Allergy chest x ray

2023-06-07T13:40:08Z

Laith Adnan Allaham:

2023-06-07T13:23:13Z

Laith Adnan Allaham:

2023-02-02T01:25:06Z

Laith Adnan Allaham:

ST elevation myocardial infarction pathophysiology

2023-01-25T21:17:22Z

Laith Adnan Allaham:

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__NOTOC__
{{ST elevation myocardial infarction}}
{{CMG}}; {{AE}} {{CZ}}

==Overview==
ST elevation myocardial infarction is largely influenced by the role of plaque rupture.

==The Role of Plaque Rupture in ST Elevation Myocardial Infarction==
[[Atherosclerosis]], or hardening of the [[arteries]], is the gradual buildup of [[cholesterol]] and [[fibrous tissue]] ([[collagen]] and [[smooth muscle cells]]) throughout the [[vascular]] tree. When there is localized accumulation of [[lipids]] and [[scar tissue]], this is called a "plaque". Somewhat paradoxically, it is not the most severe plaque narrowing that leads to ST elevation MI. [[Pathological]] studies indicate that it is often mild-to-moderate, [[lipid]]-laden, inflamed plaques that are the ones most likely to rupture and cause an ST elevation MI ([[STEMI]]) or a non ST elevation MI ([[NSTEMI]]). <ref name="pmid7634481">{{cite journal |author=Falk E, Shah PK, Fuster V |title=Coronary plaque disruption |journal=Circulation |volume=92 |issue=3 |pages=657–71 |year=1995 |month=August |pmid=7634481 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7634481}}</ref> The role of plaque rupture in STEMI and NSTEMI is supported by studies demonstrating that plaque rupture is present in about 70% and superficial erosion is present in 30% of patients who die suddenly in whom there is documented [[coronary artery disease]]. <ref name="pmid9113930">{{cite journal |author=Burke AP, Farb A, Malcom GT, Liang YH, Smialek J, Virmani R |title=Coronary risk factors and plaque morphology in men with coronary disease who died suddenly |journal=N. Engl. J. Med. |volume=336 |issue=18 |pages=1276–82 |year=1997 |month=May |pmid=9113930 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=9113930&promo=ONFLNS19}}</ref> Exposure of the [[blood stream]] to the [[Thrombogenicity|thrombogenic]] components of the plaque leads to activation of the [[coagulation cascade]] and [[thrombus]] formation. In STEMI, the [[clot]] completely occludes the epicardial artery, and there is a complete lack of blood flow to the involved territory. This causes transmural injury and ST elevation. In NSTEMI, there is partial obstruction with [[embolus|embolization]]. This causes [[ischemia]] and [[subendocardial]] injury that are manifested by [[ST depression]].

[[Image:Plaque rupture.jpg|frame|none|500px|Shown here are multiple slices of the LAD. The proximal LAD is located to the left. Plaque rupture with thrombus formation begins in the second slice of the LAD.]]

[[Image:Plaque rupture2 copy.jpg|frame|none|500px|Shown here is a magnified view of the second slice from the left. In yellow is atherosclerotic plaque, in red is clot that has formed inside the ruptured plaque and in the lumen of the coronary artery.]]

==Pathophysiology of and Risk Factors for Plaque Rupture==
#[[Macrophage]] accumulation has been shown to be present to a greater degree in patients with [[acute coronary syndromes]] than in those patients with [[chronic stable angina]] <ref name="pmid8044947">{{cite journal |author=Moreno PR, Falk E, Palacios IF, Newell JB, Fuster V, Fallon JT |title=Macrophage infiltration in acute coronary syndromes. Implications for plaque rupture |journal=Circulation |volume=90 |issue=2 |pages=775–8 |year=1994 |month=August |pmid=8044947 |doi= |url=}}</ref> <ref name="pmid8281670">{{cite journal |author=van der Wal AC, Becker AE, van der Loos CM, Das PK |title=Site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the dominant plaque morphology |journal=Circulation |volume=89 |issue=1 |pages=36–44 |year=1994 |month=January |pmid=8281670 |doi= |url=}}</ref> These activated [[macrophages]] can release enzymes such as [[metalloproteinases]], [[collagenase|interstitial collagenase]], [[gelatinase]], and stromelysin that degrade [[collagen]], [[elastin]], and [[proteoglycan|proteoglycans]]. <ref name="pmid7664441">{{cite journal |author=Shah PK, Falk E, Badimon JJ, ''et al'' |title=Human monocyte-derived macrophages induce collagen breakdown in fibrous caps of atherosclerotic plaques. Potential role of matrix-degrading metalloproteinases and implications for plaque rupture |journal=Circulation |volume=92 |issue=6 |pages=1565–9 |year=1995 |month=September |pmid=7664441 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7664441}}</ref> This [[enzymatic]] degradation in turn leads to breakdown of the [[fibrous]] cap. The thin shoulders or edges of the [[fibrous]] cap appear to be particularly vulnerable to erosion and breakdown.
#[[Neovascularization]] of the plaque Moreno et have shown that microvessel density was increased in ruptured plaques when compared with nonruptured plaques (P=0.0001). Furthermore, among lesions with severe [[macrophage]] infiltration at the fibrous cap, [[microvessel]] density was increased (P=0.0001) was well as at the edges or shoulders of the plaque (P=0.0001). [[hemorrhage|Intraplaque hemorrhage]] was also associated with an increase in [[microvessel]] density (P=0.04) as was the presence of thin-cap fibroatheromas (P=0.038). [[Microvessel]] density at the base of the plaque was identified as an independent (P=0.003) correlate of plaque rupture. <ref name="pmid15451780">{{cite journal |author=Moreno PR, Purushothaman KR, Fuster V, ''et al'' |title=Plaque neovascularization is increased in ruptured atherosclerotic lesions of human aorta: implications for plaque vulnerability |journal=Circulation |volume=110 |issue=14 |pages=2032–8 |year=2004 |month=October |pmid=15451780 |doi=10.1161/01.CIR.0000143233.87854.23 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15451780}}</ref>
# High oscillatory shear stress
# [[Vasoconstriction]]
# [[Spontaneous coronary dissection]]

==Pathophysiology of and Risk Factors for Thrombosis Following Plaque Rupture==
There are numerous systemic risk factors associated with thrombus formation following plaque rupture:

#[[Smoking]]: Smoking increases [[platelet aggregation]] and [[plasma]] [[epinephrine]] levels <ref name="pmid7586342">{{cite journal |author=Hung J, Lam JY, Lacoste L, Letchacovski G |title=Cigarette smoking acutely increases platelet thrombus formation in patients with coronary artery disease taking aspirin |journal=Circulation |volume=92 |issue=9 |pages=2432–6 |year=1995 |month=November |pmid=7586342 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7586342}}</ref>
#[[Fibrinogen]]: Elevated levels of [[fibrinogen]] have been associated with [[thrombosis]] including abnormal levels of [[fibrinogen]] <ref name="pmid7845427">{{cite journal |author=Thompson SG, Kienast J, Pyke SD, Haverkate F, van de Loo JC |title=Hemostatic factors and the risk of myocardial infarction or sudden death in patients with angina pectoris. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group |journal=N. Engl. J. Med. |volume=332 |issue=10 |pages=635–41 |year=1995 |month=March |pmid=7845427 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=7845427&promo=ONFLNS19}}</ref>
#[[Von Willebrand factor]] antigen <ref name="pmid7845427">{{cite journal |author=Thompson SG, Kienast J, Pyke SD, Haverkate F, van de Loo JC |title=Hemostatic factors and the risk of myocardial infarction or sudden death in patients with angina pectoris. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group |journal=N. Engl. J. Med. |volume=332 |issue=10 |pages=635–41 |year=1995 |month=March |pmid=7845427 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=7845427&promo=ONFLNS19}}</ref>
#[[Tissue plasminogen activator]] <ref name="pmid7845427">{{cite journal |author=Thompson SG, Kienast J, Pyke SD, Haverkate F, van de Loo JC |title=Hemostatic factors and the risk of myocardial infarction or sudden death in patients with angina pectoris. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group |journal=N. Engl. J. Med. |volume=332 |issue=10 |pages=635–41 |year=1995 |month=March |pmid=7845427 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=7845427&promo=ONFLNS19}}</ref>
#[[Anticardiolipin antibodies]] <ref name="pmid7805207">{{cite journal |author=Vaarala O, Mänttäri M, Manninen V, ''et al'' |title=Anti-cardiolipin antibodies and risk of myocardial infarction in a prospective cohort of middle-aged men |journal=Circulation |volume=91 |issue=1 |pages=23–7 |year=1995 |month=January |pmid=7805207 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7805207}}</ref>
# Cross-linked [[fibrin-degradation products]] <ref name="pmid7955179">{{cite journal |author=Ridker PM, Hennekens CH, Cerskus A, Stampfer MJ |title=Plasma concentration of cross-linked fibrin degradation product (D-dimer) and the risk of future myocardial infarction among apparently healthy men |journal=Circulation |volume=90 |issue=5 |pages=2236–40 |year=1994 |month=November |pmid=7955179 |doi= |url=}}</ref>
# [[Polymorphisms]] of a [[platelet]] [[glycoprotein]] receptor <ref name="pmid8598867">{{cite journal |author=Weiss EJ, Bray PF, Tayback M, ''et al'' |title=A polymorphism of a platelet glycoprotein receptor as an inherited risk factor for coronary thrombosis |journal=N. Engl. J. Med. |volume=334 |issue=17 |pages=1090–4 |year=1996 |month=April |pmid=8598867 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=8598867&promo=ONFLNS19}}</ref>

==Gross Pathology Findings in Plaque Rupture==

[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 6.jpg|Left anterior descending coronary artery: Atherosclerosis Plaque Ruptured with Thrombosis: Gross; natural color; four cross sections, close-up view (acute anterior myocardial infarction with rupture)
Image:Plaque rupture 7.jpg|Coronary artery: Atherosclerotic Plaque: Gross natural color close-up view of a typical plaque
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 8.jpg|Coronary Atherosclerosis: Gross, natural color, close-up view of large atherosclerotic plaque with soft atheroma (a quite good example in 54yo male. Smoker with hypertension). This slide shows the left main artery
Image:Plaque rupture 9.jpg|Coronary artery: Atherosclerotic Plaque: Gross, natural color, close-up view of plaque with atheroma core causing more than 90% lumen occlusion (an excellent example)
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 10.jpg|Coronary artery: Atherosclerotic Plaque with Hemorrhage and Thrombosis: Gross, natural color, cross section, close-up, an excellent example of right coronary artery in 71yo female.
Image:Plaque rupture 11.jpg|Coronary artery: Atherosclerotic Plaque with Hemorrhage and Thrombosis: Gross, natural color, cross sections; there is excellent example of hemorrhagic plaque and thrombus at and just below the origin of first diagonal artery. Another one (a more acute one) was in the right coronary artery.
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 12.jpg|Coronary artery: Atherosclerotic Plaque with Thrombus: Gross natural color, close-up of cross section.
Image:Plaque rupture 13.jpg|Coronary artery: Atherosclerotic Plaque with Hemorrhage: Gross fixed tissue, cross sections. LAD and 1st diagonal with large plaques and several apparent areas of hemorrhage.
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 14.jpg|Coronary artery: Atherosclerosis: Gross, an excellent close-up atherosclerosis with hemorrhage into plaque.
Image:Plaque rupture 15.jpg|Coronary artery: Atherosclerosis: Gross, cross sections coronary artery with hemorrhage into plaque (image shows full length of the artery).
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 16.jpg|Coronary artery: Atherosclerosis: Gross, cross sections of artery showing plaques (an excellent example)
Image:Plaque rupture 17.jpg|Coronary artery: Atherosclerosis: Gross natural color in situ cross section with large fibrocalcific plaque with hemorrhage (an excellent example)
</gallery>
</div>

===Plaque Rupture Histopathological Findings===

[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 1.jpg|Coronary artery: Atherosclerosis: Micro H&E med mag; A good example of plaque rupture with thrombosis.
Image:Plaque rupture 2.jpg|Right coronary artery: Ruptured Plaque: Micro low mag H&E; Ruptured plaque with foam cell lesion (near rupture site).
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 3.jpg|Right coronary artery: Atherosclerosis Plaque Ruptured with Thrombus: Micro low mag H&E; an excellent view of ruptured plaque with thrombus and some old fibrin in it.
Image:Plaque rupture 4.jpg|Right coronary artery: Atherosclerosis Plaque Ruptured with Thrombus: Micro low mag trichrome.
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque rupture 5.jpg|Right coronary artery: Atherosclerosis Plaque Ruptured: Micro low mag H&E; large plaque with hemorrhage; (an excellent example of hemorrhage).
Image:Plaque 1.jpg|Coronary artery: Atherosclerosis: Micro H&E low mag injected artery fairly typical uncomplicated atheromatous plaque
</gallery>
</div>

<div align="left">
<gallery heights="175" widths="175">
Image:Plaque 2.jpg|Coronary artery: Atherosclerosis: Micro H&E low mag, injected artery has typical fibrous plaque with small hemorrhage in atheroma.
Image:Plaque 3.jpg|Coronary artery: Atherosclerosis: Micro H&E low mag, injected artery is a very good example of marked lumen stenosis due to typical fibrous plaque with calcification
</gallery>
</div>

==The Consequence of Plaque Rupture and Vessel Occlusion: The Time Dependent Wavefront of Necrosis==

[[Image:Slow-wavefront.gif|left|Time dependent wavefront of necrosis working its way from the subendocardium to the subepicardium]]
In 1940, Blumgart ligated or tied off the coronary artery in dogs and cats and for the first time demonstrated a wavefront of cell death folllowing [[Blood vessel|vessel]] occlusion <ref>Blumgart HL, Schlesinge MJ, Davis D: Studies on the relation of the clinical manifestations of angina pectoris, coronary thrombosis, and myocardial infarction to the pathologic findings, with particular reference to the significance of collateral circulation. Amer Heart J 19: 1, 1940 </ref> <ref>Blumgart HL, Zoll PM, Freedberg AS, Gilligan DR: The experimental production of intercoronary arterial anastomoses and their functional significance. Circulation 1: 10, 1950 PMID 15401193 </ref> <ref>Blumgart HL, Zoll PM, Kurland CS: Discussion of direct relief of coronary occlusion. Arch Intern Med (Chicago) 104: 862, 1959 PMID 13801751 </ref> <ref>Blumgart HL, Zoll PM. Pathologic physiology of angina pectoris and acute myocardial infarction. Circulation. 1960 Aug;22:301-7. PMID 13801752 </ref>
<ref>Blumgart HL, Zoll PM, Clinical Pathologic Correlations in Coronary Artery Disease, Circulation, Volume XLVII, No 6, June 1973, 1139-43 PMID 4575525 </ref>

Irreversible injury of ischemic myocytes occurs first in the subendocardial zone. With more extended [[ischemia]], a wavefront of cell death moves through the myocardium to involve progressively more of the transmural thickness of the ischemic zone. The precise location, size, and specific morphologic features of an [[acute myocardial infarction]] depend on:

#The location, severity, and rate of development of coronary atherosclerotic obstructions,
#The size of the vascular bed perfused by the obstructed vessels
#The duration of the coronary artery occlusion
#The metabolic / oxygen needs of the myocardium at risk,
#The extent of collateral blood vessels

Decrease of ATP levels in myocytes in reaction to ischemia starts within seconds and causes loss of [[contractility]] in first two minutes. If [[ischemia]] persists, [[Adenosine triphosphate|ATP]] levels reduced to its half level within 10 minutes and to 1/10 within 40 minutes. Irreversible cell injury occurs between 20-40 minutes and [[Microvascular bed|microvascular]] level injury starts if [[ischemia]] lasts more than an hour.<ref>Robbins Pathologic Basis of Disease, Kumar V, 7th ed</ref>

If impaired [[blood]] flow to the heart lasts long enough, it triggers a process called the [[ischemic cascade]]; the [[Myocardium|heart cells]] die (chiefly through [[necrosis]]) and do not grow back. A [[collagen]] [[scar]] forms in its place. Recent studies indicate that another form of cell death called [[apoptosis]] also plays a role in the process of [[Tissue (biology)|tissue]] damage subsequent to myocardial infarction.<ref name="Krijnen-2002">{{cite journal | author=Krijnen PA, Nijmeijer R, Meijer CJ, Visser CA, Hack CE, Niessen HW. | title=Apoptosis in myocardial ischaemia and infarction. | journal=J Clin Pathol | year=2002 | volume=55 | issue=11 | pages=801-11 | id=PMID 12401816}}</ref> As a result, the patient's heart can be permanently damaged. This [[scar tissue]] also puts the patient at risk for potentially life threatening [[arrhythmias]].

==Pathophysiology of ST segment elevation on the electrocardiogram==
In ST segment myocaridal infarction (STEMI), the [[ST segments]] on the [[The electrocardiogram|ECG]] are by definition elevated and there is [[myonecrosis]] (death of [[myocytes]]) as reflected by elevation of [[Cardiac biomarkers|biomarkers]] such as [[creatine kinase]] MB fraction ([[CK-MB]]) or [[troponin]] T or I (tn). The [[ST segments]] are elevated due to full thickness injury of the [[myocardium]].

