Ischemic stroke is terrible, but recurrence is even more terrible!

*It is only for medical professionals to read for reference.
Keeping learning is a kind of literacy! As the most common type of stroke, ischemic stroke accounts for up to 80% of strokes in my country.

Ischemic stroke has the characteristics of high incidence, high disability, high mortality, and high recurrence rate.

Prevention of recurrence of ischemic stroke requires the development of measures and standardized strategies for the cause and risk factors.
Secondary prevention strategies for ischemic stroke include antithrombotic, lipid lowering, blood pressure management, blood sugar management, etc.
, which are essential to reduce stroke recurrence.

In addition, the intervention of behavioral risk factors of ischemic stroke by improving diet, increasing physical exercise, and quitting smoking and limiting alcohol are also important for preventing stroke recurrence [1].

1.
Etiology assessment and screening of ischemic stroke At present, the stroke classification system widely used in clinical trials and clinical practice is the Org10172 trial TOAST classification for acute stroke treatment [2] (Figure 1) and China's ischemic stroke Subtype (China ischemic stroke subclassification, CISS) classification [3] (Figure 2).

Through the standard etiological screening and evaluation process during the patient's hospitalization [1] (Figure 3), it can help us clarify the etiology of ischemic stroke and lay the foundation for guiding the formulation of secondary prevention programs for ischemic stroke.

Figure 1: TOAST classification of ischemic stroke Figure 2: CISS classification Figure 3: In-hospital screening and etiological assessment process for patients with ischemic stroke 2.
Development of secondary prevention strategies for different causes 1 Non-cardiac ischemic stroke Antithrombotic treatment of anti-platelet drugs with sufficient evidence-based medicine at present include: aspirin, clopidogrel, aspirin and dipyridamole compound preparations.

In my country, aspirin and clopidogrel are often used as long-term drugs for secondary prevention of non-cardiac stroke.

The principle of the use of antithrombotic therapy for non-cardiac stroke is based on the pathogenesis of stroke and evidence-based medical evidence to choose antiplatelet drugs as a single agent or combination therapy; aspirin combined with clopidogrel can significantly reduce high-risk non-disabling ischemia 3-month ischemic event risk in patients with HR-NICE [4,5]; The American Heart Association (AHA) in 2019 pointed out in the acute phase treatment guidelines for ischemic cerebrovascular disease that It is recommended for patients with non-cardiac minor stroke [National Institutes of Health Stroke Scale (NIHSS) score ≤ 3 points] and high-risk transient ischemic attack (TIA) who are treated with intravenous recombinant tissue plasminogen activator Initiation of dual antiplatelet therapy (aspirin combined with clopidogrel, continuous medication for 21 days) can effectively reduce the risk of recurrence of ischemic stroke at 90 days (level I recommendation, evidence of type A).

Figure 4: Non-cardiac origin Studies on antithrombotic therapy of ischemic stroke 2 Antithrombotic therapy of cardiogenic stroke and TIA For non-valvular atrial fibrillation, warfarin and new oral anticoagulants (NOACs), including dabigatran etexilate and riva Saban, apixaban, and edoxaban can be used as the first-choice drugs for secondary prevention; for mechanical valve replacement/severe mitral valve stenosis and end-stage renal disease, warfarin anticoagulant therapy is recommended, and the international standardized ratio The target value is 2.
0~3.
0; patients with ischemic stroke or TIA with acute myocardial infarction, imaging examination found left ventricular mural thrombosis, it is recommended to give warfarin oral anticoagulation therapy for at least 3 months; not accompanied Patients with ischemic stroke or TIA who have atrial fibrillation and non-rheumatic mitral valve disease or other valvular disease (mitral annulus calcification, mitral valve prolapse, etc.
) may consider antiplatelet drugs as secondary prevention [6 ,7].

   Figure 5: Studies on antithrombotic therapy for cardiogenic ischemic stroke 3 Lipid-lowering therapy should be used for patients with acute ischemic stroke who are ≤75 years old and have a very high risk of atherosclerotic cardiovascular disease High-intensity statin treatment can reduce the level of low-density lipoprotein cholesterol (LDL-C) by ≥50% [8]; for atherosclerotic ischemic stroke and TIA, reduce LDL-C to <1.
8 mmol/ Compared with lowering L to 2.
3~2.
8 mmol/L, it can significantly reduce the risk of cardiovascular events [9]. Figure 6: Research on lipid-lowering treatment of ischemic stroke 4 Blood pressure control For patients with lacunar stroke, a target value of systolic blood pressure <130 mmHg is safe and beneficial for preventing stroke recurrence [10]; blood pressure management for ischemic stroke Following the principle of individualization, systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg can be considered as blood pressure goals [1].

