This document provides guidelines for preventing stroke in patients who have had a stroke or transient ischemic attack (TIA). It discusses risk factors like hypertension, diabetes, dyslipidemia, lifestyle factors, and recommends treatments and lifestyle changes to reduce risk. For hypertension, it recommends blood pressure management and provides evidence from clinical trials supporting treatment. It also recommends statin therapy and lifestyle changes to manage dyslipidemia and other risk factors.
ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
ASA/AHA 2014 guidelines for the Primary Prevention of Stroke
Hypertension and dyslipidemia impact on stroke development and prevention
SPRINT and HOPE-3
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Vymada Tablet (ARNI: Angiotensin Receptor Neprilysin Inhibitor) is an anti-hypertensive drug used in combination with Sacubitril & Valsartan to reduce the risk of cardiovascular events in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Vymada Tablet (ARNI: Angiotensin Receptor Neprilysin Inhibitor) is an anti-hypertensive drug used in combination with Sacubitril & Valsartan to reduce the risk of cardiovascular events in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Stroke prevention for nonvalvular AF, summary of evidence-based guidelinesErsifa Fatimah
Ternyata... guideline yang ngebahas prevensi stroke pada nonvalvular AF tu banyak banget! Yang dirilis komunitas Neuro maupun Cardio, yang internasional maupun yang lokal. Dan pertanyaan besarnya tetep: What's the best strategy?
*Bonus special issue: manajemen prevensi stroke infark dengan antikoagulan pasca brain hemorrhage.
Secondary prevention of ischemic strokeSudhir Kumar
A patient who has suffered ischemic stroke is at a higher risk of getting strokes in future. This is called recurrent stroke. The current presentation looks at the factors responsible for stroke recurrence, and discusses strategies to reduce the risk of stroke recurrence.
University of Calgary researchers have found a ground-breaking procedure developed through a clinical trial, which drastically reduces the likelihood of death or disability for stroke patients. Dr. Michael Hill and Dr. Mayank Goyal, two of the key researchers behind this breakthrough, shed light on how the procedure helps treat stroke and provides them with better chances of recovery. To watch the webinar recording, go to http://www.ucalgary.ca/explore/faster-way-treat-stroke
Atrial fibrillation (afib) is one of the main causes of strokes in the US. New treatment options are available - both medical therapy (such as new blood thinners) and procedures (watchman left atrial appendage closure).
Residual Inflammatory Risk inPatients With Low LDL CholesterolLevels Underg...Shadab Ahmad
Patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) are at high risk of future adverse ischemic events.
Indeed, increased inflammatory status pre- and post-PCI has also been associated with poor prognosis, and control of the residual inflammatory risk (RIR) in the CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) trial has recently opened new perspectives in the field of secondary prevention.
Controlling heart disease in a high-risk group such as patients with diabetes requires an understanding and management of several factors (see slide deck). As usual, please consult a physician for specific case information.
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
This presentation contains information about Dementia in Young onset. Also it describes the etiologies, clinical feature of common YOD & their management.
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...
Guidelines for the prevention of stroke in patients
1. AAN Guidelines for the Prevention of
Stroke in Patients With
Stroke and Transient Ischemic Attack
2014
Dr. Nishtha Jain
Senior Resident
Department of Neurology
GMC, Kota.
2. • Hypertension
• Glucose Disorders
• Dyslipidemia
• Alcohol consumption and smoking
• Extracranial athersclerosis
• Intracranial atherosclerosis
• Cardiac disorders
• Hypercoaguable states
• Pregnancy
Recommendations include
3. • On average, the annual risk for future ischemic stroke
after an initial ischemic stroke or TIA is ≈3% to 4%.
• The estimated risk for an individual patient will be
affected by specific characteristics of the event and the
person, including age, event type, comorbid illness, and
adherence to preventive therapy.
4. • The distinction between TIA and ischemic stroke has
become less important in recent years because many of
the preventive approaches are applicable to both.
• Recommendations provided by this guideline are
believed to apply to both stroke and TIA.
5. Hypertension
• Treatment of hypertension is possibly the most important
intervention for secondary prevention of ischemic stroke.
• The prevalence among patients with a recent ischemic
stroke is ≈70%.
• The risk for a first ischemic stroke is directly related to
blood pressure (BP) starting with an SBP as low as 115
mm Hg.
• The relationship with recurrent stroke has been less well
studied but is presumably similar.