==Videos of STEMI pathophysiology==
The following are excellent videos demonstrating the underlying pathophysiology.
{{#ev:youtube|L6EiPLli5x8}}
{{#ev:youtube|cOMzh2hf_Vw}}
{{#ev:youtube|a8Idk4EUYTs}}

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}

* Reimer KA, Jennings RB. The "wavefront phenomenon" of myocardial ischemic cell death. II. Transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. Lab Invest. 1979 Jun 40(6): 633-44. PMID 449273
* Hasche ET, Fernandes C, Freedman SB, Jeremy RW. Relation between ischemia time, infarct size, and left ventricular function in humans. Circulation. 1995 Aug 15; 92(4): 710-9. PMID 7641348
* Gibson CM, Kirtane AJ, Morrow DA, Palabrica TM, Murphy SA, Stone PH, Scirica BM, Jennings LK, Herrmann HC, Cohen DJ, McCabe CH, Braunwald E; TIMI Study Group. Association between thrombolysis in myocardial infarction myocardial perfusion grade, biomarkers, and clinical outcomes among patients with moderate- to high-risk acute coronary syndromes: observations from the randomized trial to evaluate the relative PROTECTion against post-PCI microvascular dysfunction and post-PCI ischemia among antiplatelet and antithrombotic agents-Thrombolysis In Myocardial Infarction 30 (PROTECT-TIMI 30). Am Heart J. 2006 Oct; 152 (4): 756-61. PMID 16996854
* Christian TF, Schwartz RS, Gibbons RJ. Determinants of infarct size in reperfusion therapy for acute myocardial infarction. Circulation. 1992 Jul; 86(1): 81-90. PMID 1617793
* Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E; TIMI Study Group. Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation 2002 Apr 23; 105 (16): 1909-13. PMID 11997276
* Kandzari DE, Tcheng JE, Gersh BJ, Cox DA, Stuckey T, Turco M, Mehran R, Garcia E, Zimetbaum P, McGlaughlin MG, Lansky AJ, Costantini CO, Grines CL, Stone GW; CADILLAC Investigators. Relationship between infarct artery location, epicardial flow, and myocardial perfusion after primary percutaneous revascularization in acute myocardial infarction. Am Heart J. 2006 Jun; 151(6): 1288-95. PMID 16781238
* Elsman P, van 't Hof AW, de Boer MJ, Hoorntje JC, Suryapranata H, Dambrink JH, Zijlstra F; Zwolle Myocardial Infarction Study Group. Role of collateral circulation in the acute phase of ST-segment-elevation myocardial infarction treated with primary coronary intervention. Eur Heart J. 2004 May; 25(10): 854-8. PMID 15140533
* Ortiz-Pérez JT, Meyers SN, Lee DC, Kansal P, Klocke FJ, Holly TA, Davidson CJ, Bonow RO, Wu E. Angiographic estimates of myocardium at risk during acute myocardial infarction: validation study using cardiac magnetic resonance imaging. Eur Heart J. 2007 Jul;28(14):1670-2. Epub 2007 Jun 22 PMID 17586811
* Maehara A, Mintz GS, Bui AB, Walter OR, Castagna MT, Canos D, Pichard AD, Satler LF, Waksman R, Suddath WO, Laird JR Jr, Kent KM, Weissman NJ. Morphologic and angiographic features of coronary plaque rupture detected by intravascular ultrasound. J Am Coll Cardiol. 2002 Sep 4;40 (5): 904-10. PMID 12225714
* Gibson CM, Murphy SA, Kirtane AJ, Giugliano RP, Cannon CP, Antman EM, Braunwald E; TIMI Study Group. Association of duration of symptoms at presentation with angiographic and clinical outcomes after fibrinolytic therapy in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2004 Sep 1; 44 (5): 980-7. PMID 15337207
* D. Garcia-Dorado, P. Theroux, M. Desco, J. Solares, J. Elizaga, F. Fernandez-Aviles, J. Alonso and J. Soriano, Cell-to-cell interaction: a mechanism to explain wave-front progression of myocardial necrosis. Am J Physiol Heart Circ Physiol 256: H1266-H1273, 1989; 0363-6135/89 $5.00 PMID 2719127
* Sorajja P, Gersh BJ, Cox DA, McLaughlin MG, Zimetbaum P, Costantini C, Stuckey T, Tcheng JE, Mehran R, Lansky AJ, Grines CL, Stone GW. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J. 2007 Jul; 28(14): 1709-16. Epub 2007 Jun 7. PMID 17556348
* Brener S. Insights into the pathophysiology of ST-elevation myocardial infarction. American Heart Journal, Volume 151, Issue 6, Pages S4 - S10, 2006 PMID 16777509
* Biasucci LM, Leo M, De Maria GL. Local and Systemic Mechanisms of Plaque Rupture. Angiology. 2008 Jun 10. [Epub ahead of print] PMID 1854458
* El-Menyar AA. Cytokines and coronary artery disease: the state of the art. Crit Pathw Cardiol. 2008 Jun; 7(2): 139-51. PMID 18520532
* Kaneda H. Coronary plaque rupture and vessel remodeling. Am J Cardiol 2008 May 15; 101 (10): 1519; PMID 18471472
* Sorajja P, Gersh BJ, Mehran R, Lansky AJ, Krucoff MW, Webb J, Cox DA, Brodie BR, Stone GW. Impact of collateral flow on myocardial reperfusion and infarct size in patients undergoing primary angioplasty for acute myocardial infarction. Am Heart J. 2007 Aug;154(2):379-84. PMID 17643592
* Kitabata H, Kubo T, Akasaka T.Identification of multiple plaque ruptures by optical coherence tomography in a patient with acute myocardial infarction: a three-vessel study. Heart 2008; 94: 544; doi:10.1136/hrt.2007.124339 PMID 18411345
* Hong MK, Mintz GS, Lee CW, Park KM, Lee BK, Kim YH, Kang DH, Cheong SS, Song JK, Kim JJ, Park SW, Park SJ. Plaque ruptures in stable angina pectoris compared with acute coronary syndrome. Int J Cardiol. 2007 Jan 2; 114(1): 78-82. Epub 2006 May 18. PMID 1671298
* Kubo T, Imanishi T, Takarada S, Kuroi A, Ueno S, Yamano T, Tanimoto T, Matsuo Y, Masho T, Kitabata H, Tsuda K, Tomobuchi Y, Akasaka T. Assessment of culprit lesion morphology in acute myocardial infarction: ability of optical coherence tomography compared with intravascular ultrasound and coronary angioscopy. J Am Coll Cardiol. 2007 Sep 4;50(10):933-9. Epub 2007 Aug 20. PMID 17765119
* Rioufol G, Finet G, Ginon I, André-Fouët X, Rossi R, Vialle E, Desjoyaux E, Convert G, Huret JF, Tabib A. Multiple atherosclerotic plaque rupture in acute coronary syndrome: a three-vessel intravascular ultrasound study. Circulation. 2002 Aug 13; 106(7): 804-8. PMID 12176951
* Hong MK, Mintz GS, Lee CW, Lee BK, Yang TH, Kim YH, Song JM, Han KH, Kang DH, Cheong SS, Song JK, Kim JJ, Park SW, Park SJ. The site of plaque rupture in native coronary arteries: a three-vessel intravascular ultrasound analysis. J Am Coll Cardiol. 2005 Jul 19; 46 (2): 261-5. PMID 16022952
* Kusama I, Hibi K, Kosuge M, Nozawa N, Ozaki H, Yano H, Sumita S, Tsukahara K, Okuda J, Ebina T, Umemura S, Kimura K. Impact of plaque rupture on infarct size in ST-segment elevation anterior acute myocardial infarction. J Am Coll Cardiol. 2007 Sep 25;50(13):1230-7. Epub 2007 Sep 10. PMID 17888839
* Tanaka N, Ehara M, Surmely JF, Matsubara T, Terashima M, Tsuchikane E, Katoh O, Suzuki T. Images in cardiovascular medicine. Sixty-four-multislice computed tomography image of a ruptured coronary plaque. Circulation. 2006 Oct 3; 114 (14): e519-20. PMID 17015797
* Fujii K, Mintz GS, Carlier SG, Costa JR Jr, Kimura M, Sano K, Tanaka K, Costa RA, Lui J, Stone GW, Moses JW, Leon MB. Intravascular ultrasound profile analysis of ruptured coronary plaques. Am J Cardiol. 2006 Aug 15;98(4):429-35. Epub 2006 Jun 19. PMID 16893692
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* Appelbaum E, Kirtane AJ, Clark A, Pride YB, Gelfand EV, Harrigan CJ, Kissinger KV, Manning WJ, Gibson CM. Association of TIMI Myocardial Perfusion Grade and ST-segment resolution with cardiovascular magnetic resonance measures of microvascular obstruction and infarct size following ST-segment elevation myocardial infarction. J Thromb Thrombolysis. 2008 Feb 2. [Epub ahead of print] PMID 18246410
* Leshnower BG, Sakamoto H, Hamamoto H, Zeeshan A, Gorman JH 3rd, Gorman RC. Progression of myocardial injury during coronary occlusion in the collateral-deficient heart: a non-wavefront phenomenon. Am J Physiol Heart Circ Physiol. 2007 Sep;293(3):H1799-804. Epub 2007 Jul 20. PMID 17644569
{{refend}}
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Ischemic stroke medical therapy

2023-01-19T16:12:52Z

Laith Adnan Allaham:

__NOTOC__
{{Ischemic stroke}}
{{CMG}}{{AE}}{{AA}}

==Overview==
The medical therapy of [[ischemic stroke]] is mainly directed to fibrinolysis of clot by r-tPA with in 3 to 4.5 hours of symptom onset. Acute treatment with antiplatelets may have a role if given within 24-48 hours of stroke onset. Long term management with statins, antiplatelets, anticoagulants, antihypertensive and antidiabetic agents may help prevent the recurrence.<ref>{{cite journal |author=Hackam DG, Spence JD |title=Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study |journal=Stroke |volume=38 |issue=6 |pages=1881–5 |year=2007 |pmid=17431209 |doi=10.1161/STROKEAHA.106.475525}}</ref>
Acute treatment to control blood pressure, blood glucose and fever may help prevent the complications and have a prognostic significance.

==Medical Therapy==

*The reported cases of treatment for [[COVID-19]]-associated [[stroke]] have followed the same guidelines as patients with no [[COVID-19]] infection. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
*[[Alteplase|IV alteplase]] is always preferred over mechanical [[thrombectomy]] when there are no contraindications.<ref name="SaverGoyal2016">{{cite journal|last1=Saver|first1=Jeffrey L.|last2=Goyal|first2=Mayank|last3=van der Lugt|first3=Aad|last4=Menon|first4=Bijoy K.|last5=Majoie|first5=Charles B. L. M.|last6=Dippel|first6=Diederik W.|last7=Campbell|first7=Bruce C.|last8=Nogueira|first8=Raul G.|last9=Demchuk|first9=Andrew M.|last10=Tomasello|first10=Alejandro|last11=Cardona|first11=Pere|last12=Devlin|first12=Thomas G.|last13=Frei|first13=Donald F.|last14=du Mesnil de Rochemont|first14=Richard|last15=Berkhemer|first15=Olvert A.|last16=Jovin|first16=Tudor G.|last17=Siddiqui|first17=Adnan H.|last18=van Zwam|first18=Wim H.|last19=Davis|first19=Stephen M.|last20=Castaño|first20=Carlos|last21=Sapkota|first21=Biggya L.|last22=Fransen|first22=Puck S.|last23=Molina|first23=Carlos|last24=van Oostenbrugge|first24=Robert J.|last25=Chamorro|first25=Ángel|last26=Lingsma|first26=Hester|last27=Silver|first27=Frank L.|last28=Donnan|first28=Geoffrey A.|last29=Shuaib|first29=Ashfaq|last30=Brown|first30=Scott|last31=Stouch|first31=Bruce|last32=Mitchell|first32=Peter J.|last33=Davalos|first33=Antoni|last34=Roos|first34=Yvo B. W. E. M.|last35=Hill|first35=Michael D.|title=Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis|journal=JAMA|volume=316|issue=12|year=2016|pages=1279|issn=0098-7484|doi=10.1001/jama.2016.13647}}</ref>
*The usefulness of [[anticoagulants]] such as [[thrombin]] inhibitors ([[dabigatran]]) and [[factor Xa]] inhibitors ([[rivaroxaban]], [[apixaban]], [[edoxaban]]) is not well established in the acute setting of [[stroke]].<ref name="GioiaKate2016">{{cite journal|last1=Gioia|first1=Laura C.|last2=Kate|first2=Mahesh|last3=Sivakumar|first3=Leka|last4=Hussain|first4=Dulara|last5=Kalashyan|first5=Hayrapet|last6=Buck|first6=Brian|last7=Bussiere|first7=Miguel|last8=Jeerakathil|first8=Thomas|last9=Shuaib|first9=Ashfaq|last10=Emery|first10=Derek|last11=Butcher|first11=Ken|title=Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation|journal=Stroke|volume=47|issue=7|year=2016|pages=1917–1919|issn=0039-2499|doi=10.1161/STROKEAHA.116.013491}}</ref>
*The use of [[thrombolysis]] via ultrasound waves concomitant to [[Fibrinolysis|IV fibrinolysis]] is not recommended.<ref name="NacuKvistad2017">{{cite journal|last1=Nacu|first1=Aliona|last2=Kvistad|first2=Christopher E.|last3=Naess|first3=Halvor|last4=Øygarden|first4=Halvor|last5=Logallo|first5=Nicola|last6=Assmus|first6=Jörg|last7=Waje-Andreassen|first7=Ulrike|last8=Kurz|first8=Kathinka D.|last9=Neckelmann|first9=Gesche|last10=Thomassen|first10=Lars|title=NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)|journal=Stroke|volume=48|issue=2|year=2017|pages=335–341|issn=0039-2499|doi=10.1161/STROKEAHA.116.014644}}</ref>
*High-intensity [[statin]] therapy should be initiated in patients younger than 75 with clinical [[Coronary heart disease|ASCVD]], to achieving a reduction in [[LDL-C]] levels of at least 50%.
*In patients older than 75 years of age with clinical [[Coronary heart disease|ASCVD]], it is reasonable to initiate moderate or high-intensity [[statin]] therapy after reviewing [[adverse effects]] and [[Drug interaction|drug interactions]].<ref name="PowersRabinstein2019">{{cite journal|last1=Powers|first1=William J.|last2=Rabinstein|first2=Alejandro A.|last3=Ackerson|first3=Teri|last4=Adeoye|first4=Opeolu M.|last5=Bambakidis|first5=Nicholas C.|last6=Becker|first6=Kyra|last7=Biller|first7=José|last8=Brown|first8=Michael|last9=Demaerschalk|first9=Bart M.|last10=Hoh|first10=Brian|last11=Jauch|first11=Edward C.|last12=Kidwell|first12=Chelsea S.|last13=Leslie-Mazwi|first13=Thabele M.|last14=Ovbiagele|first14=Bruce|last15=Scott|first15=Phillip A.|last16=Sheth|first16=Kevin N.|last17=Southerland|first17=Andrew M.|last18=Summers|first18=Deborah V.|last19=Tirschwell|first19=David L.|title=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|journal=Stroke|volume=50|issue=12|year=2019|issn=0039-2499|doi=10.1161/STR.0000000000000211}}</ref><ref name="SanossianSaver2006">{{cite journal|last1=Sanossian|first1=Nerses|last2=Saver|first2=Jeffrey L.|last3=Liebeskind|first3=David S.|last4=Kim|first4=Doojin|last5=Razinia|first5=Tannaz|last6=Ovbiagele|first6=Bruce|title=Achieving Target Cholesterol Goals After Stroke|journal=Archives of Neurology|volume=63|issue=8|year=2006|pages=1081|issn=0003-9942|doi=10.1001/archneur.63.8.1081}}</ref>
*Risk and beneffits should be discussed before initiation of statin therapy to weight [[Coronary heart disease|ASCVD]] risk reduction against the potential for statin-associated side effects.<ref name="PowersRabinstein2019" />
*Continuation of statin therapy during the acute period of [[ischemic stroke]] is reasonable among patients already taking [[Statins (patient information)|statins]].

====Alteplase====

*[[Alteplase|IV alteplase]] is recommended for selected patients who can be treated within 3-4.5 hours of [[ischemic stroke]] [[symptom]] [[onset]] or patient last known well or at [[Baseline (medicine)|baseline]] state.<ref name="LeesEmberson2016">{{cite journal|last1=Lees|first1=Kennedy R.|last2=Emberson|first2=Jonathan|last3=Blackwell|first3=Lisa|last4=Bluhmki|first4=Erich|last5=Davis|first5=Stephen M.|last6=Donnan|first6=Geoffrey A.|last7=Grotta|first7=James C.|last8=Kaste|first8=Markku|last9=von Kummer|first9=Rüdiger|last10=Lansberg|first10=Maarten G.|last11=Lindley|first11=Richard I.|last12=Lyden|first12=Patrick|last13=Murray|first13=Gordon D.|last14=Sandercock|first14=Peter A.G.|last15=Toni|first15=Danilo|last16=Toyoda|first16=Kazunori|last17=Wardlaw|first17=Joanna M.|last18=Whiteley|first18=William N.|last19=Baigent|first19=Colin|last20=Hacke|first20=Werner|last21=Howard|first21=George|last22=Marler|first22=John|last23=Halls|first23=Heather|last24=Holland|first24=Lisa|last25=Mathews|first25=Clare|last26=Smith|first26=Samantha|last27=Wilson|first27=Kate|last28=Koga|first28=Masatoshi|last29=Albers|first29=Gregory|last30=Brott|first30=Thomas|last31=Cohen|first31=Geoffrey|last32=Koga|first32=Masatoshi|last33=Olivot|first33=Jean Marc|last34=Parsons|first34=Mark|last35=Tilley|first35=Barbara|last36=Wahlgren|first36=Nils|last37=del Zoppo|first37=Gregory J|title=Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes|journal=Stroke|volume=47|issue=9|year=2016|pages=2373–2379|issn=0039-2499|doi=10.1161/STROKEAHA.116.013644}}</ref><ref name="PowersRabinstein2019" /><ref>{{cite journal|title=The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial|journal=The Lancet|volume=379|issue=9834|year=2012|pages=2352–2363|issn=01406736|doi=10.1016/S0140-6736(12)60768-5}}</ref>
*The [[dose]] of [[Alteplase|IV alteplase]] is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the [[dose]] given as a [[bolus]] over 1 min.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.<ref name="PowersRabinstein2019" />
*[[Hyperglycemia]] should be treated during the first 24 hours after [[ischemic stroke]], to achieve values of 140 to 180 mg/dL.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] may cause bleeding and [[angioedema]].<ref name="PowersRabinstein2019" />
*[[Glycoprotein IIb/IIIa inhibitors]] ([[Tirofiban detailed information|tirofiban]], [[apiximab]], [[eptifibatide]]) should not be coadministered with [[Alteplase|IV alteplase]].<ref name="PowersRabinstein2019" /><ref name="AdeoyeSucharew2015">{{cite journal|last1=Adeoye|first1=Opeolu|last2=Sucharew|first2=Heidi|last3=Khoury|first3=Jane|last4=Tomsick|first4=Thomas|last5=Khatri|first5=Pooja|last6=Palesch|first6=Yuko|last7=Schmit|first7=Pamela A.|last8=Pancioli|first8=Arthur M.|last9=Broderick|first9=Joseph P.|title=Recombinant Tissue-Type Plasminogen Activator Plus Eptifibatide Versus Recombinant Tissue-Type Plasminogen Activator Alone in Acute Ischemic Stroke|journal=Stroke|volume=46|issue=2|year=2015|pages=461–464|issn=0039-2499|doi=10.1161/STROKEAHA.114.006743}}</ref>
*[[Alteplase|IV alteplase]] may be used in patients under warfarin if the [[INR]] is lower than 1.7.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] should not be administered to patients who have received a full dose of [[low-molecular-weight heparin]] within the previous 24 hours (including [[Prophylaxis|prophylactic]] doses).<ref name="PowersRabinstein2019" /><ref name="PowersDerdeyn2015">{{cite journal|last1=Powers|first1=William J.|last2=Derdeyn|first2=Colin P.|last3=Biller|first3=José|last4=Coffey|first4=Christopher S.|last5=Hoh|first5=Brian L.|last6=Jauch|first6=Edward C.|last7=Johnston|first7=Karen C.|last8=Johnston|first8=S. Claiborne|last9=Khalessi|first9=Alexander A.|last10=Kidwell|first10=Chelsea S.|last11=Meschia|first11=James F.|last12=Ovbiagele|first12=Bruce|last13=Yavagal|first13=Dileep R.|title=2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment|journal=Stroke|volume=46|issue=10|year=2015|pages=3020–3035|issn=0039-2499|doi=10.1161/STR.0000000000000074}}</ref>
*[[Blood pressure]] should be sustained lower than 180/105 mmHg the first 24 hours after [[Alteplase|IV alteplase]] administration. 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Truong|last634=Cam|first634=L. Dam Thi|last635=Kim|first635=T. Ngo Thi|last636=Nguyen|first636=B. Pham|last637=Dat|first637=A. Nguyen|last638=Van|first638=C. Nguyen|last639=Duy|first639=T. Mai|last640=Viet|first640=P. Dao|last641=Tien|first641=D. Nguyen|last642=Van|first642=T. Vo|last643=Le Kim|first643=K.|last644=Ngoc|first644=T. Bui|last645=Le Thanh|first645=T. Tran|last646=Hoanh|first646=S. Nguyen|last647=Phuoc|first647=S. Pham|last648=Van|first648=T. Tran|last649=Thi|first649=B. Doan|last650=Thu|first650=H. Nguyen Thi|last651=Duy|first651=M. Nguyen|last652=Van|first652=D. Ngo|title=Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial|journal=The Lancet|volume=393|issue=10174|year=2019|pages=877–888|issn=01406736|doi=10.1016/S0140-6736(19)30038-8}}</ref>
*In case of [[Intracranial hemorrhage|intracranial bleeding]] due to [[alteplase]] administration, [[alteplase]] should be suspended, blood draws should be taken ([[Complete blood count|CBC]], [[coagulation studies]]), [[tranexamic acid]] should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested [[Computed tomography|CT scan]] of the head taken.<ref name="SloanPrice1995">{{cite journal|last1=Sloan|first1=M. A.|last2=Price|first2=T.R.|last3=Petito|first3=C. K.|last4=Randall|first4=A. M. Y.|last5=Solomon|first5=R. E.|last6=Terrin|first6=M. L.|last7=Gore|first7=J.|last8=Collen|first8=D.|last9=Kleiman|first9=N.|last10=Feit|first10=F.|last11=Babb|first11=J.|last12=Herman|first12=M.|last13=Roberts|first13=W. C.|last14=Sopko|first14=G.|last15=Bovill|first15=E.|last16=Forman|first16=S.|last17=Knatterud|first17=G. L.|title=Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: The Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial Combined experience|journal=Neurology|volume=45|issue=4|year=1995|pages=649–658|issn=0028-3878|doi=10.1212/WNL.45.4.649}}</ref>
*The use of [[Alteplase|IV alteplase]] should be used cautiously in patients who undergone a [[major surgery]] in the past 2 weeks.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] for [[ischemic stroke]] is contraindicated in patients with a severe [[head trauma]] or [[Subarachnoid hemorrhage|subarachnoid hemorrage]] in the preceding 3 months.<ref name="PowersRabinstein2019" />

