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. 2022 Sep;7(3):I-II.
doi: 10.1177/23969873221100032. Epub 2022 Jun 3.

European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack

Jesse Dawson  1 , Yannick Béjot  2   3 , Louisa M Christensen  4 , Gian Marco De Marchis  5 , Martin Dichgans  6   7 , Guri Hagberg  8   9 , Mirjam R Heldner  10 , Haralampos Milionis  11 , Linxin Li  12 , Francesca Romana Pezzella  13 , Martin Taylor Rowan  1 , Cristina Tiu  14   15 , Alastair Webb  12
Affiliations

European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack

Jesse Dawson et al. Eur Stroke J. 2022 Sep.

Abstract

Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.

Keywords: Guideline; antiplatelet; diabetes; dyslipidaemia; hypertension; stroke; systematic review.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed a declaration of competing interests and details are available in Supplemental Table 1.

Figures

Figure 1.
Figure 1.
Forest plot for the risk of any stroke in randomised trials of antihypertensive medication versus placebo after stroke or TIA. Heterogeneity; I2 = 53, p = 0.03.
Figure 2.
Figure 2.
Forest plot for the risk of recurrent major adverse cardiovascular events in randomised trials of antihypertensive medication versus placebo after stroke or TIA. Heterogeneity: I2 = 72.506; Q = 21.823; p = 0.001.
Figure 3.
Figure 3.
Forest plot for the difference in achieved mean blood pressure between ‘treatment as usual’ and introduction of home or remote blood pressure monitoring after stroke or TIA. Heterogeneity: I2 = 0.000; Q = 1.509; p = 0.470.
Figure 4.
Figure 4.
Forest plot for the reduction in the risk of recurrent stroke after TIA or minor stroke in participants randomised to an intensive blood pressure lowering strategy (<130/80) versus a less intensive strategy (<140/90). Heterogeneity: I2 = 0.000; Q = 1.509; p = 0.470.
Figure 5.
Figure 5.
Forest plot for the reduction in the risk of recurrent haemorrhagic stroke after TIA or stroke in participants randomised to an intensive blood pressure lowering strategy (<130/80) versus a less intensive strategy (<140/90). Heterogeneity: I2 = 36.402; Q = 1.572; p = 0.210.
Figure 6.
Figure 6.
Forest plot for the risk of any stroke in trials comparing treatment with HMGCoA reductase inhibitors versus placebo after TIA or stroke. Heterogeneity: I2 = 0.000; Q-value = 2.473.
Figure 7.
Figure 7.
Forest plot for the risk of haemorrhagic stroke in trials comparing treatment with HMGCoA reductase inhibitors versus placebo after TIA or stroke. I2 = 4.423; q = 2.093, p = 0.351.
Figure 8.
Figure 8.
Forest plot for the risk of recurrent stroke in trials comparing treatment with PCSK9 inhibitors or ezetimibe versus placebo after TIA or stroke. Heterogeneity: I2 = 13.843; Q-value = 2.321, p = 0.313.
Figure 9.
Figure 9.
Forest plot for the risk of any major cardiovascular event in trials comparing treatment with PCSK9 inhibitors versus placebo after TIA or stroke. Heterogeneity: I2 = 0.000; Q = 0.278; p = 0.598.
Figure 10.
Figure 10.
Forest plot for the risk of any stroke in trials comparing treatment with an antiplatelet versus placebo after TIA or stroke. I2 = 0.000; q = 6.075, p = 0.639. With ESPS1 included, OR = 0.78 (0.68–0.89).
Figure 11.
Figure 11.
Forest plot for the risk of major cardiovascular events in trials comparing treatment with an antiplatelet versus placebo after TIA or stroke. I2 = 44.134; q = 10.740; p = 0.097.
Figure 12.
Figure 12.
Forest plot for the risk of recurrent stroke in trials comparing treatment with dual versus single antiplatelets for more than 90 days after TIA or stroke. Heterogeneity I2 = 57.089; q = 9.322, p = 0.054.
Figure 13.
Figure 13.
Forest plot for the risk of haemorrhagic stroke in trials comparing treatment with dual versus single antiplatelets for more than 90 days after TIA or stroke.
Figure 14.
Figure 14.
Forest plot for the risk of any stroke in trials comparing treatment with pioglitazone versus placebo in people with TIA or stroke and diabetes or impaired glucose tolerance. Heterogeneity: I2 = 19.462; Q = 2.483.
See this image and copyright information in PMC

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