6. • Two major studies for the role of antihypertensive
treatment for stroke prevention:
• Post-Stroke Antihypertensive Treatment Study (PATS).
• Perindopril Protection Against Recurrent Stroke Study
(PROGRESS).
7. • PATS- 5665 patients with a recent TIA or minor stroke
(hemorrhagic or ischemic) to indapamide or placebo.
• The main outcome of recurrent stroke was observed in
44.1% of patients assigned to placebo and 30.9% of
those assigned to indapamide.
8. • PROGRESS trial: 6105 patients with a history of TIA or
stroke (ischemic or hemorrhagic) to active treatment with
a perindopril-based regimen or placebo.
• Active therapy reduced the primary end point of fatal or
nonfatal stroke by 28%.
9. RECOMMENDATIONS
• Initiation of BP therapy is indicated for previously
untreated patients with ischemic stroke or TIA who, after
the first several days, have an established BP ≥140 mm
Hg systolic or ≥90 mm Hg diastolic (Class I; Level of
Evidence B).
• Initiation of therapy for patients with BP <140 mm Hg
systolic and <90 mm Hg diastolic is of uncertain benefit
(Class IIb; Level of Evidence C).
10. • Resumption of BP therapy is indicated for previously
treated patients with known hypertension for both
prevention of recurrent stroke and prevention of other
vascular events in those who have had an ischemic
stroke or TIA and are beyond the first several days
(Class I; Level of Evidence A).
• Goals for target BP level or reduction from pretreatment
baseline are uncertain and should be individualized, but
it is reasonable to achieve a systolic pressure <140 mm
Hg and a diastolic pressure <90 mm Hg (Class IIa; Level
of Evidence B).
11. • For patients with a recent lacunar stroke, it might be
reasonable to target an SBP of <130 mm Hg (Class IIb;
Level of Evidence B).
• Several lifestyle modifications have been associated with
BP reductions and are a reasonable part of a
comprehensive antihypertensive therapy (Class IIa;
Level of Evidence C). These include salt restriction;
weight loss; the consumption of a diet rich in fruits,
vegetables, and low-fat dairy products; regular aerobic
physical activity; and limited alcohol consumption.
12. • The optimal drug regimen to achieve the recommended
level of reductions is uncertain because direct
comparisons between regimens are limited.
• The available data indicate that diuretics or the
combination of diuretics and an angiotensin-converting
enzyme inhibitor is useful (Class I; Level of Evidence A).
13. • The choice of specific drugs and targets should be
individualized on the basis of pharmacological
properties, mechanism of action, and consideration of
specific patient characteristics for which specific agents
are probably indicated (eg, extracranial cerebrovascular
occlusive disease, renal impairment, cardiac disease,
and DM) (Class IIa; Level of Evidence B).
14. Dyslipidemia
• The important studies for correction of dyslipidemia in
this group of patients:
• Stroke Prevention by Aggressive Reduction in
Cholesterol Levels (SPARCL) study
• Atherothrombosis Intervention in Metabolic Syndrome
With Low HDL/High Triglycerides: Impact on Global
Health Outcomes (AIM-HIGH) trial
• HPS 2-Treatment of HDL to Reduce the Incidence of
Vascular Events (HPS-2 THRIVE) study
15. • SPARCL trial : achieving an LDL-C level of <70 mg/dL
was related to a 28% reduction in risk of stroke without a
significant rise in the risk of hemorrhagic stroke.
• In addition, stroke and TIA patients with ≥50% reduction
in LDL-C had a 35% reduction in combined risk of
nonfatal and fatal stroke.
16. • AIM-HIGH trial and HPS-2 THRIVE study indicate that
the combination of extended-release niacin with statin
treatment did not significantly reduce the risk of the
combination of coronary deaths, nonfatal MI, strokes, or
coronary revascularizations versus statin therapy alone.
17. • Statin therapy with intensive lipid-lowering effects is
recommended to reduce risk of stroke and
cardiovascular events among patients with ischemic
stroke or TIA presumed to be of atherosclerotic origin
and an LDL-C level ≥100 mg/dL with or without evidence
for other clinical ASCVD (Class I; Level of Evidence B).
18. • Statin therapy with intensive lipid-lowering effects is
recommended to reduce risk of stroke and
cardiovascular events among patients with ischemic
stroke or TIA presumed to be of atherosclerotic origin, an
LDL-C level <100 mg/dL, and no evidence for other
clinical ASCVD (Class I; Level of Evidence C).
