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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

Originally publishedhttps://doi.org/10.1161/STR.0000000000000211Stroke. 2019;50:e344–e418

Abstract

Background and Purpose—

The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines.

Methods—

Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format.

Results—

These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.

Conclusions—

These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

See related article, p 3331

New high-quality evidence has produced major changes in the evidence-based treatment of acute ischemic stroke (AIS) since the publication of the guidelines for the early management of patients with acute ischemic stroke in 2013.1 Much of this new evidence has been incorporated into American Heart Association (AHA) focused updates, guidelines, or scientific statements on specific topics relating to the management of patients with AIS since 2013. The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. These guidelines address prehospital care, urgent and emergency evaluation and treatment with intravenous (IV) and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are often begun during the initial hospitalization. We have restricted our recommendations to adults and to secondary prevention measures that are appropriately instituted within the first 2 weeks. We have not included recommendations for cerebral venous sinus thrombosis because these were covered in a 2011 scientific statement and there is no new evidence that would change those conclusions.2

An independent Evidence Review Committee was commissioned to perform a systematic review of a limited number of clinical questions identified in conjunction with the writing group, the results of which were considered by the writing group for incorporation into the “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke” (2018 AIS Guidelines)2a and this 2019 update. The systematic reviews for the 2018 AIS Guidelines have been previously published.3,4

These guidelines use the American College of Cardiology (ACC)/AHA Class of Recommendations (COR) and Level of Evidence (LOE) format shown in Table 1. New or revised recommendations that supersede previous guideline recommendations are accompanied by 250-word knowledge bytes and data supplement tables summarizing the key studies supporting the recommendations in place of extensive text. These data supplement tables can be found in Data Supplement 1 and literature search information for all data supplement tables can be found in Data Supplement 2. Because this guideline represents an update of the 2018 AIS Guidelines, the term “New Recommendation” refers to recommendations that are new to either the 2018 AIS Guidelines or to this 2019 update. Existing recommendations that are unchanged are reiterated with reference to the previous publication. These previous publications and their abbreviations used in this document are listed in Table 2. When there is no new pertinent evidence for these unchanged recommendations, no knowledge byte or data supplement is provided. For some unchanged recommendations, there are new pertinent data that support the existing recommendation, and these are provided. Additional abbreviations used in this guideline are listed in Table 3.

Table 1. Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)

Table 1.

Table 2. Guidelines, Policies, and Statements Relevant to the Management of AIS

Document TitleYear PublishedAbbreviation Used in This Document
“Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care: A Policy Statement From the American Heart Association”52009N/A
“Diagnosis and Management of Cerebral Venous Thrombosis: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”22011N/A
“Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”120132013 AIS Guidelines
“Interactions Within Stroke Systems of Care: A Policy Statement From the American Heart Association/American Stroke Association”620132013 Stroke Systems of Care
“2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society”72014N/A
“Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”820142014 Brain Swelling
“Palliative and End-of-Life Care in Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”920142014 Palliative Care
“Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”1020142014 Secondary Prevention
“Clinical Performance Measures for Adults Hospitalized With Acute Ischemic Stroke: Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association”112014N/A
“Part 15: First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid”1220152015 CPR/ECC
“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: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”1320152015 Endovascular
“Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”1420152015 IV Alteplase
“Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”1520162016 Rehab Guidelines
“Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”162017N/A
“Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”172017N/A
“2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”182018N/A
“2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”1920182018 Cholesterol Guidelines

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; AIS, acute ischemic stroke; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; CPR, cardiopulmonary resuscitation; ECC, emergency cardiovascular care; HRS, Heart Rhythm Society; IV, intravenous; N/A, not applicable; NLA, National Lipid Association; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.

Table 3. Abbreviations in This Guideline

ACCAmerican College of Cardiology
AHAAmerican Heart Association
AISAcute ischemic stroke
ARDAbsolute risk difference
ASAAmerican Stroke Association
ASCVDAtherosclerotic cardiovascular disease
ASPECTSAlberta Stroke Program Early Computed Tomography Score
BPBlood pressure
CEACarotid endarterectomy
CeADCervical artery dissection
CMBCerebral microbleed
CORClass of recommendation
CPAPContinuous positive airway pressure
CSConscious sedation
CTComputed tomography
CTAComputed tomographic angiography
CTPComputed tomographic perfusion
DTNDoor-to-needle
DVTDeep vein thrombosis
DW-MRIDiffusion-weighted magnetic resonance imaging
EDEmergency department
EMSEmergency medical services
EVTEndovascular therapy
GAGeneral anesthesia
GWTGGet With The Guidelines
HBOHyperbaric oxygen
HRHazard ratio
HTHemorrhagic transformation
ICHIntracerebral hemorrhage
IPCIntermittent pneumatic compression
IVIntravenous
LDL-CLow-density lipoprotein cholesterol
LMWHLow-molecular-weight heparin
LOELevel of evidence
LVOLarge vessel occlusion
M1Middle cerebral artery segment 1
M2Middle cerebral artery segment 2
M3Middle cerebral artery segment 3
MCAMiddle cerebral artery
MIMyocardial infarction
MRMagnetic resonance
MRAMagnetic resonance angiography
MRIMagnetic resonance imaging
mRSModified Rankin Scale
mTICIModified Thrombolysis in Cerebral Infarction
NCCTNoncontrast computed tomography
NIHSSNational Institutes of Health Stroke Scale
NINDSNational Institute of Neurological Disorders and Stroke
OROdds ratio
OSAObstructive sleep apnea
PFOPatent foramen ovale
RCTRandomized clinical trial
RRRelative risk
rt-PARecombinant tissue-type plasminogen activator
SBPSystolic blood pressure
sICHSymptomatic intracerebral hemorrhage
TIATransient ischemic attack
UFHUnfractionated heparin

