Part I: Risk factor control for all patients with TIA or ischemic stroke
Hypertension
1. Patients with ischemic stroke or TIA who have not received previous antihypertensive therapy should initiate antihypertensive therapy if their systolic blood pressure is ≥140 mmHg or diastolic blood pressure is ≥90 mmHg several days after onset (Class I, Level B evidence); for patients with blood pressure <140/90 mmHg, the antihypertensive benefit is not clear (Class IIb, Level C evidence). (Revised recommendation: description of parameters for initiating antihypertensive therapy)
2. Patients with ischemic stroke and TIA who have pre-existing hypertension and are receiving antihypertensive therapy should resume antihypertensive therapy after several days in order to prevent stroke recurrence and other vascular events (Class I, Level A evidence). (Revised recommendation: description of parameters for resumption of antihypertensive therapy)
3. The target value for blood pressure lowering in patients with stroke or TIA is unclear and should be determined on a patient-by-patient basis. It is generally accepted that blood pressure should be controlled to below 140/90 mmHg (Class IIa, Level B evidence). In patients with recent lacunar stroke, systolic blood pressure control below 130 mmHg may be reasonable (Class IIb, Level B evidence). (revised recommendation: revised guideline target value)
4. Some lifestyle changes can lower blood pressure and are reasonable components of a full range of antihypertensive therapy (Class IIa, Level C evidence). These changes include salt restriction, weight loss, consumption of a diet rich in fruits, vegetables, and low-fat products, regular aerobic exercise, and limiting alcohol intake.
5. The optimal drug formulation to obtain the recommended level of blood pressure reduction is uncertain, as direct comparisons between drugs are limited. The available data suggest that diuretics and the combination of diuretics and ACEIs are useful (Class I, Level A evidence).
6. The selection of specific drugs and target values should be individualized. Depending on pharmacological properties, mechanism of action, and consideration of each patient’s characteristics, certain specific drugs may be required (e.g., extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and diabetes) (Class IIa, Level B evidence).
Dyslipidemia
1. In patients with atherosclerosis-derived ischemic stroke or TIA with LDL-C ≥100 mg/dL and with or without other clinical evidence of ASCVD, it is recommended to receive high-intensity statin therapy to reduce stroke and cardiovascular events (Class I, Level B evidence). (New recommendation: consistent with 2013 ACC/AHA cholesterol guidelines)
2. In patients with atherosclerosis-derived ischemic stroke or TIA with LDL-C <100 mg/dL and no other clinical evidence of ASCVD, high-intensity statin therapy is recommended to reduce stroke and cardiovascular events (Class I, Level C evidence). (New recommendation: consistent with 2013 ACC/AHA cholesterol guidelines, but lower level of evidence at LDL-C <100 mg/dL)
3. Patients with ischemic stroke or TIA with other ASCVD require alternative interventions, including lifestyle changes, diet and medication recommendations, in accordance with the 2013 ACC/AHA lipid guidelines (Class I, Level A evidence). (Revised recommendations, consistent with the 2013 ACC/AHA cholesterol guidelines)
Glucose metabolism disorders
1. After TIA or ischemic stroke, all patients should probably be screened for diabetes by rapid glucose testing, glycated hemoglobin (HbA1c), or oral glucose tolerance testing. Because acute illness may temporarily disrupt glucose testing, the method and timing of testing should be selected based on clinical judgment and awareness. In general, testing HbA1c immediately after a clinical event may be more accurate than other screening tests (Class IIa, Level C evidence). (New recommendation)
2. Patients with stroke or TIA who have diabetes are recommended to use existing guidelines for glycemic control and cardiovascular risk factor management (Class I, Level B evidence).
Obesity
1. All patients with TIA or stroke should be screened for obesity using BMI (Class I, Level C evidence). (New recommendation)
2. Despite the definite benefit of weight loss on cardiovascular risk factors, however, the benefit of weight loss in obese patients with recent TIA or ischemic stroke is not clear (Class IIb, Level C evidence). (New recommendation)
Metabolic syndrome
1. At present, the significance of screening for metabolic syndrome after stroke is not proven (Class IIb, Level C evidence).
2. If patients are found to have metabolic syndrome after screening, management should include persuasion for lifestyle changes (diet, exercise, and weight loss) to reduce the risk of vascular disease (Class I, Level C evidence).
3. Preventive measures for patients with metabolic syndrome should include rational treatment of the components of the syndrome, which are also risk factors for stroke, particularly lipid metabolism disorders and hypertension (Class I, Level A evidence).
