 Home > Active Ingredient News > Study of Nervous System > Heavy! After 8 years, the "Chinese Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack 2022" was released, and the recommended opinions are delivered by express!

Heavy! After 8 years, the "Chinese Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack 2022" was released, and the recommended opinions are delivered by express!

 Last Update: 2022-11-01
 Source: Internet
 Author: User

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Ischemic stroke and transient ischemic attack (TIA) are the most common types of cerebrovascular disease, accounting for more than 80%.

Evidence-based and effective secondary prevention strategies are important to
reduce patient relapse, disability and mortality.
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 and relevant evidence-based medical evidence at home and abroad, the relevant experts of 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 2014", combined with the clinical practice in China in the past 8 years and relevant evidence-based medical evidence at home and abroad 2022》
。 This guideline systematically updates the risk factor control, etiological diagnosis and assessment, drug and non-drug treatment for the cause, and the quality of medical services for ischemic stroke and secondary prevention of TIA, aiming to provide evidence-based normative guidance
for the clinical practice of ischemic stroke and secondary prevention of TIA in China.
Check
out the latest recommendations.

Risk factor control

➤ High blood pressure

➤ Recommendations: (1) Patients with ischemic stroke or TIA who have not received antihypertensive therapy in the past, if the systolic blood pressure ≥ 140mmHg or diastolic blood pressure ≥ 90mmHg after several days of onset and stable condition, if there is no absolute contraindication, antihypertensive therapy can be initiated (level I recommendation, level A evidence).

(2) Patients with ischemic stroke or TIA who have a history of hypertension and take long-term medication, if there is no absolute contraindication, can restart antihypertensive therapy after several days of onset and stable condition (level I recommendation, level A evidence); For patients with blood pressure < 140/90 mmHg, the benefit of initiating antihypertensive therapy is unclear (level II recommendation, level B evidence).

(3) For antihypertensive targets, if the patient can tolerate it, it is recommended that systolic blood pressure be reduced to less than 130mmHg and diastolic blood pressure should be reduced to less than 80mmHg (level I recommendation, level B evidence); For patients with ischemic stroke or TIA caused by intracranial large artery stenosis (70%~99%), if the patient can tolerate it, it is recommended to reduce systolic blood pressure to less than 140mmHg and diastolic blood pressure to less than 90mmHg (level II recommendation, level B evidence); In patients with stroke or TIA due to hypohaemodynamic causes, the effects of speed and amplitude of blood pressure reduction on patient tolerability and haemodynamics should be weighed (level IV recommendation, level D evidence).

(4) The type and dose of antihypertensive drugs and the target value of antihypertensive drugs should be individualized, and the three factors of drugs, stroke characteristics and individual patient conditions should be fully considered (level II recommendation, level B evidence).

➤Hypercholesterolemia➤Recommendations: (1) For patients with non-cardiogenic ischemic stroke or TIA, the LDL-C level ≥ 2.
6mmol/L (1000mg/L), and high-intensity statin therapy is recommended (see Table 1 for statins and lipid-lowering strength) to reduce the risk of stroke recurrence (level I recommendation, level A evidence).

(2) For patients with non-cardiogenic ischemic stroke or TIA with evidence of extracranial and extracranial atherosclerosis, high-intensity statin therapy is recommended, combined with ezetimibe when necessary, to control LDL-C levels at 1.
8 mmol/L (700 mg/L) and below or reduce LDL-C levels by 50% or more to reduce the risk of stroke and cardiovascular events (level I recommendation, level A evidence).

(3) For patients with very high-risk ischemic stroke, if the LDL-C is still higher than 1.
8mmol/L after the maximum tolerated dose of statin therapy, it is recommended to be combined with ezetimibe (level I recommendation, level B evidence); If LDL-C levels still do not reach target levels after combination therapy with statin and ezetimibe, combination therapy with PCSK9 inhibitors is recommended to prevent ASCVD events (level II recommendation, level B evidence).

(4) For patients with statin intolerance or contraindications to statin therapy, PCSK9 inhibitors or ezetimibe may be considered according to the target value of LDL-C level (level II recommendation, level B evidence).

