For patients who have a noncardioembolic AIS while taking antiplatelet therapy, switching to warfarin is not indicated for secondary stroke prevention. III: No Benefit B-NR New recommendation. In patients taking aspirin at the time of baseline stroke in WARSS (Warfarin Aspirin Recurrent Stroke Study; n=181), there was no difference in recurrence of stroke between those randomized to remain on aspirin and those who In addition, post hoc analysis from the WASID trial found no difference in the primary outcome of ischemic stroke, brain hemorrhage, or vascular death in patients taking antiplatelet therapy at the time of their qualifying event who were subsequently randomized to warfarin.376,377 See Table LXXXIX in online Data Supplement 1. In patients with noncardioembolic ischemic stroke, treatment with triple antiplatelet therapy (aspirin+clopidogrel+dipyridamole) for secondary stroke prevention is harmful and should not be administered. III: Harm B-R New recommendation. The TARDIS trial (N=3096) was a multicenter, prospective, randomized, open-label trial conducted in Denmark, Georgia, New Zealand, and the United Kingdom of short-term triple antiplatelet therapy for secondary stroke prevention in patients with recent noncardioembolic ischemic stroke or TIA.350 The open-label treatment arms included aspirin+clopidogrel+dipyridamole versus either clopidogrel alone or aspirin and dipyridamole for 30 days from symptom onset. There was no benefit of triple therapy in prevention of stroke or TIA at 90 days (6% versus 7%; HR, 0.90 [95% CI, 0.67 1.20]; P=0.47). Moreover, there was a significant increase in risk of all hemorrhage (20% versus P=0.0063), and extracranial hemorrhage (HR, 2.37; 95% CI, 1.93 2.91; P<0.0001). See Table XLVIII in online Data Supplement 1. 6.6.2. Atrial Fibrillation COR LOE New, Revised, or Unchanged For most patients with an AIS in the setting of atrial fibrillation, it is reasonable to initiate oral anticoagulation between 4 and 14 days after the onset of neurological symptoms.


Atrial Fibrillation COR LOE New, Revised, or Unchanged For most patients with an AIS in the setting of atrial fibrillation, it is reasonable to initiate oral anticoagulation between 4 and 14 days after the onset of neurological symptoms. IIa B-NR Recommendation revised from 2014 Secondary Prevention. A multicenter prospective cohort of 1029 patients with AIS and newly diagnosed atrial fibrillation showed a better composite outcome of stroke, TIA, systemic embolism, sICH, and major extracranial bleeding within 90 days when anticoagulant was initiated 4 to 14 days from stroke onset (HR 0.53 [95% CI, 0.30 0.93] for starting anticoagulation at 4 14 days compared with <4 days); high CHA2 -VASc score, high NIHSS score, large ischemic lesions, and type of anticoagulation were associated with poorer outcomes.378 In a prospective, open-label study of 60 patients with atrial fibrillation and either mild to moderate AIS with NIHSS score <9 (n=49) or TIA (n=11) who were treated with rivaroxaban within14 days of onset, 50 were available for follow-up at 7 days after drug initiation. None developed symptomatic hemorrhagic transformation (HT). Of the 23 with AIS who had HT at baseline, 5 demonstrated asymptomatic radiographic progression, and 18 showed neither clinical nor radiographic progression. Of the remaining 27 who did not have HT at baseline, 3 developed asymptomatic HT.227 See Table LI in online Data Supplement 1. For patients with a history of ischemic stroke, atrial fibrillation, and coronary artery disease, the usefulness of adding antiplatelet therapy to oral anticoagulants is uncertain for purposes of reducing the risk of ischemic cardiovascular and cerebrovascular events. Unstable angina and coronary artery stenting represent special circumstances in which management may warrant dual antiplatelet/oral anticoagulation. IIb C-LD Recommendation reworded for clarity from 2014 Secondary Prevention. COR unchanged. LOE amended to conform with ACC/AHA 2015 Recommendation Classification System.