Figure 7: Research on blood pressure management related to ischemic stroke 5 Blood glucose control For ischemic stroke patients with diabetes, secondary prevention can control blood glucose to close to normal blood glucose levels to reduce the risk of cardiovascular events; but it is not yet sufficient Evidence suggests that intensive blood glucose control in the acute phase of ischemic stroke can benefit.

Figure 8: Studies on blood glucose management related to ischemic stroke 6 Intracranial and extracranial artery stenosis For patients with ischemic stroke or TIA with symptomatic intracranial atherosclerotic stenosis ≥70%, when standard medical treatment is ineffective, Endovascular interventional therapy can be selected as an auxiliary technical means of medical drug treatment, but the selection of patients should be strict and cautious; in terms of the timing of surgery, carotid artery endarterectomy should be performed within 2 weeks after non-disabling ischemic stroke or TIA Surgery (CEA) can improve the outcome, but performing CEA within the first 48 hours is associated with an increased risk of early stroke recurrence.

Percutaneous Carotid Stent Angioplasty (CAS) can help reduce adverse events such as thrombosis and embolism; for patients with high risk of restenosis, anesthesia, and surgery after endarterectomy, CAS may be considered.

However, for patients ≥70 years of age, the risk of perioperative stroke and death of CAS is greater than CEA[1].

7 Other risk factors The Risk Factors for Ischaemic and Intracerebral Haemorrhagic Stroke in 22 Countries (INTERSTROKE) study found that a history of hypertension or blood pressure ≥160/90 mmHg, less physical activity, 10 risk factors such as high apolipoprotein B (ApoB)/ApoA1 ratio, diet, high waist-to-hip ratio, psychosocial stress and depression, smoking, cardiac causes (such as atrial fibrillation and previous myocardial infarction), alcoholism and diabetes can explain the world The attributable risk of ischemic stroke population is 91.
5% [11]. References: [1] Wang Yongjun.
Secondary prevention of ischemic stroke[J].
Chinese Journal of Neurology, 2021, 54 (02): 139-148.
DOI: 10.
3760/cma.
j.
cn113694-20201009-00766[ 2]AdamsHP,BendixenBH,KappelleLJ,et al.
Classification of subtype of acute ischemic stroke.
Definitions for use in a multicenter clinical trial.
TOAST.
Trial of Org 10172 in Acute Stroke Treatment[J].
Stroke,1993,24(1) ：35-41.
DOI: 10.
1161/01.
str.
24.
1.
35.
[3]GaoS,WangYJ,XuAD,et al.
Chinese ischemic stroke subclassification[J].
Front Neurol,2011,2:6.
DOI:10.
3389/ fneur.
2011.
00006.
[4]WangY,WangY,ZhaoX,et al.
Clopidogrel with aspirin in acute minor stroke or transient ischemic attack[J].
N Engl J Med,2013,369(1):11-19.
DOI:10.
1056 /NEJMoa1215340.
[5]JohnstonSC,EastonJD,FarrantM,et al.
Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA[J].
N Engl J Med,2018,379(3):215-225.
DOI:10.
1056 /NEJMoa1800410.
[6] The National Health Commission, Stroke Prevention and Treatment Expert Committee, Atrial Fibrillation Stroke Prevention and Treatment Committee, Chinese Medical Association Electrophysiology and Pacing Branch, Chinese Medical Doctor Association, Cardiology Professional Committee.
Guidelines for the Prevention and Treatment of Cardiogenic Stroke in China (2019)[J].
Chinese Journal of Arrhythmia, 2019,23(6):463-484.
DOI: 10.
3760/cma.
j.
issn.
1007-6638.
2019.
06.
002.
[7] NishimuraRA,OttoCM,BonowRO,et al.
2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines [J].
Circulation,2017,135(25):e1159-e1195.
DOI:10.
1161/CIR.
0000000000000503.
[8]GrundySM,StoneNJ,BaileyAL,et al.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines[J].
Circulation,2019,139(25): e1082-e1143.
DOI: 10.
1161/CIR.
0000000000000625.
[9]AmarencoP,KimJS,LabreucheJ,et al.
A comparison of two LDL cholesterol targets after ischemic stroke[J].
N Engl J Med,2020,382（1)：9.
DOI：10.
1056/NEJMoa1910355.
[10]InvestigatorsSPS3,BenaventeOR,HartRG,et al.
Effects of clopidogrel added to aspirin in patients with recent lacunar stroke[J].
N Engl J Med,2012,367(9):817-825.
DOI:10.
1056/NEJMoa1204133.
[11]O′DonnellMJ,XavierD,LiuL,et al.
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study[J].
Lancet,2010,376(9735):112-123.
DOI:10.
1016/S0140-6736(10)60834-3 .
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study[J].
Lancet,2010,376(9735):112-123.
DOI:10.
1016/S0140-6736(10)60834 -3.
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study[J].
Lancet,2010,376(9735):112-123.
DOI:10.
1016/S0140-6736(10)60834 -3.