(5) Patients with ischemic stroke or TIA complicated with hypercholesterolemia, after 4~12 weeks of starting statins, should evaluate the therapeutic effect and lifestyle adjustment of LDL-C lowering drugs according to fasting blood lipid levels and safety indicators (hepatic transaminases and muscle enzymes), and then evaluate the adherence and safety of drug treatment every 3~12 months based on the need to adjust the drug (level I recommendation, level A evidence).

(6) Long-term use of statin therapy is generally safe, and patients with non-cardiogenic ischemic stroke or TIA with a history of intracerebral hemorrhage should weigh the risks and benefits of rational use (level II recommendation, level B evidence).

Table 1 Different doses of statins and their corresponding lipid-lowering intensity ➤ Prediabetes and diabetes ➤ Recommendations: (1) Diabetes, prediabetes or insulin resistance are independent risk factors for recurrence or death of ischemic stroke, and attention should be paid to screening for the glucose metabolism status of stroke patients (level II recommendation, level B evidence).

(2) It is reasonable for patients with ischemic stroke or TIA to receive fasting blood glucose, HbA1c or OGTT to screen for abnormal glucose metabolism after the onset of the disease, and it is recommended to use HbA1c to screen for diabetes and prediabetes in the acute phase, and patients with no clear history of diabetes or diabetes are recommended to receive OGTT to screen for prediabetes and diabetes after the acute phase (level II recommendation, level B evidence).

(3) For patients with ischemic stroke or TIA with diabetes, the target value of glycemic control after the acute phase should be individualized, and the effect of strict blood glucose control (such as HbA1c≤7%) in preventing stroke recurrence is unclear (level II recommendation, level B evidence); Develop individualized glycemic control goals and be alert to the harm caused by hypoglycaemic events (level II recommendation, level B evidence).

(4) For patients with ischemic stroke or TIA with prediabetes, lifestyle interventions (including healthy diet, regular physical activity, and smoking cessation) are beneficial in preventing progression to diabetes (level II recommendation, level B evidence).

(5) For patients with ischemic stroke or TIA with diabetes, a combination of lifestyle intervention, nutritional support, diabetes self-management education and hypoglycemic drugs is recommended (level I recommendation, level C evidence); Newer glucose-lowering agents such as GLP1 receptor agonists and SGLT2 inhibitors that have been shown to be beneficial in reducing the risk of cardiovascular and cerebrovascular events (including stroke, myocardial infarction, and vascular death) may be considered (level II recommendation, level B evidence).

(6) For non-diabetic patients with recent ischemic stroke or TIA with insulin resistance, the use of pioglitazone may be beneficial in preventing stroke recurrence after eliminating contraindications (level II recommendation, level B evidence).

➤Smoking➤Recommendations: (1) Patients with ischemic stroke or TIA with a history of smoking should quit smoking (level I recommendation, level A evidence).

Patients with ischaemic stroke or TIA should stay away from smoking and avoid passive smoking regardless of smoking history (level I recommendation, level B evidence).

(2) Comprehensive tobacco control measures can be taken to intervene in smokers including those with a history of stroke, and the main smoking cessation methods include psychological counseling, nicotine replacement therapy or oral smoking cessation drugs (bupropion or varenicline, etc.
) (level I recommendation, level A evidence).

➤Sleep apnea➤Recommendations: (1) For patients with ischemic stroke/TIA, clinical evaluation can be carried out to assist in the diagnosis of sleep apnea according to the needs of the condition (level II recommendation, level B evidence).

(2) For patients with ischemic stroke/TIA and OSA, positive pressure ventilation therapy can help neurological function recovery and improve OSA-related symptoms (level II recommendation, level B evidence).

➤Hyperhomocysteinemia➤Recommendation: For patients with recent ischemic stroke or TIA and HHcy, folic acid, vitamin B6 and vitamin B12 supplementation can reduce homocysteine levels, However, there is no evidence to support that lowering homocysteine levels reduces the risk of stroke recurrence (level II recommendation, level B evidence).

➤ Lifestyle (1) Diet and nutrition ➤ Recommendations: (1) Patients with ischemic stroke or TIA should diversify their diets, their intake of energy and nutrients should be reasonable, increase the consumption of whole grains, legumes, fruits, vegetables and low-fat dairy products, and reduce the intake of saturated fatty acids and trans fatty acids (level I recommendation, level B evidence).