====Tenecteplase====

*[[Tenecteplase]] may be useful in patients with minor [[neurological]] impairment.<ref name="HuangCheripelli2015">{{cite journal|last1=Huang|first1=Xuya|last2=Cheripelli|first2=Bharath Kumar|last3=Lloyd|first3=Suzanne M|last4=Kalladka|first4=Dheeraj|last5=Moreton|first5=Fiona Catherine|last6=Siddiqui|first6=Aslam|last7=Ford|first7=Ian|last8=Muir|first8=Keith W|title=Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study|journal=The Lancet Neurology|volume=14|issue=4|year=2015|pages=368–376|issn=14744422|doi=10.1016/S1474-4422(15)70017-7}}</ref>
*The dose of [[tenecteplase]] is a single IV [[bolus]] of 0.25-mg/kg (maximum 25 mg).<ref name="CampbellMitchell2018">{{cite journal|last1=Campbell|first1=Bruce C.V.|last2=Mitchell|first2=Peter J.|last3=Churilov|first3=Leonid|last4=Yassi|first4=Nawaf|last5=Kleinig|first5=Timothy J.|last6=Dowling|first6=Richard J.|last7=Yan|first7=Bernard|last8=Bush|first8=Steven J.|last9=Dewey|first9=Helen M.|last10=Thijs|first10=Vincent|last11=Scroop|first11=Rebecca|last12=Simpson|first12=Marion|last13=Brooks|first13=Mark|last14=Asadi|first14=Hamed|last15=Wu|first15=Teddy Y.|last16=Shah|first16=Darshan G.|last17=Wijeratne|first17=Tissa|last18=Ang|first18=Timothy|last19=Miteff|first19=Ferdinand|last20=Levi|first20=Christopher R.|last21=Rodrigues|first21=Edrich|last22=Zhao|first22=Henry|last23=Salvaris|first23=Patrick|last24=Garcia-Esperon|first24=Carlos|last25=Bailey|first25=Peter|last26=Rice|first26=Henry|last27=de Villiers|first27=Laetitia|last28=Brown|first28=Helen|last29=Redmond|first29=Kendal|last30=Leggett|first30=David|last31=Fink|first31=John N.|last32=Collecutt|first32=Wayne|last33=Wong|first33=Andrew A.|last34=Muller|first34=Claire|last35=Coulthard|first35=Alan|last36=Mitchell|first36=Ken|last37=Clouston|first37=John|last38=Mahady|first38=Kate|last39=Field|first39=Deborah|last40=Ma|first40=Henry|last41=Phan|first41=Thanh G.|last42=Chong|first42=Winston|last43=Chandra|first43=Ronil V.|last44=Slater|first44=Lee-Anne|last45=Krause|first45=Martin|last46=Harrington|first46=Timothy J.|last47=Faulder|first47=Kenneth C.|last48=Steinfort|first48=Brendan S.|last49=Bladin|first49=Christopher F.|last50=Sharma|first50=Gagan|last51=Desmond|first51=Patricia M.|last52=Parsons|first52=Mark W.|last53=Donnan|first53=Geoffrey A.|last54=Davis|first54=Stephen M.|title=Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke|journal=New England Journal of Medicine|volume=378|issue=17|year=2018|pages=1573–1582|issn=0028-4793|doi=10.1056/NEJMoa1716405}}</ref>

====Antiplatelet therapy====

*Administration of [[aspirin]] is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with [[Alteplase|IV alteplase]], aspirin administration is generally delayed until 24 hours later.<ref name="JeongKim2016">{{cite journal|last1=Jeong|first1=Han-Gil|last2=Kim|first2=Beom Joon|last3=Yang|first3=Mi Hwa|last4=Han|first4=Moon-Ku|last5=Bae|first5=Hee-Joon|last6=Lee|first6=Seung-Hoon|title=Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment|journal=Neurology|volume=87|issue=10|year=2016|pages=996–1002|issn=0028-3878|doi=10.1212/WNL.0000000000003083}}</ref>
*The dose of [[aspirin]] is usually between 160-300mg daily.<ref name="pmid9174558">{{cite journal |vauthors= |title=The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group |journal=Lancet |volume=349 |issue=9065 |pages=1569–81 |date=May 1997 |pmid=9174558 |doi= |url=}}</ref>
*[[Aspirin|IV aspirin]] administration within 90 minutes after the start of [[Alteplase|IV alteplase]] is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.<ref name="PowersRabinstein2019" /><ref name="ZinkstokRoos2012">{{cite journal|last1=Zinkstok|first1=Sanne M|last2=Roos|first2=Yvo B|title=Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial|journal=The Lancet|volume=380|issue=9843|year=2012|pages=731–737|issn=01406736|doi=10.1016/S0140-6736(12)60949-0}}</ref>
*[[Dual antiplatelet therapy]] with [[aspirin]] and [[clopidogrel]] (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after [[symptom]] onset and continued for 21 days in patients with no cardioembolic [[ischemic stroke]].<ref name="JohnstonEaston2018">{{cite journal|last1=Johnston|first1=S. Claiborne|last2=Easton|first2=J. Donald|last3=Farrant|first3=Mary|last4=Barsan|first4=William|last5=Conwit|first5=Robin A.|last6=Elm|first6=Jordan J.|last7=Kim|first7=Anthony S.|last8=Lindblad|first8=Anne S.|last9=Palesch|first9=Yuko Y.|title=Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA|journal=New England Journal of Medicine|volume=379|issue=3|year=2018|pages=215–225|issn=0028-4793|doi=10.1056/NEJMoa1800410}}</ref>
*[[Aspirin]] should not substitute [[Alteplase|IV alteplase]] or mechanical thrombectomy in patients eligible for these therapies.<ref name="PowersRabinstein2019" />

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! rowspan="2" style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Medical treatment}}
! rowspan="2" style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF|Drug class}}
! colspan="2" style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Recommendations}}
|-
! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Acute}}
! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Long-Term}}
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Reperfusion therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tissue plasminogen activator|'''Tissue plasminogen activator''']] '''(t-PA)'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref><ref name="pmid 22315273">{{cite journal| author=Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE et al.| title=Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e601S-36S | pmid= 22315273 | doi=10.1378/chest.11-2302 | pmc=3278065 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315273 }} </ref><ref>{{cite web|url=http://www.aaem.org/em-resources/position-statements/clinical-practice/thrombolytic-therapy |title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke |publisher=American Academy of Emergency Medicine |accessdate=2008-01-25}}</ref> and [[systematic review]]s<ref name="pmid25871671">{{cite journal| author=Prabhakaran S, Ruff I, Bernstein RA| title=Acute stroke intervention: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 14 | pages= 1451-62 | pmid=25871671 | doi=10.1001/jama.2015.3058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871671 }} </ref><ref name="pmid25072528">{{cite journal| author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ| title=Thrombolysis for acute ischaemic stroke. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 7 | issue= | pages= CD000213 | pmid=25072528 | doi=10.1002/14651858.CD000213.pub3 | pmc=4153726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528 }} </ref><ref name="pmid25106063">{{cite journal| author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.| title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. | journal=Lancet | year= 2014 | volume= | issue= | pages= | pmid=25106063 | doi=10.1016/S0140-6736(14)60584-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* None
|-
| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antithrombotic agents'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Antiplatelet agents|'''Antiplatelet agents''']]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Oral administration of [[aspirin]] (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
*Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
*DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term therapy with [[clopidogrel]] or aspirin extended release [[dipyridamole]] may be used for secondary prevention of non cardioembolic stroke
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Anticoagulants]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke<ref name="pmid17204681"> {{cite journal |author=Paciaroni M, Agnelli G, Micheli S, Caso V |title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials |journal=Stroke |volume=38 |issue=2 |pages=423-30 | year=2007 |pmid=17204681 |doi=10.1161/01.STR.0000254600.92975.1f }} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis]</ref>

| style="padding: 5px 5px; background: #F5F5F5;" |
*Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease<ref name="pmid17577005">{{cite journal |author=Hart RG, Pearce LA, Aguilar MI |title=Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation |journal=Ann. Intern. Med. |volume=146 |issue=12 |pages=857-67 |year=2007 |pmid=17577005 |doi=}}</ref>
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Antilipid therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Statins]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease
*Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
|-
| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antihypertensive therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Intravenous [[antihypertensives]]'''
'''([[Labetalol|Labetolol]], [[nitroprusside]])'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Oral antihypertensive therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Recommended after 24 hours in patient having [[hypertension]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Antihyperglycemic agents'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Insulin]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with [[diabetes mellitus]]
|-
|}

== 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<ref name="pmid31662037">{{cite journal| author=Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K | display-authors=etal| title=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. | journal=Stroke | year= 2019 | volume= 50 | issue= 12 | pages= e344-e418 | pmid=31662037 | doi=10.1161/STR.0000000000000211 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31662037 }}</ref> ==

=== IV Alteplase Eligibility ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' Administration of IV alteplase in eligible patients without first obtaining MRI to exclude cerebral microbleeds (CMBs) is recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|-
| bgcolor="LightGreen" |'''2.'''In patients eligible for IV alteplase, because benefit of therapy is time dependent, treatment should be initiated as quickly as possible and not delayed for additional multimodal neuroimaging, such as CT and MRI perfusion imaging.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.''' In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5 hours from last known well or at baseline state, MRI to identify diffusion-positive FLAIR-negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== IV Alteplase - General Priniciples ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' In patients eligible for IV alteplase, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|-
| bgcolor="LightGreen" |'''2.''' In patients undergoing fibrinolytic therapy, physicians should be prepared to treat potential emergent adverse effects, including bleeding complications and angioedema that may cause partial airway obstruction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|-
| bgcolor="LightGreen" |'''3.''' The potential risks should be discussed during IV alteplase eligibility deliberation and weighed against the anticipated benefits during decision- making.''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

=== Time Windows ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who can be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 8 to determine patient eligibility.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|-
| bgcolor="LightGreen" |'''2.''' IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 8 to determine patient eligibility. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.'''IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) administered within 4.5 hours of stroke symptom recognition can be beneficial in patients with AIS who awake with stroke symptoms or have unclear time of onset >4.5 hours from last known well or at baseline state and who have a DW-MRI lesion smaller than one-third of the MCA territory and no visible signal change on FLAIR. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Antiplatelet Treatment ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|-
| bgcolor="LightGreen" |'''2.''' In patients presenting with minor noncardioembolic ischemic stroke (NIHSS score ≤3) who did not receive IV alteplase, treatment with dual antiplatelet therapy (aspirin and clopidogrel) started within 24 hours after symptom onset and continued for 21 days is effective in reducing recurrent ischemic stroke for a period of up to 90 days from symptom onset. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.'''The efficacy of the IV glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide in the treatment of AIS is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Anticoagulants ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.''' The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|-
| bgcolor="LemonChiffon" |'''2.''' The safety and usefulness of short-term anticoagulation for nonocclusive, extracranial intraluminal thrombus in the setting of AIS are not well established.. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]-LD)''
|-
| bgcolor="LemonChiffon" |'''3.''' At present, the usefulness of argatroban, dabigatran, or other thrombin inhibitors for the treatment of patients with AIS is not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|-
| bgcolor="LemonChiffon" |'''4.''' The safety and usefulness of oral factor Xa inhibitors in the treatment of AIS are not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]-LD)''
|}
== 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association<ref name="pmid34024117">{{cite journal| author=Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D | display-authors=etal| title=2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2021 | volume= 52 | issue= 7 | pages= e364-e467 | pmid=34024117 | doi=10.1161/STR.0000000000000375 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34024117 }}</ref> ==

=== Recommendations for Intracranial Large Artery Atherosclerosis Referenced studies that support recommendations are summarized in online Data Supplements 20-27 ===

==== Antithrombotic therapy ====
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in preference to warfarin to reduce the risk of recurrent ischemic stroke and vascular death.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with recent (within 24 hours) minor stroke or high-risk TIA and concomitant ipsilateral >30% stenosis of a major intracranial artery, the addition of ticagrelor 90 mg twice a day to aspirin for up to 30 days might be considered to further reduce recurrent stroke risk.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
4. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered to reduce recurrent stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
5. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the usefulness of clopidogrel alone, the combination of aspirin and dipyridamole, ticagrelor alone, or cilostazol alone for secondary stroke prevention is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

==== Risk Factor Management ====
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |6. In patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mm Hg, high-intensity statin therapy, and at least moderate physical activity are recommended to prevent recurrent stroke and vascular events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

==== Angioplasty and Stenting ====
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |7. In patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140 mm Hg, and high- intensity statin therapy (so-called medical failures), the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Extracranial Carotid Stenosis Referenced studies that support recommendations are summarized in online Data Supplement 28 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |3. In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid-lowering therapy, and treatment of hypertension, is recommended to reduce stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}

=== Recommendations for Extracranial Vertebral Artery Stenosis Referenced studies that support recommendations are summarized in online Data Supplement 28 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with recently symptomatic extracranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid lowering, BP control) is recommended to reduce stroke risk.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}

=== Recommendations for Aortic Arch Atherosclerosis Referenced studies that support recommendations are summarized in online Data Supplement 29 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with a stroke or TIA and evidence of an aortic arch atheroma, intensive lipid management to an LDL cholesterol target <70 mg/dL is recommended to prevent recur-rent stroke''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
2. In patients with a stroke or TIA and evidence of an aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Moyamoya Disease Referenced studies that support recommendations are summarized in online Data Supplement 30 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1. In patients with moyamoya disease and a history of ischemic stroke or TIA, surgical revascularization with direct or indirect extracranial-intracranial bypass can be beneficial for the prevention of ischemic stroke or TIA''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |2. In patients with moyamoya disease and a history of ischemic stroke or TIA, the use of anti-platelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA may be reasonable.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Small Vessel Stroke Referenced studies that support the recommendation are summarized in online Data Supplement 31 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |1.In patients with ischemic stroke related to small vessel disease, the usefulness of cilostazol for secondary stroke prevention is uncertain''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Recommendations for AF Referenced studies that support recommendations are summarized in online Data Supplement 32 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with nonvalvular AF and stroke or TIA, oral anticoagulation (eg, apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
2. In patients with AF and stroke or TIA, oral anticoagulation is indicated to reduce the risk of recurrent stroke regardless of whether the AF pattern is paroxysmal, persistent, or permanent.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
3. In patients with stroke or TIA and AF who do not have moderate to severe mitral stenosis or a mechanical heart valve, apixaban, dabigatran, edoxaban, or rivaroxaban is recommended in preference to warfarin to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
4. In patients with atrial flutter and stroke or TIA, anticoagulant therapy similar to that in AF is indicated to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
5. In patients with AF and stroke or TIA, without moderate to severe mitral stenosis or a mechanical heart valve, who are unable to maintain a therapeutic INR level with warfarin, use of dabigatran, rivaroxaban, apixaban, or edoxaban is recommended to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |6. In patients with stroke at high risk of hemorrhagic conversion in the setting of AF, it is reasonable to delay initiation of oral anticoagulation beyond 14 days to reduce the risk of ICH.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
7. In patients with TIA in the setting of nonvalvular AF, it is reasonable to initiate anticoagulation immediately after the index event to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |8. In patients with stroke or TIA in the setting of nonvalvular AF who have contraindications for lifelong anticoagulation but can tolerate at least 45 days, it may be reasonable to consider percutaneous closure of the left atrial appendage with the Watchman device to reduce the chance of recurrent stroke and bleeding.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
9. In patients with stroke at low risk for hemorrhagic conversion in the setting of AF, it may be reasonable to initiate anticoagulation 2 to 14 days after the index event to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
10. In patients with AF and stroke or TIA who have end-stage renal disease or are on dialysis, it may be reasonable to use warfarin or apixaban (dose adjusted if indicated) for anticoagulation to reduce the chance of recurrent stroke.
''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