19.
20. • Decreasing the statin dose may be considered when 2
consecutive values of LDL-C are <40 mg/dL.
• This recommendation was based on the approach taken
in 2 RCTs.
• However, no data were identified that suggest an excess
of adverse events occurred when LDL-C levels were
below this level.
21. Disorders of Glucose Metabolism and
DM
• DM is associated with a substantially increased risk for
first ischemic stroke.
• DM may be responsible for >8% of first ischemic strokes.
• Up to 28% of patients with ischemic stroke have pre-DM,
and 25% to 45% have overt DM.
22. • In a substudy of the Cardiovascular Health Study that
enrolled patients with a first ischemic stroke, DM was
associated with a 60% increased risk for recurrence.
• In the absence of DM, insulin resistance is associated
with a doubling of the risk for ischemic stroke.
23. • After a TIA or ischemic stroke, all patients should
probably be screened for DM with testing of fasting
plasma glucose, HbA1c, or an oral glucose tolerance
test. In general, HbA1c may be more accurate than other
screening tests in the immediate postevent period (Class
IIa; Level of Evidence C).
24.
25.
26. Overweight and Obesity
• Obesity is associated with increased risk for incident
stroke.
• The risk increases in a near-linear fashion starting at a
BMI of 20 kg/m2 such that a 1-kg/m2 increase in BMI is
associated with a 5% increase in risk for stroke.
• The association between adiposity and risk for stroke is
more evident for central obesity than for general obesity,
for middle-aged adults than for older adults, and for
ischemic stroke than for hemorrhagic stroke.
27. • Despite this relationship, however, obesity has not been
established as a risk factor for recurrent stroke.
• In fact, the results of recent studies indicate that obese
patients with stroke had somewhat lower risk for a major
vascular event than did lean patients.
• This unexpected relationship of obesity with improved
prognosis after stroke has been termed the obesity
paradox and has led some to question the
appropriateness of recommending weight loss.
28. • All patients with TIA or stroke should be screened for
obesity with measurement of BMI (Class I; Level of
Evidence C).
• Despite the demonstrated beneficial effects of weight
loss on cardiovascular risk factors, the usefulness of
weight loss among patients with a recent TIA or ischemic
stroke and obesity is uncertain (Class IIb; Level of
Evidence C).
29. Metabolic Syndrome
• The AHA and several other organizations proposed a
widely accepted definition that requires any 3 of the
following features:
• elevated waist circumference
• plasma triglyceride ≥150 mg/dL ,
• HDL-C <40 mg/dL for men or <50 mg/dL for women,
• BP ≥130 mm Hg systolic or ≥85 mm Hg diastolic, or
• fasting glucose ≥100 mg/dL
30. • At this time, the usefulness of screening patients for the
metabolic syndrome after stroke is unknown (Class IIb;
Level of Evidence C).
• For patients who are screened and classified as having
the metabolic syndrome, management should focus on
counseling for lifestyle modification (diet, exercise, and
weight loss) for vascular risk reduction (Class I; Level of
Evidence C).
31. • Preventive care for patient with the metabolic syndrome
should include appropriate treatment for individual
components of the syndrome, which are also stroke risk
factors, particularly dyslipidemia and hypertension (Class
I; Level of Evidence A).
32. Physical Inactivity
• For patients with ischemic stroke or TIA who are capable
of engaging in physical activity, at least 3 to 4 sessions
per week of moderate- to vigorous-intensity aerobic
physical exercise are reasonable to reduce stroke risk
factors.
• Sessions should last an average of 40 minutes.
• Moderate-intensity exercise is typically defined as
sufficient to break a sweat or noticeably raise heart rate.
(Class IIa; Level of Evidence C).
33. • For patients who are able and willing to initiate increased
physical activity, referral to a comprehensive,
behaviorally oriented program is reasonable (Class IIa;
Level of Evidence C).
• For individuals with disability after ischemic stroke,
supervision by a healthcare professional such as a
physical therapist or cardiac rehabilitation professional,
at least on initiation of an exercise regimen, may be
considered (Class IIb; Level of Evidence C).
34. Nutrition
• The prevalence of protein-calorie undernutrition among
patients with acute stroke has been estimated as 8% to
13%.
• Among micronutrients, there is evidence that low serum
levels of vitamin D and low dietary potassium may be
associated with increased risk for stroke.
• Vitamin Intervention for Stroke Prevention (VISP) study
suggested that patients with hyperhomocysteinemia and
intermediate vitamin B12 serum levels may benefit from
therapy.
