for the los angeles for the los angeles county department of health services and associate chief medical director of neurological services and chief of neurology at la county and university of southern california medical center dr tofighi's research has focused on healthcare delivery redesign to improve access to care quality of care and patient outcomes in safety net settings to reduce inequalities she has collaborated closely with ucla researchers developing and testing novel models of healthcare delivery in the department of health safety net system she's published extensively on sex race ethnic and social economic disparities in stroke and has tested interventions designed to address disparities in post-stroke care she received the robert g seeker new investigator and stroke award from the american heart association and the michael s pesson stroke leadership prize from the american academy of neurology she served as chair of the american stroke association quality and outcomes committee and served on numerous writing groups for american heart association scientific statements and guidelines including chair of the post-stroke depression scientific statement and she's the vice chair of the secondary stroke prevention guidelines which she will be presenting today it's my pleasure to turn over the presentation to dr tufigi thank you so much for that kind of introduction deb and it's really my pleasure to be here discussing the secondary stroke prevention guidelines today these guidelines are an update to the 2014 guidelines for the secondary for secondary stroke prevention um i just want to acknowledge our amazing writing group i served as the vice chair don kleindorfer was the chair of the guideline committee and we had a terrific work group working on these guidelines for the past two years i have no disclosures so there's three learning objectives for today the first is to compare and contrast the changes that were made to the new guidelines with respect to format and sections the second is to explain rationale for specific strategies for secondary stroke prevention and the third is to be able to describe the top 10 most important takeaway points from the guidelines so just to give you a little bit of background in 2017 the american heart association changed the way they were doing guidelines in the past the guidelines had been very wordy had been really like extensive systematic reviews of the literature and were hard to read so in 2017 they made changes to make the text much shorter and to have module modular chunks for each topic and in each chunk you have a table of recommendations a brief synopsis of the recommendations and for each recommendation there's specific text supporting that recommendation we try to incorporate flow diagrams and algorithms whenever possible and uh the references are hyperlinked and you can refer to the data supplement which is a separate document that has all the evidence tables if you want to get more information about where the recommendations came from i also want to tell you a little bit about the scope of this guideline this guideline pertains specifically to secondary prevention of ischemic stroke so individuals who've had an ischemic stroke or tia what do you do to prevent a recurrent stroke we did cover some things in the acute care setting only if it was pertinent to secondary stroke prevention and we did not include topics that are covered in other guidelines such as acute management intracerebral hemorrhage primary prevention and a few special considerations such as special considerations in women which was a scientific statement that we released as well as the cerebral venous sinus thrombosis recommendations compared to 2014 there were a few changes in the way it was organized we added a new section on diagnostic evaluation as it pertains to secondary stroke prevention then we had a category a section on vascular risk factor management and the third category was on management by etiology and by etiology we went with the toast classification that includes large vessel atheros small vessel disease cardio embolism other and a new section on embolic stroke of a determinate source and finally we had a section on systems of care for secondary stroke prevention each section has knowledge gaps and future research uh segments um with recommendations on additional areas for research i want to talk briefly about how the the guy the the strength of recommendation as well as the quality of evidence so for every recommendation you'll see a class which is 1 2 a 2 b 3 benefit and no benefit and 3 harm so if um if a treatment strategy causes much more benefit than risk that would be a class 1 strong recommendation class 2a is if the benefit is still greater than the risk and class 2b is if the benefit is greater than or equal to risk now there's two class three recommendations one is no benefit that's if the benefit equals the risk and then there's a class three harm where the risk is greater than the benefit now the strength of the recommendation has nothing to do with the quality of the data the quality of the data are covered under the level of evidence so level a is when there's one or more high quality randomized control trials or meta-analyses of high-quality randomized control trials level two sorry level b r is moderate evidence from one or more randomized trials or meta-analyses of moderate quality randomized trials vnr is moderate quality evidence from well-executed non-randomized studies cld is limited data so there may be randomized or non-randomized observational observational registries that have limitations in design and level ceo is expert opinion so here you're not we're not basing it on randomized trials or even