Oleh

Dr. Wahyudi Sugiono, Sp.S

Antithrombotic agents:

Anticoagulation: Warfarin.
Antiplatelet Agents: Aspirin, Aspirin plus extended release dipyridamole
(Aggrenox), Clopidogel (Plavix), Ticlopidine (Ticlid).

Blood pressure control:

JNC VI recommendations for life style modification, initiation of

specific therapy, and multidisciplinary management strategies.

Carotid Endarterectomy/Cholesterol management:

Statin agents in patients with CHD and Adult Treatment Panel
(ATP III) guideline principles for dietary and pharmacologic
management of patients with hyperlipidemia.

Depression screening:

Estimates of the prevalence of post stroke depression ranges

from 30% to 50%. Treatment should consist of anti-depressant
medication, psychotherapy (if indicated), family support and
education.

Diabetes management:
E

In the presence of diabetes mellitus considerable attention

must be given to blood pressure control and lipid
management. Appropriate hypoglycemic therapy is important
to achieving near-normal plasma glucose.
ducation:
Smoking cessation, weight management, physical
activity, alcohol consumption.

Given the preventive nature of early Stroke

management this Guideline speaks to certain
circumstances of early post-stroke management
(i.e. carotid endarterectomy). This Guideline is in
no means a comprehensive document addressing
postischemic stroke management.

I. ANTICOAGULATION THERAPY:
Stroke (cardioembolic) in the setting of atrial fibrillation:
Long-term (life-time) warfarin should be used in all patients who have
suffered a stroke or TIA in the setting of AF (Target INR 2.5; range 2.03.0). Warfarin should be used in preference to antiplatelet therapy
because of its greater efficacy, unless contraindicated.
(Grade A)
Warfarin should be considered for prevention of recurrent
cardioembolic stroke in patients with other high-risk cardiac sources
such as prosthetic heart valves.
(Grade C)

SPESIAL CONSIDERATIONS:
ACUTE STROKE: Anticoagulation should be delayed or given with
caution in patients with large infarcts, particular those with mass
effect or hemorrhagic conversion.
BLEEDING HISTORY: Only patients with an active source of GI
bleeding, recent intracranial hemorrhage, or other major bleeding
disorder should not receive anticoagulation treatment.
TRANSIENT OR PAROXYSMAL AF: Stroke or TIA in the setting of
transient AF should also be treated with life long anticoagulation
therapy or until appropriate monitoring has determined that AF not
only has not recurred but is also unlikely to recur.
BLOOD PRESSURE CONTROL: Blood pressure in AF patients on
warfarin should be closely monitored. Uncontrolled hypertension is
associated with an increased risk for intracranial hemorrhage.

II. ANTIPLATELET THERAPY:

Antiplatelet agents should be prescribed promptly (within 48
hours) for the prevention of recurrent stroke and other vascular
events in patients who have experienced a noncardioembolic
(atherothrombotic, lacunar, or cryptogenic) stroke or TIA.
Intracranial hemorrhage should be excluded by computed
tomography brain scanning.
(Grade A)
In patients who are aspirin intolerant or in whom aspirin is
contraindicated alternative antiplatelet agents e.g., clopidogrel
75 mg qd or ticlopidine 250 mg bid. Clopidogrel is
recommended over ticlopidine due to its lower adverse effect
profile.
(Grade C)

III. CAROTID ENDARTERECTOMY:

Carotid endarterectomy reduces the risk or major stroke and
death in patients with a recent carotid territory TIA or nondisabling carotid territory ischemic stroke, whose grade of
stenosis > 70% of the ipsilateral carotid artery, and when surgical
morbidity and mortality is < 6%.
Grade A
ASA should be given 81-325 mg/d prior to carotid endarterectomy,
and anti-platelet therapy should be continued following the
procedure, alternative antiplatelet agents may also be
considered. (Aggrenox, Plavix)
Grade A

Special Considerations: (Grade C)

INFARCTS OF THE ENTIRE INTERNAL CAROTID TERRITORY: In strokes
where the entire distribution of the internal carotid artery is
infarcted, carotid endarterectomy should not be performed.
CAROTID ENDARTERECTOMY STENOSIS IN 50-69% RANGE: The utility
of carotid endarterectomy is marginal in this range. The risk vs,
benefit in this group needs to be individualized and decisions made
after discussion with the patient. Second-choice therapy is
represented by the antiplatelet agents.
SELECTION OF SURGEONS AND INSTITUTIONS SHOULD BE BASED ON
THOSE SURGEONS AND HOSPITALS WITH LOW RATES OF
COMPLICATIONS. There is wide variation in surgical risk, depending on
the surgeon, operating team, and hospital.