=== Recommendations for Valvular Disease Referenced studies that support recommendations are summarized in online Data Supplement 33 and 34 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and valvular AF (moderate to severe mitral steno-sis or any mechanical heart valve), warfarin is recommended to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
2. In patients with a mechanical mitral valve and a history of ischemic stroke or TIA before valve replacement, aspirin (75–100 mg/d) is recommended in addition to warfarin with an INR target of 3.0 (range, 2.5–3.5) to reduce the risk of thrombosis and recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD)]]''
3. In patients with ischemic stroke or TIA and native aortic or nonrheumatic mitral valve disease (eg, mitral annular calcification or mitral valve prolapse) who do not have AF or another indication for anticoagulation, anti-platelet therapy is recommended to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
4. In patients with a bioprosthetic aortic or mitral valve, a history of ischemic stroke or TIA before valve replacement, and no other indication for anticoagulation therapy beyond 3 to 6 months from the valve placement, long-term therapy with aspirin is recommended in preference to long-term anticoagulation to reduce the risk of recur-rent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|-
|
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |6. In patients with history of ischemic stroke or TIA and a mechanical aortic valve, anti-coagulation with higher-intensity warfarin to achieve an INR of 3.0 (range, 2.5–3.5) or the addition of aspirin (75–100 mg/d) can be beneficial to reduce the risk of thromboembolic events''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}

=== Recommendations for LV Thrombus Referenced studies that support recommendations are summarized in online Data Supplement 35 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with stroke or TIA and LV thrombus, anticoagulation with therapeutic warfarin for at least 3 months is recommended to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with stroke or TIA and new LV thrombus (<3 months), the safety of anticoagulation with a direct oral anticoagulant to reduce risk of recurrent stroke is uncertain.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD)]]''
4. In patients with stroke or TIA in the setting of acute anterior MI with reduced ejection fraction (EF; <50%) but no evidence of LV thrombus, empirical anticoagulation for at least 3 months might be considered to reduce the risk of recurrent cardioembolic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}

=== Recommendations for Cardiomyopathy Referenced studies that support recommendations are summarized in online Data Supplements 36 and 37 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and left atrial or left atrial appendage thrombus in the setting of ischemic, nonischemic, or restrictive cardiomyopathy and LV dysfunction, anticoagulant therapy with warfarin is recommended for at least 3 months to reduce the risk of recurrent stroke or TIA. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA in the setting of a mechanical assist device, treatment with warfarin and aspirin can be beneficial to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
3. In patients with ischemic stroke or TIA in the setting of LV noncompaction, treatment with warfarin can be beneficial to reduce the risk of recurrent stroke or TIA. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |4. In patients with ischemic stroke or TIA in sinus rhythm with ischemic or nonischemic cardio-myopathy and reduced EF without evidence of left atrial or LV thrombus, the effectiveness of anticoagulation compared with antiplatelet therapy is uncertain, and the choice should be individualized.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Recommendations for Congenital Heart Disease Referenced studies that support recommendations are summarized in online Data Supplements 40 and 41 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and Fontan palliation, anticoagulation with warfarin is recommended to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with cyanotic congenital heart disease and other complex lesions, ischemic stroke or TIA of presumed cardioembolic origin, therapy with warfarin is reasonable to reduce the risk of recurrent stroke or TIA''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

=== Recommendations for Dissection Referenced studies that support recommendations are summarized in online Data Supplements 43 and 44 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA after an extracranial carotid or vertebral arterial dis-section, treatment with antithrombotic therapy for at least 3 months is indicated to prevent recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA who are <3 months after an extracranial carotid or vertebral arterial dissection, it is reasonable to use either aspirin or warfarin to prevent recur-rent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with stroke or TIA and extracranial carotid or vertebral artery dissection who have recurrent events despite antithrombotic therapy, endovascular therapy may be considered to prevent recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Hematologic Traits Referenced studies that support the recommendation are summarized in online Data Supplement 45 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1. In patients with ischemic stroke or TIA of unknown source despite thorough diagnostic evaluation and no other thrombotic history who are found to have prothrombin 20210A mutation, activated protein C resistance, elevated factor VIII levels, or deficiencies of protein C, protein S, or antithrombin III, anti-platelet therapy is reasonable to reduce the risk of recurrent stroke or TIA ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Antiphospholipid Syndrome Referenced studies that support recommendations are summarized in online Data Supplement 46 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA who have an isolated antiphospholipid antibody but do not fulfill the criteria for antiphospholipid syndrome, antiplatelet therapy alone is recommended to reduce the risk of recurrent stroke. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA with confirmed antiphospholipid syndrome treated with warfarin, it is reasonable to choose a target INR between 2 and 3 over a target INR >3 to effectively balance the risk of excessive bleeding against the risk of thrombosis.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
3. In patients with ischemic stroke or TIA who meet the criteria for the antiphospholipid syndrome, it is reasonable to anticoagulate with warfarin to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Malignancy Referenced studies that support the recommendation are summarized in online Data Supplement 48 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1. In patients with ischemic stroke or TIA in the setting of AF and cancer, it is reasonable to consider anticoagulation with DOACs in preference to warfarin for stroke prevention ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

=== Recommendations for Sickle Cell Disease Referenced studies that support recommendations are summarized in online Data Supplement 49 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with sickle cell disease (SCD) and prior ischemic stroke or TIA, chronic blood transfusion(s) to reduce hemoglobin S to <30% of total hemoglobin is recommended for the prevention of recurrent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with SCD with prior ischemic stroke or TIA for whom transfusion therapy is not available or practical, treatment with hydroxyurea is reasonable for the prevention of recurrent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Recommendations for Autoimmune Vasculitis Referenced studies that support recommendations are summarized in online Data Supplement 50 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1.In patients with ischemic stroke or TIA and symptoms attributed to giant cell arteritis, immediate initiation of oral high-dose glucocorticoids is recommended to reduce recurrent stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA and diagnosis of giant cell arteritis, methotrexate or tocilizumab therapy adjunctive to steroids is reasonable to lower the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
3. In patients with ischemic stroke or TIA and diagnosis of primary CNS angiitis, induction therapy with glucocorticoids and/or immunosuppressants followed by long-term maintenance therapy with steroid-sparing immunosuppressants is reasonable to lower the risk of stroke recurrence.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

=== Recommendations for Infectious Vasculitis Referenced studies that support recommendations are summarized in online Data Supplement 51 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and infectious vasculitis such as varicella zoster virus (VZV) cerebral vasculitis, neurosyphilis, or bacterial meningitis, treating the underlying infectious etiology is indicated to reduce the risk of stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA in the context of HIV vasculopathy, daily aspirin plus HIV viral control with combined antiretroviral therapy is reasonable to reduce the risk of recurrent stroke''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Other Genetic Disorders Referenced studies that support recommendations are summarized in online Data Supplements 51 and 52 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and cystathionine β-synthase deficiency, pyridoxine (in responsive patients) and a low-methionine, cysteine-enhanced diet supplemented with pyridoxine, vitamin B12, and folate are recommended to reduce plasma homocysteine to population normal levels and thereby reduce the risk of recurrent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA and Anderson-Fabry disease, agalsidase alfa or agalsidase beta is of uncertain value in preventing recurrent stroke or TIA ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

=== Recommendations for Carotid Web Referenced studies that support recommendations are summarized in online Data Supplement 53 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with carotid web in the distribution of ischemic stroke and TIA, without other attributable causes of stroke, antiplatelet therapy is recommended to prevent recurrent ischemic stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |2. In patients with carotid web in the distribution of ischemic stroke refractory to medical management, with no other attributable cause of stroke despite comprehensive workup, carotid stenting or CEA may be considered to prevent recurrent ischemic stroke. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Fibromuscular Dysplasia Referenced studies that support recommendations are summarized in online Data Supplement 54 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with fibromuscular dysplasia (FMD) and a history of ischemic stroke or TIA without other attributable causes, antiplatelet therapy, BP control, and lifestyle modification are recommended for the prevention of future ischemic events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with a history of ischemic stroke or TIA attributable to dissection, with FMD, and no evidence of intraluminal thrombus, it is reasonable to administer antiplatelet therapy for the prevention of future ischemic events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with cervical carotid artery FMD and recurrent ischemic stroke without other attributable causes despite optimal medical management, carotid angioplasty with or without stenting may be reasonable to prevent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Dolichoectasia Referenced studies that support the recommendation are summarized in online Data Supplement 55 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1.In patients with vertebrobasilar dolichoectasia and a history of ischemic stroke or TIA without other attributable causes, the use of antiplatelet or anticoagulant therapy is reasonable for the prevention of recurrent ischemic events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Antithrombotic Medications Referenced studies that support recommendations are summarized in online Data Supplement 57-59 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with non-cardioembolic ischemic stroke or TIA, antiplatelet therapy is indicated in preference to oral anticoagulation to reduce the risk of recurrent ischemic stroke and other cardiovascular events while minimizing the risk of bleeding.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
2. For patients with non-cardioembolic ischemic stroke or TIA, aspirin 50 to 325 mg daily, clopidogrel 75 mg, or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is indicated for secondary prevention of ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
3. For patients with recent minor (NIHSS score ≤3) non-cardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥4), DAPT (aspirin plus clopidogrel) should be initiated early (ideally within 12–24 hours of symptom onset and at least within 7 days of onset) and continued for 21 to 90 days, followed by SAPT, to reduce the risk of recurrent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |4. For patients with recent (< 24 hours) minor to moderate stroke (NIHSS score ≤5), high-risk TIA (ABCD2 score ≥6), or symptomatic intra-cranial or extracranial ≥30% stenosis of an artery that could account for the event, DAPT with ticagrelor plus aspirin for 30 days may be considered to reduce the risk of 30-day recurrent stroke but may also increase the risk of serious bleeding events, including ICH.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
5. For patients already taking aspirin at the time of non-cardioembolic ischemic stroke or TIA, the effectiveness of increasing the dose of aspirin or changing to another antiplatelet medication is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR )]]''
|}

'''For AHA/ASA guidelines for Intravenous Fibrinolysis in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Intravenous Fibrinolysis|click here]]<br>
'''For AHA/ASA guidelines for General Supportive Care and Treatment of Acute Complications in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Supportive Care and Treatment of Acute Complications|click here]]<br>
'''For AHA/ASA guidelines on anticoagulants usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Anticoagulants|click here]]<br>
'''For AHA/ASA guidelines on antiplatelets usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Antiplatelets|click here]]<br>
'''For AHA/ASA guidelines on volume resuscitation usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Volume Expansion, Vasodilators, and Induced Hypertension|click here]]<br>
'''For AHA/ASA guidelines on neuroprotective agents in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Neuroprotective Agents|click here]]<br>
'''For AHA/ASA guidelines on General Stroke Care in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Stroke Care|click here]]

==References==
{{reflist|2}}

{{WS}}
{{WH}}

Ischemic stroke medical therapy

2023-01-19T15:50:08Z

Laith Adnan Allaham:

__NOTOC__
{{Ischemic stroke}}
{{CMG}}{{AE}}{{AA}}

==Overview==
The medical therapy of [[ischemic stroke]] is mainly directed to fibrinolysis of clot by r-tPA with in 3 to 4.5 hours of symptom onset. Acute treatment with antiplatelets may have a role if given within 24-48 hours of stroke onset. Long term management with statins, antiplatelets, anticoagulants, antihypertensive and antidiabetic agents may help prevent the recurrence.<ref>{{cite journal |author=Hackam DG, Spence JD |title=Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study |journal=Stroke |volume=38 |issue=6 |pages=1881–5 |year=2007 |pmid=17431209 |doi=10.1161/STROKEAHA.106.475525}}</ref>
Acute treatment to control blood pressure, blood glucose and fever may help prevent the complications and have a prognostic significance.

==Medical Therapy==

*The reported cases of treatment for [[COVID-19]]-associated [[stroke]] have followed the same guidelines as patients with no [[COVID-19]] infection. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
*[[Alteplase|IV alteplase]] is always preferred over mechanical [[thrombectomy]] when there are no contraindications.<ref name="SaverGoyal2016">{{cite journal|last1=Saver|first1=Jeffrey L.|last2=Goyal|first2=Mayank|last3=van der Lugt|first3=Aad|last4=Menon|first4=Bijoy K.|last5=Majoie|first5=Charles B. L. M.|last6=Dippel|first6=Diederik W.|last7=Campbell|first7=Bruce C.|last8=Nogueira|first8=Raul G.|last9=Demchuk|first9=Andrew M.|last10=Tomasello|first10=Alejandro|last11=Cardona|first11=Pere|last12=Devlin|first12=Thomas G.|last13=Frei|first13=Donald F.|last14=du Mesnil de Rochemont|first14=Richard|last15=Berkhemer|first15=Olvert A.|last16=Jovin|first16=Tudor G.|last17=Siddiqui|first17=Adnan H.|last18=van Zwam|first18=Wim H.|last19=Davis|first19=Stephen M.|last20=Castaño|first20=Carlos|last21=Sapkota|first21=Biggya L.|last22=Fransen|first22=Puck S.|last23=Molina|first23=Carlos|last24=van Oostenbrugge|first24=Robert J.|last25=Chamorro|first25=Ángel|last26=Lingsma|first26=Hester|last27=Silver|first27=Frank L.|last28=Donnan|first28=Geoffrey A.|last29=Shuaib|first29=Ashfaq|last30=Brown|first30=Scott|last31=Stouch|first31=Bruce|last32=Mitchell|first32=Peter J.|last33=Davalos|first33=Antoni|last34=Roos|first34=Yvo B. W. E. M.|last35=Hill|first35=Michael D.|title=Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis|journal=JAMA|volume=316|issue=12|year=2016|pages=1279|issn=0098-7484|doi=10.1001/jama.2016.13647}}</ref>
*The usefulness of [[anticoagulants]] such as [[thrombin]] inhibitors ([[dabigatran]]) and [[factor Xa]] inhibitors ([[rivaroxaban]], [[apixaban]], [[edoxaban]]) is not well established in the acute setting of [[stroke]].<ref name="GioiaKate2016">{{cite journal|last1=Gioia|first1=Laura C.|last2=Kate|first2=Mahesh|last3=Sivakumar|first3=Leka|last4=Hussain|first4=Dulara|last5=Kalashyan|first5=Hayrapet|last6=Buck|first6=Brian|last7=Bussiere|first7=Miguel|last8=Jeerakathil|first8=Thomas|last9=Shuaib|first9=Ashfaq|last10=Emery|first10=Derek|last11=Butcher|first11=Ken|title=Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation|journal=Stroke|volume=47|issue=7|year=2016|pages=1917–1919|issn=0039-2499|doi=10.1161/STROKEAHA.116.013491}}</ref>
*The use of [[thrombolysis]] via ultrasound waves concomitant to [[Fibrinolysis|IV fibrinolysis]] is not recommended.<ref name="NacuKvistad2017">{{cite journal|last1=Nacu|first1=Aliona|last2=Kvistad|first2=Christopher E.|last3=Naess|first3=Halvor|last4=Øygarden|first4=Halvor|last5=Logallo|first5=Nicola|last6=Assmus|first6=Jörg|last7=Waje-Andreassen|first7=Ulrike|last8=Kurz|first8=Kathinka D.|last9=Neckelmann|first9=Gesche|last10=Thomassen|first10=Lars|title=NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)|journal=Stroke|volume=48|issue=2|year=2017|pages=335–341|issn=0039-2499|doi=10.1161/STROKEAHA.116.014644}}</ref>
*High-intensity [[statin]] therapy should be initiated in patients younger than 75 with clinical [[Coronary heart disease|ASCVD]], to achieving a reduction in [[LDL-C]] levels of at least 50%.
*In patients older than 75 years of age with clinical [[Coronary heart disease|ASCVD]], it is reasonable to initiate moderate or high-intensity [[statin]] therapy after reviewing [[adverse effects]] and [[Drug interaction|drug interactions]].<ref name="PowersRabinstein2019">{{cite journal|last1=Powers|first1=William J.|last2=Rabinstein|first2=Alejandro A.|last3=Ackerson|first3=Teri|last4=Adeoye|first4=Opeolu M.|last5=Bambakidis|first5=Nicholas C.|last6=Becker|first6=Kyra|last7=Biller|first7=José|last8=Brown|first8=Michael|last9=Demaerschalk|first9=Bart M.|last10=Hoh|first10=Brian|last11=Jauch|first11=Edward C.|last12=Kidwell|first12=Chelsea S.|last13=Leslie-Mazwi|first13=Thabele M.|last14=Ovbiagele|first14=Bruce|last15=Scott|first15=Phillip A.|last16=Sheth|first16=Kevin N.|last17=Southerland|first17=Andrew M.|last18=Summers|first18=Deborah V.|last19=Tirschwell|first19=David L.|title=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|journal=Stroke|volume=50|issue=12|year=2019|issn=0039-2499|doi=10.1161/STR.0000000000000211}}</ref><ref name="SanossianSaver2006">{{cite journal|last1=Sanossian|first1=Nerses|last2=Saver|first2=Jeffrey L.|last3=Liebeskind|first3=David S.|last4=Kim|first4=Doojin|last5=Razinia|first5=Tannaz|last6=Ovbiagele|first6=Bruce|title=Achieving Target Cholesterol Goals After Stroke|journal=Archives of Neurology|volume=63|issue=8|year=2006|pages=1081|issn=0003-9942|doi=10.1001/archneur.63.8.1081}}</ref>
*Risk and beneffits should be discussed before initiation of statin therapy to weight [[Coronary heart disease|ASCVD]] risk reduction against the potential for statin-associated side effects.<ref name="PowersRabinstein2019" />
*Continuation of statin therapy during the acute period of [[ischemic stroke]] is reasonable among patients already taking [[Statins (patient information)|statins]].