35. • Some micronutrients appear to be harmful in excess.
• There is evidence that increased intake of sodium, and
possibly calcium supplementation, may be associated
with increased risk for stroke.
36. • It is reasonable to conduct a nutritional assessment for
patients with a history of ischemic stroke or TIA, looking
for signs of overnutrition or undernutrition (Class IIa;
Level of Evidence C ).
• Patients with a history of ischemic stroke or TIA and
signs of undernutrition should be referred for
individualized nutritional counseling. (Class I; Level of
Evidence B).
37. • Routine supplementation with a single vitamin or
combination of vitamins is not recommended (Class III;
Level of Evidence A).
• It is reasonable to recommend that patients with a
history of stroke or TIA reduce their sodium intake to less
than ≈2.4 g/d. Further reduction to <1.5 g/d is also
reasonable and is associated with even greater BP
reduction (Class IIa; Level of Evidence C).
38. • It is reasonable to counsel patients with a history of
stroke or TIA to follow a Mediterranean-type diet instead
of a low-fat diet. The Mediterranean-type diet
emphasizes vegetables, fruits, and whole grains and
includes low-fat dairy products, poultry, fish, legumes,
olive oil, and nuts. It limits intake of sweets and red
meats (Class IIa; Level of Evidence C).
39. Obstructive Sleep Apnea
• Sleep apnea is present in approximately half to three
quarters of patients with stroke or TIA.
• Despite being highly prevalent, as many as 70% to 80%
of patients with sleep apnea are neither diagnosed nor
treated.
• Sleep apnea has been associated with poor outcomes
among patients with cerebrovascular disease, including
higher mortality, delirium, depressed mood, and worse
functional status.
40. • Martínez-García et al reported that patients ≥2 months
after stroke with sleep apnea who did not use CPAP had
much higher recurrent stroke rates than patients who
used CPAP and a higher adjusted incidence of nonfatal
vascular events.
• The number needed to treat to prevent 1 new vascular
event was 4.9 patients.
41. Recommendations
• A sleep study might be considered for patients with an
ischemic stroke or TIA on the basis of the very high
prevalence of sleep apnea in this population and the
strength of the evidence that the treatment of sleep
apnea improves outcomes in the general population
(Class IIb; Level of Evidence B).
• Treatment with CPAP might be considered for patients
with ischemic stroke or TIA and sleep apnea given the
emerging evidence in support of improved outcomes
(Class IIb; Level of Evidence B).
42. Cigarette Smoking
• Healthcare providers should strongly advise every
patient with stroke or TIA who has smoked in the past
year to quit (Class I; Level of Evidence C).
• It is reasonable to advise patients after TIA or ischemic
stroke to avoid environmental (passive) tobacco smoke
(Class IIa; Level of Evidence B).
• Counseling, nicotine products, and oral smoking
cessation medications are effective in helping smokers
to quit (Class I; Level of Evidence A).
43. Alcohol Consumption
• Patients with ischemic stroke, TIA, or hemorrhagic stroke
who are heavy drinkers should eliminate or reduce their
consumption of alcohol (Class I; Level of Evidence C).
• Light to moderate amounts of alcohol consumption (up
to 2 drinks per day for men and up to 1 drink per day for
nonpregnant women) may be reasonable, although
nondrinkers should not be counseled to start drinking
(Class IIb; Level of Evidence B).
44. Extracranial Carotid Disease
• Three major randomized trials(The European Carotid
Surgery trial (ECST), the North American Symptomatic
Carotid Endarterectomy Trial (NASCET), and the
Veterans Affairs Cooperative Study Program (VACS)
have demonstrated the superiority of CEA plus medical
therapy over medical therapy alone for symptomatic
patients with a high-grade (>70% angiographic stenosis)
atherosclerotic carotid stenosis.
45. • Additionally, each of these major trials showed that for
patients with stenoses <50%, surgical intervention did
not offer benefit in terms of stroke risk reduction.
• Patients with a moderate (50%–69%) stenosis who are
at reasonable surgical and anesthetic risk may benefit
from intervention when performed by a surgeon with
excellent operative skills, current guidelines advise
proceeding with CEA only if the surgeon’s rate for
perioperative stroke or death is <6%.
46. • In medically treated patients, the risk of stroke was
greatest in the first 2 weeks and declined subsequently.