non-randomized trials these are just clinical experience of experts so i'm going to talk about the first section which is the diagnostic evaluation which was a new section for these guidelines so i mentioned before that we divided the management according to stroke subtypes so in order to figure out what the stroke subtype is you need a diagnostic evaluation and to just ground you in just the um the nomenclature here as you know about 85 to 88 of strokes are ischemic strokes and amongst ischemic strokes about one quarter are lacunar and the rest are non-lacunar and amongst non-lacunar strokes they can be divided into cardioembolism cryptogenic large artery athero and other now within cryptogenic strokes there's two types there's embolic stroke of undetermined source or esis and non-aesis so when you think about isis think about a stroke that is cryptogenic that looks embolic in origin and when i say embolican origin i'm talking about it might be bilateral or in anterior and posterior circulations and often cortical strokes throughout the guidelines um we assume that clinicians will be doing shared decision making with their patients describing the risks benefits and options to patients and developing a plan that take into account patients wishes and the second thing that i want to point out is um it's so important to assess adherence at every visit and not to assume that a recurrent stroke is due to a failure of a medication but to check whether or not the patient is taking the medication um i feel that often that is forgotten when people are talking about this antiplatelet versus that antiplatelet um a key thing is our patients taking their medications and if not what can we do to help them to to be able to take their medications so for the diagnostic evaluation section we have um an algorithm and i'm just going to rather than walk you through the entire algorithm i'm just going to tell you a few key basic points so we have class 1 recommendations for get for diagnostic imaging of the brain parenchyma to diagnose a stroke so either ct or mri is class 1. if there's no stroke seen on the initial ct or mri it's reasonable to do repeat imaging the second class 1 recommendation is to do ekg and basic lab tests and those are delineated in the guideline but they include things such as electrolytes cbc coax a1c lipid profile um then the the other class one medication is non-invasive carotid imaging with cta mra or ultrasound and um class 2a recommendations for intracranial imaging of the vasculature as well as extra cranial vertebral basilar system there's a class two b recommendation for echocardiography to look for cardio embolic sources and with all of those those studies if a cause is not identified um then there's a class one recommendation for prolonged rhythm monitoring to um uh to detect uh atrial fibrillation and class two recommendations for other studies such as screening for a pfo testing for genetic stroke symptoms vasculitis and other causes of stroke all of these depend on the clinical picture of course and um we do not recommend sending all these studies without a clinical reason so the next section is on vascular risk factor management i'm going to start with antithrombotic medications this is really one of the big pillars of secondary stroke prevention it is such an important and controversial topic that we actually asked for a separate systematic review which was published by a separate group that there was basically a wall between the guideline committee and the evidence review committee who did this evidence-based review some of the guidelines here are based on the evidence-based review but we specifically asked them about single versus stool anti-platelet therapy and our guidelines cover a little bit more than that so we have um uh the wars trial from many years ago looked at warfare versus aspirin and showed that aspirin is superior to warfarin for secondary stroke prevention because of the bleeding risk with warfarin and so there's a class one recommendation for anti-platelet therapy over anticoagulation additionally multiple trials have shown that either aspirin plus extended release diperinimal aspirin alone clopidogrel alone are um are reasonable options for secondary stroke prevention and the trials include um capri that looked at aspirin plus clopidogrel esps2 and esprit that looked at extended release uh diprotomal plus aspirin versus aspirin and profess which looked at agronox versus clopidogrel now um we have a few new trials so chance and point looked at dual anti-platelet therapy for this for a short time period after minor stroke or high risk tia and uh based on these two trials there's a level there's a class one a recommendation for dual anti-platelet therapy with aspirin plus clip integral for three weeks to 90 days followed by single antiplatelet therapy in patients who have a high risk tia or a low a small stroke a minor non-cardioembolic stroke um additionally there was a trial that looked at titagalore in patients with minor to moderate stroke and high-risk tiaa the high-risk ti was defined a little bit differently in this trial um and um this was the thales trial and so it's reasonable to give tycagular plus aspirin for 30 days however it may increase the risk of bleeding therefore it's a 2b recommendation in patients who are already taking aspirin the effectiveness of increasing the dose or changing to another is not well established there have been a couple of uh post hoc analyses of sps3 and chance however we need more data on this and finally continuous use of dual anti-platelet therapy is not indicated and can cause harm with excess risk of hemorrhage without benefit so we don't recommend and a dual antiplatelet beyond 90 