====Alteplase====

*[[Alteplase|IV alteplase]] is recommended for selected patients who can be treated within 3-4.5 hours of [[ischemic stroke]] [[symptom]] [[onset]] or patient last known well or at [[Baseline (medicine)|baseline]] state.<ref name="LeesEmberson2016">{{cite journal|last1=Lees|first1=Kennedy R.|last2=Emberson|first2=Jonathan|last3=Blackwell|first3=Lisa|last4=Bluhmki|first4=Erich|last5=Davis|first5=Stephen M.|last6=Donnan|first6=Geoffrey A.|last7=Grotta|first7=James C.|last8=Kaste|first8=Markku|last9=von Kummer|first9=Rüdiger|last10=Lansberg|first10=Maarten G.|last11=Lindley|first11=Richard I.|last12=Lyden|first12=Patrick|last13=Murray|first13=Gordon D.|last14=Sandercock|first14=Peter A.G.|last15=Toni|first15=Danilo|last16=Toyoda|first16=Kazunori|last17=Wardlaw|first17=Joanna M.|last18=Whiteley|first18=William N.|last19=Baigent|first19=Colin|last20=Hacke|first20=Werner|last21=Howard|first21=George|last22=Marler|first22=John|last23=Halls|first23=Heather|last24=Holland|first24=Lisa|last25=Mathews|first25=Clare|last26=Smith|first26=Samantha|last27=Wilson|first27=Kate|last28=Koga|first28=Masatoshi|last29=Albers|first29=Gregory|last30=Brott|first30=Thomas|last31=Cohen|first31=Geoffrey|last32=Koga|first32=Masatoshi|last33=Olivot|first33=Jean Marc|last34=Parsons|first34=Mark|last35=Tilley|first35=Barbara|last36=Wahlgren|first36=Nils|last37=del Zoppo|first37=Gregory J|title=Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes|journal=Stroke|volume=47|issue=9|year=2016|pages=2373–2379|issn=0039-2499|doi=10.1161/STROKEAHA.116.013644}}</ref><ref name="PowersRabinstein2019" /><ref>{{cite journal|title=The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial|journal=The Lancet|volume=379|issue=9834|year=2012|pages=2352–2363|issn=01406736|doi=10.1016/S0140-6736(12)60768-5}}</ref>
*The [[dose]] of [[Alteplase|IV alteplase]] is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the [[dose]] given as a [[bolus]] over 1 min.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.<ref name="PowersRabinstein2019" />
*[[Hyperglycemia]] should be treated during the first 24 hours after [[ischemic stroke]], to achieve values of 140 to 180 mg/dL.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] may cause bleeding and [[angioedema]].<ref name="PowersRabinstein2019" />
*[[Glycoprotein IIb/IIIa inhibitors]] ([[Tirofiban detailed information|tirofiban]], [[apiximab]], [[eptifibatide]]) should not be coadministered with [[Alteplase|IV alteplase]].<ref name="PowersRabinstein2019" /><ref name="AdeoyeSucharew2015">{{cite journal|last1=Adeoye|first1=Opeolu|last2=Sucharew|first2=Heidi|last3=Khoury|first3=Jane|last4=Tomsick|first4=Thomas|last5=Khatri|first5=Pooja|last6=Palesch|first6=Yuko|last7=Schmit|first7=Pamela A.|last8=Pancioli|first8=Arthur M.|last9=Broderick|first9=Joseph P.|title=Recombinant Tissue-Type Plasminogen Activator Plus Eptifibatide Versus Recombinant Tissue-Type Plasminogen Activator Alone in Acute Ischemic Stroke|journal=Stroke|volume=46|issue=2|year=2015|pages=461–464|issn=0039-2499|doi=10.1161/STROKEAHA.114.006743}}</ref>
*[[Alteplase|IV alteplase]] may be used in patients under warfarin if the [[INR]] is lower than 1.7.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] should not be administered to patients who have received a full dose of [[low-molecular-weight heparin]] within the previous 24 hours (including [[Prophylaxis|prophylactic]] doses).<ref name="PowersRabinstein2019" /><ref name="PowersDerdeyn2015">{{cite journal|last1=Powers|first1=William J.|last2=Derdeyn|first2=Colin P.|last3=Biller|first3=José|last4=Coffey|first4=Christopher S.|last5=Hoh|first5=Brian L.|last6=Jauch|first6=Edward C.|last7=Johnston|first7=Karen C.|last8=Johnston|first8=S. Claiborne|last9=Khalessi|first9=Alexander A.|last10=Kidwell|first10=Chelsea S.|last11=Meschia|first11=James F.|last12=Ovbiagele|first12=Bruce|last13=Yavagal|first13=Dileep R.|title=2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment|journal=Stroke|volume=46|issue=10|year=2015|pages=3020–3035|issn=0039-2499|doi=10.1161/STR.0000000000000074}}</ref>
*[[Blood pressure]] should be sustained lower than 180/105 mmHg the first 24 hours after [[Alteplase|IV alteplase]] administration. 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Truong|last634=Cam|first634=L. Dam Thi|last635=Kim|first635=T. Ngo Thi|last636=Nguyen|first636=B. Pham|last637=Dat|first637=A. Nguyen|last638=Van|first638=C. Nguyen|last639=Duy|first639=T. Mai|last640=Viet|first640=P. Dao|last641=Tien|first641=D. Nguyen|last642=Van|first642=T. Vo|last643=Le Kim|first643=K.|last644=Ngoc|first644=T. Bui|last645=Le Thanh|first645=T. Tran|last646=Hoanh|first646=S. Nguyen|last647=Phuoc|first647=S. Pham|last648=Van|first648=T. Tran|last649=Thi|first649=B. Doan|last650=Thu|first650=H. Nguyen Thi|last651=Duy|first651=M. Nguyen|last652=Van|first652=D. Ngo|title=Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial|journal=The Lancet|volume=393|issue=10174|year=2019|pages=877–888|issn=01406736|doi=10.1016/S0140-6736(19)30038-8}}</ref>
*In case of [[Intracranial hemorrhage|intracranial bleeding]] due to [[alteplase]] administration, [[alteplase]] should be suspended, blood draws should be taken ([[Complete blood count|CBC]], [[coagulation studies]]), [[tranexamic acid]] should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested [[Computed tomography|CT scan]] of the head taken.<ref name="SloanPrice1995">{{cite journal|last1=Sloan|first1=M. A.|last2=Price|first2=T.R.|last3=Petito|first3=C. K.|last4=Randall|first4=A. M. Y.|last5=Solomon|first5=R. E.|last6=Terrin|first6=M. L.|last7=Gore|first7=J.|last8=Collen|first8=D.|last9=Kleiman|first9=N.|last10=Feit|first10=F.|last11=Babb|first11=J.|last12=Herman|first12=M.|last13=Roberts|first13=W. C.|last14=Sopko|first14=G.|last15=Bovill|first15=E.|last16=Forman|first16=S.|last17=Knatterud|first17=G. L.|title=Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: The Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial Combined experience|journal=Neurology|volume=45|issue=4|year=1995|pages=649–658|issn=0028-3878|doi=10.1212/WNL.45.4.649}}</ref>
*The use of [[Alteplase|IV alteplase]] should be used cautiously in patients who undergone a [[major surgery]] in the past 2 weeks.<ref name="PowersRabinstein2019" />
*[[Alteplase|IV alteplase]] for [[ischemic stroke]] is contraindicated in patients with a severe [[head trauma]] or [[Subarachnoid hemorrhage|subarachnoid hemorrage]] in the preceding 3 months.<ref name="PowersRabinstein2019" />

====Tenecteplase====

*[[Tenecteplase]] may be useful in patients with minor [[neurological]] impairment.<ref name="HuangCheripelli2015">{{cite journal|last1=Huang|first1=Xuya|last2=Cheripelli|first2=Bharath Kumar|last3=Lloyd|first3=Suzanne M|last4=Kalladka|first4=Dheeraj|last5=Moreton|first5=Fiona Catherine|last6=Siddiqui|first6=Aslam|last7=Ford|first7=Ian|last8=Muir|first8=Keith W|title=Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study|journal=The Lancet Neurology|volume=14|issue=4|year=2015|pages=368–376|issn=14744422|doi=10.1016/S1474-4422(15)70017-7}}</ref>
*The dose of [[tenecteplase]] is a single IV [[bolus]] of 0.25-mg/kg (maximum 25 mg).<ref name="CampbellMitchell2018">{{cite journal|last1=Campbell|first1=Bruce C.V.|last2=Mitchell|first2=Peter J.|last3=Churilov|first3=Leonid|last4=Yassi|first4=Nawaf|last5=Kleinig|first5=Timothy J.|last6=Dowling|first6=Richard J.|last7=Yan|first7=Bernard|last8=Bush|first8=Steven J.|last9=Dewey|first9=Helen M.|last10=Thijs|first10=Vincent|last11=Scroop|first11=Rebecca|last12=Simpson|first12=Marion|last13=Brooks|first13=Mark|last14=Asadi|first14=Hamed|last15=Wu|first15=Teddy Y.|last16=Shah|first16=Darshan G.|last17=Wijeratne|first17=Tissa|last18=Ang|first18=Timothy|last19=Miteff|first19=Ferdinand|last20=Levi|first20=Christopher R.|last21=Rodrigues|first21=Edrich|last22=Zhao|first22=Henry|last23=Salvaris|first23=Patrick|last24=Garcia-Esperon|first24=Carlos|last25=Bailey|first25=Peter|last26=Rice|first26=Henry|last27=de Villiers|first27=Laetitia|last28=Brown|first28=Helen|last29=Redmond|first29=Kendal|last30=Leggett|first30=David|last31=Fink|first31=John N.|last32=Collecutt|first32=Wayne|last33=Wong|first33=Andrew A.|last34=Muller|first34=Claire|last35=Coulthard|first35=Alan|last36=Mitchell|first36=Ken|last37=Clouston|first37=John|last38=Mahady|first38=Kate|last39=Field|first39=Deborah|last40=Ma|first40=Henry|last41=Phan|first41=Thanh G.|last42=Chong|first42=Winston|last43=Chandra|first43=Ronil V.|last44=Slater|first44=Lee-Anne|last45=Krause|first45=Martin|last46=Harrington|first46=Timothy J.|last47=Faulder|first47=Kenneth C.|last48=Steinfort|first48=Brendan S.|last49=Bladin|first49=Christopher F.|last50=Sharma|first50=Gagan|last51=Desmond|first51=Patricia M.|last52=Parsons|first52=Mark W.|last53=Donnan|first53=Geoffrey A.|last54=Davis|first54=Stephen M.|title=Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke|journal=New England Journal of Medicine|volume=378|issue=17|year=2018|pages=1573–1582|issn=0028-4793|doi=10.1056/NEJMoa1716405}}</ref>

====Antiplatelet therapy====

*Administration of [[aspirin]] is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with [[Alteplase|IV alteplase]], aspirin administration is generally delayed until 24 hours later.<ref name="JeongKim2016">{{cite journal|last1=Jeong|first1=Han-Gil|last2=Kim|first2=Beom Joon|last3=Yang|first3=Mi Hwa|last4=Han|first4=Moon-Ku|last5=Bae|first5=Hee-Joon|last6=Lee|first6=Seung-Hoon|title=Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment|journal=Neurology|volume=87|issue=10|year=2016|pages=996–1002|issn=0028-3878|doi=10.1212/WNL.0000000000003083}}</ref>
*The dose of [[aspirin]] is usually between 160-300mg daily.<ref name="pmid9174558">{{cite journal |vauthors= |title=The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group |journal=Lancet |volume=349 |issue=9065 |pages=1569–81 |date=May 1997 |pmid=9174558 |doi= |url=}}</ref>
*[[Aspirin|IV aspirin]] administration within 90 minutes after the start of [[Alteplase|IV alteplase]] is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.<ref name="PowersRabinstein2019" /><ref name="ZinkstokRoos2012">{{cite journal|last1=Zinkstok|first1=Sanne M|last2=Roos|first2=Yvo B|title=Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial|journal=The Lancet|volume=380|issue=9843|year=2012|pages=731–737|issn=01406736|doi=10.1016/S0140-6736(12)60949-0}}</ref>
*[[Dual antiplatelet therapy]] with [[aspirin]] and [[clopidogrel]] (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after [[symptom]] onset and continued for 21 days in patients with no cardioembolic [[ischemic stroke]].<ref name="JohnstonEaston2018">{{cite journal|last1=Johnston|first1=S. Claiborne|last2=Easton|first2=J. Donald|last3=Farrant|first3=Mary|last4=Barsan|first4=William|last5=Conwit|first5=Robin A.|last6=Elm|first6=Jordan J.|last7=Kim|first7=Anthony S.|last8=Lindblad|first8=Anne S.|last9=Palesch|first9=Yuko Y.|title=Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA|journal=New England Journal of Medicine|volume=379|issue=3|year=2018|pages=215–225|issn=0028-4793|doi=10.1056/NEJMoa1800410}}</ref>
*[[Aspirin]] should not substitute [[Alteplase|IV alteplase]] or mechanical thrombectomy in patients eligible for these therapies.<ref name="PowersRabinstein2019" />

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! rowspan="2" style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Medical treatment}}
! rowspan="2" style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF|Drug class}}
! colspan="2" style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Recommendations}}
|-
! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Acute}}
! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Long-Term}}
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Reperfusion therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tissue plasminogen activator|'''Tissue plasminogen activator''']] '''(t-PA)'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref><ref name="pmid 22315273">{{cite journal| author=Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE et al.| title=Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e601S-36S | pmid= 22315273 | doi=10.1378/chest.11-2302 | pmc=3278065 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315273 }} </ref><ref>{{cite web|url=http://www.aaem.org/em-resources/position-statements/clinical-practice/thrombolytic-therapy |title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke |publisher=American Academy of Emergency Medicine |accessdate=2008-01-25}}</ref> and [[systematic review]]s<ref name="pmid25871671">{{cite journal| author=Prabhakaran S, Ruff I, Bernstein RA| title=Acute stroke intervention: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 14 | pages= 1451-62 | pmid=25871671 | doi=10.1001/jama.2015.3058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871671 }} </ref><ref name="pmid25072528">{{cite journal| author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ| title=Thrombolysis for acute ischaemic stroke. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 7 | issue= | pages= CD000213 | pmid=25072528 | doi=10.1002/14651858.CD000213.pub3 | pmc=4153726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528 }} </ref><ref name="pmid25106063">{{cite journal| author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.| title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. | journal=Lancet | year= 2014 | volume= | issue= | pages= | pmid=25106063 | doi=10.1016/S0140-6736(14)60584-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* None
|-
| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antithrombotic agents'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Antiplatelet agents|'''Antiplatelet agents''']]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Oral administration of [[aspirin]] (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
*Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
*DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term therapy with [[clopidogrel]] or aspirin extended release [[dipyridamole]] may be used for secondary prevention of non cardioembolic stroke
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Anticoagulants]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke<ref name="pmid17204681"> {{cite journal |author=Paciaroni M, Agnelli G, Micheli S, Caso V |title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials |journal=Stroke |volume=38 |issue=2 |pages=423-30 | year=2007 |pmid=17204681 |doi=10.1161/01.STR.0000254600.92975.1f }} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis]</ref>

| style="padding: 5px 5px; background: #F5F5F5;" |
*Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease<ref name="pmid17577005">{{cite journal |author=Hart RG, Pearce LA, Aguilar MI |title=Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation |journal=Ann. Intern. Med. |volume=146 |issue=12 |pages=857-67 |year=2007 |pmid=17577005 |doi=}}</ref>
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Antilipid therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Statins]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease
*Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
|-
| rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antihypertensive therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Intravenous [[antihypertensives]]'''
'''([[Labetalol|Labetolol]], [[nitroprusside]])'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Oral antihypertensive therapy'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Recommended after 24 hours in patient having [[hypertension]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Antihyperglycemic agents'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Insulin]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205 }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with [[diabetes mellitus]]
|-
|}

== 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<ref name="pmid31662037">{{cite journal| author=Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K | display-authors=etal| title=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. | journal=Stroke | year= 2019 | volume= 50 | issue= 12 | pages= e344-e418 | pmid=31662037 | doi=10.1161/STR.0000000000000211 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31662037 }}</ref> ==

=== IV Alteplase Eligibility ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' Administration of IV alteplase in eligible patients without first obtaining MRI to exclude cerebral microbleeds (CMBs) is recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|-
| bgcolor="LightGreen" |'''2.'''In patients eligible for IV alteplase, because benefit of therapy is time dependent, treatment should be initiated as quickly as possible and not delayed for additional multimodal neuroimaging, such as CT and MRI perfusion imaging.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.''' In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5 hours from last known well or at baseline state, MRI to identify diffusion-positive FLAIR-negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== IV Alteplase - General Priniciples ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' In patients eligible for IV alteplase, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|-
| bgcolor="LightGreen" |'''2.''' In patients undergoing fibrinolytic therapy, physicians should be prepared to treat potential emergent adverse effects, including bleeding complications and angioedema that may cause partial airway obstruction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|-
| bgcolor="LightGreen" |'''3.''' The potential risks should be discussed during IV alteplase eligibility deliberation and weighed against the anticipated benefits during decision- making.''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

=== Time Windows ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who can be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 8 to determine patient eligibility.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|-
| bgcolor="LightGreen" |'''2.''' IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 8 to determine patient eligibility. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.'''IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) administered within 4.5 hours of stroke symptom recognition can be beneficial in patients with AIS who awake with stroke symptoms or have unclear time of onset >4.5 hours from last known well or at baseline state and who have a DW-MRI lesion smaller than one-third of the MCA territory and no visible signal change on FLAIR. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Antiplatelet Treatment ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|-
| bgcolor="LightGreen" |'''2.''' In patients presenting with minor noncardioembolic ischemic stroke (NIHSS score ≤3) who did not receive IV alteplase, treatment with dual antiplatelet therapy (aspirin and clopidogrel) started within 24 hours after symptom onset and continued for 21 days is effective in reducing recurrent ischemic stroke for a period of up to 90 days from symptom onset. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.'''The efficacy of the IV glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide in the treatment of AIS is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Anticoagulants ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.''' The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|-
| bgcolor="LemonChiffon" |'''2.''' The safety and usefulness of short-term anticoagulation for nonocclusive, extracranial intraluminal thrombus in the setting of AIS are not well established.. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]-LD)''
|-
| bgcolor="LemonChiffon" |'''3.''' At present, the usefulness of argatroban, dabigatran, or other thrombin inhibitors for the treatment of patients with AIS is not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|-
| bgcolor="LemonChiffon" |'''4.''' The safety and usefulness of oral factor Xa inhibitors in the treatment of AIS are not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]-LD)''
|}
== 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association<ref name="pmid34024117">{{cite journal| author=Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D | display-authors=etal| title=2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. | journal=Stroke | year= 2021 | volume= 52 | issue= 7 | pages= e364-e467 | pmid=34024117 | doi=10.1161/STR.0000000000000375 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34024117 }}</ref> ==

=== Recommendations for Intracranial Large Artery Atherosclerosis Referenced studies that support recommendations are summarized in online Data Supplements 20-27 ===

==== Antithrombotic therapy ====
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with a stroke or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg/d is recommended in preference to warfarin to reduce the risk of recurrent ischemic stroke and vascular death.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99%) of a major intracranial artery, the addition of clopidogrel 75 mg/d to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with recent (within 24 hours) minor stroke or high-risk TIA and concomitant ipsilateral >30% stenosis of a major intracranial artery, the addition of ticagrelor 90 mg twice a day to aspirin for up to 30 days might be considered to further reduce recurrent stroke risk.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
4. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered to reduce recurrent stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
5. In patients with stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, the usefulness of clopidogrel alone, the combination of aspirin and dipyridamole, ticagrelor alone, or cilostazol alone for secondary stroke prevention is not well established.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

==== Risk Factor Management ====
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |6. In patients with a stroke or TIA attributable to 50% to 99% stenosis of a major intracranial artery, maintenance of SBP below 140 mm Hg, high-intensity statin therapy, and at least moderate physical activity are recommended to prevent recurrent stroke and vascular events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

==== Angioplasty and Stenting ====
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |7. In patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140 mm Hg, and high- intensity statin therapy (so-called medical failures), the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Extracranial Carotid Stenosis Referenced studies that support recommendations are summarized in online Data Supplement 28 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |3. In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid-lowering therapy, and treatment of hypertension, is recommended to reduce stroke risk''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}

=== Recommendations for Extracranial Vertebral Artery Stenosis Referenced studies that support recommendations are summarized in online Data Supplement 28 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with recently symptomatic extracranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid lowering, BP control) is recommended to reduce stroke risk.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
|}