LOE amended to conform with ACC/AHA 2015 Recommendation Classification System. See Table XCV in online Data Supplement 1 for original wording. 6.6.3. Arterial Dissection COR LOE New, Revised, or Unchanged For patients with AIS and extracranial carotid or vertebral arterial dissection, treatment with either antiplatelet or anticoagulant therapy for 3 to 6 months is reasonable. IIa B-NR Recommendation revised from 2014 Secondary Prevention. Although there has not been a randomized trial of antithrombotic therapy versus placebo in patients with acute cervical artery dissection (CeAD), numerous observational studies and expert opinion suggest that it is reasonable to initiate antithrombotic therapy in the acute setting to prevent early thromboembolic events. The CADISS (Cervical Artery Dissection in Stroke Study) group published a randomized, open-label phase II feasibility trial of anticoagulation versus antiplatelet therapy in 250 participants with extracranial carotid or vertebral artery dissection recruited from 46 centers in the United Kingdom and Australia.379 The primary outcome was ipsilateral stroke or all-cause mortality within 3 months of randomization in an intention-to-treat analysis, and there were no significant differences between groups. There was also no difference in rates of major bleeding. As a phase II trial, the study concluded that a definitive phase III trial would not be feasible, primarily because of the low event rates in both groups. Additional limitations included a lack of central radiological confirmation in 20% of cases and a mean time to randomization of 3.65 days that perhaps limits generalizability of the results to the hyperacute period. Nonetheless, the CADISS trial supports numerous previous observational studies that found no significant difference in clinical outcomes with the use of anticoagulation compared with antiplatelet therapy in patients with CeAD.


Nonetheless, the CADISS trial supports numerous previous observational studies that found no significant difference in clinical outcomes with the use of anticoagulation compared with antiplatelet therapy in patients with CeAD. In addition, in a follow-up CADISS analysis of dissecting aneurysms (DAs), there was no association between treatment allocation (antiplatelets versus anticoagulants) and whether DAs at baseline persisted at follow-up or whether new DAs developed. During 12 months of follow-up, stroke occurred in 1 of 48 patients with DA and in 7 of 216 patients without DA (age- and sex-adjusted OR, 0.84 [95% CI, 0.10 7.31]; P=0.88). A review of published studies, mainly retrospective, showed a similarly low risk of stroke and no evidence of an increased stroke rate in patients with DA.380 These data provide evidence that DAs may have a benign prognosis, and therefore, medical treatment should be considered. See Tables LI and XC in online Data Supplement 1. For patients with AIS and extracranial carotid or extracranial vertebral arterial dissection who have definite recurrent cerebral ischemic events despite medical therapy, the value of extracranial EVT (stenting) is not well established. IIb C-LD Recommendation revised from 2014 Secondary Prevention. There have been no controlled trials of EVT and stenting in patients with extracranial CeAD. The published literature reflects small case series, individual case reports, and several systematic reviews.381 A systematic review of the literature published until 2009 found 31 published reports (N=140) with a technical success rate of 99% and procedural complication rate of 1.3%. However, these observational data are prone to selection and reporting biases. A retrospective analysis of patients with CeAD (n=161) comparing extracranial EVT (with and without stenting) with medical therapy alone found no difference in 90-day outcomes (adjusted OR, 0.62 [95% CI, 0.12 3.14]; P=0.56).