(2) Patients with ischemic stroke or TIA can moderately reduce sodium and increase potassium intake, and it is recommended to eat potassium-containing salt substitutes, which is beneficial to lowering blood pressure, thereby reducing the risk of stroke recurrence (level I recommendation, level B evidence).

(3) recommended timely risk assessment of nutritional status of patients with ischemic stroke or TIA after hospitalization (level II recommendation, level C evidence); For patients with stroke at nutritional risk, develop individualized nutrition plans, provide nutritional interventions, and screen regularly to reduce poor prognosisRisk (level II recommendation, level C evidence).

(2) Physical activity ➤ recommendations: (1) Health care professionals should conduct adequate exercise capacity screening for patients with chronic ischemic stroke with dyskinesia, formulate individualized exercise programs, and supervise (level II recommendation, level B evidence).

(2) For patients with active ischemic stroke or TIA, moderate intensity (such as brisk walking) at least 3~4 times a week for at least 10min each time is recommended after the acute phase or aerobic exercise (such as brisk walking, jogging) at least 2 times a week for at least 20min each time (level I recommendation, level B evidence); Aerobic exercise training is not recommended for patients with moderate (NIHSS score 5~12) subacute ischemic stroke (level II recommendation, level B evidence).

(3) Alcohol consumption ➤ recommendations: (1) Recommended for people with ischemic stroke or TIA to abstain from alcohol or reduce alcohol intake (level I recommendation, level A evidence).

(2) For those who have not quit drinking, the amount of alcohol consumed should be moderate, and the daily alcohol intake of men should not exceed 24g, and the daily alcohol intake of women should be halved (level II recommendation, level B evidence).

(4) Obesity ➤ Recommendations: (1) For overweight or obese ischemic stroke or TIA patients, weight loss can improve the risk of atherosclerotic cardiovascular and cerebrovascular disease (level I recommendation, level B evidence).

(2) For obese patients with ischemic stroke or TIA, it is recommended to adopt a variety of intensive lifestyle modification behavioral strategies according to individual conditions to achieve weight achievement (level I recommendation, level B evidence).

Evaluation of the diagnosis of etiology

➤Etiology classification
➤Recommendation: For patients with ischemic stroke or TIA, it is recommended to improve the etiological classification and guide the formulation of the best strategy for secondary stroke prevention (level I recommendation, level B evidence).

➤Examination related to etiology evaluation➤Recommendations: (1) For patients with ischemic stroke and TIA, recommended hematological tests, including complete blood count, PT, APTT, blood glucose, HbA1c, creatinine and blood lipids, etc.
, Information to assess risk factors and corresponding treatment goals (level I recommendation, level B evidence).

(2) For patients with ischemic stroke, CT or MRI structural imaging is recommended to clarify the location, size and distribution of infarction to assist in etiological evaluation (level I recommendation, level B evidence).

(3) For patients with ischemic stroke and TIA, it is recommended to improve intracranial and extracranial vascular evaluation to assist in etiological evaluation, and TCD, neck vascular ultrasound, head MRA and CTA can be selected
.
Screening for carotid plaque, stenosis, dissection, and carotid webbing is reasonable, and noninvasive carotid imaging studies, including carotid ultrasound, CTA, and MRA (level I recommendation, level B evidence),
are preferred.
(4) For patients with ischemic stroke and TIA, ECG examination is recommended to screen for arrhythmias such as atrial fibrillation (level I recommendation, level B evidence).

(5) For patients with cryptogenic stroke, long-range ECG monitoring is recommended, including portable remote monitors and implantable ECG monitors, to determine whether there are arrhythmias such as paroxysmal atrial fibrillation (level II recommendation, level B evidence).

(6) For patients with suspected cardioembolism or cryptogenic stroke, cardiac ultrasonography with or without contrast is recommended to evaluate possible structural heart disease (level II recommendation, level B evidence).

(7) For patients with ischemic stroke or TIA who consider that the cause may be PFO, a TCD foaming test is recommended to screen for right-to-left shunting (level II recommendation, level C evidence).