Lack of physical activity
1. Patients with ischemic stroke or TIA who are able to participate in physical activity may consider moderate-intensity aerobic exercise at least once to three times per week for 40 min, i.e., the former to the point of sweating or significantly increasing heart rate (e.g., brisk walking, pedaling an exercise bike) and the latter such as jogging, to reduce stroke risk factors (Class IIa, Level C evidence).
2. For those who are able and willing to increase physical activity, a comprehensive, behaviorally oriented program may be recommended (Class IIa, Level C evidence). (New recommendation)
3. For patients with disability after ischemic stroke, consider instruction by a healthcare professional (e.g., physical therapist or cardiac rehabilitation specialist), at least at the beginning of the exercise program (Class IIb, Level C evidence).
Nutrition
1. Overnutrition or malnutrition is judged reasonable by nutritional assessment in patients with a history of ischemic stroke or TIA (Class IIa, Level C evidence).
2. Nutritional counseling should be performed in malnourished patients with a history of ischemic stroke or TIA (Class I, Level B evidence).
3. Routine supplementation with a particular vitamin or multivitamin is not recommended (Class III, Level A evidence).
4. In patients with a history of stroke or TIA, it is recommended to reduce sodium intake below 2.4 g/day, further reduction to 1.5 g/day is also reasonable and is associated with lower blood pressure (Class IIa, Level C evidence).
5. For patients with a history of stroke or TIA, a Mediterranean diet is recommended, emphasizing: vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, olive oil and nuts, and limiting the intake of sugars and red meat (Class IIa, Level C evidence).
Sleep apnea
1. Because of the high rate of sleep apnea in patients with ischemic stroke or TIA and evidence that treatment of sleep apnea improves prognosis, the ischemic stroke and TIA population should be tested for sleep apnea (Class IIb, Level B evidence).
2. Because there is evidence that treatment of sleep apnea improves prognosis, patients with ischemic stroke or TIA combined with sleep apnea should receive continuous positive airway pressure ventilation (Class IIb, Level B evidence). (New recommendation)
Smoking cessation
1. Patients with stroke or TIA who have a history of smoking should be strongly advised by their healthcare provider to quit smoking (Class I, Level C evidence).
2. It is reasonable to avoid environmental (passive) smoking in patients with ischemic stroke or TIA (Class IIa, Level B evidence).
3. Smoking cessation instructions, nicotine products and oral cessation medications help smokers to quit (Class I, Level A evidence).
Alcohol consumption
1. Patients with ischemic stroke, TIA or hemorrhagic stroke who are heavy drinkers should stop or reduce alcohol intake (Class I, Level C evidence).
2. Mild to moderate alcohol intake (no more than 2 drinks per day for men and 1 drink per day for non-pregnant women) may be reasonable; non-drinkers should not be persuaded to start drinking (Class IIb, Level B evidence).
Part II: Interventions for patients with large-artery atherosclerotic stroke
Extracranial carotid artery disease
1. CEA is recommended for patients with a recent TIA or ischemic stroke combined with severe (70% to 99%) ipsilateral carotid stenosis within 6 months if the expected risk of perioperative morbidity and mortality is <6% (Class I, Level A evidence).
2. CEA is recommended for patients with a recent TIA or ischemic stroke combined with ipsilateral moderate (50% to 69%) carotid stenosis within 6 months, if the expected risk of perioperative morbidity and mortality is <6%, depending on patient demographics such as age, sex, and coexisting disease (Class I, Level B evidence).
3. No indication for carotid recanalization (either CEA or CAS) when stenosis is <50% (Class III, Level A evidence).
4, When a patient with TIA or stroke has an indication for CEA, it is reasonable to perform the procedure within two weeks rather than delaying the procedure if there is no contraindication to early recanalization (Class IIa, Level B evidence).
5. CAS may be an alternative to CEA in symptomatic patients with an average or low risk of complications from endovascular manipulation when the degree of internal carotid lumen diameter stenosis is >70% by noninvasive imaging or >50% by catheter imaging and periprocedural stroke or mortality is expected to be <6% (Class IIa, Level B evidence). (Revised recommendation: recommendation category changed from Class I to Class IIa)
6. It is reasonable to consider patient age when making treatment choices for CAS and CEA. In older patients (e.g., 70 years or older), CEA is associated with a better prognosis compared with CAS, especially when arterial dissection is not conducive to performing endovascular interventions. In younger patients, CAS is comparable to CEA in terms of risk of perioperative complications (e.g., stroke, infarction, or death) and long-term risk of ipsilateral occurrence of stroke (Class IIa; Level B evidence).
