The American Heart Association and American Stroke Association (AHA/ASA) have released an update to their 2018 guidelines for the early management of acute ischemic stroke (AIS), which was published in a new edition of Stroke. In this update, the AHA/ASA provide new recommendations on smoking cessation, antihypertensive medications, timing of statin treatment, screening, and nutrition for secondary stroke prevention.

In January 2018, an update of the 2013 AIS Guidelines was released, and a revision to this update was subsequently published online in April 2018. The present guideline supersedes the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. The purpose of this update is to provide a comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke. These recommendations addressed prehospital care, urgent and emergency evaluation and treatment with intravenous (IV) and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The final document was approved by the AHA Science Advisory and Coordinating Committee and Executive Committee.

Prehospital Stroke Management

The importance of public health leaders and medical professionals in designing and implementing public education programs on stroke systems and emergency care was emphasized in this update. In the updated guideline, the AHA/ASA writing committee suggested that such programs should be designed with the public, physicians, hospital personnel, and professionals from the emergency medical services (EMS) in mind. Education programs may be associated with improving the use of the 9-1-1 EMS system, decreasing stroke onset to emergency department (ED) arrival times, and increasing timely use of thrombolysis.

The update issued a new recommendation with level A evidence (evidence based on high-quality data from meta-analyses and/or >1 randomized controlled trial) for the combination of ED education and multidisciplinary teams with access to neurologic expertise can increase intravenous fibrinolytic treatment while improving the overall functioning of hospital stroke teams. The committee also revised the 2013 recommendation for the development of stroke systems of care in order to achieve faster onset-to-treatment time in fibrinolytic-eligible patients and mechanical thrombectomy-eligible patients. The committee newly recommended that medical centers establish a time target goal for presentation time to treatment with IV fibrinolytics. Recommendations for appropriate use of telemedicine, including teleradiology and telestroke, for improving rapid imaging review and improving IV alteplase eligibility decision-making were also revised and strengthened in the update.

Emergency Evaluation and Treatment

In terms of new imaging recommendations, the AHA/ASA 2019 update recommended establishing systems to enable rapid brain imaging studies in patients who may be eligible for IV fibrinolysis and/or mechanical thrombectomy. In regards to the selection of candidates for mechanical thrombectomy who presented in the window of 6 to 24 hours since symptoms onset, the updated guideline also recommended computed tomographic angiography with computed tomographic perfusion (CTP) or magnetic resonance angiography (MRA) plus diffusion-weighted magnetic resonance imaging (DW-MRI) either with or without magnetic resonance perfusion.

Based on data from the DAWN and DEFUSE 3 trials, the updated guideline specifically recommended this imaging in patients who present in the designated window with large vessel occlusion in anterior circulation.

Further, the update recommended the administration of IV alteplase without MRI for the exclusion of cerebral microbleeds, which several trials including NINDS and ECASS III have established is beneficial; because treatment is time-dependent, expeditious administration of alteplase is recommended when AIS is strongly suspected.

Supportive Care and Emergency Management

Randomized controlled trials published since the 2013 AIS Guidelines have found no benefit to the use of sonothrombolysis as adjuvant therapy with IV fibrinolysis immediately after stroke onset. Based on these data, the updated guideline does not recommend sonothrombolysis as adjuvant therapy.

The committee used data regarding the risk for symptomatic intracranial hemorrhage, provided by the ARTIS trial, to newly recommend against the administration of IV aspirin within 90 minutes of the initiation of IV alteplase. The committee also reaffirmed previous recommendations against dual or overlapping antiplatelet/antithrombotic treatment for specified patient populations within specified periods.  

Conversely, the CHANCE and the POINT trials formed the basis of a new recommendation for antiplatelet therapy. Based on data from these trials, the AHA/ASA now recommended initiating dual antiplatelet therapy (ie, aspirin and clopidogrel) within 24 hours following symptom onset for patients who present with minor noncardioembolic AIS; continuing this therapy for 21 days in an effort to reduce recurrent ischemic stroke for up to 90 days is also recommended.

In conjunction with the aforementioned recommendations for imaging in eligible patients with large vessel occlusion, as per data from DAWN and DEFUSE 3 trials, the committee also recommended expeditious intervention with mechanical thrombectomy in patients who present within 6 to 16 hours of symptom onset.

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In-Hospital AIS Management

The committee issued 2 new recommendations under the heading Blood Pressure. It is recommended that hypotension and hypovolemia be corrected to maintain a level of perfusion necessary to sustain organ function; in patients with AIS who have comorbid acute heart failure, aortic dissection, concomitant acute coronary event, among other states that increase blood pressure, early treatment of hypertension is indicated.

In regards to general supportive in-hospital AIS care, and the update recommended initiating an enteral diet within 7 days of admission following an acute stroke.

For preventing brain swelling and herniation in patients with large territorial cerebral and cerebellar infarctions, the updated guideline recommended that clinicians discuss care options and potential outcomes with patients and/or family or next of kin. In severe cases, surgery may be the only effective option for managing brain swelling, and this should be discussed to facilitate shared decision-making.

Prevention

To prevent recurrent stroke, MRI and echocardiography can guide appropriate secondary stroke prevention treatments in some patients, as recommended by a consensus of expert opinion. A brain MRI can also help identify patients’ eligibility for randomized controlled trials examining the effect of mechanical closure of patent foramen ovale on recurrent stroke prevention.

The guideline did not recommend routine screening for obstructive sleep apnea for identifying recurrent stroke risk, as based on the lack of high-quality evidence supporting this preventative measure. New evidence did, however, indicate an increased risk for hemorrhage in patients with noncardioembolic ischemic stroke was associated with triple antiplatelet therapy (ie, aspirin plus clopidogrel plus dipyridamole).

Statin therapy has been established to assist in secondary stroke prevention, and the updated guideline reaffirms its previous recommendations for in-hospital initiation of statin therapy, as it is reasonable for eligible patients with AIS.

In smokers with AIS, the guideline now recommends in-hospital initiation of high-intensity behavioral programs focused on smoking cessation. Nicotine replacement therapy is also recommended in addition to these behavioral change programs. Varenicline administered in the hospital setting may also be considered for promoting smoking cessation.

Reference

Powers WJ, Rabinstein AA, Ackerson T, et al; for the American Heart Association Stroke Council. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke [published online October 30, 2019]. Stroke. doi: 10.1161/STR.0000000000000211