(8) For patients with cryptogenic stroke, it is recommended to undergo coagulation, infection, inflammation, vasculitis, tumor, drug abuse and genetics to help further clarify the cause and risk factors, and pay attention to the clinical characteristics of the patient and other examination results to select targeted examinations as much as possible (level II recommendation, level C evidence).

Secondary preventive treatment

1.
Non-cardiogenic ischemic stroke and TIA (1) Antiplatelet drug treatment ➤ Recommendations: (1) For patients with non-cardiogenic TIA
or ischemic stroke, Oral antiplatelet agents rather than anticoagulants are recommended to prevent stroke and other cardiovascular events (level I recommendation, level A evidence).

(2) Aspirin (50~325mg) or clopidogrel (75mg) daily monotherapy can be used as the preferred antiplatelet drug
.
Aspirin (25 mg) + extended-release dipyridamole (200 mg) twice daily or cilostazol (100 mg) twice daily may be used as an alternative to aspirin and clopidogrel (level II recommendation, level B evidence).

(3) For patients with non-cardiogenic mild ischemic stroke (NIHSS score ≤ 3 points) or high-risk TIA (ABCD2 score ≥ 4 points) within 24 hours, if there is no drug contraindication, it is recommended to give clopidogrel (75mg) combined with aspirin (75~100mg) dual antiplatelet therapy for 21d (the first dose is given clopidogrel loading dose 300mg and aspirin 75~300mg), It was later changed to monotherapy antiplatelet therapy (level I recommendation, level A evidence).

(4) For 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 CYP2C19 gene rapid testing to determine whether they are carriers of CYP2C19 functional deletion alleles to determine the next treatment decision (level I recommendation, level B evidence).

(5) For patients with non-cardiogenic mild ischemic stroke (NIHSS score ≤ 3) or high-risk TIA (ABCD2 score ≥ 4 points) within 24 hours, if they have completed CYP2C19 gene testing and are carriers of CYP2C19 functional deletion alleles, it is recommended to be given ticagrelor combined with aspirin for 21 days, and then continue to use ticagrelor (90mg, 2 times/d) monotherapy (level I recommendation, level A evidence)
。 (2) Antiplatelet drug treatment in patients with ischemic stroke and TIA with intracranial and external artery stenosis ➤ Recommendation: (1) For patients with non-cardiogenic mild ischemic stroke (NIHSS score ≤ 5 points) or high-risk TIA (ABCD2 score ≥ 4 points) with onset within 24 hours, and accompanied by mild or above stenosis of the ipsilateral intracranial artery (stenosis rate> 30%), aspirin combined with ticagrelor (90mg, 2 times / d), and change to monotherapy antiplatelet therapy after 30 days of bispecific antibody therapy, clinicians should fully weigh the benefits and bleeding risks brought by this treatment (level II recommendation, level B evidence)
。 (2) For ischemic stroke or TIA patients with severe stenosis of the symptomatic intracranial artery (stenosis rate 70%~99%) within 30 days of onset, aspirin combined with clopidogrel treatment is recommended for 90 days, after which aspirin or clopidogrel monotherapy can be used as long-term secondary prevention drugs (level II recommendation, level B evidence).

(3) For patients with symptomatic intracranial or extracranial artery stenosis (stenosis rate 50%~99%) or TIA or non-acute ischemic stroke with more than two risk factors, cilostazol combined with aspirin or clopidogrel individualized treatment (level II recommendation, level B evidence)
is recommended.
(4) For patients with ischemic stroke or TIA caused by aortic atherosclerotic plaque, antiplatelet therapy is recommended to prevent stroke recurrence (level II recommendation, level B evidence).

(5) For patients with non-cardiogenic TIA and ischemic stroke, routine long-term use of aspirin combined with clopidogrel or triple antiplatelet therapy is not recommended (level I recommendation, level A evidence).

2.
Cardiogenic embolism (1) Atrial fibrillation ➤ Recommendations: (1) For ischemic stroke or TIA patients with non-valvular atrial fibrillation, whether paroxysmal, persistent or permanent, Both recommend oral anticoagulants to reduce stroke recurrence (level I recommendation, level B evidence).