days a really simple algorithm to help you remember when to use dual is high risk tia or small stroke with a nih stroke scale of less than three reasonable to do dual antique platelet for 90 days after which you go with single antiplatelet and if you're not if you don't have a high risk tia or a small stroke then just go with single antiplatelet so um with regards to risk factor management a really important component is nutrition and um so our nutrition uh data is really based on primary stroke prevention studies we don't have data on secondary stroke prevention but the predimed trial which used a mediterranean diet with supplementation of extra virgin olive oil or nuts versus a low-fat diet showed a reduction in stroke for those on the mediterranean diet this is primary stroke similarly the leon diet heart trial looked at a mediterranean diet with supplemental canola oil in patients after an mi and found a reduction in cardiovascular disease and total mortality and um with regards to salt um again we're looking at uh primary uh prevention data a one gram reduction is associated with a twenty percent uh reduction in cardiovascular events and if you reduce it to 2.5 um gram sorry if you reduce it to 1.5 grams per day um you reduce blood pressure by another five millimeters and so the reason these are not class one recommendations is because they're based on um uh primary prevention uh studies rather than um secondary prevention now for physical activity uh unfortunately there have not been that many studies looking at physical activity and individuals with stroke however with limited data we are advising for moderate intensity activity for at least 10 minutes four times a week or vigorous intensity activity for 20 minutes twice a week this is based on a post hoc analysis of the sampras trial which was a medical management versus stenting trial for intracranial athero and they found that those who did not engage in that amount of activity had a five times higher risk of stroke mi or vascular death additionally we know that the two systematic reviews of exercise classes with counseling showed a reduction in cardiometabolic risk factors but not reduction in stroke um and the bust stroke trial is actually an important neutral that showed that if you break up sedentary activity everything 30 minutes with three minutes of light bouts of light activity there's an improvement in cardiovascular health with regards to uh smoking and substance news there's really nothing new here and patients who smoke they should be counseled to stop and um uh provided resources for counseling and or uh drug therapy with nicotine replacement bupropion or very various very clean um and um they should uh be advised to stop in patients with a history of stroke or ta they should also be a council to avoid passive smoking because there is an association between environmental smoke or secondary smoke and uh stroke with regards to alcohol there is a j shaped curve so that there is a lower risk at about two drinks a day for men and over one drink per day at one drink per day for women however because it's a j shaped curve the risk increases exponentially after that amount so if they're drinking that amount they should be cancelled to reduce or eliminate uh drinking additionally in individuals who are using stimulants or iv drug use they should be counseled to to stop and as you know it's not enough to just tell someone to stop uh referral to specialized services to help them with their dependency is critical um with regards to hypertension management so there are several trials which are not new um and systematic reviews that have shown that a thiazide diuretic ace inhibitor or angiotensin receptor blocker are associated with reduced risk of recurrent stroke in individuals with stroke however what is new is the blood pressure goal so meta-analysis of four randomized control trials respect past bp sps3 and podcast showed that an intensive goal of less than 120 or less than 130 depending on which trial was superior to a goal of less than 140 or less than 150. therefore we have a class 1 br recommendation for a blood pressure goal of less than 130 over 80. in addition there's a recommendation to to choose medication based on patients comorbidities and in patients who do not have a history of high blood pressure but do have a blood pressure of over 130 over 80 we are recommending starting medications with respect to hyperlipidemia there are some new studies here so first of all the sparkle trial showed that a torba 80 versus placebo reduces risk of recurrent stroke however we did not know the target ldl so the tst study gave us that information they found that individuals with a target ldl of less than 70 had a reduced risk of recurrent stroke compared to those with a goal of 90 to 110 and based on that we have a new class one 1 a recommendation to treat to a goal of less than 70 using acetamide if needed in addition to a statin and in patients who are high risk defined as stroke plus another major atherosclerotic cardiovascular disease or stroke plus multiple high risk conditions there's a recommendation to also add psk9 therapy if a statin and azadomide do not reduce the the ldl to below 70. for hypertriglyceridemia we have new recommendations as well so the first is based on the reduce at trial where they randomize individuals with atherosclerotic cardiovascular disease including a history of ischemic stroke they had quite a few people with ischemic stroke in this trial and they randomized them to icosapentyl ethyl 2 grams vid plus statin versus statin alone and showed a reduction in the primary endpoint of adverse cardiovascular events therefore we have a 2a recommendation a 2a because it's not