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Due to the emergence of newly published clinical trial data, the American Heart Association/American Stroke Association (AHA/ASA) recently published a position statement which updates recommendations for the prevention of stroke in patients with a stroke or transient ischemic attack (TIA). The statement is an update from 2006 that was intended to provide a brief overview of new data, update specific recommendations, and provide a rationale for modification. In particular, the new AHA/ASA statement assesses the use of specific antiplatelet agents for stroke prevention in patients with a history of non-cardioembolic ischemic stroke or TIA and the use of statins to prevent recurrent stroke.

The AHA’s Stroke Council has monitored the literature since 2006 and decided that sufficient accumulation of data was available and necessitated an update to current recommendations. The hope is that this new update will serve as a guide to physicians in the interim between the 2006 statement and the next generation of the recommendations, which will likely be issued in 2009.

Modifications for Antiplatelet Therapy

The first area addressed in the updated position statement was the use of antiplatelet agents for stroke prevention in patients with a history of non-cardioembolic ischemic stroke or TIA. Similar to the 2006 statement, three choices for antiplatelet therapy are suggested. However, findings from the Clopidogrel and Aspirin Versus Aspirin Alone for the Prevention of Atherothrombotic Events trial, or CHARISMA, have led to a fine tuning of the wording for the first-line recommendation for aspirin. The new recommendation reinforces the use of aspirin or clopidogrel monotherapy as initial therapy instead of aspirin plus clopidogrel.

In addition, the combination of aspirin and extended-release dipyridamole is now a Class I, Level of Evidence B recommendation (versus Class II, Level of Evidence A in 2006) over aspirin alone based on data from the European/Australasian Stroke Prevention in Reversible Ischemia Trial, or ESPRIT. Ideally, the selection of antiplatelet therapy for preventing recurrent strokes should continue to be driven by individual patient characteristics. This includes past medical history, comorbidities, drug side effects, cost, and history of compliance.

Changes for Using Statin Therapy

The second major modification to the recommendations focused on the utilization of statin therapy in the prevention of recurrent stroke. Results from the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial led to the development of a new recommendation—the administration of statin therapy for intensive lipid-lowering in patients with atherosclerotic ischemic stroke or TIA and without known coronary heart disease. The therapy should be initiated to reduce the risk of stroke and cardiovascular events. The weight of evidence from SPARCL for statin therapy is profound and has demonstrated beneficial effects on recurrent stroke prevention.

Whether or not the effects observed in SPARCL are a result of the specific drug assessed in the study (atorvastatin) or the statin drug class is unknown at the present time, but a drug-class effect is assumed. According to the AHA, unless there’s contrary evidence, a more conservative way to view the data is to assume a class effect. Studies investigating the class-versus-drug effect of statin therapy on stroke outcomes would be useful. However, statin therapy is so much a part of our approach to secondary prevention for vascular disease that it would be surprising if any other similar study would challenge the data that emerged from this study.

Robert J. Adams, MS, MD, FAHA, has indicated to Physician’s Weekly that he has served as a speaker for Boehringer Ingelheim, Genentech, BMS-Sanofi partnership, and Novartis. Dr. Adams has also disclosed that he is a stockholder of Reach Call, Inc.