The following are key points to remember from a review article comparing American and European guideline recommendations for diagnostic workup and secondary prevention of ischemic stroke and transient ischemic attack (TIA):

1. Guidelines are important for guiding treatment decisions based on available evidence and to provide recommendations in areas of uncertainty.
2. The American Heart Association/American Stroke Association (AHA/ASA) guidelines and the European Stroke Organization (ESO) guidelines for stroke workup and secondary prevention are similar but differ in some recommendations.
3. Interestingly, 35% (22 of 63) of the ESO recommendations are based on expert opinion compared to 6% (5 of 82) of AHA/ASA recommendations. The authors suggest that “ESO exhibited a more cautious stance in determining the threshold for what constituted sufficient evidence.”
4. Key topics of agreement between the AHA/ASA and ESO guidelines include long-term antiplatelet use to reduce recurrent stroke; screening for carotid stenosis; consideration of long-term cardiac monitoring for cryptogenic stroke; short-term dual antiplatelet therapy after non-cardioembolic minor ischemic stroke or high-risk transient ischemic attack; use of a direct oral anticoagulant for secondary stroke prevention in nonvalvular atrial fibrillation (AF); avoiding angioplasty and stenting for intracranial arterial disease; carotid endarterectomy (CEA) in severe (70-99%) symptomatic carotid stenosis, targeting revascularization within 2 weeks of the index stroke/TIA; targeting a low-density lipoprotein cholesterol level of <70 mg/dL in atherosclerotic stroke etiology; and targeting a long-term blood pressure of <130/80 mm Hg.
5. The AHA/ASA guidelines recommend a TIA/stroke workup within 48 hours of the index event, whereas the ESO guidelines recommend this workup be completed within 24 hours.
6. The AHA/ASA guidelines recommend CEA for symptomatic moderate (50-69%) carotid stenosis depending on patient-specific factors including age and sex, whereas the ESO guidelines recommend CEA for symptomatic moderate stenosis independent of age and sex.
7. The AHA/ASA guidelines recommend consideration of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in very high-risk patients, whereas the ESO guidelines note that there is continued uncertainty regarding the use of PCSK9 inhibitors to reduce the risk of recurrent stroke.
8. The AHA/ASA guidelines recommend consideration of left atrial appendage occlusion with the Watchman device for patients with a contraindication to lifelong anticoagulation who can tolerate anticoagulation for 45 days. The ESO guidelines note that there are insufficient data to suggest a role for Watchman occlusion.
9. Areas of residual uncertainty include the timing of anticoagulation for AF after stroke; whether patent foramen ovale (PFO) closure is superior to long-term anticoagulation for secondary stroke prevention; and whether PFO closure is indicated in patients ≥60 years old.
10. The authors suggest that the AHA/ASA guidelines are more user-friendly than the ESO guidelines, as they attempt to provide practical advice in areas of uncertainty.

Clinical Topics: Prevention, Vascular Medicine

Keywords: Ischemic Attack, Transient, Ischemic Stroke, Secondary Prevention

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