in a purely stroke population of um adding icosapentyl ethyl 2 grams bid for individuals who have high triglycerides but less than 500 additionally we have a recommendation to address severe hypertriglyceridemia because it can cause multiple adverse effects including pancreatitis for glucose there's a few key points one is that the eight we recommend an a1c goal of less than seven percent with those who have diabetes and especially those who are less than 65. in addition the the treatment of diabetes should include a glucose lowering agent with proven cardiovascular benefit the glp-1 receptor agonists have been shown to have cardiovascular benefit and should be added in individuals with established cardiovascular disease as um as with any uh stroke uh there's a recommendation to include lifestyle counseling nutritional management diabetes self-management education and support and medications now with respect to the a1c level we do not know if a lower a1c goal is a benefit for reducing recurrent stroke the studies did show higher rates of hypoglycemia with more strict glucose control and then in individuals with pre-diabetes metformin can be beneficial for lowering the blood sugar and reducing the risk of diabetes and in individuals with insulin resistance pioglitazone can be considered this is based on the iris trial which showed a reduced risk of recurrent stroke in individuals treated with pioglitazone of note you uh patients with a severe congestive heart failure and bladder cancer would be excluded from pioglitazone treatment with regards to obesity obesity and sleep apnea we recommend weight loss and multi-component behavioral lifestyle interventions for individuals with obesity we also recommend checking a bmi at the time of the stroke and annually thereafter for individuals with sleep apnea we recommend positive airway pressure and it is reasonable to evaluate for sleep apnea during a stroke workup particularly in individuals who you think are at high risk for sleep apnea so now we move to the section uh by etiology and the section is a little bit dense um but uh i'll hope to i'll try to make it as simple as possible so we're going to start with intercranial large artery atherosclerosis so we know that individuals who have at least moderate stenosis of an intracranial artery aspirin 325 is recommended this was based on the wasat trial which looked at warfarin versus aspirin and found aspirin to be superior to warfarin in individuals with severe stenosis at least 70 percent addition of clopidogrel to aspirin for up to three months is reasonable now this is um not a based on randomized controlled trial data it's looking at the medical management arm of sampras which was a trial of medical management versus stenting and looking at the event rate in the sampras trial when medical management was clopidogrel plus aspirin and comparing that event rate to the wasat trial aspirin arm so aspirin arm in the watson trial versus aspirin was clever girl in the sampus trial and they found lower event rates in the sampus trial so it's an indirect comparison um but based on that it's reasonable to consider um dual antiplatelets for three months and somebody with symptomatic severe stenosis now if somebody has epsilon stenosis of at least 30 percent the thales trial showed that addition of ticagrelor plus aspirin might be considered and there have been numerous studies looking at celostazole plus aspirin or cellos dissolve plus clovida girl in patients with moderate to severe stenosis and the data has been mixed so there's a toss one tossed to catharsis and csps trials the csps trial showed a benefit of celostazol plus aspirin for reduction of recurrent events catharsis just showed a benefit for reduction of vascular events and silent brain infarcts and toss one and tossed it did not show a benefit so that's a 2b limited data recommendation i'd also like to point out that those trials were done in a predominantly asian population so it may not be generalizable and the last recommendation is in anyone with uh moderate to severe intracranial athero it's unknown whether to use clopidogryl agronox ticagrelor or celostazole alone because those have not been studied so bottom line moderate to severe stenosis aspirin 325 if it's severe um symptomatic stenosis reasonable to add clopidogrel to aspirin for 90 days and um it's also reasonable to consider adding ticagrelor plus aspirin for up to 30 days but that data is not as convincing the other thing to keep in mind is in the past we often used to let the blood pressure ride a little bit higher in patients with symptomatic intracranial athero however post-hoc analyses from wasab sampras and the chinese intracranial athero registry showed that those who had a blood pressure of less than 140 actually had a lower risk of recurrent stroke than those with a higher blood pressure so in anyone with moderate to severe intracranial athero we recommend high intensity statin antiplatelet systolic blood pressure less than 140 and physical activity to reduce risk of recurrent stroke with regards to angioplasty and stenting there have been three studies that have looked at um percutaneous transluminal angioplasty and stenting versus medical management in patients with symptomatic intracranial arthro and the um and there's harm to for in the stenting arm so there are there's a three harm recommendation for stenting in a symptomatic intracranial athero um that's based on those three studies and um that's where for symptomatic severe stenosis um since uh the event rates in moderate stresses are even lower we extended that to a three-harm recommendation for moderate stenosis even though there has not been a trial for that with regards to bypass um