheckedregularly.Diabetesshouldbemanagedwithlifestylemodificationandindividualizedpharmacological

therapy(ClassIV,LevelC).Indiabeticpatients,highbloodpressureshouldbemanagedintensively(ClassI,LevelA)aimingforlevelsbelow130/80mmHg(ClassIV,LevelC).Wherepossible,treatmentshouldincludeanangiotensinconvertingenzymeinhibitororangiotensinreceptorantagonist(ClassI,LevelA)RiskFactorManagementRecommendations(3/4)Bloodcholesterolshouldbecheckedregularly.Highbloodcholesterol(e.g.LDL>150mg/dl[3,9mMol/l])shouldbemanagedwithlifestylemodification(ClassIV,LevelC)andastatin(ClassI,LevelA)Cigarettesmokingshouldbediscouraged(ClassIII,LevelB)Heavyuseofalcoholshouldbediscouraged(ClassIII,LevelB)Regularphysicalactivityisrecommended(ClassIII,LevelB)RiskFactorManagementRecommendations(4/4)Adietlowinsaltandsaturatedfat,highinfruitandvegetablesandrichinfibreisrecommended(ClassIII,LevelB)Subjectswithanelevatedbodymassindexarerecommendedtotakeaweight-reducingdiet(ClassIII,LevelB)Antioxidantvitaminsupplementsarenotrecommended(ClassI,LevelA)Hormonereplacementtherapyisnotrecommendedfortheprimarypreventionofstroke(ClassI,LevelA)BackgroundInlowriskpersonslowdoseaspirinreducedcoronaryevents,butnotstroke1Inwomenover45yearsaspirinreducestheriskofischaemicstroke(OR0.76;)2AspirinreducesMIinpatientswithasymptomaticcarotidarterydisease3AntithromboticTherapy1:BartolucciAetal.:AmJCardiol(2006)98:746-7502:BergerJetal.:JAMA(2006)295:306-3133:HobsonR,2ndetal.:JVascSurg(1993)17:257-263Background

Averagestrokerateof5%peryearAspirinreducesstroke(RR0.78)inpatientswithnon-valvularAF1Warfarin(INR2.0-3.0)ismoreeffectivethanaspirinatreducingstroke(RR0.36;95%CI0.26-0.51)1Combinationofaspirinandclopidogrelislesseffectivethanwarfarinandhasasimilarbleedingrate2Atrialfibrillation(AF)1:HartRGetal.:AnnInternMed(2007)146:857-8672:ConnollySetal.:Lancet(2006)367:1903-1912BackgroundAnticoagulationwithanINRbelow2.0isnoteffectiveIncreasedriskforbleedingcomplicationswithanINR>3.5Patients<65yearsofagewith“l(fā)oneAF〞(withoutotherriskfactors)areatlowrisk,whereaspatientsolderthan65yearsareatahigherriskforembolicstrokeAnticoagulationcanbesafeandeffectiveinolderindividuals1,2Atrialfibrillation(AF)1:RashAetal.:AgeAgeing(2007)36:151-1562:MantJetal.:Lancet(2007)370:493-503AntithromboticTherapyRecommendations(1/4)Low-doseaspirinisrecommendedinwomenaged45yearsormorewhoarenotatincreasedriskforintracerebralhaemorrhageandwhohavegoodgastro-intestinaltolerance;however,itseffectisverysmall(ClassI,LevelA)Low-doseaspirinmaybeconsideredinmenfortheprimarypreventionofmyocardialinfarction;however,itdoesnotreducetheriskofischaemicstroke(ClassI,LevelA)AntithromboticTherapyRecommendations(2/4)Antiplateletagentsotherthanaspirinarenotrecommendedforprimarystrokeprevention(ClassIV,GCP)Aspirinmayberecommendedforpatientswithnon-valvularAFwhoareyoungerthan65yearsandfreeofvascularriskfactors(ClassI,LevelA)Unlesscontraindicated,eitheraspirinoranoralanticoagulant(internationalnormalizedratio[INR]2.0-3.0)isrecommendedforpatientswithnon-valvularAFwhoareaged65-75yearsandfreeofvascularriskfactors(ClassI,LevelA)AntithromboticTherapyRecommendations(3/4)Unlesscontraindicated,anoralanticoagulant(INR2.0–3.0)isrecommendedforpatientswithnon-valvularAFwhoareaged>75,orwhoareyoungerbuthaveriskfactorssuchashighbloodpressure,leftventriculardysfunction,ordiabetesmellitus(ClassI,LevelA)AntithromboticTherapyRecommendations(4/4)PatientswithAFwhoareunabletoreceiveoralanticoagulantsshouldbeofferedaspirin(ClassI,LevelA)PatientswithAFwhohavemechanicalprostheticheartvalvesshouldreceivelong-termanticoagulationwithatargetINRbasedontheprosthesistype,butnotlessthanINR2–3(ClassII,LevelB)Lowdoseaspirinisrecommendedforpatientswithasymptomaticinternalcarotidartery(ICA)stenosis>50%toreducetheirriskofvascularevents(ClassII,LevelB)Background1,2Carotidendarterectomy(CEA)isstillamatterofcontroversyinasymptomaticindividualsRRRforstenosis>60%NASCETis38-53%