(2) For ischemic stroke or TIA patients with non-valvular atrial fibrillation, warfarin or new oral anticoagulant anticoagulant therapy is recommended to prevent recurrent thromboembolic events, and the target dose of warfarin is to maintain an INR of 2.
0~3.
0 (level I recommendation, level A evidence).

(3) Ischemic stroke or TIA patients with non-valvular atrial fibrillation, if anticoagulation is not available, aspirin monotherapy is recommended (level II recommendation, level B evidence).

Aspirin plus clopidogrel antiplatelet therapy may also be an option, noting bleeding risk (level II recommendation, level B evidence).

(4) For patients with ischemic stroke or TIA with non-valvular atrial fibrillation, the timing
of initiation of anticoagulation should be selected according to the severity of ischemia and the risk of bleeding transformation.
For patients at high risk of transformation of cerebral infarction hemorrhage, anticoagulation can be postponed until 14 days after the onset of the disease; Patients with low risk of bleeding transformation can consider starting anticoagulation therapy within 2~14d days after onset to reduce the risk of stroke recurrence, and TIA patients can start anticoagulation therapy in time to reduce the risk of stroke (level II recommendation, level C evidence).

(5) For ischemic stroke or TIA patients with non-valvular atrial fibrillation, if there are contraindications to lifelong anticoagulation therapy, but anticoagulation can be tolerated for 45 days, left atrial appendage occlusion can be considered to reduce the risk of stroke recurrence and bleeding (level II recommendation, level B evidence).

(2) Other cardiogenic embolism 1.
Left ventricular thrombosis associated with acute myocardial infarction ➤ Recommendation: (1) For ischemic stroke or TIA patients with left ventricular thrombosis, warfarin anticoagulation is recommended for at least 3 months (INR range: 2.
0~3.
0) to reduce the risk of stroke recurrence (level I recommendation, level B evidence).

(2) For patients with ischemic stroke or TIA with new left ventricular thrombosis (< 3 months), the efficacy and safety of direct oral anticoagulant therapy to reduce the risk of stroke recurrence are uncertain (level II recommendation, level C evidence).

(3) For patients with ischemic stroke or TIA with acute anterior myocardial infarction with reduced left ventricular ejection fraction (<50%) but no evidence of left ventricular thrombosis, oral anticoagulant therapy for at least 3 months is recommended to reduce the risk of recurrence of cardiogenic stroke (level II recommendation, level C evidence).

2.
Valvular heart disease ➤ Recommendations: (1) For ischemic stroke or TIA patients with valvular atrial fibrillation (that is, patients with moderate to severe mitral stenosis or mechanical valvular heart disease with atrial fibrillation), warfarin anticoagulation is recommended to reduce the risk of stroke (level II recommendation, Grade B evidence).

(2) For ischemic stroke or TIA patients with aortic valve or non-rheumatic mitral valve lesions (such as mitral annular calcification or mitral valve prolapse), if there is no atrial fibrillation or other indications for anticoagulation, antiplatelet therapy is recommended to reduce the risk of stroke recurrence (level II recommendation, level B evidence).

(3) For ischemic stroke or TIA patients implanted with biological valves, without atrial fibrillation and other anticoagulation indications, warfarin anticoagulation is recommended for 3~6 months after valve replacement, and then long-term aspirin antiplatelet therapy (level I recommendation, level C evidence).

(4) For patients who have undergone mechanical valve replacement, if there is a history of ischemic stroke or TIA before valve replacement, and the risk of bleeding is low, aspirin is recommended on top of warfarin anticoagulation (level II recommendation, level B evidence).

3.
Heart Tumor ➤ Recommendation: In patients with ischemic stroke or TIA, if a heart tumor located in the left heart system is found, surgical removal of the tumor can help reduce the risk of stroke recurrence (level II recommendation, level C evidence).

3.
Symptomatic atherosclerotic ischemic stroke/TNon-pharmacological treatment of IA (a) Carotid extracranial stenosis ➤ Recommendations: (1) For patients with recent TIA or ischemic stroke within 6 months with severe ipsilateral carotid extracranial stenosis (70%~99%), if the risk of perioperative death and stroke recurrence is expected to be <6%, CEA or CAS treatment is recommended (level I recommendation, level A evidence).

