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Anticoagulants & Preventing Stroke in Atrial Fibrillation

Depending on a patient’s comorbidities and history of prior cerebrovascular events, the rate of stroke among adults with atrial fibrillation (AF) varies widely, ranging between 1% and 20% annually. It is important to stratify the risk of stroke to determine whether prophylactic treatment with an anticoagulant is warranted because the medications used to lower the incidence of AF-related stroke are associated with bleeding. “Aspirin and warfarin have been the primary medications used to prevent stroke in patients with nonvalvular AF (NVAF),” says Larry B. Goldstein, MD, FAAN, FAHA. “Aspirin is indicated primarily for lower-risk patients, while warfarin is reserved for those at greater thromboembolic risk.” Until recently, the American Heart Association and the American Stroke Association (AHA/ASA) have centered their recommendations on preventing stroke in patients with NVAF around using aspirin or warfarin. There are also some data reflecting the use of clopidogrel plus aspirin as compared to warfarin or aspirin alone. The Role of Newer Antithrombotic Agents The new antithrombotics are alternatives to warfarin and aspirin for patients with NVAF. In the August 2, 2012 online issue of Stroke, the AHA/ ASA released a science advisory for healthcare professionals reviewing these new oral antithrombotic agents and providing revised management recommendations. The AHA/ASA scientific advisory updates its existing guidelines based on clinical trial data for three new antithrombotic drugs that have been evaluated in patients with NVAF. “When selecting specific agent for stroke prevention in AF, clinicians must individualize treatment decisions based on risk factors, cost, and tolerability.” —Larry B. Goldstein, MD, FAAN, FAHA “We reviewed recent trials that tested the safety and efficacy of dabigatran—a direct thrombin inhibitor—and...

Depression After Stroke & TIA

A North Carolina study team has found that the rates of depression at 3 and 12 months after hospitalization appear to be similar in stroke and transient ischemic attack (TIA) patients. Among the findings: Following Stroke Following TIA Proportional Frequency of Depression at 3 Months 17.9% 14.3% Proportional Frequency of Depression at 12 Months 16.4% 12.8% Rate of Newly Identified Depression Between Months 3 and 12 8.7% 6.2% Antidepressant Use in Those With Persistent Depression 67.9% 70.0%   Abstract: Stroke, June...

Updated Guidelines for Secondary Stroke Prevention

The American Heart Association/American Stroke Association (AHA/ASA) released updated guidelines to prevent subsequent stroke in survivors of ischemic strokes or transient ischemic attacks (TIAs). Specifically, the guidelines—which were published in the January 2011 issue of Stroke—include new recommendations for treating metabolic syndrome, stenting of the carotid artery, and atrial fibrillation, among other updates. The update revised previous recommendations from 2006 and reflected new evidence from recent investigations and analyses pertaining to secondary stroke prevention. This guideline is one of five “flagship” evidence based statements from the AHA/ASA, which are revised every 3 years. They are designed to assist clinicians in making important treatment decisions after stroke or TIA. Metabolic Syndrome & Stenting Updates Among the new recommendations made in the section on metabolic syndrome is that clinicians are now advised to treat individual components that are also stroke risk factors, particularly dyslipidemia and hypertension, in order to prevent a second stroke or TIA in individuals with metabolic syndrome. All patients with carotid artery stenosis and a TIA or stroke should receive optimal medical therapy, including antiplatelet therapy and statins, as well as risk factor modifications. Another important note is that the utility of screening patients for metabolic syndrome after stroke is unknown, so more research is necessary in this component of stroke management. “As the data continue to shed light on emerging therapies and technologies, the hope is that we’ll be able to decrease the burden of stroke and TIA more in the future.”  The section on carotid artery stenting (CAS) for extracranial symptomatic carotid disease was also updated because of recent large clinical trials. CAS can be used as...

Making the Case for Statins

According to national guidelines, patients with ischemic stroke or transient ischemic attack (TIA) should be put on lipid-lowering therapies such as statins during hospitalization. They should continue this treatment even after they are discharged, along with plans for proper diet and exercise. This is a top tier recommendation because studies have shown that lipid-lowering medications and statins, in particular, can dramatically lower the rates of subsequent heart attacks, strokes, and the need for procedures to reopen clogged arteries. Statin Usage Following Acute Stroke Cholesterol-lowering targets have been established by recommendations from the National Cholesterol Education Project Adult Treatment Panel III for patients with documented coronary heart disease and those that have had an ischemic stroke or TIA. For patients who have no other manifestations of atherosclerosis (other than cerebrovascular disease), the latest American Heart Association (AHA)/American Stroke Association (ASA) guidelines recommend intensive lipid-lowering therapy. “We know from prior experience that medications started at the time of discharge are much more likely to be continued by patients in the year after the event,” explains Lee H. Schwamm, MD. “Starting lipid-lowering medications, especially statins, at discharge in appropriately selected patients hospitalized for ischemic stroke or TIA makes good sense and should be considered good clinical practice. “Starting lipid-lowering medications, especially statins, at discharge in appropriately selected patients hospitalized for ischemic stroke or TIA makes good sense and should be considered good clinical practice.” Cholesterol-lowering targets have been established by recommendations from the National Cholesterol Education Project Adult Treatment Panel III for patients with documented coronary heart disease and those that have had an ischemic stroke or TIA. For patients who have...
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