New Stroke Prevention Guidelines: A Quick and Easy Guide
New Stroke Prevention Guidelines: A Quick and Easy Guide
• Counseling plus drug therapy
• Abstinence in those who have never smoked
The Bottom Line: There is a clear link between cigarette smoking and an increased risk for ischemic stroke and SAH. Data showing that smoking cessation programs reduce the incidence of stroke are lacking; however, epidemiologic findings suggest that quitting smoking is associated with a reduced risk for stroke. The new guidelines comment that community- or state-wide bans on smoking in public spaces are a reasonable means of reducing risk for stroke and myocardial infarction.
• Valvular AF and high stroke risk (CHA2DS2-VASc score ≥ 2): Initiate long-term warfarin therapy; target international normalized ratio (INR), 2.0-3.0
• Nonvalvular AF, CHA2DS2-VASc score ≥ 2, and low risk for hemorrhagic complications: Individualize care and consider warfarin, dabigatran, apixaban, or rivaroxaban
• AF screening in the primary care setting in those older than 65 years
• Nonvalvular AF and CHA2DS2-VASc score of 0: reasonable to omit antithrombotic therapy
• Nonvalvular AF, CHA2DS2-VASc score 1, and low risk for hemorrhagic complications: No antithrombotic therapy, anticoagulant therapy, or aspirin therapy can be considered; selection of antithrombotic agent should be individualized on the basis of patient risk factors
• High-risk patients with AF who are unsuitable for anticoagulation: Consider left atrial appendage closure, if performed at a center with a low complication rate
The Bottom Line: Selecting a stroke prevention strategy in patients with AFcan be challenging, given that the data are ever-changing and numerous therapies are available. However, risk stratification with CHA2DS2-VASc scores is helpful in determining stroke risk and selecting a course of action.
The novel anticoagulants, including dabigatran, rivaroxaban and apixaban, should be considered in patients who may have a higher risk for intracerebral hemorrhage (ICH), because each of them has been associated with a lower risk for ICH than warfarin. Apixaban is the only one with a trend toward lower gastrointestinal bleeding than warfarin. Dosing needs to be selected carefully on the basis of the patient's renal function.
Smoking
The Basics
• Counseling plus drug therapy
• Abstinence in those who have never smoked
The Bottom Line: There is a clear link between cigarette smoking and an increased risk for ischemic stroke and SAH. Data showing that smoking cessation programs reduce the incidence of stroke are lacking; however, epidemiologic findings suggest that quitting smoking is associated with a reduced risk for stroke. The new guidelines comment that community- or state-wide bans on smoking in public spaces are a reasonable means of reducing risk for stroke and myocardial infarction.
Atrial Fibrillation
The Basics
• Valvular AF and high stroke risk (CHA2DS2-VASc score ≥ 2): Initiate long-term warfarin therapy; target international normalized ratio (INR), 2.0-3.0
• Nonvalvular AF, CHA2DS2-VASc score ≥ 2, and low risk for hemorrhagic complications: Individualize care and consider warfarin, dabigatran, apixaban, or rivaroxaban
• AF screening in the primary care setting in those older than 65 years
• Nonvalvular AF and CHA2DS2-VASc score of 0: reasonable to omit antithrombotic therapy
• Nonvalvular AF, CHA2DS2-VASc score 1, and low risk for hemorrhagic complications: No antithrombotic therapy, anticoagulant therapy, or aspirin therapy can be considered; selection of antithrombotic agent should be individualized on the basis of patient risk factors
• High-risk patients with AF who are unsuitable for anticoagulation: Consider left atrial appendage closure, if performed at a center with a low complication rate
The Bottom Line: Selecting a stroke prevention strategy in patients with AFcan be challenging, given that the data are ever-changing and numerous therapies are available. However, risk stratification with CHA2DS2-VASc scores is helpful in determining stroke risk and selecting a course of action.
The novel anticoagulants, including dabigatran, rivaroxaban and apixaban, should be considered in patients who may have a higher risk for intracerebral hemorrhage (ICH), because each of them has been associated with a lower risk for ICH than warfarin. Apixaban is the only one with a trend toward lower gastrointestinal bleeding than warfarin. Dosing needs to be selected carefully on the basis of the patient's renal function.
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