there have um there are higher higher rates of stroke with bypass in patients um who um had bypass for for symptomatic uh stenosis so there's no benefit for bypass either so we've talked about intracranial athero now let's talk about extra cranial large artery athero so numerous studies have shown that uh for symptomatic severe ica stenosis carotid endoderectomy is better than medical management provided the perioperative risk is less than six percent this is uh based on a rothwell meta-analysis dr rothwell did a meta-analysis which included nasa ecst and the va trial um the in this meta-analysis there was a 16 absolute benefit over five years for severe stenosis and a five percent benefit over five years for moderate stenosis the peri procedural risk of six percent is based on those studies as well as crest and um statistical modeling now um anyone with symptomatic ic stenosis should be on antiplatelet statin that has their blood pressure management now the question of stenting versus ca is um discussed in a couple of recommendations so in those with who are at least 70 years old it's reasonable to select cea over stenting to reduce the risk of the pair procedural stroke risk additionally if you're going to do it within one week it's reasonable to choose cea over stenting because there's higher risk with stenting if revascularizing with stenting or cea it's best to do it within two weeks of the index event this is do uh a 2a recommendation with limited data and if if somebody has anatomic or medical conditions that increase the risk of surgery it's reasonable to stenting over cea and it's also reasonable to choose stenting over cea in symptomatic patients who are at average or low risk of com of complications um the other uh recommendation that's new is uh there's a new procedure called trans-carotid artery revasculation vascularization or tcar we have limited data on this and so we don't know if this is beneficial in cardiac stenosis and we do know in patients with recent tia or stroke bypass is not recommended in patients who have an occlusion this is based on the cost trial if the if a patient has symptomatic ica stenosis of less than 50 percent cea or stenting is not recommended and that's based on a rothwell meta-analysis we did have a separate section of vertebral athero in patients with vertebral artery stenosis there's no benefit for stenting and aortic arch atheros so this has been a topic of conversation for many years unfortunately the arc study did not answer the question of aspirin of anti-platelet versus anti-coagulation as it was underpowered they had much fewer events in the study than they anticipated likely due to intensive medical management so at this time in patients with aortic arch athero we recommend uh intensive lipid management as well as antiplatelet therapy for small vessel disease there have been numerous studies looking at celostazole versus aspirin um actually two studies csbs and csbs2 these um and csps2 uh about two thirds of the patients had small vessel disease they looked at celostasol versus aspirin and although was a celostal was associated with a lower ischemic a lower risk of ischemic or hemorrhagic stroke when you only look at ischemic stroke there was a non-significant reduction therefore at this time it's still uncertain whether to use cellostazol for small vessel disease atrial fibrillation um we have a class one recommendation to use anticoagulation um for patients with atrial fibrillation and that includes either warfarin or doulac now we have another class one recommendation to use um anyone who is non-valvular afib to use a doc over warfarin and that's based on the four randomized trials aristotle rely engage af timmy 48 and um rocket af the other two recommendations are that you should treat paroxysmal and persistent afib the same and that you should treat a flutter the same as a-fib in addition in patients who have uh contraindications to long-term anticoagulation you can consider watchmen device so it's a left atrial appendage occlusion device it has been shown to have a non-significant increase in thrombotic risk but a lower bleeding risk so in somebody who can tolerate short duration of anticoagulation of 45 days a watchman device is reasonable now the other thing is um when do you start anticoagulation after a stroke this is a question that comes up pretty often so let's say you have your stroke if it's a tia and the patient is bound to be an afib it's fine to start anticoagulation immediately if there's no evidence of stroke now if it's a small stroke with low risk for hemorrhagic transformation it's reasonable to start between days 2 and 14 and if it's a larger stroke or high risk for hemorrhagic conversion you're going to want to start anticoagulation after day 14 to reduce the risk of hemorrhagic transformation for valvular heart disease we divided it into three categories so patients with valvular disease plus afib patients who have valvular disease who are in sinus and patients who have valvular disease with endocarditis so in patients with afib if you have valvular afib which is defined as moderate to severe mitral stenosis or a mechanical valve warfarin is recommended non-valuable or a-fip we recommend a delac if you're in sinus rhythm the oh and you have non-rheumatic mitral valve disease aortic valve disease mitral valve or aortic valve prosthesis you're going to be on an anti-platelet and if you have a mechanical mitral or aortic valve we recommend warfarin now i'll talk a little bit about this in the next slide but generally mitral valve has a higher um goal a inr of 2.5 to 3.5 an aortic valve is two to three unless you have a stroke in which case it's reasonable to intensify the treatment goal to 