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For the chapter in the Wells Handbook, please go to Chapter 13. Stroke.


Content Update

Nov. 15, 2018

New Guidelines for Stroke Prevention in Patients with Atrial Fibrillation: In November 2018, the American College of Chest Physicians (ACCP) published updated guidelines for prevention of stroke in patients with atrial fibrillation (AF). The recommendations address antithrombotic selection, patient assessment tools, patient monitoring, management during various clinical situations, and other issues. Based on evidence from randomized clinical trials, the guidelines recommend use of direct oral anticoagulants (DOACs) over warfarin due to a significantly lower risk of stroke, intracranial hemorrhage, or fatal bleeding. Antiplatelet agents are no longer recommended, even in low-risk patients. Several patient assessment tools are recommended to guide patient care decisions in select situations, including the CHADS2-Vasc2 score, the HAS-BLED score, and the SAMe-TT2R2 scoring system. Systematic follow-up, patient education, and monitoring of medication adherence are important for all patients.



  • Image not available. Stroke can be either ischemic (87%) or hemorrhagic (13%) and the two types are treated differently.

  • Image not available. Transient ischemic attacks (TIAs) require urgent intervention to reduce the risk of stroke, which is known to be highest in the first few days after TIA.

  • Image not available. Carotid endarterectomy should be performed in ischemic stroke patients with 70% to 99% stenosis of the ipsilateral carotid artery, provided that it is done in an experienced center.

  • Image not available. Carotid stenting is an option for stroke patients eligible for carotid endarterectomy, especially in patients younger than 70 years.

  • Image not available. Early reperfusion (less than 4.5 hours from onset) with tissue plasminogen activator (tPA) has been shown to reduce the ultimate disability due to ischemic stroke.

  • Image not available. Endovascular thrombectomy with a stent retriever (within 6 hours) improves stroke outcomes in selected patients with proximal large artery occlusion and preservable penumbral tissue.

  • Image not available. Antiplatelet therapy is the cornerstone of antithrombotic therapy for the secondary prevention of noncardioembolic ischemic stroke.

  • Image not available. Oral anticoagulation is recommended for the secondary prevention of cardioembolic stroke in patients with atrial fibrillation.

  • Image not available. Blood pressure lowering is effective in both the primary and secondary prevention of both ischemic and hemorrhagic stroke.

  • Image not available. Blood pressure lowering in the acute ischemic stroke period (first 7 days) may result in decreased cerebral blood flow and worsened symptoms.

Image not available. Stroke is the leading cause of disability among adults and the fifth leading cause of death in the United States, behind cardiovascular disease, cancer, chronic lower respiratory diseases, and accidental death.1 Despite a 35% reduction in stroke mortality between 2001 and 2011, stroke occurs in the United States at a rate of almost 800,000 per year and resulted in 128,932 deaths in 2011.1,2 Aggressive efforts to organize stroke care at the local and regional levels and increased utilization of evidence-based recommendations and national guidelines may have contributed to the improved outcomes.

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