Members of the writing committee were appointed by the AHA Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the AHA conflict-of-interest policy was maintained throughout the writing and consensus process. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. Writing group members accepted topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations. Draft recommendations and supporting evidence were discussed by the writing group, and the revised recommendations for each topic were reviewed by a designated writing group member. The full writing group then evaluated the complete guidelines. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft 2018 guidelines was performed by 4 expert peer reviewers and by the members of the Stroke Council’s Scientific Statements Oversight Committee and Stroke Council Leadership Committee. The 2018 AIS Guidelines were approved by the AHA Science Advisory and Coordinating Committee on November 29, 2017, and by the AHA Executive Committee on December 11, 2017. It was published online January 24, 2018. On April 18, 2018, the AHA published a revision to the AIS Guidelines online, deleting 7 specific recommendations and all of Section 6, In-Hospital Institution of Secondary Prevention. The writing group was asked to review the entire guideline, including the deleted recommendations. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials (RCTs) with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent out to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. This revised document was reviewed by Stroke Council’s Scientific Statements Oversight Committee and the AHA Science Advisory and Coordinating Committee. To allow these guidelines to be as timely as possible, RCTs addressing AIS published between November 2018 and April 2019 were reviewed by the writing group. Modifications of Section 3.5.6., Recommendation 1, Section 3.6., Recommendation 4, and Section 3.7.2., Recommendation 2 resulted. To allow these modifications to be incorporated, the standard peer review process was abbreviated, with review provided by the members of the Stroke Council’s Scientific Statements Oversight Committee and by liaisons from the endorsing organizations listed on the masthead. The list of these reviewers is provided at the end of the guideline. The final document was approved by the AHA Science Advisory and Coordinating Committee and Executive Committee.

These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. They will not be applicable to all patients. Local resources and expertise, specific clinical circumstances and patient preferences, and evidence published since the issuance of these guidelines are some of the additional factors that should be considered when making individual patient care decisions. In many instances, only limited data exist demonstrating the urgent need for continued research on treatment of AIS.

A focused update addressing data from additional relevant recent RCTs is in process.

1. Prehospital Stroke Management and Systems of Care

1.1. Prehospital Systems

1.2. EMS Assessment and Management

1.3. EMS Systems

1.4. Hospital Stroke Capabilities

1.5. Hospital Stroke Teams

1.6. Telemedicine

1.7. Organization and Integration of Components

1.8. Establishment of Data Repositories

1.9. Stroke System Care Quality Improvement Process

2. Emergency Evaluation and Treatment

2.1. Stroke Scales

Table 4. National Institutes of Health Stroke Scale

Tested ItemTitleResponses and Scores
1ALevel of consciousness0—Alert
1—Drowsy
2—Obtunded
3—Coma/unresponsive
1BOrientation questions (2)0—Answers both correctly
1—Answers 1 correctly
2—Answers neither correctly
1CResponse to commands (2)0—Performs both tasks correctly
1—Performs 1 task correctly
2—Performs neither
2Gaze0—Normal horizontal movements
1—Partial gaze palsy
2—Complete gaze palsy
3Visual fields0—No visual field defect
1—Partial hemianopia
2—Complete hemianopia
3—Bilateral hemianopia
4Facial movement0—Normal
1—Minor facial weakness
2—Partial facial weakness
3—Complete unilateral palsy
5Motor function (arm)0—No drift
a. Left1—Drift before 10 s
b. Right2—Falls before 10 s
3—No effort against gravity
4—No movement
6Motor function (leg)0—No drift
a. Left1—Drift before 5 s
b. Right2—Falls before 5 s
3—No effort against gravity
4—No movement
7Limb ataxia0—No ataxia
1—Ataxia in 1 limb
2—Ataxia in 2 limbs
8Sensory0—No sensory loss
1—Mild sensory loss
2—Severe sensory loss
9Language0—Normal
1—Mild aphasia
2—Severe aphasia
3—Mute or global aphasia
10Articulation0—Normal
1—Mild dysarthria
2—Severe dysarthria
11Extinction or inattention0—Absent
1—Mild loss (1 sensory modality lost)
2—Severe loss (2 modalities lost)

Adapted from Lyden et al.74 Copyright © 1994, American Heart Association, Inc.