2.5 to 3.5 in patients with infected endocarditis the question is are you going to do surgery early or later now if there's a if the patient has interest a risk for hemorrhage has intracranial hemorrhage or a large stroke the recommendation is to delay surgery if they have a mobile vegetation or that's at least 10 millimeters or they're having recurrent strokes despite antibiotics early surgery is reasonable so this um algorithm goes back to what i was talking about the the inr goal so by prosthetic valve you're going to do anti-platelet mechanical valve if it's a mitral valve you're going to do an inr goal of 2.5 to 3.5 if they had a stroke you're going to add aspirin to that and for a mechanical aortic valve if they have a stroke while they have their valve and they're on anticoagulation it's reasonable to either intensify the iron article to 2.5 to 3.5 or add a baby aspirin and there have been studies that showed that dabigatran should not be used in the setting of a mechanical valve for cardiomyopathy acute a few key recommendations um and also intracardiac thomas so lv or left atrial thrombus you're going to anticoagulate if there's an lvad then the recommendation is warfarin plus aspirin lv non-compaction warfarin and others it's going to be based on the individual condition now pfo is a relatively controversial topic there have been numerous different um guidelines with respect to pfo but i'm going to kind of give you our recommendations in a nutshell so first you have to look at the age of the patient so in individuals who are 18 to 60 that's the age range in which these studies were done and they have a non-lacunar stroke and a pfo you're going to look for other causes if you don't find any other causes then it's possible that it's a paradoxical embolism now the two the things you should think about are is it a high-risk pfo or low-risk pfo high risk would be someone with either an atrial septal aneurysm or a large right to left shunt and this has been defined differently but in different studies but one example of a definition is at least 20 micro bubbles so high risk pfo pf pfo closure is reasonable it's a 2a recommendation if it's a low-risk pfo then the benefit of closure is not well established and then you want to look at other things to help make your decision one really useful tool is the rope score which is the risk of paradoxical embolism score that tells you the likelihood that the pfo is related to the stroke the next slide is on dissection now there is a separate scientific statement on dissection but we have a short section here um so the main points are antithrombotic therapy for at least three months and the catas trial looked at anti-platelet versus anticoagulation and basically showed no difference in the primary endpoint at one year so it is reasonable to use either aspirin or warfarin to prevent recurrent stroke or tia now in patients who are having recurrent strokes despite maximal medical management it or if they develop a pseudoaneurysm it is reasonable to consider endovascular therapy but that's a 2b recommendation we have a new section on embolic stroke of undetermined source this has been a topic of active research now just remember the definition of esis is a cryptogenic stroke that looks symbolic um and uh so in patients with esis treatment with doax is not recommended and that's based on the navigate thesis and respect issues trials in addition uh treatment with ticagrelor is not recommended and that's based on a post-hoc analysis of patients with issues who are enrolled in the socrates trial this is the last section and it's the systems of care section so we divided it into health systems based intervention so interventions that are changing the way you deliver care in the health system versus uh behavior change interventions where you're expecting the patient to change their behavior and there have been numerous studies with really mixed results but a few things are being recommended one is that it's important for hospitals and outpatient clinics to look at quality and improvement programs to look at nationally accepted evidence-based guidelines for secondary stroke prevention the second which is based on some randomized controlled trials is to use a multidisciplinary team and what we mean by a multi-disciplinary team that can include advanced practice providers nurses and pharmacists to control vascular risk factors and on the left you can see a few of the studies that utilize multi-disciplinary teams the third is to use a decision support tool so the fastest trial looked at a electronic decision support tool for managing um secondary stroke prevention there are numerous trials that are currently underway um looking at strategies to optimize secondary stroke prevention it's an area of active research and then the second section is on behavioral oh sorry i skipped a slide so behavior change interventions so these are interventions where you're trying to help the patient change their behavior whether it's regards with regards to diet lifestyle medication adherence and so in order to do a behavior change intervention it's really important to use a model of behavior change the social sciences have very robust models of behavior change so our first recommendation is to to target stroke literacy lifestyle factors and medication adherence for cardiovascular events the second is that we don't know the optimal tools but motivational interviewing has been shown to be useful in the mistrial as well as a text messaging uh trial of sms for stroke showed that text messaging was helpful for medication adherence um a meta-analyses of lifestyle interventions have shown that you have larger effects if you combine a kind of counseling