Treating metabolic syndrome, undergoing carotid angioplasty

Last updated in 2006, the evidence-based guidelines for doctors will be published in Stroke: Journal of the American Heart Association.

"Patients who've had a stroke or TIA are at highest risk for having another event," said Karen Furie, M.D., M.P.H., writing committee chair and stroke neurologist. "Since the last update, we've had results from several studies testing different interventions. We need to reevaluate the science every few years to optimize prevention."

Nearly a quarter of the 795,000 strokes in America each year happen in someone who has already had a stroke.

Ischemic stroke accounts for about 87 percent of all strokes, which are caused by a lack of blood to the brain, resulting in tissue death. TIA occurs when blockage of blood to the brain is only temporary and thus doesn't cause tissue death.

The new guidelines feature several key updates for stroke or TIA survivors, including:

• The value of screening for metabolic syndrome after stroke is still not clear; however, if it's diagnosed, patients should receive counseling for lifestyle changes (including diet, exercise and weight loss) and treatments for metabolic syndrome components that are also stroke risk factors, especially high blood pressure and high cholesterol.
• If a stroke survivor has severe blockage of the carotid artery, angioplasty and stenting may be an alternative to surgery if he or she is at low risk for complications.
• Excluding patients whose stroke or TIA was caused by a clot from the heart, among those taking an antiplatelet drug to prevent another stroke, either aspirin alone, aspirin combined with dipyridamole, or clopidogrel are reasonable options. Therefore, patients and doctors must consider risk factors, cost, tolerance and other characteristics to tailor the appropriate therapy.
• Stroke or TIA survivors who are diabetic should follow existing guidelines for blood sugar control.
• All stroke or TIA patients who have carotid artery blockage should aim for optimal medical therapy through a multifaceted approach, including antiplatelet drugs, statin therapy and lifestyle risk factor changes such as blood pressure management.
• When patients with high stroke risk due to atrial fibrillation (an abnormal heart rhythm) need to temporarily stop taking the anti-clotting drug warfarin, they should receive low molecular weight heparin as bridging therapy to reduce the risk of blood clots.

High blood pressure is the most critical risk factor for recurrent stroke. Doctors should work with patients to find the best drug regimen to suit each individual's blood pressure control needs, said Furie, director of the Massachusetts General Hospital Stroke Service and an associate professor at Harvard Medical School.

Co-authors are: Scott E. Kasner, M.D.; Robert J. Adams, M.D.; Gregory W. Albers, M.D.; Ruth L. Bush, M.D., M.P.H.; Susan C. Fagan, Pharm.D.; Jonathan L. Halperin, M.D.; S. Claiborne Johnston, M.D., Ph.D.; Irene Katzan, M.D.; Walter N. Kernan, M.D.; Pamela H. Mitchell, Ph.D, R.N.; Bruce Ovbiagele, M.D.; Yuko Y. Palesch, Ph.D.; Ralph L. Sacco, M.D.; Lee H. Schwamm, M.D.; Sylvia Wassertheil-Smoller, M.D., Ph.D.; Tanya N. Turan, M.D.; and Deidre Wentworth, M.S.N., R.N.