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Stroke Association Reviewing Stroke Definition, New Anticoagulants

March 29, 2012

The American Stroke Association is developing a host of new guidelines and statements, including a consensus statement on the definition of stroke and a scientific review of new anticoagulants.

The first new guideline – on the Management of Aneurysmal Subarachnoid Hemorrhage (SAH) – is complete and has been submitted for publication, said Dr. Colin Derdeyn, a member of the ASA’s Stroke Scientific Statement Oversight Committee.

Dr. Ralph L. Sacco

Dr. Derdeyn is the program director for endovascular surgical neuroradiology at Washington University in St. Louis.

The SAH paper was authored by 13 clinicians who represent all disciplines involved in subarachnoid hemorrhage care, said Dr. Alejandro Rabinstein, who is vice chair of the group that wrote the guidelines.

There will be some new sections and some revised sections for 2012, said Dr. Rabinstein, a professor of neurology at the Mayo Clinic, Rochester, Minn. Dr. Rabinstein said that it has evolved into a more balanced document.

Also to be completed soon is a paper on the “Early Management of Patients with Ischemic Stroke.” The paper will be very detailed, with more than 1,000 references and 15 authors, Dr. Rabinstein said. The chairman of the writing committee is Dr. Edward Jauch, professor of medicine at the Medical University of South Carolina, Charleston. The vice-chair is Dr. Jeffrey Saver, director of stroke and vascular neurology at the University of California, Los Angeles, Health System.

Two new papers – one reviewing the new anticoagulants on the market, and the other a consensus statement on the definition of stroke – are likely to garner a lot of attention, both as they are developed and when they are completed, Dr. Rabinstein said. “Novel Anticoagulants for the Prevention of Stroke in Atrial Fibrillation” will be completed fairly soon; it will be a science advisory, not a guideline or consensus statement. It will review the evidence on dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban. It will basically attempt to make sense of “the anticoagulant avalanche,” Dr. Rabinstein said. The cochairs are Dr. Karen Furie, director of the stroke service and stroke prevention clinic at Massachusetts General Hospital, Boston, and Dr. Larry Goldstein, director of the Duke Stroke Center in Durham, N.C.

The consensus statement on the updated definition of stroke will be “a little bit more contentious,” Dr. Rabinstein said. The goal is to update the definition of a transient ischemic attack. Among the questions to be addressed are whether an inclusion of the duration of symptoms is appropriate, and whether imaging should be required. The cochairs are Dr. Ralph Sacco, president of the American Heart Association and chairman of neurology at the University of Miami, and Dr. Scott Kasner, director of the comprehensive stroke center at the University of Pennsylvania, Philadelphia.

Another consensus will be issued on “Risk Adjustment for Stroke Outcome Measures.” The goal is to recommend which variables should be included in risk adjustment models to assess the main stroke outcomes – before such benchmarks are imposed from the outside, Dr. Rabinstein said. The measures will be extremely important in both quality of care reporting and reimbursement going forward, he noted at the meeting, which was sponsored by the American Heart Association.

Several additional scientific statements are in development. One, “Stroke as Outcome and Risk Equivalent in Vascular Disease Risk Scores,” will review the evidence supporting the inclusion of stroke in the outcome cluster of a risk equivalent and the designation of stroke itself as a risk equivalent to coronary events.

A statement will be issued next year on declining stroke mortality. Stroke was previously the third-leading cause of death; it is now the fourth, Dr. Rabinstein said. The goal is to determine the factors behind the decline: whether it is due to better prevention and treatment, and if so, to further explain how the decline translated into fewer deaths. Another aim is to figure out how to reproduce such knowledge in the future.

Dr. Robert Holloway, a professor of neurology at the University of Rochester (N.Y.) who is also board certified in palliative medicine, is chairing a group that is developing a statement on “Palliative Care and End of Life.” The statement will review best end-of-life practices and provide recommendations on how to optimize care for patients with terminal cerebrovascular disease.

Finally, the ASA is trying to develop a statement on “Cervical Dissections and Chiropractic Manipulation.” Dr. José Biller, chairman of neurology at Loyola University, Maywood, Ill., will lead the group. Some of the issues to be addressed include determining the risk of cervical arterial dissection in patients undergoing neck manipulations and how to avoid complications. So far, chiropractic organizations have declined to be a part of the statement process, Dr. Rabinstein said.





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