lifestyle intervention with an actual exercise based group exercise based intervention in addition several small cardiac rehab trials have shown evidence of improvement in cardiovascular risk factors but not secondary stroke and the one clear thing that we know is that it's not not enough to just give someone a pamphlet or handout in order to change their behavior you really need more robust behavioral intervention and finally we have a section on health equity um there have been numerous uh trial secondary stroke prevention trials trying to reduce disparities and stroke they've all had mixed results but there are a few key take-home points one is that it's critical to address social determinants of health the second is that it's it's helpful as mentioned earlier to monitor evidence-based performance measures the third and this is based on an aha scientific statement is to use the ahrq precautions toolkit for health literacy to ensure that your materials are appro appropriate um for individuals with limited english proficiency and finally in patients who are from vulnerable groups um the uh the the best model for reducing risk factors for stroke remains unknown and i included a few of these key knowledge gaps here so i'm just going to give you our top 10 take-home messages i know that was really a lot of information i tried to give you the the key um the key messages but let's just summarize real quick so one your strategy for secondary stroke uh prevention depends on the etiology of the stroke the second is you need to manage vascular risk factors those include hypertension diabetes dyslipidemia diet and physical activity and that segways into number three that it's really critical to address lifestyle and that you can't change someone's behavior with just a handout you need to refer them to a more robust program that includes either motivational interviewing or some kind of group support or self-management support anti-thrombotics are recommended in most patients the only time you're going to use dual antiplatelets is for short-term use in either patients with small stroke or high risk tia for the first uh three months or in patients with symptomatic intracranial athero for three months in atrial fibrillation anticoagulation is recommended um in most cases you're gonna we're gonna recommend a doc over a warfarin and if somebody has embolic stroke fund determines us source it's um we recommend looking for occult afib with long-term rhythm monitoring for severe extra training extra cranial stenosis we recommend um either cea or stenting depending on patient circumstances and severe intracranial stenosis don't stent as first line use aggressive medical management which includes anti thrombotic statin therapy blood pressure control and diet and physical activity for pfos in certain circumstances it's reasonable to close the pfo particularly in those under 60 with a high risk pfo and finally essa should not be treated empirically with anticoagulants or ticagrelor and there are ongoing studies to determine the optimal management of esis um and so that leaves us some time for q and and we have about 10 minutes for questions thank you um anybody have any questions i do see one but feel free to type them into the chat box and dr taffigi will toffee sorry we'll answer those and um or you can star six to unmute yourself so the first question is can you further discuss aspects that influence which patient should have a tte or a tee to determine stroke etiology the 2019 aha ais guidelines state the benefit of routine use of echocardiogram is uncertain for example should lacunar strokes have cardiac structures imaged if the patient has known vascular risk factors um so that's a great question um so if we go back to the diagnostic slide one sec um so it's a 2b recommendation to look for cardiac sources of envelopes um with tte or t-e-e um and so i think you know you're gonna find different practices based on the institution where you work we um we don't have um great evidence but just because something hasn't been tried um you know there hasn't been a randomized controlled trial doesn't mean that it shouldn't be done and so in this case you're going to find different practices at different institutions okay thank you um any additional questions you can either star sticks to unmute yourself type them in or you can unmute yourself at the bottom of your screen okay so i'm not seeing any additional questions so i just want to thank you so much for this excellent presentation thank you everybody who joined us and we will be sending out a link to the presentation within the next week or so so that you'll have that available and if you have any further questions feel free to reach out anytime and i just want to point you to the guidelines on the go that's an excellent resource looks like we do have one more question here is there a reason that the new nursing guidelines did not use the same evidence-based criteria um i cannot speak to that um so the the do you mean the level of evidence and the strength of the recommendations yes she says okay um so the i'm not sure the um the aha um has pretty strict rules um about the using the level of evidence and circle recommendations so i would uh i don't know enough about the new nursing guidelines to to comment on that i'm not sure if someone else can comment on that i can look into it she said thank you and i can look into it donna for you and see if i can find any information and get back to you any additional questions okay again thank you so much for joining the presentation it's an excellent presentation and we really appreciate your time and expertise so thank you so much for having me yep have a great rest of your day everybody bye bye