2.2. Head and Neck Imaging

2.3. Other Diagnostic Tests

3. General Supportive Care and Emergency Treatment

3.1. Airway, Breathing, and Oxygenation

3.2. Blood Pressure

Table 5. Options to Treat Arterial Hypertension in Patients With AIS Who Are Candidates for Emergency Reperfusion Therapy*

Table 5.

3.3. Temperature

3.4. Blood Glucose

3.5. IV Alteplase

Table 6. Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After Administration of IV Alteplase for Treatment of AIS

Table 6.

Table 7. Management of Orolingual Angioedema Associated With IV Alteplase Administration for AIS

Table 7.

Table 8. Eligibility Recommendations for IV Alteplase in Patients With AIS

Table 8.

Table 9. Treatment of AIS: IV Administration of Alteplase

Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min.
Admit the patient to an intensive care or stroke unit for monitoring.
If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a worsening neurological examination, discontinue the infusion (if IV alteplase is being administered) and obtain emergency head CT scan.
Measure BP and perform neurological assessments every 15 min during and after IV alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase treatment.
Increase the frequency of BP measurements if SBP is >180 mm Hg or if DBP is >105 mm Hg; administer antihypertensive medications to maintain BP at or below these levels (Table 5).
Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them.
Obtain a follow-up CT or MRI scan at 24 h after IV alteplase before starting anticoagulants or antiplatelet agents.

AIS indicates acute ischemic stroke; BP, blood pressure; CT, computed tomography; DBP, diastolic blood pressure; IV, intravenous; MRI, magnetic resonance imaging; and SBP, systolic blood pressure.

Reprinted from Jauch et al.1 Copyright © 2013, American Heart Association, Inc.

3.6. Other IV Fibrinolytics and Sonothrombolysis

3.7. Mechanical Thrombectomy

3.8. Other Endovascular Therapies

3.9. Antiplatelet Treatment

3.10. Anticoagulants

3.11. Volume Expansion/Hemodilution, Vasodilators, and Hemodynamic Augmentation

3.12. Neuroprotective Agents

3.13. Emergency Carotid Endarterectomy Carotid Angioplasty and Stenting Without Intracranial Clot

3.14. Other

4. In-Hospital Management of AIS: General Supportive Care

4.1. Stroke Units

4.2 Head Positioning

4.3. Supplemental Oxygen

Note: Recommendations in this section are repeated from Section 3.1 because they apply to in-hospital management as well.

4.4. Blood Pressure

Note: Recommendation 1 in this section is repeated from Section 3.2 because it applies to in-hospital management as well.

4.5. Temperature

Note: Recommendations in this section are repeated from Section 3.3 because they apply to in-hospital management as well.

4.6. Glucose

Note: Recommendations in this section are repeated from Section 3.4 because they apply to in-hospital management as well.

4.7. Dysphagia

4.8. Nutrition

4.9. Deep Vein Thrombosis Prophylaxis

4.10. Depression Screening

4.11. Other

4.12. Rehabilitation

5. In-Hospital Management of AIS: Treatment of Acute Complications

5.1. Brain Swelling

5.2. Seizures

6. In-Hospital Institution of Secondary Stroke Prevention

The recommendations in this section reference other current AHA guidelines for secondary stroke prevention where applicable (Table 10). These other guidelines should be referred to for further information on secondary stroke prevention not covered in this document. These other guidelines are updated regularly, and the most recent versions should be used.

Table 10. Guidelines Relevant to Secondary Stroke Prevention

Document TitleYear PublishedAbbreviation Used in This Document
“Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”1020142014 Secondary Prevention
“2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”182017N/A
“2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines”1920182018 Cholesterol Guidelines

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; N/A, not applicable; NLA, National Lipid Association; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.

6.1. Brain Imaging

6.2. Vascular Imaging

6.3. Cardiac Evaluation

6.4. Glucose

6.5. Other Tests for Secondary Prevention

6.6. Antithrombotic Treatment

6.7. Carotid Revascularization

6.8. Treatment of Hyperlipidemia

6.9. Institution of Antihypertensive Medications

6.10. Smoking Cessation Intervention

6.11. Stroke Education

Additional reference support for this guideline is provided in online Data Supplement 1.394–544

Footnotes

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 12, 2019, and the American Heart Association Executive Committee on October 3, 2019. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 843-216-2533 or email .

The online-only Data Supplements are available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STR.0000000000000211.

The American Heart Association requests that this document be cited as follows: Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; on behalf of the American Heart Association Stroke Council. 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. Stroke. 2019;50:e344–e418 doi: 10.1161/STR.0000000000000211.

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

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