A retrospective analysis of patients with CeAD (n=161) comparing extracranial EVT (with and without stenting) with medical therapy alone found no difference in 90-day outcomes (adjusted OR, 0.62 [95% CI, 0.12 3.14]; P=0.56). With medical therapy alone, the overall prognosis and natural history of CeAD, including DAs, are favorable.379,380 Therefore, the benefit of extracranial EVT and stenting in patients with CeAD and definite recurrent cerebral ischemic events despite medical therapy is not well established. See Table LI in online Data Supplement 1. Powers et al 2019 Guidelines for Management of AIS e395 6.6.4. Hemorrhagic Transformation COR LOE New, Revised, or Unchanged For patients with AIS and HT, initiation or continuation of antiplatelet or anticoagulation therapy may be considered, depending on the specific clinical scenario and underlying indication. IIb C-LD Recommendation revised from 2014 Secondary Prevention. Several observational studies suggest that antithrombotics can be safely initiated or continued in patients with AIS and HT. In a prospective, open-label study of 60 patients with atrial fibrillation and either mild to moderate AIS with an NIHSS score <9 (n=49) or TIA (n=11) who were treated with rivaroxaban within 14 days of onset, 50 were available for follow-up at 7 days after drug initiation. None developed symptomatic HT. Of the 23 with AIS who had HT at baseline, 5 demonstrated asymptomatic radiographic progression, and 18 showed neither clinical nor radiographic progression. Of the remaining 27 who did not have HT at baseline, 3 developed asymptomatic HT.227 A retrospective stroke registry analysis identified 222 patients with AIS and HT. The frequency of composite events (neurological deterioration, vascular events, and death) at 1 month was significantly lower in patients treated with antithrombotics compared with those who were not (1.6% versus 11.1%; P=0.041).


The frequency of composite events (neurological deterioration, vascular events, and death) at 1 month was significantly lower in patients treated with antithrombotics compared with those who were not (1.6% versus 11.1%; P=0.041). Neither antiplatelet (n=72) nor anticoagulant (n=28) treatment after HT was associated with enlargement of the original HT or development of new HT or neurological deterioration.382 Individual assessment of the clinical indication, benefits, and associated risks is warranted.10,382,383 See Table LI in online Data Supplement 1. 6.7. Carotid Revascularization 6.7. Carotid Revascularization COR LOE New, Revised, or Unchanged When revascularization is indicated for secondary prevention in patients with minor, nondisabling stroke (mRS score 0 2), it is reasonable to perform the procedure between 48 hours and 7 days of the index event rather than delay treatment if there are no contraindications to early revascularization. IIa B-NR Recommendation revised from 2014 Secondary Prevention. The risk of recurrent stroke resulting from symptomatic carotid stenosis is highest in the first few days after the initial Although there is evidence that early or emergency revascularization via either CEA or carotid angioplasty and stenting may be safe in selected cases,330 332 there are no high-quality prospective data supporting early versus late carotid revascularization in all cases.333 In cases of minor, nondisabling stroke, a meta-analysis by De Rango et demonstrates favorable rates of complications when treated at least 48 hours after the initial event, and the risks are not different when treated between 0 to 7 and 0 to 15 days. Revascularization between 48 hours and 7 days after initial stroke is supported by these data in cases of nondisabling stroke (mRS score 0 2).334 See Table LXXVIII in online Data Supplement 1. 6.8. Treatment of Hyperlipidemia 6.8.1.


Revascularization between 48 hours and 7 days after initial stroke is supported by these data in cases of nondisabling stroke (mRS score 0 2).334 See Table LXXVIII in online Data Supplement 1. 6.8. Treatment of Hyperlipidemia 6.8.1. General Principles COR LOE New, Revised, or Unchanged Patients with AIS should be managed according to the 2018 ACC/AHA Cholesterol Guidelines, which include lifestyle modification, dietary recommendations, and medication recommendations. I A Recommendation, COR, and LOE updated from 2014 Secondary Prevention to reference 2018 Cholesterol Guidelines The 2018 Cholesterol Guidelines provide a comprehensive set of recommendations for managing hyperlipidemia.19 Those recommendations that are most pertinent to the in-hospital management of patients with AIS are excerpted here. The full guidelines should be used for guidance in managing these disorders in patients with AIS and for supporting evidence. In adults who are 20 years of age or older and not on lipid-lowering therapy, measurement of either a fasting or a nonfasting plasma lipid profile is effective in estimating atherosclerotic cardiovascular disease (ASCVD) risk and documenting baseline low-density lipoprotein cholesterol (LDL-C). I B-NR Recommendation unchanged from 2018 Cholesterol Guidelines. Adherence to changes in lifestyle and effects of LDL-C lowering medication should be assessed by measurement of fasting lipids and appropriate safety indicators 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter based on need to assess adherence or safety. I A Recommendation unchanged from 2018 Cholesterol Guidelines. 6.8.2. Choice of Lipid-lowering Drugs for Patients with Clinical ASCVD* COR LOE New, Revised, or Unchanged In patients who are 75 years of age or younger with clinical ASCVD, high- intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels. I A Recommendation unchanged from 2018 Cholesterol Guidelines.