CEA or CAS can be selected on an individual basis (level II recommendation, level B evidence).

(2) For patients with recent TIA or ischemic stroke within 6 months with ipsilateral carotid extracranial stenosis (50%~69%), if the risk of perioperative death and stroke recurrence is expected to be <6%, CEA or CAS treatment is recommended (level I recommendation, level B evidence).

CEA or CAS can be selected on an individual basis (level II recommendation, level B evidence).

(3) When the carotid extracranial stenosis rate < 50%, CEA or CAS treatment is not recommended (level I recommendation, level A evidence).

(4) For patients aged ≥ 70 years with ischemic stroke or TIA, when considering carotid artery reconstruction, the overall risk of CAS is higher than that of CEA, and the surgical method can be individualized (level II recommendation, level B evidence).

(5) CAS treatment is recommended for patients with symptomatic severe carotid extracranial stenosis (≥70%) and high-risk patients for CEA (such as radiation stenosis or restenosis after CEA).

(6) For patients with symptomatic internal carotid artery stenosis, when noninvasive imaging shows that the internal carotid artery stenosis rate is ≥ 70% or DSA examination stenosis > 50% and the expected perioperative stroke or death risk is <6%, if the risk of interventional surgical complications is low, especially patients with serious cardiovascular comorbidities, CAS treatment can be considered (level II recommendation, level B evidence).

(7) When patients with mild ischemic stroke or TIA have indications for CEA or CAS treatment, if there is no contraindication to early recanalization, surgery can be performed within 2 weeks (level II recommendation, level B evidence).

For patients who plan to undergo revascularization within 1 week of stroke, the risk of CAS is higher than that of CEA, and the procedure can be individualized (level II recommendation, level B evidence).

(8) Extracranial intracranial bypass surgery is not recommended for
patients with recent (within 120d) carotid atherosclerotic stenosis or occlusion leading to TIA or ipsilateral ischemic stroke.
(2) Extracranial vertebral artery stenosis ➤ Recommendation: For patients with symptomatic extracranial atherosclerotic stenosis (50%~99%), when medical drug treatment is ineffective, stenting can be selected as an auxiliary technical means for medical drug treatment.
However, the effectiveness of stent placement has not been fully demonstrated (level II recommendation, level C evidence).

(3) Subclavian artery stenosis and brachiocephalchial trunk stenosis ➤ Recommendation: (1) When symptomatic subclavian artery stenosis (50%~99% or ischemic stroke with posterior circulatory ischemic symptoms due to occlusion or in patients with TIA who do not respond to standard medical therapy and there are no contraindications to surgery, stenting or surgical treatment is recommended (level II recommendation, level C evidence).

(2) Common carotid artery or cephalic brachial trunk stenosis (50%~99%) leading to ischemic stroke or TIA patients, when medical treatment is ineffective, and there are no contraindications to surgery, stenting or surgical treatment can be performed (level II recommendation, level C evidence).

(4) Intracranial artery stenosis ➤ Recommendation: (1) For patients with symptomatic intracranial atherosclerotic severe stenosis (70%~99%), balloonplasty or stenting should not be used as the initial treatment plan for such patients.
Even if the patient was already taking antiplatelet drugs at the time of stroke or TIA episode (level I recommendation, level A evidence).

(2) For patients with symptomatic intracranial atherosclerotic severe stenosis (70%~99%), after receiving aspirin combined with clopidogrel, strict control of systolic blood pressure < 140mmHg and intensive statin treatment, symptoms still progress or stroke recurs, and the effectiveness of balloon plasty or stent plasty as an adjunct to medical drug treatment is unclear (level II recommendation, level B evidence); Balloon plasty or stent plasty may be considered after rigorous and careful evaluation (level II recommendation, level B evidence).

Medical stents may reduce the risk of long-term stent restenosis and stroke events compared with bare stents (level II recommendation, level B evidence).

(3) For patients with symptomatic intracranial atherosclerotic moderate stenosis (50%~69%), balloonplasty or stent plasty has a higher risk of disability and death than medical drug treatment, and endovascular therapy is not supported (level I recommendation, level B evidence).

