R 12.1 a
Grade B |
To better
implement the procedure for the secondary prevention of stroke,
audit procedures are recommended. |
R 12.1 b
Grade B |
To improve
the prescription of the procedures for stroke recurrence prevention,
the use of computer-aided supports - such as reminders -
is recommended. |
R 12.2
Grade A |
In TIA and
non-cardioembolic ischaemic stroke the antiplatelet treatment
is recommended to prevent
recurrences. |
R 12.3a
Grade A |
Treatment with
ASA (100-325 mg per day) is recommended
in TIA and non cardio-embolic ischaemic stroke. |
|
*GPP
|
The SPREAD Collaboration recommends the dose of 100 mg per
day for long-term therapy. |
R 12.3b
Grade A |
Treatment with
clopidoprel 75 mg per day is recommended
in TIA and non cardio-embolic ischaemic stroke. |
|
*GPP
|
Clopidogrel is recommended
as an alternative in case ASA is nor tolerated or ineffective. |
R 12.3c
Grade A |
Treatment with
ticlopidine 500 mg per day is recommended
in TIA and non cardio-embolic ischaemic stroke. It exhibits, however,
a safety profile less favourable than that of clopidogrel and
requires blood count
twice monthly for the first 3 months. |
|
*GPP
|
The SPREAD Collaboration
recommends Clopidogrel in case a thienopyridine has to be
prescribed. |
R 12.4a
Grade A |
The combination
of ASA 50 mg per day plus controlled release dipyridamole 400 mg
per day is more effective than ASA alone (NNT=100).
The combination is
therefore recommended in TIA and
non cardio-embolic ischaemic stroke. |
|
*GPP
|
The SPREAD Collaboration
recommends the combination ASA plus dipyridamole as
an alternative to ASA, which remains the first choice. |
R 12.4b
Grade D |
The combination
of ASA and clopidogrel
is not recommended to prevent
recurrences of ischaemic strokes because it increases the
haemorrhagic risks without increasing the expected benefits. |
|
*GPP
|
According to the SPREAD Collaboration also the
combination of ASA and ticlopidine is
not recommended because it presumably implies the
same decrease of the benefit-to-risk ratio as the combination with
clopidogrel. |
| S 12-1 |
The MATCH study,
in patients with recent stroke or TIA, history of myocardial,
cerebral or peripheral ischaemia or diabetes, showed that the
combination of ASA and clopidogrel, while decreasing the
ischaemic events, after three months of therapy is associated to
increased major and life-threatening haemorrhagic complications. |
|
S 12-2 |
The CHARISMA
study observed neither significant benefits nor increased
risks when combining clopidogrel and ASA the in the prevention
of atherothrombotic events. |
|
S 12-3 |
The complex
statistical evaluations of the recent studies on antiplatelets used
alone or in combination, suggest that the physician should make
choices as individualised as possible taking into account the
specific clinical conditions of each patient. Aspirin remains the
first choice for the secondary prevention of cerebrovascular events,
however, the use of clopidogrel in patient with intolerance or
documented resistance to ASA, as well as in those who had a new
event while being treated with ASA or ASA plus dipyridamole,
should be considered. |
R 12.5
Grade C |
In patients with cardio-embolic stroke or TIA
associated with heart or valvular diseases with embolic risk,
oral anticoagulation (target INR between 2.0 and 3.0)
is
recommended. |
|
S 12-4 |
In selected and appropriately trained patients,
self-monitoring of oral anticoagulation is feasible provided that
regular checks are performed by the general physician. |
|
S 12-5 |
In the analysis
of the unplanned subgroups from the SPORTIF III and IV studies, the
combination treatment of ASA (<100 mg per day) and warfarin (INR
2-3) to prevent recurrences in patients with non valvular atrial
fibrillation, increased the risk of major haemorrhages by 1.6% per
year. A difference of this size may, however, be explained by the
play of chance. |
R 12.6 a
Grade B |
After stroke or TIA, lowering of high blood