7. CAS may be considered in patients with symptomatic severe stenosis (>70%) when the stenosis is beyond the reach of the procedure, when medical conditions substantially increase the risk of surgery, or when other special circumstances exist, such as radiation-induced stenosis or restenosis after CEA (Class IIa, Level B evidence). (revised recommendation)
8. In symptomatic patients, operators should control for perioperative stroke and mortality <6% when CAS and CEA are performed in the above circumstances, similar to that observed in studies comparing CEA with drug therapy and in recent observational studies (Class I, Level B evidence). (revised recommendation: recommendation category changed from Class IIa to Class I)
9. Long-term routine follow-up with extracranial carotid circulation imaging using carotid bifunctional ultrasound is not recommended (Class III, Level B evidence). (New recommendation)
10, Routine EC/IC bypass is not recommended for patients with symptomatic extracranial carotid artery occlusion (Class III, Level A evidence)
11, In patients with ipsilateral distal carotid stenosis or occlusion (not reached by surgery) or midcervical carotid occlusion, the benefit of EC/IC bypass surgery warrants consideration when ischemic symptoms recur or progress after optimal drug therapy (Class IIb, Level C evidence). (New recommendation)
12. The optimal pharmacologic regimen, including antiplatelet therapy, statin therapy, and risk factor control, discussed elsewhere in this guideline is recommended for all patients with TIA or stroke who have carotid stenosis (Class I, Level B evidence).
Extracranial vertebrobasilar artery lesions
1. Routine prophylaxis including antiplatelet therapy, statin therapy and risk factor control is recommended for all patients with recent symptomatic vertebral artery stenosis (Class I, Level C evidence).
2. Endovascular therapy may be considered in patients with extracranial vertebral artery stenosis who develop symptoms despite optimal drug therapy (Class IIb, Level C evidence).
3. Patients with extracranial vertebral artery stenosis who become symptomatic despite optimal drug therapy may be considered for surgical treatment (Class IIb, Level C evidence).
Intracranial atherosclerosis
1. For patients with stroke or TIA caused by intracranial large artery stenosis of 50% to 99%, aspirin 325 mg/d is recommended instead of warfarin (Class I, Level B evidence).
2. For patients with a recent stroke or TIA (within 30 days) caused by severe intracranial large artery stenosis (70%C99%), aspirin plus clopidogrel 75 mg/d for 90 days is reasonable (Class IIb, Level B evidence). (New recommendation)
3. In patients with stroke or TIA caused by intracranial large artery stenosis (50% C99%), the evidence for the combination of clopidogrel, aspirin and dipyridamole alone or cilostazol alone is not yet sufficient (Class IIb, Level C evidence). (New recommendation)
4. For patients with stroke or TIA caused by intracranial large artery stenosis (50% to 99%), SBP <140/90 mmHg and high-intensity statin therapy are recommended (Class I, Level B evidence). (Revised recommendation: lipid recommendations are consistent with the 2013 ACC/AHA lipid guidelines, with the recommendation category changed from Class IIa to Class I)
5. For patients with stroke or TIA caused by moderate intracranial large artery stenosis of 50% to 69%, angiography or stenting is not recommended in view of the lower stroke risk with pharmacologic therapy and the inherent perioperative risks of endovascular therapy (Class III, Level B evidence). (New recommendation)
6. Wingspan stenting is not recommended as an initial treatment for patients with stroke or TIA caused by severe intracranial stenosis of the large arteries (70%-99%), even for patients receiving antithrombotic medication at the time of stroke or TIA (Class III, Level B evidence). (New recommendation)
7. In patients with stroke or TIA caused by severe stenosis (70% to 99%) of the large intracranial arteries, the role of angiography alone or stenting with stents other than the Wingspan stent is unclear and warrants continued study (Class IIb, Level C evidence). (Revised recommendation: stenosis level changed from 50% to 99% to 70% to 99%)
8. The benefit of angiography or Wingspan stenting alone or other stenting in patients with severe stenosis (70% to 99%) of the large intracranial arteries who have recurrent TIA or stroke despite combined treatment with aspirin and clopidogrel, SBP <140 mmHg, and high-intensity statin therapy is unclear and warrants continued study (Class IIb, Level C evidence). (New recommendation)
9. In patients with severe intracranial large artery stenosis (70% to 99%) who have active progression of symptoms despite treatment with aspirin combined with clopidogrel, the benefit of angiography or Wingspan stenting or other stenting alone is unclear and warrants continued study (Class IIb, Level C evidence). (New recommendation)
10. EC/IC bypass is not recommended for patients with stroke or TIA due to intracranial large artery stenosis of 50% to 99% (Class III, Level B evidence).