=== Recommendations for Aortic Arch Atherosclerosis Referenced studies that support recommendations are summarized in online Data Supplement 29 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with a stroke or TIA and evidence of an aortic arch atheroma, intensive lipid management to an LDL cholesterol target <70 mg/dL is recommended to prevent recur-rent stroke''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
2. In patients with a stroke or TIA and evidence of an aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Moyamoya Disease Referenced studies that support recommendations are summarized in online Data Supplement 30 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1. In patients with moyamoya disease and a history of ischemic stroke or TIA, surgical revascularization with direct or indirect extracranial-intracranial bypass can be beneficial for the prevention of ischemic stroke or TIA''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |2. In patients with moyamoya disease and a history of ischemic stroke or TIA, the use of anti-platelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA may be reasonable.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Small Vessel Stroke Referenced studies that support the recommendation are summarized in online Data Supplement 31 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |1.In patients with ischemic stroke related to small vessel disease, the usefulness of cilostazol for secondary stroke prevention is uncertain''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Recommendations for AF Referenced studies that support recommendations are summarized in online Data Supplement 32 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with nonvalvular AF and stroke or TIA, oral anticoagulation (eg, apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
2. In patients with AF and stroke or TIA, oral anticoagulation is indicated to reduce the risk of recurrent stroke regardless of whether the AF pattern is paroxysmal, persistent, or permanent.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
3. In patients with stroke or TIA and AF who do not have moderate to severe mitral stenosis or a mechanical heart valve, apixaban, dabigatran, edoxaban, or rivaroxaban is recommended in preference to warfarin to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
4. In patients with atrial flutter and stroke or TIA, anticoagulant therapy similar to that in AF is indicated to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
5. In patients with AF and stroke or TIA, without moderate to severe mitral stenosis or a mechanical heart valve, who are unable to maintain a therapeutic INR level with warfarin, use of dabigatran, rivaroxaban, apixaban, or edoxaban is recommended to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |6. In patients with stroke at high risk of hemorrhagic conversion in the setting of AF, it is reasonable to delay initiation of oral anticoagulation beyond 14 days to reduce the risk of ICH.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
7. In patients with TIA in the setting of nonvalvular AF, it is reasonable to initiate anticoagulation immediately after the index event to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}

{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |8. In patients with stroke or TIA in the setting of nonvalvular AF who have contraindications for lifelong anticoagulation but can tolerate at least 45 days, it may be reasonable to consider percutaneous closure of the left atrial appendage with the Watchman device to reduce the chance of recurrent stroke and bleeding.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
9. In patients with stroke at low risk for hemorrhagic conversion in the setting of AF, it may be reasonable to initiate anticoagulation 2 to 14 days after the index event to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
10. In patients with AF and stroke or TIA who have end-stage renal disease or are on dialysis, it may be reasonable to use warfarin or apixaban (dose adjusted if indicated) for anticoagulation to reduce the chance of recurrent stroke.
''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

=== Recommendations for Valvular Disease Referenced studies that support recommendations are summarized in online Data Supplement 33 and 34 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and valvular AF (moderate to severe mitral steno-sis or any mechanical heart valve), warfarin is recommended to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
2. In patients with a mechanical mitral valve and a history of ischemic stroke or TIA before valve replacement, aspirin (75–100 mg/d) is recommended in addition to warfarin with an INR target of 3.0 (range, 2.5–3.5) to reduce the risk of thrombosis and recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD)]]''
3. In patients with ischemic stroke or TIA and native aortic or nonrheumatic mitral valve disease (eg, mitral annular calcification or mitral valve prolapse) who do not have AF or another indication for anticoagulation, anti-platelet therapy is recommended to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
4. In patients with a bioprosthetic aortic or mitral valve, a history of ischemic stroke or TIA before valve replacement, and no other indication for anticoagulation therapy beyond 3 to 6 months from the valve placement, long-term therapy with aspirin is recommended in preference to long-term anticoagulation to reduce the risk of recur-rent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|-
|
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |6. In patients with history of ischemic stroke or TIA and a mechanical aortic valve, anti-coagulation with higher-intensity warfarin to achieve an INR of 3.0 (range, 2.5–3.5) or the addition of aspirin (75–100 mg/d) can be beneficial to reduce the risk of thromboembolic events''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}

=== Recommendations for LV Thrombus Referenced studies that support recommendations are summarized in online Data Supplement 35 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with stroke or TIA and LV thrombus, anticoagulation with therapeutic warfarin for at least 3 months is recommended to reduce the risk of recurrent stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with stroke or TIA and new LV thrombus (<3 months), the safety of anticoagulation with a direct oral anticoagulant to reduce risk of recurrent stroke is uncertain.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD)]]''
4. In patients with stroke or TIA in the setting of acute anterior MI with reduced ejection fraction (EF; <50%) but no evidence of LV thrombus, empirical anticoagulation for at least 3 months might be considered to reduce the risk of recurrent cardioembolic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO)]]''
|}

=== Recommendations for Cardiomyopathy Referenced studies that support recommendations are summarized in online Data Supplements 36 and 37 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and left atrial or left atrial appendage thrombus in the setting of ischemic, nonischemic, or restrictive cardiomyopathy and LV dysfunction, anticoagulant therapy with warfarin is recommended for at least 3 months to reduce the risk of recurrent stroke or TIA. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA in the setting of a mechanical assist device, treatment with warfarin and aspirin can be beneficial to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
3. In patients with ischemic stroke or TIA in the setting of LV noncompaction, treatment with warfarin can be beneficial to reduce the risk of recurrent stroke or TIA. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |4. In patients with ischemic stroke or TIA in sinus rhythm with ischemic or nonischemic cardio-myopathy and reduced EF without evidence of left atrial or LV thrombus, the effectiveness of anticoagulation compared with antiplatelet therapy is uncertain, and the choice should be individualized.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

=== Recommendations for Congenital Heart Disease Referenced studies that support recommendations are summarized in online Data Supplements 40 and 41 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA and Fontan palliation, anticoagulation with warfarin is recommended to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with cyanotic congenital heart disease and other complex lesions, ischemic stroke or TIA of presumed cardioembolic origin, therapy with warfarin is reasonable to reduce the risk of recurrent stroke or TIA''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}

=== Recommendations for Dissection Referenced studies that support recommendations are summarized in online Data Supplements 43 and 44 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA after an extracranial carotid or vertebral arterial dis-section, treatment with antithrombotic therapy for at least 3 months is indicated to prevent recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA who are <3 months after an extracranial carotid or vertebral arterial dissection, it is reasonable to use either aspirin or warfarin to prevent recur-rent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |3. In patients with stroke or TIA and extracranial carotid or vertebral artery dissection who have recurrent events despite antithrombotic therapy, endovascular therapy may be considered to prevent recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Hematologic Traits Referenced studies that support the recommendation are summarized in online Data Supplement 45 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1. In patients with ischemic stroke or TIA of unknown source despite thorough diagnostic evaluation and no other thrombotic history who are found to have prothrombin 20210A mutation, activated protein C resistance, elevated factor VIII levels, or deficiencies of protein C, protein S, or antithrombin III, anti-platelet therapy is reasonable to reduce the risk of recurrent stroke or TIA ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendations for Antiphospholipid Syndrome Referenced studies that support recommendations are summarized in online Data Supplement 46 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with ischemic stroke or TIA who have an isolated antiphospholipid antibody but do not fulfill the criteria for antiphospholipid syndrome, antiplatelet therapy alone is recommended to reduce the risk of recurrent stroke. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with ischemic stroke or TIA with confirmed antiphospholipid syndrome treated with warfarin, it is reasonable to choose a target INR between 2 and 3 over a target INR >3 to effectively balance the risk of excessive bleeding against the risk of thrombosis.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
3. In patients with ischemic stroke or TIA who meet the criteria for the antiphospholipid syndrome, it is reasonable to anticoagulate with warfarin to reduce the risk of recurrent stroke or TIA.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}

=== Recommendation for Malignancy Referenced studies that support the recommendation are summarized in online Data Supplement 48 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1. In patients with ischemic stroke or TIA in the setting of AF and cancer, it is reasonable to consider anticoagulation with DOACs in preference to warfarin for stroke prevention ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}

=== Recommendations for Sickle Cell Disease Referenced studies that support recommendations are summarized in online Data Supplement 49 ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with sickle cell disease (SCD) and prior ischemic stroke or TIA, chronic blood transfusion(s) to reduce hemoglobin S to <30% of total hemoglobin is recommended for the prevention of recurrent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with SCD with prior ischemic stroke or TIA for whom transfusion therapy is not available or practical, treatment with hydroxyurea is reasonable for the prevention of recurrent ischemic stroke.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

'''For AHA/ASA guidelines for Intravenous Fibrinolysis in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Intravenous Fibrinolysis|click here]]<br>
'''For AHA/ASA guidelines for General Supportive Care and Treatment of Acute Complications in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Supportive Care and Treatment of Acute Complications|click here]]<br>
'''For AHA/ASA guidelines on anticoagulants usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Anticoagulants|click here]]<br>
'''For AHA/ASA guidelines on antiplatelets usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Antiplatelets|click here]]<br>
'''For AHA/ASA guidelines on volume resuscitation usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Volume Expansion, Vasodilators, and Induced Hypertension|click here]]<br>
'''For AHA/ASA guidelines on neuroprotective agents in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Neuroprotective Agents|click here]]<br>
'''For AHA/ASA guidelines on General Stroke Care in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Stroke Care|click here]]

==References==
{{reflist|2}}

{{WS}}
{{WH}}

Ischemic stroke medical therapy

2023-01-19T14:50:11Z

Laith Adnan Allaham:

Ischemic stroke medical therapy

2023-01-18T02:04:51Z

Laith Adnan Allaham:

2023-01-12T14:28:27Z

Laith Adnan Allaham:

Ischemic stroke CT

2023-01-12T14:24:51Z

Laith Adnan Allaham:

2022-12-14T03:27:18Z

Laith Adnan Allaham:

Atrial fibrillation catheter ablation

2022-12-14T03:26:55Z

Laith Adnan Allaham:

__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br>
| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{| class="infobox" style="float:right;"
|-
| [[File:Critical_Pathways.gif|88px|link=Atrial fibrillation critical pathways]]|| <br> || <br>
|}
{| class="infobox" style="float:right;"
|-
| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]
|}
{{Atrial fibrillation}}
{{CMG}}; {{AE}} {{CZ}} {{Anahita}} {{VR}} {{Laith}}

==Overview==
In [[patients]] with [[atrial fibrillation]] where [[heart rate|rate]] control [[medications|drugs]] are ineffective and it is not possible to restore [[sinus rhythm]] using [[cardioversion]], non-[[pharmacology|pharmacological]] alternatives are available. One of the techniques used is called [[catheter ablation]], where the bundle of [[Cell (biology)|cells]] that pace the [[heart]] in the [[atrioventricular node]], are destroyed using [[radiofrequency]] energy source, the dominant energy source for [[catheter ablation]]. [[Cryoablation]] has more recently been developed as a tool for [[atrial fibrillation]] ([[atrial fibrillation|AF]]) [[ablation]] procedures. Other energy sources and tools are in various stages of development and/or clinical investigation. There are three classes of indications for using [[catheter ablation]] for [[atrial fibrillation]] ([[atrial fibrillation|AF]]). The cornerstone for most [[atrial fibrillation]] [[ablation]] procedures are [[ablation]] strategies that target the [[pulmonary veins]] and/or [[pulmonary vein|pulmonary vein antrum]] while electrical isolation is the goal. Due to high risk of [[thromboembolism]] in [[patients]] with [[atrial fibrillation]], careful attention and starting [[anticoagulation]] in [[atrial fibrillation]] [[patients]] before, during, and after [[ablation]] is important. Moreover, possible [[Complication (medicine)|complications]] and [[Adverse effect (medicine)|adverse effects]] associated with [[catheter ablation]] in [[atrial fibrillation]] [[patients]] should be considerd.

==Indications for Catheter and Surgical Ablation==
*The indications of [[ablation]] among [[patients]] with [[atrial fibrillation]] are stratified as class I, class IIa, class IIb, and class III.<ref name="Sarabanda-2005">{{Cite journal | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
*One of the primary indications (class I) of [[ablation]] among [[patients]] with [[atrial fibrillation]] is the presence of [[symprtom|symptomatic]] [[atrial fibrillation]], which is refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>
*Balloon-based [[ultrasound]] [[ablation]] and [[Laser ablation|laser based ablation]] systems have also been developed for [[ablation]] of [[atrial fibrillation]] ([[AF]]).<ref>{{Cite journal | last1 = Meininger | first1 = GR. | last2 = Calkins | first2 = H. | last3 = Lickfett | first3 = L. | last4 = Lopath | first4 = P. | last5 = Fjield | first5 = T. | last6 = Pacheco | first6 = R. | last7 = Harhen | first7 = P. | last8 = Rodriguez | first8 = ER. | last9 = Berger | first9 = R. | title = Initial experience with a novel focused ultrasound ablation system for ring ablation outside the pulmonary vein. | journal = J Interv Card Electrophysiol | volume = 8 | issue = 2 | pages = 141-8 | month = Apr | year = 2003 | doi = | PMID = 12766506 }}</ref><ref>{{Cite journal | last1 = Metzner | first1 = A. | last2 = Chun | first2 = KR. | last3 = Neven | first3 = K. | last4 = Fuernkranz | first4 = A. | last5 = Ouyang | first5 = F. | last6 = Antz | first6 = M. | last7 = Tilz | first7 = R. | last8 = Zerm | first8 = T. | last9 = Koektuerk | first9 = B. | title = Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation. | journal = Europace | volume = 12 | issue = 2 | pages = 188-93 | month = Feb | year = 2010 | doi = 10.1093/europace/eup416 | PMID = 20089752 }}</ref><ref>{{Cite journal | last1 = Neven | first1 = K. | last2 = Schmidt | first2 = B. | last3 = Metzner | first3 = A. | last4 = Otomo | first4 = K. | last5 = Nuyens | first5 = D. | last6 = De Potter | first6 = T. | last7 = Chun | first7 = KR. | last8 = Ouyang | first8 = F. | last9 = Kuck | first9 = KH. | title = Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 260-5 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.922930 | PMID = 20504943 }}</ref><ref name="Metzner-2011">{{Cite journal | last1 = Metzner | first1 = A. | last2 = Schmidt | first2 = B. | last3 = Fuernkranz | first3 = A. | last4 = Wissner | first4 = E. | last5 = Tilz | first5 = RR. | last6 = Chun | first6 = KR. | last7 = Neven | first7 = K. | last8 = Konstantinidou | first8 = M. | last9 = Rillig | first9 = A. | title = One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation. | journal = Heart Rhythm | volume = 8 | issue = 7 | pages = 988-93 | month = Jul | year = 2011 | doi = 10.1016/j.hrthm.2011.02.030 | PMID = 21354329 }}</ref><ref name="pmid16908781">{{cite journal |author=Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL |title=ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society |journal=[[Circulation]] |volume=114 |issue=7 |pages=e257–354 |year=2006 |month=August |pmid=16908781 |doi=10.1161/CIRCULATIONAHA.106.177292 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16908781 |accessdate=2013-01-07}}</ref>
===Class I Indications===
In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III]] [[antiarrhythmic medication]], [[catheter ablation]] is recommended.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>

===Class IIa Indications===
*In [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] is reasonable.<ref name="Sarabanda-2005">{{Cite journal | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
*In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]], prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with either [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[catheter ablation]] is reasonable.
*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]], refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[surgery|surgical]] [[ablation]] is reasonable.
*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|persistent AF]], refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[surgery|surgical ablation]] is reasonable.
*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]], refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[surgery|surgical ablation]] is reasonable.
*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with either [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[surgery|surgical ablation]] is reasonable.
*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|persistent AF]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with either [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[surgery|surgical ablation]] is reasonable.

===Class IIb Indications===
*In [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] may be considered.<ref name="Sarabanda-2005">{{Cite journal | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
*In [[patients]] with [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] may be considered.
*In [[patients]] with [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] may be considered.
*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[surgery|surgical ablation]] may be considered.
*In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have not failed [[catheter ablation]] but prefer a [[surgery|surgical approach]].
*In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have failed one or more attempts at [[catheter ablation]].
*In [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one tion|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have not failed [[catheter ablation]] but prefer a [[surgery|surgical approach]].
*In [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one tion|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have failed one or more attempts at [[catheter ablation]].
*In [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have not failed [[catheter ablation]] but prefer a [[surgery|surgical approach]].
*In [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have failed one or more attempts at [[catheter ablation]].

===Class III Indications===
In [[symptom|symptomatic]] paroxysmal or persistent or longstanding persistent [[atrial fibrillation]] [[patients]], prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], stand alone [[surgery|surgical ablation]] is not recommended.<ref name="Sarabanda-2005">{{Cite journal | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>

==Recommendations Regarding Catheter Ablation Technique==
*The cornerstone for most [[atrial fibrillation]] [[ablation]] procedures are [[ablation]] strategies that target the [[pulmonary veins]] and/or [[pulmonary vein|pulmonary vein antrum]].<ref name="pmid14557355">{{cite journal| author=Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E | display-authors=etal| title=Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. | journal=Circulation | year= 2003 | volume= 108 | issue= 19 | pages= 2355-60 | pmid=14557355 | doi=10.1161/01.CIR.0000095796.45180.88 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557355 }} </ref><ref name="pmid15604320">{{cite journal| author=Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M| title=Catheter ablation for atrial fibrillation. | journal=Heart | year= 2005 | volume= 91 | issue= 1 | pages= 7-9 | pmid=15604320 | doi=10.1136/hrt.2003.030205 | pmc=1768634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15604320 }} </ref>
*While targeting the [[pulmonary veins]], electrical isolation should be the goal.<ref name="pmid14557355">{{cite journal| author=Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E | display-authors=etal| title=Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. | journal=Circulation | year= 2003 | volume= 108 | issue= 19 | pages= 2355-60 | pmid=14557355 | doi=10.1161/01.CIR.0000095796.45180.88 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557355 }} </ref>
*Electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the [[pulmonary vein]].<ref name="pmid14557355">{{cite journal| author=Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E | display-authors=etal| title=Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. | journal=Circulation | year= 2003 | volume= 108 | issue= 19 | pages= 2355-60 | pmid=14557355 | doi=10.1161/01.CIR.0000095796.45180.88 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557355 }} </ref><ref name="pmid15604320">{{cite journal| author=Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M| title=Catheter ablation for atrial fibrillation. | journal=Heart | year= 2005 | volume= 91 | issue= 1 | pages= 7-9 | pmid=15604320 | doi=10.1136/hrt.2003.030205 | pmc=1768634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15604320 }} </ref>
*Monitoring for [[pulmonary vein]] reconduction for 20 minutes following initial [[pulmonary vein]] isolation should be considered.
*Careful identification of the [[pulmonary vein]] ostia is mandatory to avoid [[ablation]] within the [[pulmonary veins]].
*If a focal trigger is identified outside a [[pulmonary vein]] at the time of an [[atrial fibrillation]] [[ablation]] procedure, [[ablation]] of that focal trigger should be considered.
*If additional linear lesions are applied, operators should consider using mapping and pacing maneuvers to assess for line completeness.
*[[Ablation]] of the [[Tricuspid valve|cavotricuspid isthmus]] (fibrous [[Tissue (biology)|tissue]] in the lower [[right atrium]] between the [[inferior vena cava]] and the |[[tricuspid valve]]) is recommended in [[patients]] with a history of typical [[atrial flutter]] or inducible [[tricuspid valve|cavotricuspid isthmus]] dependent [[atrial flutter]].<ref name="pmid15604320">{{cite journal| author=Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M| title=Catheter ablation for atrial fibrillation. | journal=Heart | year= 2005 | volume= 91 | issue= 1 | pages= 7-9 | pmid=15604320 | doi=10.1136/hrt.2003.030205 | pmc=1768634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15604320 }} </ref>
*If [[patients]] with long standing persistent [[atrial fbrillation]] are approached, operators should consider more extensive [[ablation]] based on linear lesions or complex fractionated electrograms.
*It is recommended that [[radiofrequency]] power be reduced when creating lesions along the posterior wall near the [[esophagus]].