pressure is recommended, preferably using agents active on the
renin-angiotensin system, calcium channel blockers and diuretics. |
R 12.6 b
Grade B |
In
patients with stroke or TIA, the use of the ACE inhibitor
perindopril in combination with the diuretic indapamide, or
eprosartan,
are recommended to obtain an
adequate blood pressure decrease reducing the risk of recurrent
stroke. |
R 12.7
Grade A |
In patients
with stroke or TIA even without elevated
cholesterol levels, the use of statins is
recommended since it reduces the risk of major ischaemic
events. |
|
S 12-6 |
The HPS study showed the efficacy of simvastatin in
reducing the risk of recurrent vascular events, even in patients
with normal cholesterol levels. |
|
S 12-7 |
The SPARCL study,
which recruited 4731 patient with stroke or TIA, LDL-cholesterol
between 100 and 190 but without coronary disease, showed after 4.9
years of treatment with atorvastatin 80 mg an absolute decrease of
2.2% of stroke and TIA, and of 3.5% of cardiovascular events, in
comparison with placebo. Transaminases persistently increased in
a greater number of atorvastatin-treated patients. |
R 12.8
Grade A |
 After a stroke or TIA
of arterial origin, oral
anticoagulation is not recommended
because there is no documented
evidence of an higher benefit compared with antiplatelet therapy
at an INR range of 2.0-3.0, while the risk of cerebral
haemorrhagic complications is higher at an INR >3.0. |
R 12.9
Grade A |
Oral anticoagulation (INR 2.0-3.0)
is recommended after a cardio-embolic stroke or TIA associated with non valvular
atrial fibrillation. |
R 12.10
Grade A |
ASA (325 mg per day)
is recommended after a
cardio-embolic stroke or TIA associated with non valvular atrial
fibrillation, when oral anticoagulation cannot be administered. |
R 12.11
Grade
B |
Indobufen (100-200 mg twice daily)
is recommended
after a cardio-embolic stroke or TIA associated with non valvular
atrial fibrillation, when oral anticoagulation cannot be
administered. |
R 12.12
Grade
C |
Oral
anticoagulation (INR 2.0-3.0) is
recommended after a cardio-embolic stroke or TIA
associated with dilated cardiomyopathy, isolated or associated with
nonvalvular atrial fibrillation of ventricular thrombus. |
R
12.13 a
Grade D |
ASA
is recommended after an
ischaemic stroke or TIA associated with patent foramen ovale (PFO),
if no deep venous thrombosis is documented and this is the first
thromboembolic event. |
R 12.13 b
Grade
D |
In patients
with stroke or TIA and:
 | PFO associated with atrial septal aneurysm and first-ever
event; |
| isolated PFO and DVT or coagulation abnormalities of
thrombophilic nature; |
| isolated PFO with large shunt and multiple ischaemic events, |
if other possible causes are excluded, it
is recommended to make a choice between anticoagulant
therapy (INR 2-3) and percutaneous transcatheter closure of the
foramen, after evaluating relevant risks and benefits. |
R 12.13 c
Grade
D |
In patients
with stroke or TIA and:
| PFO associated with atrial septal aneurysm and first-ever
event, in presence of DVT or coagulation abnormalities of
thrombophilic nature and contraindications to anticoagulant
therapy; |
| PFO with recurrent symptoms in spite of anticoagulant therapy; |
if other possible causes are excluded, percutaneous transcatheter
closure of the foramen and, should this fail, surgical closure
is recommended. |
|
S 12-8 |
In agreement
with Recommendation 5-17, the trans-cranial Doppler (TCD) should be
selected instead of trans-oesophageal echocardiography (TEE) as less
invasive but equally sensitive technique to identify the
right-to-left shunt. To date, the shunt size is not considered
relevant to drive the therapeutic decisions. |
R 12.14
Grade
C |
After a recurrent stroke or TIA in patients with
prosthetic heart valve who are already on adequate oral
anticoagulation, the combination of oral anticoagulants plus
dypiridamole (400 mg per day) or ASA (100 mg per day)
is
recommended. |
