Table I.
American Heart Association/American Stroke Association recommendations for risk factor modification in secondary stroke prevention[13,14]
| Recommendation | Class/level of evidencea |
|---|---|
| Hypertension | |
| Antihypertensive treatment is recommended for all ischaemic stroke or TIA patients who are beyond the hyperacute period | I/A |
| Drug choices should be individualized based on the available data and specific patient characteristics | I/A |
| Absolute BP levels are uncertain and should be individualized | IIa/B |
| Comprehensive therapy should include proven lifestyle modifications | IIb/C |
| Diabetes mellitus | |
| ACE inhibitors and ARBs should be prescribed as they reduce renal disease progression | I/A |
| Glucose levels should be as near to normoglycaemia as possible in patients with ischaemic stroke or TIA | I/A |
| HbA1c should be ≤7% | IIa/B |
| BP and lipids should be more rigorously controlled | IIa/B |
| Cholesterol | |
| Ischaemic stroke or TIA patients with elevated cholesterol, co-morbid CAD or evidence of an atherosclerotic origin should be managed according to NCEP III guidelines | I/A |
| HMG-CoA reductase inhibitors (statins) are recommended with a target LDL-C goal of <100 mg/dL (<70 mg/dL for high-risk patients) | I/A |
| Ischaemic stroke or TIA patients without known CHD should receive statin therapy to reduce the risk of stroke and cardiovascular events | I/B |
| Ischaemic stroke or TIA patients with low HDL-C may be treated with niacin or gemfibrozil | IIb/B |
| Smoking | |
| All patients who smoked in the past year should be encouraged to quit | I/C |
| A combination of counselling, nicotine products and oral smoking cessation products should be considered | IIa/B |
| Environmental smoke should be avoided | IIa/C |
| Alcohol | |
| Heavy drinkers should eliminate or reduce their alcohol consumption | I/A |
| ≤2 drinks/day for men and 1 drink/day for nonpregnant women may be considered | IIb/C |
| Obesity | |
| A goal BMI of 18.5–24.9 kg /m2 and a waist circumference <35 cm for women and <40 cm for men should be encouraged | IIb/C |
| Physical activity | |
| At least 30 minutes of moderate-intensity physical activity per day should be considered for all capable patients | IIb/C |
Class I: conditions for which there is evidence for and/or general agreement that it is useful and effective; class IIa: weight of evidence is in favour; class IIb: usefulness/efficacy is less well established; level of evidence A: data derived from multiple randomized clinical trials; level of evidence B: data derived from a single randomized trial or nonrandomized studies; level of evidence C: expert opinion or case studies.
ARB = angiotensin II type 1 receptor antagonist (angiotensin receptor blocker); BMI = body mass index; BP = blood pressure; CAD = coronary artery disease; CHD = coronary heart disease; HbA1c = glycosylated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; NCEP = National Cholesterol Education Program; TIA = transient ischaemic attack.