• By 2 to 3 years, the annual rate of stroke in medically
treated patients was low and approached the rate
observed for asymptomatic patients.
47. • ECST and NASCET showed that for patients with ≥70%
carotid stenosis, the attributable risk reduction for any
ipsilateral stroke or any stroke or death within 30 days of
trial surgery fell from 30% when surgery occurred within
2 weeks of the most recent cerebrovascular event to
18% at 2 to 4 weeks and 11% at 4 to 12 weeks.
48. • CAS has been offered mainly to those patients
considered high risk for open endarterectomy.
• High risk is defined as
• (1) patients with severe comorbidities (class III/IV
congestive heart failure, class III/IV angina, left main
CAD, ≥2-vessel CAD, left ventricular (LV) ejection
fraction ≤30%, recent MI, severe lung disease, or severe
renal disease) or
49. • (2) challenging technical or anatomic factors, such as
prior neck operation (ie, radical neck dissection) or neck
irradiation, postendarterectomy restenosis, surgically
inaccessible lesions (ie, above C2, below the clavicle),
contralateral carotid occlusion, contralateral vocal cord
palsy, or the presence of a tracheostomy.
50. • The major trials comparing the two operative procedures
include:
• Carotid and Vertebral Artery Transluminal Angioplasty
Study (CAVATAS).
• SAPPHIRE trial (Stenting and Angioplasty With
Protection in Patients at High Risk for Endarterectomy)
• EVA-3S (Endarterectomy Versus Angioplasty in Patients
With Symptomatic Severe Carotid Stenosis),
• SPACE (Stent-Supported Percutaneous Angioplasty of
the Carotid Artery versus Endarterectomy),
• and ICSS (International Carotid Stenting Study)
51. • A preplanned meta-analysis of these studies found that
the rate of stroke and death at 120 day after
randomization was 8.9% for CAS and 5.8% for CEA.
• Among numerous subgroup analyses, age was shown to
modify the treatment effect.
• Among patients aged ≥70 years, the rate of stroke or
death at 120 days was 12.0% with CAS compared with
5.9% with CEA.
• In patients younger than 70 years of age, there was no
significant difference in outcome between CAS and CEA.
52. Recommendations
• For patients with a TIA or ischemic stroke within the past
6 months and ipsilateral severe (70%–99%) carotid
artery stenosis as documented by noninvasive imaging,
CEA is recommended if the perioperative morbidity and
mortality risk is estimated to be <6% (Class I; Level of
Evidence A).
53. • For patients with recent TIA or ischemic stroke and
ipsilateral moderate (50%–69%) carotid stenosis as
documented by catheter-based imaging or noninvasive
imaging with corroboration, CEA is recommended
depending on patient-specific factors, such as age, sex,
and comorbidities, if the perioperative morbidity and
mortality risk is estimated to be <6% (Class I; Level of
Evidence B).
54. • When the degree of stenosis is <50%, CEA and CAS are
not recommended (Class III; Level of Evidence A).
• When revascularization is indicated for patients with TIA
or minor, nondisabling stroke, it is reasonable to perform
the procedure within 2 weeks of the index event rather
than delay surgery if there are no contraindications to
early revascularization (Class IIa; Level of Evidence B).
55. • CAS is indicated as an alternative to CEA for
symptomatic patients at average or low risk of
complications associated with endovascular intervention
when the diameter of the lumen of the ICA is reduced by
>70% by noninvasive imaging or >50% by catheter-
based imaging and the anticipated rate of periprocedural
stroke or death is <6% (Class IIa; Level of Evidence B).
56. • It is reasonable to consider patient age in choosing
between CAS and CEA. For older patients (ie, older than
≈70 years), CEA may be associated with improved
outcome compared with CAS, particularly when arterial
anatomy is unfavorable for endovascular intervention.
For younger patients, CAS is equivalent to CEA in terms
of risk for periprocedural complications and long-term
risk for ipsilateral stroke (Class IIa; Level of Evidence B).
57. • Among patients with symptomatic severe stenosis
(>70%) in whom anatomic or medical conditions are
present that greatly increase the risk for surgery or when
other specific circumstances exist such as radiation-
induced stenosis or restenosis after CEA, CAS is
reasonable (Class IIa; Level of Evidence B).
58. • CAS and CEA in the above settings should be performed
by operators with established periprocedural stroke and
mortality rates of <6% for symptomatic patients, similar
to that observed in trials comparing CEA to medical
therapy and more recent observational studies (Class I;
Level of Evidence B).
