Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV

The Joint British Societies’ guidelines (JBS 2) on cardiovascular disease prevention in clinical practice were developed by a Working Party (see table) with nominated representatives from six professional societies. All members contributed to the text and those from the specialist societies of hypertension, lipids, and diabetes were specifically responsible for developing the sections on blood pressure, lipids, and glucose. All sections of the document represent an evidence based consensus by all professional societies involved. The scientific literature which informs the recommendations is referenced throughout the text and Dr Kornelia Kotseva is thanked for all her help in searches for systematic reviews and meta-analyses, and checking the referencing of all sections. We are grateful to both Mr Harry Heyes of the Department of Medical Illustration, University of Manchester, for the cardiovascular risk prediction charts artwork, and Mr Daniel Prais of Crawford’s Business Services, Salford, for the computer programming. Dr Paola Primatesta is thanked for providing prevalence estimates of total CVD risk in the adult population from the Health Survey for England. Mr Tim Collier (Statistician, London School of Hygiene and Tropical Medicine) is also thanked for preparing the figures on lipid trials. Despoina Xenikaki provided the Working Party with invaluable administrative support. This guideline was reviewed and approved by the boards of all the professional societies. 

View this table:

JBS 2 Working Party 



### SUMMARY

The aim of these new Joint British Societies’ guidelines (JBS 2) developed by the British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, and The Stroke Association is to promote a consistent multidisciplinary approach to the management of people with established atherosclerotic cardiovascular disease (CVD) and those at high risk of developing symptomatic atherosclerotic disease.

We recommend that CVD prevention in clinical practice should focus equally on (i) people with established atherosclerotic CVD, (ii) people with …

https://heart.bmj.com/content/heartjnl/91/suppl_5/v1.full.pdf

JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice

Summary Background There is much uncertainty about the effects of early lowering of elevated blood pressure (BP) after acute intracerebral haemorrhage (ICH). Our aim was to assess the safety and efficiency of this treatment, as a run-in phase to a larger trial. Methods Patients who had acute spontaneous ICH diagnosed by CT within 6 h of onset, elevated systolic BP (150–220 mm Hg), and no definite indication or contraindication to treatment were randomly assigned to early intensive lowering of BP (target systolic BP 140 mm Hg; n=203) or standard guideline-based management of BP (target systolic BP 180 mm Hg; n=201). The primary efficacy endpoint was proportional change in haematoma volume at 24 h; secondary efficacy outcomes included other measurements of haematoma volume. Safety and clinical outcomes were assessed for up to 90 days. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00226096. Findings Baseline characteristics of patients were similar between groups, but mean haematoma volumes were smaller in the guideline group (12·7 mL, SD 11·6) than in the intensive group (14·2 mL, SD 14·5). From randomisation to 1 h, mean systolic BP was 153 mm Hg in the intensive group and 167 mm Hg in the guideline group (difference 13·3 mm Hg, 95% CI 8·9–17·6 mm Hg; p Interpretation Early intensive BP-lowering treatment is clinically feasible, well tolerated, and seems to reduce haematoma growth in ICH. A large randomised trial is needed to define the effects on clinical outcomes across a broad range of patients with ICH. Funding National Health and Medical Research Council of Australia.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(08)70069-3.pdf

Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial.

In 334 consecutive admissions for acute stroke, the blood pressure was elevated in 84% on the day of admission. The blood pressure decreased spontaneously an average of 20 mm Hg systolic and 10 mm Hg diastolic in the ten days following the acute event without specific antihypertensive therapy and was elevated in only one third of the cases on the tenth hospital day. The early elevation in blood pressure is likely a physiological response to brain ischemia, and blood pressure falls as recovery of brain function occurs. (JAMA1981;246:2177-2180)

J. D. Wallace

Papers

Blood pressure after stroke.