(4) For patients with stroke or TIA caused by ICAS (50%~99%) or occlusion, intracranial and extracranial vascular bypass surgery is not recommended (level I recommendation, level B evidence).

4.
Other causes (1) Patent foramen ovale ➤ Recommendations: (1) Patients with ischemic stroke with PFO of unknown etiology should be properly and comprehensively evaluated, to exclude stroke due to other mechanisms
.
If a possible causal relationship between PFO and ischaemic stroke is considered after a thorough evaluation, it is recommended that the patient, neurologist, and cardiologist make a joint decision on PFO closure or pharmacotherapy (level I recommendation, level C evidence).

(2) For patients aged 18~60 years old with ischemic stroke whose etiology is still unknown after comprehensive evaluation of PFO, 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).

(3) For patients aged 18~60 years old with ischemic stroke whose etiology is still unknown after comprehensive evaluation of PFO, if PFO does not have high-risk anatomical features, compared with antiplatelet therapy alone, the benefit of transcatheter closure PFO on the prevention of stroke recurrence is not clear, and routine transcatheter closure of PFO is not recommended (level II recommendation, level C evidence).

(4) For ischemic stroke patients aged 18~60 years with PFO whose etiology is still unknown after comprehensive evaluation, the benefit of transcatheter closure PFO compared with warfarin in preventing stroke recurrence is unclear (level II recommendation, level C evidence).

(5) For patients who are not suitable for transcatheter closure of PFO, choose antiplatelet drugs such as aspirin or anticoagulant drugs (including warfarin and new oral anticoagulants) according to the individual situation of the patient; Grade II recommendation, level C evidence).

Anticoagulation is recommended for patients with deep vein thrombosis or pulmonary embolism (level I recommendation, level A evidence).

(2) Arterial dissection ➤ Recommendations: (1) For patients with ischemic stroke or TIA caused by extracranial carotid artery or vertebral artery dissection, antithrombotic therapy for at least 3~6 months to prevent stroke recurrence or TIA (level I recommendation, level C evidence)
。 (2) For patients with ischemic stroke or TIA caused by extracranial carotid artery or vertebral artery dissection within 3 months of onset, it is reasonable to use antiplatelet drugs or warfarin to prevent stroke or TIA recurrence (level II recommendation, level B evidence).

(3) For patients with ischemic stroke or TIA caused by extracranial carotid artery or vertebral artery dissection, stenting can be considered when there is still a clear stroke recurrence event with the best drug treatment (level II recommendation, level C evidence).

(4) For patients with ischemic stroke or TIA caused by intracranial artery dissection, antiplatelet therapy is recommended, but attention should be paid to monitoring bleeding risk (level II recommendation, level C evidence).

(3) Muscle fiber dysplasia (FMD) ➤ Recommendations: (1) For patients with ischemic stroke or TIA with FMD alone and no other cause, antiplatelet therapy, blood pressure control, and lifestyle improvements are recommended to prevent stroke recurrence (level I recommendation, level C evidence).

In patients who have recurrent stroke with standard medical therapy, carotid angioplasty may be effective in preventing ischaemic stroke (level II recommendation, level C evidence).

(2) For patients with ischemic stroke or TIA caused by FMD and arterial dissection, antithrombotic therapy can be used (level II recommendation, level C evidence).

(4) Moyamoya disease ➤ Recommendations: (1) When ischemic stroke or TIA occurs in patients with moyamoya disease, it is recommended to effectively manage the risk factors for stroke, Individualized assessment is performed to select the appropriate timing and method of intracranial and extracranial vascular bypass surgery (level II recommendation, level B evidence).

(2) Oral aspirin antiplatelet therapy is recommended to reduce the risk of stroke recurrence, and when aspirin cannot be tolerated or the effect is poor, clopidogrel or other thiophenepyridines can be selected
.
Long-term use of antiplatelet drugs or two or more antiplatelet drugs increases the risk of bleeding (level II recommendation, level C evidence).

(5) Carotidweb ➤ Recommendation: For patients with ischemic stroke or TIA who are only accompanied by carotid webbing and no other cause, oral antiplatelet therapy can be given (level II recommendation , C-level evidence).

For patients with stroke recurrence despite standard medical therapy, stenting or carotid endarterectomy may be considered (level II recommendation, level C evidence).