59. • Routine, long-term follow-up imaging of the extracranial
carotid circulation with carotid duplex ultrasonography is
not recommended (Class III; Level of Evidence B).
• For patients with a recent (within 6 months) TIA or
ischemic stroke ipsilateral to a stenosis or occlusion of
the middle cerebral or carotid artery, EC/ IC bypass
surgery is not recommended (Class III; Level of
Evidence A).
60. • For patients with recurrent or progressive ischemic
symptoms ipsilateral to a stenosis or occlusion of a distal
(surgically inaccessible) carotid artery, or occlusion of a
midcervical carotid artery after institution of optimal
medical therapy, the usefulness of EC/IC bypass is
considered investigational (Class IIb; Level of Evidence
C).
61. Extracranial Vertebrobasilar Disease
• Routine preventive therapy with emphasis on
antithrombotic therapy, lipid lowering, BP control, and
lifestyle optimization is recommended for all patients with
recently symptomatic extracranial vertebral artery
stenosis (Class I; Level of Evidence C).
• Endovascular stenting of patients with extracranial
vertebral stenosis may be considered when patients are
having symptoms despite optimal medical treatment
(Class IIb; Level of Evidence C).
62. • Open surgical procedures, including vertebral
endarterectomy and vertebral artery transposition, may
be considered when patients are having symptoms
despite optimal medical treatment (Class IIb; Levelof
Evidence C).
63. Intracranial Atherosclerosis
• Important trials include
• WASID Trial: randomized to aspirin 1300 mg or warfarin.
• stopped early because of higher rates of death and
major hemorrhage in the warfarin arm.
64. • SAMMPRIS trial: randomized to aggressive medical
management alone or aggressive medical management
plus angioplasty and stenting with the Wingspan stent
system.
• The 30-day rate of stroke and death was significantly
higher in the stenting arm.
65. • For patients with a stroke or TIA caused by 50% to 99%
stenosis of a major intracranial artery, aspirin 325 mg/d
is recommended in preference to warfarin (Class I; Level
of Evidence B).
• For patients with recent stroke or TIA (within 30 days)
attributable to severe stenosis (70%–99%) of a major
intracranial artery, the addition of clopidogrel 75 mg/d to
aspirin for 90 days might be reasonable (Class IIb; Level
of Evidence B).
66. • For patients with stroke or TIA attributable to 50% to 99%
stenosis of a major intracranial artery, the data are
insufficient to make a recommendation regarding the
usefulness of clopidogrel alone, the combination of
aspirin and dipyridamole, or cilostazol alone (Class IIb;
Level of Evidence C).
• For patients with a stroke or TIA attributable to 50% to
99% stenosis of a major intracranial artery, maintenance
of SBP below 140 mm Hg and high intensity statin
therapy are recommended (Class I; Level of Evidence
B).
67. • For patients with a stroke or TIA attributable to moderate
stenosis (50%–69%) of a major intracranial artery,
angioplasty or stenting is not recommended given the
low rate of stroke with medical management and the
inherent periprocedural risk of endovascular treatment
(Class III; Level of Evidence B).
• For patients with stroke or TIA attributable to severe
stenosis (70%–99%) of a major intracranial artery,
stenting with the Wingspan stent system is not
recommended as an initial treatment(Class III; Level of
Evidence B).
68. • For patients with stroke or TIA attributable to severe
stenosis (70%–99%) of a major intracranial artery, the
usefulness of angioplasty alone or placement of stents
other than the Wingspan stent is unknown and is
considered investigational (Class IIb; Level of Evidence
C).
69. • For patients with severe stenosis (70%–99%) of a major
intracranial artery and recurrent TIA or stroke after
institution of aspirin and clopidogrel therapy,
achievement of SBP <140 mm Hg, and high- intensity
statin therapy, the usefulness of angioplasty alone or
placement of a Wingspan stent or other stent is unknown
and is considered investigational (Class IIb; Level of
Evidence C).
70. • For patients with severe stenosis (70%–99%) of a major
intracranial artery and actively progressing symptoms
after institution of aspirin and clopidogrel therapy, the
usefulness of angioplasty alone or placement of a
Wingspan stent or other stents is unknown and is
considered investigational (Class IIb; Level of Evidence
C).
• For patients with stroke or TIA attributable to 50% to 99%
stenosis of a major intracranial artery, EC/ IC bypass
surgery is not recommended (Class III; Level of
Evidence B).