==Radiofrequency Ablation==
*In [[patients]] with [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] who did not tolerate [[medications]] or when [[medications]] are not successful, [[radiofrequency ablation]] is recommended.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>
*To control rate it is possible to destroy the bundle of [[Cell (biology)|cells]] connecting the [[heart|upper and lower chambers of the heart]] - the [[atrioventricular node]] - which regulates [[heart rate]], and to implant a [[artificial pacemaker|pacemaker]] instead.<ref name="pmid16908781">{{cite journal |author=Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL |title=ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society |journal=[[Circulation]] |volume=114 |issue=7 |pages=e257–354 |year=2006 |month=August |pmid=16908781 |doi=10.1161/CIRCULATIONAHA.106.177292 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16908781 |accessdate=2013-01-07}}</ref>
*A more complex technique, which avoids the need for a [[Artificial pacemaker|pacemaker]], involves [[ablation|ablating]] groups of [[Cell (biology)|cells]] near the [[pulmonary veins]] where [[atrial fibrillation]] is thought to originate, or creating more extensive lesions in an attempt to prevent [[atrial fibrillation]] from establishing itself.<ref name="pmid16908781">{{cite journal |author=Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL |title=ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society |journal=[[Circulation]] |volume=114 |issue=7 |pages=e257–354 |year=2006 |month=August |pmid=16908781 |doi=10.1161/CIRCULATIONAHA.106.177292 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16908781 |accessdate=2013-01-07}}</ref>
*[[Ablation]] is a newer technique and has shown some promise for cases of recurrent [[atrial fibrillation]] that are unresponsive to conventional [[treatments]]. [[Radiofrequency ablation]] ([[RFA]]) uses radiofrequency energy to destroy abnormal electrical pathways in [[heart]] [[Tissue (biology)|tissue]].
*Radiofrequency energy is delivered by way of a [[vein|transvenous]] [[electrode]] [[catheter]]. The energy emitting probe ([[electrode]]) is placed into the [[heart]] through a [[catheter]] inserted into [[veins]] in the groin or [[neck]].
*[[Electrodes]] that can detect electrical activity from inside the [[heart]] are also inserted, and the [[Electrophysiology|electrophysiologist]] uses these to map an area of the [[heart]] in order to locate the abnormal electrical activity before eliminating the responsible [[Tissue (biology)|tissue]].
*Most [[atrial fibrillation]] [[ablations]] consist of isolating the electrical pathways from the [[pulmonary vein]]s ([[pulmonary vein|PV]]), which are located on the [[Anatomical terms of location|posterior]] wall of the [[left atrium]]. All other [[veins]] from the body (including [[neck]] and groin) lead to the [[right atrium]], so in order to get to the [[left atrium]] the [[catheters]] must get across the [[Interatrial septum|atrial septum]]. This is done by piercing a small hole in the [[Interatrial septum|septal wall]] (transseptal approach). Once the [[catheter]] is in the [[left atrium]], the [[physician]] may perform Wide Area Circumferential [[Ablation]] (WACA) to electrically isolate the [[pulmonary veins]] from the [[left atrium]].<ref name="urlMedscape Log In">{{cite web |url=http://www.medscape.com/viewarticle/532503_2 |title=Medscape Log In |format= |work= |accessdate=2013-01-09}}</ref><ref name="urlMiller Family Heart & Vascular Institute">{{cite web |url=http://www.clevelandclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm |title=Miller Family Heart & Vascular Institute |format= |work= |accessdate=2013-01-09}}</ref>
*Some more recent approaches to [[ablation|ablating]] [[atrial fibrillation]] is to target sites that are particularly disorganized in both [[atrium|atria]] as well as in the [[coronary sinus]] ([[coronary sinus|CS]]). The aforementioned sites are termed Complex Fractionated Atrial Electrogram (CFAE) sites.<ref>{{cite journal | author= Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. | title=A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate | journal=J Am Coll Cardiol | year=2004 | pages=2044–53 | volume=43 | issue=11 | pmid= 15172410 | doi= 10.1016/j.jacc.2003.12.054}}</ref>
*It is believed by some that the CFAE sites are the cause of [[atrial fibrillation]], or a combination of the [[pulmonary veins]] and CFAE sites are to blame.
*Most [[Tissue (biology)|tissues]] exposed to temperatures of 50 C or higher for more than several seconds will show irreversible [[coagulation necrosis]], and evolve into non-conducting myocardial scar.
*The following factors promote the formation of larger lesions and improve procedure efficacy:
**High power delivery
**Good [[electrode]]–[[Tissue (biology)|tissue]] contact
**Adequate [[ablation]] duration
*Significant [[Complication (medicine)|complications]] can occur during [[atrial fibrillation]] [[ablation]] if high radiofrequency power is administered in an uncontrolled fashion.
*The increased risk of [[atrial fibrillation]] [[ablation]] compared to [[ablation]] of other [[Cardiac arrhythmia|arrhythmias]] may be attributed to the great surface area of [[Tissue (biology)|tissue]] [[ablation|ablated]], the large cumulative energy delivery, the risk of systemic [[thromboembolism]], and the close location of structures susceptible to collateral [[injury]], such as [[phrenic nerve]], [[pulmonary veins]], and [[esophagus]].
*[[Thrombus]], char formation and intramural steam pops can also occur.
*[[Radiofrequency ablation|Conventional radiofrequency]] [[electrodes]] were employed earlier. But comparative trials against conventional radiofrequency [[electrodes]] have demonstrated that irrigated tip and large tip radiofrequency technologies have increased efficacy and decreased procedure duration.<ref name="Schreieck-2002">{{Cite journal | last1 = Schreieck | first1 = J. | last2 = Zrenner | first2 = B. | last3 = Kumpmann | first3 = J. | last4 = Ndrepepa | first4 = G. | last5 = Schneider | first5 = MA. | last6 = Deisenhofer | first6 = I. | last7 = Schmitt | first7 = C. | title = Prospective randomized comparison of closed cooled-tip versus 8-mm-tip catheters for radiofrequency ablation of typical atrial flutter. | journal = J Cardiovasc Electrophysiol | volume = 13 | issue = 10 | pages = 980-5 | month = Oct | year = 2002 | doi = | PMID = 12435182 }}</ref>

==Cryoablation==
*[[Cryoablation]] is recommended when [[radiofrequency ablation|point by point radiofrequency ablation]] is not proper in [[atrial fibrillation]] [[patients]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>
*[[Cryoablation]] is a new technique which uses cryothermal energy as an alternative energy source. In [[cryoablation]], [[Tissue (biology)|tissue]] freezing coolant, liquid [[nitrous oxide]] is delivered under [[pressure]] through a [[catheter]] where it changes to [[gas]], resulting in cooling of surrounding [[Tissue (biology)|tissue]]. [[Tissue (biology)|Tissue]] [[injury]] results from [[Tissue (biology)|tissue]] freezing with a creation of ice crystals within the [[Cell (biology)|cell]] that disrupts [[Cell (biology)|cell]] membranes and interrupts both [[Cell (biology)|cellular]] metabolism and any electrical activity in that [[Cell (biology)|cell]]. Interruption of microvascular [[perfusion]] also produces [[Cell (biology)|cell]] death by interrupting [[blood]] flow.<ref name="Friedman-2004">{{Cite journal | last1 = Friedman | first1 = PL. | last2 = Dubuc | first2 = M. | last3 = Green | first3 = MS. | last4 = Jackman | first4 = WM. | last5 = Keane | first5 = DT. | last6 = Marinchak | first6 = RA. | last7 = Nazari | first7 = J. | last8 = Packer | first8 = DL. | last9 = Skanes | first9 = A. | title = Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective frosty trial. | journal = Heart Rhythm | volume = 1 | issue = 2 | pages = 129-38 | month = Jul | year = 2004 | doi = 10.1016/j.hrthm.2004.02.022 | PMID = 15851143 }}</ref>
*More recently, a number of point-by-point and balloon-based [[cryoablation]] systems have been developed.<ref name="Friedman-2004">{{Cite journal | last1 = Friedman | first1 = PL. | last2 = Dubuc | first2 = M. | last3 = Green | first3 = MS. | last4 = Jackman | first4 = WM. | last5 = Keane | first5 = DT. | last6 = Marinchak | first6 = RA. | last7 = Nazari | first7 = J. | last8 = Packer | first8 = DL. | last9 = Skanes | first9 = A. | title = Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective frosty trial. | journal = Heart Rhythm | volume = 1 | issue = 2 | pages = 129-38 | month = Jul | year = 2004 | doi = 10.1016/j.hrthm.2004.02.022 | PMID = 15851143 }}</ref><ref name="Tse-2003">{{Cite journal | last1 = Tse | first1 = HF. | last2 = Reek | first2 = S. | last3 = Timmermans | first3 = C. | last4 = Lee | first4 = KL. | last5 = Geller | first5 = JC. | last6 = Rodriguez | first6 = LM. | last7 = Ghaye | first7 = B. | last8 = Ayers | first8 = GM. | last9 = Crijns | first9 = HJ. | title = Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis. | journal = J Am Coll Cardiol | volume = 42 | issue = 4 | pages = 752-8 | month = Aug | year = 2003 | doi = | PMID = 12932615 }}</ref>
*Point-by-point [[cryoablation]] approach is proved to be associated with low [[Complication (medicine)|complication]] rate, but the procedure is lengthy, and the long-term efficacy is limited. This ultimately paved way for the development of a [[cryoablation]] balloon [[ablation]] [[catheter]].
*Regional [[blood flow]] around the tip of the [[catheter]] or balloon influences the achievement of optimal [[cryoablation]]. Continuous [[blood flow]] reduces the chance of achieving a full-thickness [[cryoablation]]. Because of this, complete [[vein]] occlusion is required during the procedure.

==Ultrasound Ablation==
*Although [[radiofrequency ablation]] and [[cryoablation]] are the two standard [[ablation]] systems used for [[catheter]] [[ablation]] of [[atrial fibrillation]] today, balloon-based [[ultrasound]] [[ablation]] have also been developed for [[atrial fibrillation]] [[ablation]].<ref name="Metzner-2010">{{Cite journal | last1 = Metzner | first1 = A. | last2 = Chun | first2 = KR. | last3 = Neven | first3 = K. | last4 = Fuernkranz | first4 = A. | last5 = Ouyang | first5 = F. | last6 = Antz | first6 = M. | last7 = Tilz | first7 = R. | last8 = Zerm | first8 = T. | last9 = Koektuerk | first9 = B. | title = Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation. | journal = Europace | volume = 12 | issue = 2 | pages = 188-93 | month = Feb | year = 2010 | doi = 10.1093/europace/eup416 | PMID = 20089752 }}</ref><ref name="Neven-2010">{{Cite journal | last1 = Neven | first1 = K. | last2 = Schmidt | first2 = B. | last3 = Metzner | first3 = A. | last4 = Otomo | first4 = K. | last5 = Nuyens | first5 = D. | last6 = De Potter | first6 = T. | last7 = Chun | first7 = KR. | last8 = Ouyang | first8 = F. | last9 = Kuck | first9 = KH. | title = Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 260-5 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.922930 | PMID = 20504943 }}</ref>
*The first of the balloon [[ablation]] systems to be approved for clinical use is the focused [[ultrasound]] [[ablation]] system that uses [[high intensity focused ultrasound]] ([[high intensity focused ultrasound|HIFU]]).<ref name="Metzner-2010">{{Cite journal | last1 = Metzner | first1 = A. | last2 = Chun | first2 = KR. | last3 = Neven | first3 = K. | last4 = Fuernkranz | first4 = A. | last5 = Ouyang | first5 = F. | last6 = Antz | first6 = M. | last7 = Tilz | first7 = R. | last8 = Zerm | first8 = T. | last9 = Koektuerk | first9 = B. | title = Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation. | journal = Europace | volume = 12 | issue = 2 | pages = 188-93 | month = Feb | year = 2010 | doi = 10.1093/europace/eup416 | PMID = 20089752 }}</ref><ref name="Neven-2010">{{Cite journal | last1 = Neven | first1 = K. | last2 = Schmidt | first2 = B. | last3 = Metzner | first3 = A. | last4 = Otomo | first4 = K. | last5 = Nuyens | first5 = D. | last6 = De Potter | first6 = T. | last7 = Chun | first7 = KR. | last8 = Ouyang | first8 = F. | last9 = Kuck | first9 = KH. | title = Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 260-5 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.922930 | PMID = 20504943 }}</ref>

==Laser Ablation==
*[[Laser]] balloon [[ablation]] could be considered when [[radiofrequency ablation]] is not effective or tolerated.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>
*Balloon based [[laser ablation]] system involving a compliant balloon [[ablation]] [[catheter]] are being developed through which arcs of [[laser]] energy are delivered under visual guidance.<ref name="Dukkipati-2010">{{Cite journal | last1 = Dukkipati | first1 = SR. | last2 = Neuzil | first2 = P. | last3 = Skoda | first3 = J. | last4 = Petru | first4 = J. | last5 = d'Avila | first5 = A. | last6 = Doshi | first6 = SK. | last7 = Reddy | first7 = VY. | title = Visual balloon-guided point-by-point ablation: reliable, reproducible, and persistent pulmonary vein isolation. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 266-73 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.933283 | PMID = 20504945 }}</ref><ref name="Metzner-2011">{{Cite journal | last1 = Metzner | first1 = A. | last2 = Schmidt | first2 = B. | last3 = Fuernkranz | first3 = A. | last4 = Wissner | first4 = E. | last5 = Tilz | first5 = RR. | last6 = Chun | first6 = KR. | last7 = Neven | first7 = K. | last8 = Konstantinidou | first8 = M. | last9 = Rillig | first9 = A. | title = One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation. | journal = Heart Rhythm | volume = 8 | issue = 7 | pages = 988-93 | month = Jul | year = 2011 | doi = 10.1016/j.hrthm.2011.02.030 | PMID = 21354329 }}</ref>
*Small [[clinical trials]] have demonstrated the safety and effectiveness of this [[ablation]] system, which is now approved for use in Europe and is entering a pivotal randomized [[clinical trial]] in the United States.<ref name="Dukkipati-2010">{{Cite journal | last1 = Dukkipati | first1 = SR. | last2 = Neuzil | first2 = P. | last3 = Skoda | first3 = J. | last4 = Petru | first4 = J. | last5 = d'Avila | first5 = A. | last6 = Doshi | first6 = SK. | last7 = Reddy | first7 = VY. | title = Visual balloon-guided point-by-point ablation: reliable, reproducible, and persistent pulmonary vein isolation. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 266-73 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.933283 | PMID = 20504945 }}</ref><ref name="Metzner-2011">{{Cite journal | last1 = Metzner | first1 = A. | last2 = Schmidt | first2 = B. | last3 = Fuernkranz | first3 = A. | last4 = Wissner | first4 = E. | last5 = Tilz | first5 = RR. | last6 = Chun | first6 = KR. | last7 = Neven | first7 = K. | last8 = Konstantinidou | first8 = M. | last9 = Rillig | first9 = A. | title = One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation. | journal = Heart Rhythm | volume = 8 | issue = 7 | pages = 988-93 | month = Jul | year = 2011 | doi = 10.1016/j.hrthm.2011.02.030 | PMID = 21354329 }}</ref>

==Anticoagulation Strategies==
[[Atrial fibrillation]] [[patients]] are at increased risk of [[thromboembolism]] during, immediately following, and for several weeks to months after their [[ablation]]. Thus careful attention and starting [[anticoagulation]] in [[atrial fibrillation]] [[patients]] before, during, and after [[ablation]] for [[atrial fibrillation]] is important to avoid the occurrence of a [[thromboembolism|thromboembolic events]].

===Pre Ablation===
*In [[patients]] who have [[atrial fibrillation]] for 48 hours or longer or for an unknown duration, three weeks of systemic [[anticoagulants]] at a [[therapy|therapeutic level]] prior to the procedure is required.<ref name="Gopinath-2011">{{Cite journal | last1 = Gopinath | first1 = D. | last2 = Lewis | first2 = WR. | last3 = Di Biase | first3 = L. | last4 = Natale | first4 = A. | title = Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations. | journal = J Cardiovasc Electrophysiol | volume = 22 | issue = 2 | pages = 236-9 | month = Feb | year = 2011 | doi = 10.1111/j.1540-8167.2010.01940.x | PMID = 21044211 }}</ref>
*Prior to the [[ablation]] procedure a [[transesophageal echocardiography (TEE)|transesophageal echocardiography]] ([[TEE]]) should be performed in them.
*[[transesophageal echocardiography (TEE)|Transesophageal echocardiography]] ([[TEE]]) in [[atrial fibrillation]] [[patients]] who have [[sinus rhythm]] at the time of [[ablation]] or [[patients]] with current [[atrial fibrillation]] who also had [[atrial fibrillaton]] for 48 hours or less prior to [[atrial fibrillation]] [[ablation]] may be considered, but it is not mandatory.
*A [[left atrium|left atrial]] [[thrombus]] found during [[transesophageal echocardiography (TEE)|transesophageal echocardiography]] ([[TEE]]) is a [[contraindication]] for [[catheter]] [[ablation]] of [[atrial fibrillation]].
*[[Catheter]] [[ablation]] of [[trial fibrillation]] on a [[patient]] who is [[therapy|therapeutically]] [[anticoagulant|anticoagulated]] with [[warfarin]] should also be considered.<ref name="Gopinath-2011">{{Cite journal | last1 = Gopinath | first1 = D. | last2 = Lewis | first2 = WR. | last3 = Di Biase | first3 = L. | last4 = Natale | first4 = A. | title = Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations. | journal = J Cardiovasc Electrophysiol | volume = 22 | issue = 2 | pages = 236-9 | month = Feb | year = 2011 | doi = 10.1111/j.1540-8167.2010.01940.x | PMID = 21044211 }}</ref>

===During Ablation===
*[[Heparin]] should be administered prior to or immediately following transseptal puncture during [[atrial fibrillation]] [[ablation]] procedures.<ref name="Asbach-2011">{{Cite journal | last1 = Asbach | first1 = S. | last2 = Biermann | first2 = J. | last3 = Bode | first3 = C. | last4 = Faber | first4 = TS. | title = Early Heparin Administration Reduces Risk for Left Atrial Thrombus Formation during Atrial Fibrillation Ablation Procedures. | journal = Cardiol Res Pract | volume = 2011 | issue = | pages = 615087 | month = | year = 2011 | doi = 10.4061/2011/615087 | PMID = 21747989 }}</ref>
*[[Atrial fibrillation]] [[ablation]] in a [[patient]] who is systemically [[anticoagulant|anticoagulated]] with [[warfarin]] does not alter the need for [[Intravenous therapy|intravenous]] [[heparin]] to maintain a [[therapy|therapeutic]] [[activated clotting time]] (300 to 400 seconds) during the procedure.
*Administration of [[protamine]] following [[ablation]] to reverse [[heparin]] should be considered.

