Connor Iapoce

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A new scientific statement titled, "Primary Care of Adult Patients After Stroke," has been released by the American Heart Association/American Stroke Association (AHS/ASA), aiming to offer a guidance for goal-directed, patient-centered care for poststroke adults with a specific focus on the role that primary care providers can play in this phase of care.

The statement highlighted the need for comprehensive post-stroke management, including engaged caregivers and family members in supporting the patient. Additionally, it stressed the need for an earlier poststroke primary care appointment, in hopes of reduce hospital admission and addressing care disparities that may lead to a high risk of stroke recurrence.

Secondary stroke prevention has been a focus of the AHA/ASA in recent weeks, with the organization recently publishing 

 for its prevention in those with stroke and transient ischemic attack (TIA). The guidelines focus on improving diagnostics, managing vascular risk factors and lifestyle factors, altering patient behaviors, recommending antithrombotic therapy, monitoring atrial fibrillation (AF), extracranial carotid artery disease, severe intracranial stenosis, and embolic stroke of uncertain source, and the determinant use of patent foramen ovale closure.

In this latest release from the AHA/ASA, the complexities of stroke were highlighted, with the organization citing that approximately 800,000 adults in the US will have a new stroke each year, of which 10% will die within 30 days. Further, data show by 90 days after stroke, new stroke-related disability developed in 10% of younger adults to 30% in adults aged >65 years.

AHA Updates Guidelines for Secondary Stroke Prevention, Risk Factor Mitigation

The statement also pointed to need for screenings should assess new or chronic risk of recurrent stroke, including high blood pressure, high cholesterol, diabetes, atrial fibrillation and blockage in carotid artery, as well as complications including anxiety, depression, and cognitive impairment.

Walter N. Kernan, MD, chair of the statement writing group and professor of medicine, Yale University School of Medicine, said the new statement affirmed the new role of the primary care professional in the care of people with stroke. “Primary care professionals can ensure consistent and comprehensive care for the full needs of patients, including coordinating any additional care or services patients may need from community services providers or from subspecialty health care providers,” Kernan said in a statement.

Data suggest that the risk of recurrent stroke will reach 8% in the first year following an ischemic stroke, while the annual risk after the first year is 2%, nearly 4 times higher risk than a person without prior stroke.

The guidance mentioned that although the majority of incidences of stroke are due to cardioembolism, large-vessel disease, or small-vessel disease, it may be important to consider other causes including arterial dissection, vasculitis, or sickle cell disease. The statement indicated the first step in outpatient primary care is to confirm the cause of stroke, while diagnostic tests that have not been completed should be prioritized, including carotid imaging and cardiac rhythm monitoring. The cause of stroke remains uncertain for 30% of patients, Kernan and colleagues noted.

The statement included Class 1 treatment recommendations from the AHA/ASA. Proven treatments in the prevention of recurrent vascular events included carotid revascularization for carotid stenosis, anticoagulation for atrial fibrillation, BP lowering, statin therapy, and antiplatelet therapy.

Further, lifestyle improvements, diabetes management, and weight optimization are recommended as Class 1 due to evidence of reduction of risk factors for stroke, rather than prevention of recurrent stroke.

The importance of hypertension management was observed, citing 2 trials that showed blood pressure lowering following stroke reduced the risk for stroke recurrence by 30%. They additionally provided guidance on diagnostic evaluation, including imaging of the carotid artery for anterior circular stroke events and ECG to screen for atrial fibrillation (AF).

Next, they discussed vascular risk factor management to recommend and facilitate optimal lifestyle practices, as well as treat hypertension to a goal of <130/80 mm Hg.

The statement included additional recommendations for management of large-artery atherosclerosis, such as prescribing 325 mg/d aspirin for patients with stroke-related to 50%-99% intracranial stenosis. As well, guidance on cardioembolism included prescribing an oral anticoagulation for AF or flutter unless contraindicated and recommended warfarin over novel oral anticoagulants. Further, patient behavior guidelines included behavior change to improve stroke literacy, lifestyle, and medication adherence.

Another recommendation included health equity to address social determinants of health, including literacy level, language proficiency, medication affordability, food insecurity, housing, transportation, in managing stroke risk factors.

Lastly, the statement addressed the use of antithrombotic medications, recommending non-cardioembolic ischemic stroke or TIA, aspirin 50–325 mg, clopidogrel 75 mg, or combination aspirin 25 mg/dipyridamole 200 mg twice daily.

The full text of the AHA statement is available 

REFERENCES
1. Kernan WN, Viera AJ, Billinger SA, et al. Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association. 

. Published online July 15, 2021. doi: 10.1161/STR.0000000000000382.
2. Kleindorfer DA, Towfighi A, Chaturvedi S, et al. 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. 

 Published online May 24, 2021 doi: 0.1161/STR.0000000000000375
3. American Heart Association Statement Stresses Need for Comprehensive Post-Stroke Care. News release. AHS/ASA. Published July 15, 2021. Accessed July 20, 2021. https://newsroom.heart.org/news/comprehensive-primary-care-is-vital-to-holistic-care-and-optimal-recovery-after-a-stroke

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The collaborative newly published statement stressed the need to address gaps in care that may lead to high risk of stroke recurrence. 