Update to the AHA/ASA Recommendations for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

Abstract

The American Heart Association/American Stroke Association (AHA/ASA) Writing Committee for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack (TIA) has reviewed the results of recent trials that were published after our previous recommendations were issued.1 Our intention in the present statement is to provide a brief review of the new data, to update specific recommendations, and to provide the reasons for any modifications. The 2 areas in which major new clinical trials have been published are (1) the use of specific antiplatelet agents for stroke prevention in patients with a history of noncardioembolic ischemic stroke or TIA and (2) the use of statins in the prevention of recurrent stroke. Recently published trials have added to the evidence of the benefit of the use of specific antiplatelet agents for stroke prevention in patients with a history of noncardioembolic ischemic stroke or TIA. The secondary prevention guidelines1 have been updated to reflect this new evidence. ### Addition of Clopidogrel to Aspirin for Prevention of Vascular Events The Clopidogrel and Aspirin Versus Aspirin Alone for the Prevention of Atherothrombotic Events (CHARISMA) trial2 was a double-blinded study that randomized 15 603 subjects with cardiovascular disease or multiple risk factors for cardiovascular disease to either clopidogrel 75 mg plus low-dose aspirin (75 to 162 mg) or placebo plus aspirin (75 to 162 mg). Roughly 35% of subjects (n=4320) qualified on the basis of the presence of cerebrovascular disease within 5 years of enrollment; approximately a third experienced TIA. The median follow-up was 28 months. No significant differences were seen in the rates of nonfatal ischemic stroke between the 2 groups (1.7% versus 2.1%, P =0.07). The placebo plus aspirin group showed a higher rate of nonfatal stroke than did the clopidogrel group (1.9% versus 2.4%, P =0.03). The 2 groups experienced no differences in the rate of intracerebral hemorrhage …