Guidelines for secondary prevention of ischemic stroke and transient ischemic attack in China

On the basis of the "Chinese Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack 2014", combined with the clinical practice in China in the past 8 years and relevant evidence-based medical evidence at home and abroad, the relevant experts organized by the Neurology Branch of the Chinese Medical Association and its cerebrovascular disease group formulated the "Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack in China 2022" (hereinafter referred to as the new guidelines).

.
PART

Risk factor control

In addition to common vascular risk factors, such as hypertension, diabetes, hyperlipidemia, smoking, alcohol consumption, etc.
, the new guidelines have added new research progress
in lifestyle in secondary prevention.

1.
High blood pressure

The new guidelines add aggressive blood pressure control targets for secondary prevention, recommending a reduction in systolic blood pressure to less than 130 mmHg (1 mmHg = 0.
133 kPa) and diastolic blood pressure to less than 80 mmHg (level I recommendation, level B evidence) while the patient can tolerate it.

Risk factor control - hypertension

2.
Hypercholesterolemia

The new guide recommends:

For patients with very high-risk ischaemic stroke, low-density lipoprotein cholesterol (LDL-C) is recommended in combination with ezetimibe if the LDL-C remains above 1.
8 mmol/L despite maximally tolerated statin therapy (level I recommendation, level B evidence); If LDL-C levels do not reach target levels after combination statin and ezetimibe, combined treatment with a proprotein-converting enzyme subtilin type 9 (PCSK9) inhibitor is recommended to prevent atherosclerotic cardiovascular disease events (level II recommendation, level B evidence).

In patients with statin intolerance or contraindicated to statin therapy, PCSK9 inhibitors or ezetimibe may be considered based on LDL-C target values (level II recommendation, level B evidence).

Risk factor control - hypercholesterolemia

3.
Prediabetes and diabetes

The new guidelines recommend: For patients with ischemic stroke or TIA with diabetes, new hypoglycemic drugs that have been shown to be beneficial in reducing the risk of cardiovascular and cerebrovascular events (including stroke, myocardial infarction, and vascular death) can be considered (level II recommendation, level B evidence).

Risk factor control - prediabetes and diabetes

4.
Lifestyle

The new guidelines add new lifestyle recommendations for secondary prevention, including nutrition, physical activity, alcohol consumption and obesity, and emphasize the comprehensive management
of secondary prevention in stroke patients.

Risk factor control - lifestyle PART

Secondary preventive treatment

1.
Non-cardiogenic ischemic stroke and TIA

Antiplatelet therapy is the cornerstone of
secondary prevention of noncardiac stroke.
Currently, there are a variety of antiplatelet agents for ischemic stroke/TIA secondary prevention: aspirin, clopidogrel, aspirin and dipyridamole combinations, cilostazol, and the new generation of P2Y12 inhibitor ticagrelor
.

Based on the results of the CHANCE-2 study, the new guidelines recommend:

In patients with non-cardiogenic mild ischemic stroke (NIHSS score ≤ 3) or high-risk TIA (ABCD2 score ≥ 4 points) within 24 hours, qualified medical institutions recommend rapid testing of CYP2C19 gene to determine whether they are carriers of CYP2C19 functional deletion alleles to determine the next treatment decision (level I recommendation, level B evidence).

If the CYP2C19 gene test has been completed and the CYP2C19 function deletion allele carrier is recommended, ticagrelor combined with aspirin is recommended for 21 days, and then continued to be treated with ticagrelor (90 mg, twice daily) monotherapy (level I recommendation, level A evidence).

Noncardiogenic ischemic stroke and TIA antiplatelet therapy

Patients with ischemic stroke and TIA with intracranial and external artery stenosis are treated with antiplatelet therapy

2.
Cardioembolism

Atrial fibrillation is the most common risk factor
for cardioembolism.
For patients with atrial fibrillation who cannot be long-term anticoagulant, the new guidelines recommend that patients with ischemic stroke or TIA with nonvalvular atrial fibrillation who have contraindications to lifelong anticoagulation but can tolerate anticoagulation for 45 days may consider left atrial appendage closure to reduce the risk of stroke recurrence and bleeding (level II recommendation, level B evidence).

Secondary preventive treatment for patients with atrial fibrillation

Other cardioembolism includes: left ventricular thrombosis associated with acute myocardial infarction, valvular heart disease, and cardiac tumors
.

Secondary prevention in other patients with cardioembolism3.
Symptomatic intracranial artery stenosis

In the treatment of symptomatic intracranial artery stenosis, the new guidelines recommend balloon plasty or stentoplasty after rigorous and careful evaluation compared with the 2014 version, and state that medical stents may reduce the risk of long-term restenosis and stroke events compared with bare stents (level II recommendation, level B evidence).

Non-pharmacological treatment of ischemic stroke/TIA for symptomatic intracranial artery stenosis4.
Patent foramen ovale (PFO)

New recommendations in the new version of the guidelines: For patients aged 18~60 years with ischemic stroke whose etiology is unknown after comprehensive evaluation of PFO, such as PFO with high-risk anatomical features (atrial septal tumor or a large number of right-to-left shunts), it is reasonable to choose transcatheter closure of PFO to prevent stroke recurrence (level II recommendation, level B evidence).

Part of secondary prevention in ischemic stroke patients with PFO

Evaluation of the diagnosis of etiology

Combined with the epidemiological characteristics of stroke causes in China, the new version of the guidelines adds the diagnosis of stroke etiology and the secondary prevention of stroke of other causes (such as carotid webbing, muscle fiber dysplasia, vasculitis, cancer, etc.
), and further clarifies the importance of
guiding the precise management of secondary prevention based on the etiology of ischemic cerebrovascular disease.

Evaluation of etiological diagnosis in patients with ischaemic stroke or TIA

： ，
。   ， ，