"Chinese Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack 2022" released!

On the basis of the "Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack in China 2014", combined with clinical practice in China in the past 8 years and relevant evidence-based medical evidence at home and abroad, 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 version of the guidelines).

What are the main updates to the new guide compared to the 2014 edition? This article is summarized below
.

Risk factor control

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

1.
High blood pressure

The new guidelines add aggressive blood pressure control targets for secondary prevention, recommending a systolic blood pressure reduction below 130 mmHg (1 mmHg = 0.
133 kPa) and diastolic blood pressure below 80 mmHg (level I recommendation, level B evidence)
while keeping patient tolerated.

Risk factor control - hypertension

2.
Hypercholesterolemia

The new guide recommends:

Risk factor control - hypercholesterolemia

3.
Prediabetes and diabetes

The new guidelines recommend that patients with ischemic stroke or TIA with diabetes mellitus should consider choosing novel hypoglycemic drugs such as glucagon-like peptide 1 (GLP1) receptor agonists and sod-glucose co-transporter 2 (SGLT2) inhibitors (level II recommendation, level B evidence)
that have been shown to be beneficial in reducing the risk of cardiovascular and cerebrovascular events (including stroke, myocardial infarction, and vascular death).

Risk factor control - prediabetes and diabetes

4.
Lifestyle

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

Risk factor control - lifestyle

.
PART

Secondary preventive treatment

1.
Noncardiogenic ischemic stroke and TIA

Antiplatelet therapy is the cornerstone
of secondary prevention of noncardiogenic stroke.
Currently, a variety of antiplatelet agents are used for secondary prevention of ischaemic stroke/TIA: aspirin, clopidogrel, aspirin and dipyridamole combinations, cilostazol, and ticagrelor
with a new generation of P2Y12 inhibitors.

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

Noncardiogenic ischemic stroke and TIA antiplatelet therapy

Antiplatelet therapy in patients with ischemic stroke and TIA with intracranial and external artery stenosis

2.
Cardioembolism

Atrial fibrillation is the most common risk factor
for cardioembolism.
For patients with atrial fibrillation who cannot be anticoagulated in the long term, the new guidelines recommend that patients with ischemic stroke or TIA who have nonvalvular atrial fibrillation and can tolerate anticoagulation for 45 days may consider left atrial appendage closure to reduce the risk of stroke recurrence and bleeding if there are contraindications to lifelong anticoagulation but can tolerate anticoagulation for 45 days
.

Secondary prophylaxis in patients with atrial fibrillation

Other cardioembolisms include left ventricular thrombosis associated with acute myocardial infarction, valvular heart disease, and cardiac tumors
.

Secondary prophylaxis in other patients with cardioembolism

3.
Symptomatic intracranial artery stenosis

For the treatment of symptomatic intracranial artery stenosis, the new guidelines recommend balloon angioplasty or stentoplasty after rigorous and careful evaluation compared with the 2014 version, and note that pharmacological stents may reduce the risk of long-term stent restenosis and stroke events compared with naked stents (level II recommendation, level B evidence).

Non-pharmacologic treatment of ischemic stroke/TIA with symptomatic intracranial artery stenosis

4.
Patent foramen ovale (PFO)

The new version of the guidelines adds recommendations: For ischemic stroke patients aged 18~60 years with PFO whose etiology is still unknown after comprehensive evaluation, if PFO has 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).

Secondary prevention in patients with ischemic stroke with PFO

.
PART

Diagnostic evaluation of the cause

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

Etiologic diagnostic evaluation in patients with ischaemic stroke or TIA

References:

1.
Neurology Branch of Chinese Medical Association, Cerebrovascular Disease Group, Neurology Branch of Chinese Medical Association.
Guidelines for the secondary prevention of ischemic stroke and transient ischemic attack in China 2022 [J] .
Chinese Journal of Neurology, 2022, 55(10): 1071-1110.
DOI: 10.
3760/cma.
j.
cn113694-20220714-00548.

2.
Wang Yongjun.
New evidence, new guidelines, new norms for secondary prevention of ischemic stroke [J] .
Chinese Journal of Neurology, 2022, 55(10): 1061-1064.
DOI: 10.
3760/cma.
j.
cn113694-20220823-00637.

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