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IV. RISK FACTOR MODIFICATION:

Inference can be drawn from the findings of primary
prevention trials, and the control of hypertension,
hyperlipidemia, diabetes management, life-style
moderation, and cessation of cigarette smoking
should be advocated.

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A. BLOOD PRESSURE CONTROL

Blood pressure reduction has been demonstrated to be
effective in stroke prevention in both hypertensive and
normotensive patients
GOAL
< 140/90 mm Hg, or to its lowest level of tolerance.
< 130/85 mm Hg if co morbid heart failure or renal insufficiency.
< 130/80 mm Hg if co morbid diabetes.
Grade A
This goal may not be tolarated by all patients (chronic
hypertension & multiple large vessel occlusions)

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B. LIPID MANAGEMENT:
Primary Goal: LDL < 100 mg/dL.
Grade A (Primary Prevention)

Considerations:
Start dietary therapy in all patients (< 7% saturated fat and
<200 mg/dL cholesterol).
Promote safe levels of physical activity and weight
management.
Encourage increased consumption of omega-3 fatty acids.
Assess fasting lipid profile in all patients and within 24 hours of
hospitalization for those with an acute event.
If patients are hospitalized, consider adding drug therapy on
discharge.

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Add drug therapy according to the following guide:

LDL <100 mg/dL
(baseline or on
treatment) Further LDLlowering therapy not
required. Consider
fibrate or niacin if (HDL
<40 mg/dL or TG >200
mg/dL.

LDL 100-129 mg/dL

(baseline or on treatment)
Therapeutic Options:
Intensify LDL-lowering
agents (diets, statin or
resin) Fibrate or niacin (if
low HDL or high TG.
Consider combined drug
therapy
(statin+fibrate or niacin) if*
low HDL or high TG.

LDL > 130 mg/dL

(baseline or on
treatment).
Add or increase therapy
with lifestyle
modifications.
Intensify LDL-lowering
agents (statin or resin).

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Vigilant attention to liver function studies should be undertaken

on patients on statin and fibrate combination therapy.
Secondary Goals:
HDL > 40mg/dL. Triglycerides < 150 mg/dL.
If TGs > 200 mg/dL, then non-HDL should be < 130 mg/dL*.
Grade A (Primary Prevention
If TG > 150 mg/dL oz HDL < 40 mg/dL emphasize weight management and
physical activity.
If TG 200-499 mg/dL consider fibrate o-i niacin after LDL-lowering therapy.
If TG > 500 mg/dL consider fibrate or niacin before LDL-lowering therapy.
Consider omega-3 fatty acids as adjunct for high TG.
Adult Panel III identifies the sum of LDL + VLDL cholesterol (termed non-HDL
cholesterol which is the total cholesterol minus HDL) as a secondary target of therapy
in persons with high triglycerides > 200mg/dL.

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C. DIABETES MANAGEMENT:
In the presence of diabetes mellitus considerable attention
must be given to blood pressure control and lipid management.

Goal:
HbAlc <7%
Grade A (Primary Prevention)

Considerations:
All stroke patients should be screened for diabetes. An FBS result > 126
mg/dL on two separate occasions indicates a dx of diabetes.
Appropriate hypoglycemic therapy to achieve near-normal FBS, as
indicated by HbAlc.
Treatment of other risks (e.g., blood pressure, cholesterol
management, etc.)

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D. SMOKING:
Goal:
Complete cessation.
Grade A (Primary Prevention)

Considerations:
Assess tobacco use.
Strongly encourage patient and family to stop smoking.
Provide counseling, pharmacotherapy (including nicotine and
bupropion, and formal cessation programs as appropriate.)

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E. WEIGHT MANAGEMENT:
Goal:
BMI 18.5-24.9 kg/m2.
Grade B (Primary Prevention)
Considerations:
Calculate BMI and measure waist circumference as
part of the evaluation.
Start weight management and physical activity as
appropriate. Desirable BMI range is 18.5-24.9 kg/m2.

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F. EXERCISE:
Goal: All patients should be counseled to engage in a regimen
of regular exercise as appropriate.
Grade A (Primary Prevention)

Considerations:
Walking, swimming, and bicycling ale all associated with areduced stroke -risk.(minimal: 30 40 minute)
Even low intensity has been shown to reduce the -risk of stroke.
All patients should be counseled to engage in a -regimen of
regular exercise as appropriate

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V.POST STROKE DEPRESSION (PSD):

Estimates of the prevalence of PSD range from 30%

to 50%.

Treatment should consist of family support,

education and anti-depressant medication, and
psychotherapy when indicated.

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VI. PATIENT AND FAMILY EDUCATION:

Mechanisms of stroke and techniques to prevent
recurrent stroke is the most underutilized
intervention.
before or soon after discharge from the acute
setting.
Patients need to be able to clearly identify both
their risk factors and the intended therapeutic goal.

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