Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020

Abstract

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Program of Rehabilitative Exercise and Education to Avert Vascular Events After Non-Disabling Stroke or Transient Ischemic Attack (PREVENT Trial): A Randomized Controlled Trial

“…10 Clinical guidelines for secondary stroke prevention recommend a combination of pharmacological therapy and nonpharmacological interventions, including education, exercise, and lifestyle counselling. [11][12][13] Lack of patient awareness and knowledge of cardiovascular risks is a known barrier to averting further events. 14,15 Positive effects of exercise on cardiovascular risk factors, 16,17 exercise capacity, 16 and mental wellbeing 18 in the general population are broadly recognized.…”

Benefits of GLP-1 (Glucagon-Like Peptide 1) Receptor Agonists for Stroke Reduction in Type 2 Diabetes: A Call to Action for Neurologists

“…Diabetes Canada recommends the use of GLP-1RAs to provide cardiovascular protection in those with CVD or risk factors. 54 In the same vein, the 2020 Canadian Stroke Best Practices update for secondary prevention of stroke, 8 2021 Spanish Society of Neurology consensus statement, 9 2021 American Heart Association/American Stroke Association Guideline for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack, 7 and the Diabetes, Cardiorenal, and Metabolic Diseases Multispecialty Task Force 55 all endorse GLP-1RAs for reducing stroke risk in individuals with T2DM. Specifically, the Canadian Stroke Best Practices recommends GLP-1RAs for patients with stroke and T2DM who have not met their glycemic targets with standard antihyperglycemic agents 8 ; the American Heart Association/American Stroke Association guideline suggests GLP-1RAs as second-line to metformin regardless of baseline HbA1c in individuals with established atherosclerotic CVD to avoid further vascular events 7 ; the Diabetes, Cardiorenal, and Metabolic task force endorses the use of a long-acting GLP-1RAs for primary and secondary prevention of stroke/TIA in diabetes 55 ; but the Spanish guidelines only recommend GLP-1RAs for prevention of fatal and nonfatal stroke in individuals with T2DM and either established vascular disease or high vascular risk.…”

“…This aligns with the recommendations of other groups. 7,8,55 Figure 4 includes a practical algorithm to aid in GLP-1RA initiation, and Table 2 provides answers to some frequently asked questions with recommendations on how to safely address common concerns around the use of GLP-1RAs.…”

“…Diabetes Canada recommends the use of GLP-1RAs to provide cardiovascular protection in those with CVD or risk factors. 54 In the same vein, the 2020 Canadian Stroke Best Practices update for secondary prevention of stroke, 8 2021 Society of Neurology further vascular events 7 ; the Diabetes, Cardiorenal, and Metabolic task force endorses the use of a long-acting GLP-1RAs for primary and secondary prevention of stroke/TIA in diabetes 55 ; but the Spanish guidelines only recommend GLP-1RAs for prevention of fatal and nonfatal stroke in individuals with T2DM and either established vascular disease or high vascular risk. 9…”

MicroRNA‑126 protects SH‑SY5Y cells from ischemia/reperfusion injury‑induced apoptosis by inhibiting RAB3IP

“…Ischemic brain injury is a serious neurological condition and the third most common cause of death worldwide ( 1 – 3 ). Immediate restoration of blood flow is recommended as the standard treatment for brain ischemia, which not only delivers oxygen and transports nutrients to sustain aerobic metabolism and ATP generation, but also eliminates accumulated H + ions to normalize extracellular pH ( 4 – 7 ). However, ischemia/reperfusion (I/R) may exacerbate the risk of brain tissue injury ( 8 ).…”