(6) Vasculitis ➤ Recommendations: (1) For patients with autoimmune vasculitis-related stroke, on the basis of treating the primary disease, antiplatelet drug treatment is selected according to the condition, and multidisciplinary management is carried out (level II recommendation, Grade C evidence).

(2) For patients with infectious vasculitis and neoplastic vasculitis-related stroke, on the basis of treating the primary disease, antiplatelet or anticoagulant drugs should be selected according to the condition (level II recommendation, level C evidence).

(7) Antiphospholipid syndrome (APS) ➤ Recommendations: (1) For ischemic stroke or TIA patients who are isolated aPLs positive but do not meet the diagnostic criteria for APS, Antiplatelet therapy alone is recommended to reduce the risk of stroke recurrence (level I recommendation, level B evidence).

(2) For patients with ischemic stroke or TIA who meet the diagnostic criteria for APS, warfarin anticoagulation is recommended to prevent recurrence of thrombotic events on the basis of treatment of APS etiology (level II recommendation, level C evidence); A reasonable dose of warfarin is to maintain an INR of 2.
0~3.
0 to balance efficacy and bleeding risk (level II recommendation, level B evidence).

(3) In patients with ischemic stroke or TIA, patients with a history of thrombosis and triple antibody positive antiphospholipid syndrome, rivaroxaban is more prone to thrombotic events than warfarin, and rivaroxaban is not recommended for the secondary prevention of thrombotic events (level III recommendation, level B evidence).

(8) Cancer ➤ Recommendations: (1) For ischemic stroke or TIA patients with cancer, according to the type and time of cancer, combined with the cause of this vascular event, evaluate the benefits and risks of the patient, and give antithrombotic drug treatment (level III recommendation, level C evidence)
。 (2) For ischemic stroke or TIA patients with atrial fibrillation and cancer at the same time, on the basis of active treatment of the primary disease, new oral anticoagulants can be considered to replace warfarin anticoagulation therapy to prevent stroke recurrence (level II recommendation, level B evidence).

V.
Secondary prevention management of stroke in other special circumstances (1) Combined with unruptured intracranial aneurysm ➤ Recommendation: accompanied by a small unruptured aneurysm (maximum diameter< 10 mm) in patients with ischaemic stroke or TIA, antiplatelet therapy may be safe (level II recommendation, level C evidence).

(2) Use of antithrombotic drugs after intracranial hemorrhage ➤ Recommendation: For ischemic stroke or TIA patients with cerebral hemorrhage during the application of antithrombotic drugs, the potential risks and benefits of receiving antithrombotic therapy should be evaluated.
Decide whether to treat antithrombotic therapy and its regimen (level II recommendation, level B evidence).

6.
Recommendations of proprietary Chinese medicines➤: The efficacy of proprietary Chinese medicines for ischemic stroke or TIA needs more high-quality RCTs to further substantiate, and the selection is decided according to specific circumstances (level II recommendation, level B evidence).

Secondary prevention medication adherence and long-term management

➤ Recommendations: (1) For medical institutions that diagnose and treat patients with ischemic stroke or TIA, a medical quality monitoring and continuous improvement system should be established to improve the compliance of medical institutions and medical staff with secondary prevention guidelines (level I recommendation, level B evidence).

(2) It is recommended to implement multi-level interventions (including clinical pathways, pre-defined diagnosis and treatment protocols, quality coordinator supervision, key performance indicator monitoring and feedback) to improve the adherence of hospital clinicians to guideline recommendations such as secondary prevention (level I recommendation, level B evidence).

(3) standardized, guideline-based secondary prevention interventions may be effective in long-term medication adherence in patients with ischaemic stroke or TIA (level II recommendation, level B evidence); If possible, digital diagnosis and treatment decision-making systems can be used for drug treatment and lifestyle interventions to improve patient compliance and reduce the risk of recurrence (level II recommendation, level B evidence).

Medical pulse is organized from: Neurology Branch of Chinese Medical Association, Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association.
Guidelines for secondary prevention of ischemic stroke and transient ischemic attack in China 2022.
Chinese Journal of Neurology, Vol.
55, No.
10, October 2022

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