===Post Ablation===
*In [[patients]] who are not [[therapy|therapeutically]] [[anticoagulant|anticoagulated]] with [[warfarin]] at the time of [[atrial fibrillation]] [[ablation]], [[low molecular weight heparin]] or [[Intravenous therapy|intravenous]] [[heparin]] should be used to resume the systemic [[anticoagulant|anticoagulation]] with [[warfarin]] following [[atrial fibrillation]] [[ablation]].
*Initiation of a [[Direct thrombin inhibitor|direct thrombin]] or [[Direct Xa inhibitor|factor Xa inhibitor]] after [[ablation]] may be considered as an alternative post procedure [[anticoagulant|anticoagulation strategy]].<ref name="Mega-2012">{{Cite journal | last1 = Mega | first1 = JL. | last2 = Braunwald | first2 = E. | last3 = Wiviott | first3 = SD. | last4 = Bassand | first4 = JP. | last5 = Bhatt | first5 = DL. | last6 = Bode | first6 = C. | last7 = Burton | first7 = P. | last8 = Cohen | first8 = M. | last9 = Cook-Bruns | first9 = N. | title = Rivaroxaban in patients with a recent acute coronary syndrome. | journal = N Engl J Med | volume = 366 | issue = 1 | pages = 9-19 | month = Jan | year = 2012 | doi = 10.1056/NEJMoa1112277 | PMID = 22077192 }}</ref>
*A reduction in the dose of [[low molecular weight heparin]] (0.5 mg/kg) should be considered because of the increased risk of post procedure [[bleeding]] following a full [[dose]] (1 mg/kg bid).
*[[anticoagulant|Systemic anticoagulation]] with [[warfarin]] or a [[Direct thrombin inhibitor|direct thrombin]] or [[Direct Xa inhibitor|factor Xa inhibitor]] is recommended for at least two months following an [[atrial fibrillation]] [[ablation]] procedure. But decisions regarding the continuation of [[anticoagulant|systemic anticoagulation]] for more than two months following [[ablation]] should be based on the [[patients]] [[risk factors]] for [[stroke]].
*Discontinuation of [[anticoagulant|systemic anticoagulation]] [[therapy]] post [[ablation]] is not recommended in [[patients]] who are at high risk of [[stroke]].
*[[Patients]] in whom discontinuation of [[anticoagulant|systemic anticoagulation]] is being considered should consider undergoing continuous [[The electrocardiogram|ECG monitoring]] to screen for [[symptom|asymptomatic]] [[atrial fibrillation]].

==Outcomes and Efficacy of Catheter Ablation==
*Efficacy and risks of [[catheter]] [[ablation]] of [[atrial fibrillation]] are areas of active debate.<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref>
*A worldwide survey of the outcomes of 8745 [[ablation]] procedures demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of [[patients]] becoming [[symptom|asymptomatic]] with addition of an [[Antiarrhythmic agent|antiarrhythmic medication]].<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref>
**In 27.3% of [[patients]], more than one procedure was required to attain these results.
**There was at least one major [[complication]] in 6% of [[patients]].
*A thorough discussion of results of [[catheter]] [[ablation]] was published in 2007. <ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>
**It notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of [[Antiarrhythmic agent|antiarrhythmic therapy]], and in experience and technical proficiency.
==Prevention of Recurrence After Ablation==
*NICE guideline updated in 2021 recommends to use [[antiarrhythmic agents]] in order to prevent [[atrial fibrillation]] recurrence after [[ablation]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>
*It is important to consider [[patient]]'s preference and [[Adverse effect (medicine)|side effects]] before starting [[antiarrhythmic agents]].
*3 months after starting [[antiarrhythmic agents]] to prevent [[atrial fibrillation]] recurrence, [[patients]] should be evaluated and necessicity for continuing [[antiarrhythmic agents]] should be assessed again.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968 }} </ref>

==Complications of Catheter Ablation==
[[Catheter ablation]] of [[atrial fibrillation]] ([[AF]]) is one of the most complex interventional electrophysiologic procedures. Therefore the risk associated with [[atrial fibrillation]] ([[AF]]) [[ablation]] is higher. The following are [[Complication (medicine)|complications]] associated with [[catheter ablation]] of [[atrial fibrillation]] ([[AF]]).<ref name="Cappato-2009">{{Cite journal | last1 = Cappato | first1 = R. | last2 = Calkins | first2 = H. | last3 = Chen | first3 = SA. | last4 = Davies | first4 = W. | last5 = Iesaka | first5 = Y. | last6 = Kalman | first6 = J. | last7 = Kim | first7 = YH. | last8 = Klein | first8 = G. | last9 = Natale | first9 = A. | title = Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. | journal = J Am Coll Cardiol | volume = 53 | issue = 19 | pages = 1798-803 | month = May | year = 2009 | doi = 10.1016/j.jacc.2009.02.022 | PMID = 19422987 }}</ref><ref name="Hsu-2005">{{Cite journal | last1 = Hsu | first1 = LF. | last2 = Jaïs | first2 = P. | last3 = Hocini | first3 = M. | last4 = Sanders | first4 = P. | last5 = Scavée | first5 = C. | last6 = Sacher | first6 = F. | last7 = Takahashi | first7 = Y. | last8 = Rotter | first8 = M. | last9 = Pasquie | first9 = JL. | title = Incidence and prevention of cardiac tamponade complicating ablation for atrial fibrillation. | journal = Pacing Clin Electrophysiol | volume = 28 Suppl 1 | issue = | pages = S106-9 | month = Jan | year = 2005 | doi = 10.1111/j.1540-8159.2005.00062.x | PMID = 15683473 }}</ref><ref name="Ernst-2003">{{Cite journal | last1 = Ernst | first1 = S. | last2 = Ouyang | first2 = F. | last3 = Goya | first3 = M. | last4 = Löber | first4 = F. | last5 = Schneider | first5 = C. | last6 = Hoffmann-Riem | first6 = M. | last7 = Schwarz | first7 = S. | last8 = Hornig | first8 = K. | last9 = Müller | first9 = KM. | title = Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease. | journal = J Cardiovasc Electrophysiol | volume = 14 | issue = 4 | pages = 366-70 | month = Apr | year = 2003 | doi = | PMID = 12741706 }}</ref>

*[[atrium|Atrio]]-[[Esophagus|esophageal]] [[fistula]] and [[Esophagus|esophageal]] [[injury]]
*[[Bleeding]]
*[[heart|Cardiac]] perforation
*[[Cardiac tamponade]]
*Deep [[sternum|sternal]] [[wound]] [[infection]]/[[mediastinitis]] following [[heart|cardiac]] [[surgery]]
*[[Stomach|Gastric]] motility/[[Stomach|pyloric]] [[spasm]] disorders
*[[Myocardial infarction]]
*[[Pericarditis]]
*[[Phrenic nerve paralysis]]
*[[Pulmonary vein stenosis]]
*Silent [[cerebral embolism]]
*[[Stroke]] or [[Transient ischemic attack]] ([[Transient ischemic attack|TIA]]) post [[ablation]]
*Unanticipated [[Adverse effect (medicine)|adverse device effect]]
*[[Vagus nerve|Vagal nerve]] [[injury]]
*Vascular access [[Complication (medicine)|complications]] like [[hematoma]], [[AV fistula]] and [[pseudoaneurysm]]

== 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society<ref name="pmid30686041">{{cite journal| author=January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC | display-authors=etal| title=2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. | journal=Circulation | year= 2019 | volume= 140 | issue= 2 | pages= e125-e151 | pmid=30686041 | doi=10.1161/CIR.0000000000000665 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30686041 }}</ref> ==

=== Recommendation for Catheter Ablation in HF Referenced studies that support the new recommendation are summarized in Online Data Supplement 7 ===
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |1. AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF.S6.3.4-1,S6.3.4-2NEW: New evidence, including data on improved mortality rate, has been published for AF catheter ablation compared with medical therapy in patients with HF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>==

===Rhythm Control===

====AF catheter ablation to Maintain Sinus Rhythm====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III [[antiarrhythmic|antiarrhythmic medication]] when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Prior to consideration of [[AF]] [[catheter ablation]], assessment of the procedural risks and outcomes relevant to the individual patient is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] may be considered for symptomatic long-standing (>12 months) persistent [[AF]] refractory or intolerant to at least 1 class I or III [[antiarrhythmic|antiarrhythmic medication]], when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] may be considered prior to initiation of [[antiarrhythmic|antiarrhythmic drug therapy]] with a class I or III [[antiarrhythmic|antiarrhythmic medication]] for symptomatic persistent [[AF]], when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

==Sources==

* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>

==References==
{{reflist|2}}

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[[Category:Disease]]
[[Category:Emergency medicine]]

Atrial fibrillation

2022-12-14T03:26:40Z

Laith Adnan Allaham:

Atrial fibrillation specific patient groups

2022-12-14T03:26:21Z

Laith Adnan Allaham:

__NOTOC__
{| class="infobox" style="float:right;"
| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br>
| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Atrial fibrillation}}
{{CMG}}; {{AE}} {{CZ}} {{Laith}}

== 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society<ref name="pmid30686041">{{cite journal| author=January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC | display-authors=etal| title=2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. | journal=Circulation | year= 2019 | volume= 140 | issue= 2 | pages= e125-e151 | pmid=30686041 | doi=10.1161/CIR.0000000000000665 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30686041 }}</ref> ==

=== Recommendations for AF Complicating ACS Referenced studies that support new or modified recommendations are summarized in Online Data Supplement 8 ===
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. For patients with ACS and AF at increased risk of systemic thromboembolism (based on CHA2DS2-VASc risk score of 2 or greater), anticoagulation is recommended unless the bleeding risk exceeds the expected benefit.S7.4-1–S7.4-3MODIFIED: New published data are available. LOE was updated from C in the 2014 AF Guideline to B-R. Anticoagulation options are described in supportive text.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
2. Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control
''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''3. Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|}
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |4. If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone percutaneous coronary intervention (PCI) with stenting for ACS, it is reasonable to choose clopidogrel in preference to prasugrel.S7.4-4,S7.4-5NEW: New published data are available''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
5. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-3,S7.4-6–S7.4-8NEW: New RCT data and data from 2 registries and a retrospective cohort study are available.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
6. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with P2Y12 inhibitors (clopidogrel) and low-dose rivaroxaban 15 mg daily is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-2NEW: New published data are available
''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
7. In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple therapy.S7.4-1NEW: New published data are available''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |8. If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF who are at increased risk of stroke (based on CHA2DS2-VASc risk score of 2 or greater) and who have undergone PCI with stenting (drug eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4 to 6 weeks may be considered.S7.4-9,S7.4-10NEW: New published data are available.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
9. Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
0. Administration of nondihydropyridine calcium antagonists may be considered to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|}

=== Recommendations for Device Detection of AF and Atrial Flutter Referenced studies that support new recommendations are summarized in Online Data Supplement 9 ===

{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrillators), the presence of recorded atrial high-rate episodes (AHREs) should prompt further evaluation to document clinically relevant AF to guide treatment decisions.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR )]]''
|}

{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |2. In patients with cryptogenic stroke (ie, stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}

==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>==

===Specific Patient Groups and AF===

====Hypertrophic Cardiomyopathy====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Anticoagulation]] is indicated in patients with [[HCM]] with [[AF]] independent of the [[CHA2DS2-VASc score]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Antiarrhythmic|Antiarrhythmic medications]] can be useful to prevent recurrent [[AF]] in patients with [[HCM]]. [[Amiodarone]], or [[disopyramide]] combined with a [[beta]] blocker or [[calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium channel antagonists]] are reasonable therapies. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] can be beneficial in patients with [[HCM]] in whom a rhythm-control strategy is desired when [[antiarrhythmic drugs]] fail or are not tolerated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Sotalol]], [[dofetilide]], and [[dronedarone]] may be considered for a rhythm-control strategy in patients with [[HCM]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====AF Complicating Acute Coronary Syndrome====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Urgent direct-current [[cardioversion]] of new-onset [[AF]] in the setting of [[ACS]] is recommended for patients with [[hemodynamic]] compromise, ongoing [[ischemia]], or inadequate rate control. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Intravenous]] [[beta blockers]] are recommended to slow a rapid ventricular response to [[AF]] in patients with [[ACS]] who do not display [[HF]], [[hemodynamic]] instability, or [[bronchospasm]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For patients with [[ACS]] and [[AF]] with [[CHA2DS2-VASc score]] of 2 or greater, [[anticoagulation]] with [[warfarin]] is recommended unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Administration of [[amiodarone]] or [[digoxin]] may be considered to slow a rapid ventricular response in patients with [[ACS]] and [[AF]] associated with severe LV dysfunction and [[HF]] or [[hemodynamic]] instability. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Administration of [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonists]] might be considered to slow a rapid ventricular response in patients with [[ACS]] and [[AF]] only in the absence of significant [[HF]] or [[hemodynamic]] instability. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Hyperthyroidism====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Beta blockers]] are recommended to control ventricular rate in patients with [[AF]] complicating [[thyrotoxicosis]] unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In circumstances in which a [[beta blocker]] cannot be used, a [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] is recommended to control the ventricular rate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Pulmonary Disease====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' A [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] is recommended to control the ventricular rate in patients with [[AF]] and [[chronic obstructive pulmonary disease]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Direct-current [[cardioversion]] should be attempted in patients with pulmonary disease who become [[hemodynamic|hemodynamically]] unstable as a consequence of new onset [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Wolff-Parkinson-White and Pre-Excitation Syndromes====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Prompt direct-current [[cardioversion]] is recommended for patients with [[AF]], [[WPW]], and rapid ventricular response who are [[hemodynamic|hemodynamically]] compromised. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Intravenous]] [[procainamide]] or [[ibutilide]] to restore [[sinus rhythm]] or slow the ventricular rate is recommended for patients with [[pre-excitation|pre-excited]] [[AF]] and rapid ventricular response who are not hemodynamically compromised. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Catheter ablation]] of the [[accessory pathway]] is recommended in symptomatic patients with [[pre-excitation|pre-excited]] [[AF]], especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: No Benefit]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Administration of [[intravenous]] [[amiodarone]], [[adenosine]], [[digoxin]] (oral or [[intravenous]]), or [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonists]] (oral or [[intravenous]]) in patients with [[WPW syndrome]] who have [[pre-excitation|pre-excited]] [[AF]] is potentially harmful as these treatments accelerate the ventricular rate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

====Heart Failure====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Control of resting [[heart rate]] using either a [[beta blocker]] or a [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] is recommended for patients with persistent or permanent [[AF]] and compensated [[HF]] with preserved [[EF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In the absence of [[pre-excitation]], [[intravenous]] [[beta blocker]] administration (or a [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] in patients with [[HF|HFpEF]]) is recommended to slow the ventricular response to [[AF]] in the acute setting, with caution needed in patients with overt [[congestion]], [[hypotension]], or [[HF]] with reduced [[LVEF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In the absence of [[pre-excitation]], [[intravenous]] [[digoxin]] or [[amiodarone]] is recommended to control [[heart rate]] acutely in patients with [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Assessment of [[heart rate]] control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' [[Digoxin]] is effective to control resting [[heart rate]] in patients with [[HF]] with reduced [[EF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[AV node]] [[ablation]] should not be performed without a pharmacological trial to achieve ventricular rate control. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' For rate control, [[intravenous]] [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonists]], [[intravenous]] [[beta blockers]], and [[dronedarone]] should not be administered to patients with decompensated [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' A combination of [[digoxin]] and a [[beta blocker]] (or a [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] for patients with HFpEF), is reasonable to control resting and exercise heart rate in patients with [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' It is reasonable to perform [[AV node]] [[ablation with]] ventricular pacing to control [[heart rate]] when pharmacological therapy is insufficient or not tolerated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Intravenous]] [[amiodarone]] can be useful to control the [[heart rate]] in patients with [[AF]] when other measures are unsuccessful or contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' For patients with [[AF]] and rapid ventricular response causing or suspected of causing [[tachycardia]]-induced [[cardiomyopathy]], it is reasonable to achieve rate control by either [[AV node|AV nodal]] blockade or a rhythm-control strategy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' For patients with chronic [[HF]] who remain symptomatic from [[AF]] despite a rate-control strategy, it is reasonable to use a rhythm-control strategy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Oral [[amiodarone]] may be considered when resting and exercise [[heart rate]] cannot be adequately controlled using a [[beta blocker]] (or a [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] in patients with [[HF|HFpEF]]) or [[digoxin]], alone or in combination. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[AV node]] [[ablation]] may be considered when the rate cannot be controlled and [[tachycardia]]-mediated [[cardiomyopathy]] is suspected. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Familial (Genetic) AF====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with [[AF]] and multigenerational family members with [[AF]], referral to a tertiary care center for genetic counseling and testing may be considered. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Postoperative Cardiac and Thoracic Surgery====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Treating patients who develop [[AF]] after cardiac surgery with a [[beta blocker]] is recommended unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' A [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium antagonist]] is recommended when a [[beta blocker]] is inadequate to achieve rate control in patients with postoperative [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Preoperative administration of amiodarone reduces the incidence of [[AF]] in patients undergoing cardiac surgery and is reasonable as prophylactic therapy for patients at high risk for postoperative [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' It is reasonable to restore [[sinus rhythm]] pharmacologically with ibutilide or direct-current [[cardioversion]] in patients who develop postoperative [[AF]], as advised for nonsurgical patients. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' It is reasonable to administer [[antiarrhythmic|antiarrhythmic medications]] in an attempt to maintain [[sinus rhythm]] in patients with recurrent or refractory postoperative [[AF]], as advised for other patients who develop [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' It is reasonable to administer [[antithrombotic]] medication in patients who develop postoperative [[AF]], as advised for nonsurgical patients. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' It is reasonable to manage well-tolerated, new-onset postoperative [[AF]] with rate control and anticoagulation with cardioversion if [[AF]] does not revert spontaneously to sinus rhythm during follow-up. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Prophylactic administration of [[sotalol]] may be considered for patients at risk of developing [[AF]] following cardiac surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Administration of [[colchicine]] may be considered for patients postoperatively to reduce [[AF]] following cardiac surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

==Sources==

* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>

==References==

{{reflist|2}}

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