Choice of Lipid-lowering Drugs for Patients with Clinical ASCVD* COR LOE New, Revised, or Unchanged In patients who are 75 years of age or younger with clinical ASCVD, high- intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels. I A Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, moderate- intensity statin therapy should be initiated or continued with the aim of achieving a 30% to 49% reduction in LDL-C levels. I A Recommendation unchanged from 2018 Cholesterol Guidelines. In patients at increased ASCVD risk with chronic, stable liver disease (including nonalcoholic fatty liver disease) when appropriately indicated, it is reasonable to use statins after obtaining baseline measurements and determining a schedule of monitoring and safety checks. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD, who are judged to be very high-risk and considered for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy, maximally tolerated LDL-C lowering therapy should include maximally tolerated statin therapy and ezetimibe. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD who are judged to be very high risk and who are on maximally tolerated LDL-C lowering therapy with LDL-C 70 mg/dL or higher ( 1.8 mmol/L) or a non HDL-C level of 100 mg/dL or higher ( 2.6 mmol/L), it is reasonable to add a PCSK9 inhibitor following a clinician patient discussion about the net benefit, safety, and cost. IIa A Recommendation unchanged from 2018 Cholesterol Guidelines. At mid-2018 list prices, PCSK9 inhibitors have a low cost value (>$150000 per quality-adjusted life-year) compared to good cost value (<$50000 per quality- adjusted life-year).


At mid-2018 list prices, PCSK9 inhibitors have a low cost value (>$150000 per quality-adjusted life-year) compared to good cost value (<$50000 per quality- adjusted life-year). Value Statement: Low Value (LOE: B-NR) Statement unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD who are on maximally tolerated statin therapy and are judged to be at very high risk and have an LDL-C level of 70 mg/dL or higher ( 1.8 mmol/L), it is reasonable to add ezetimibe therapy. IIa B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug drug interactions, as well as patient frailty and patient preferences. IIa B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients older than 75 years of age who are tolerating high-intensity statin therapy, it is reasonable to continue high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug-drug interactions, as well as patient frailty and patient preferences. IIa C-LD Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with clinical ASCVD who are receiving maximally tolerated statin therapy and whose LDL-C level remains 70 mg/dL or higher ( 1.8 mmol/L), it may be reasonable to add ezetimibe. IIb B-R Recommendation unchanged from 2018 Cholesterol Guidelines. *Clinical ASCVD includes acute coronary syndrome, those with history of MI, stable or unstable angina, or coronary or other arterial revascularization, stroke, TIA, or peripheral artery disease, including aortic aneurysm, all of atherosclerotic origin. For high-intensity statin therapy, the 2018 ACC/AHA Cholesterol Guidelines recommend atorvastatin 80 mg daily or rosuvastatin 20 mg daily. Please refer to these guidelines for contraindications to high-intensity statin therapy and recommendations for moderate-intensity statin therapy.


Please refer to these guidelines for contraindications to high-intensity statin therapy and recommendations for moderate-intensity statin therapy. Very high risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions: Major ASCVD Events: Recent acute coronary syndrome (within the past 12 months) History of MI (other than recent acute coronary syndrome event listed above) History of ischemic stroke Symptomatic peripheral arterial disease (history of claudication with ankle-brachial index <0.85, or previous revascularization or amputation. High-Risk Conditions: Age 65 years Heterozygous familial hypercholesterolemia History of prior coronary artery bypass surgery or percutaneous coronary intervention outside of the major ASCVD events Diabetes mellitus Hypertension Chronic kidney disease (estimated glomerular filtration rate 15 59 mL min 1 ) Current smoking 6.8.2. Choice of Lipid-lowering Drugs for Patients with Clinical ASCVD* (Continued) COR LOE New, Revised, or Unchanged Powers et al 2019 Guidelines for Management of AIS e397 6.8.3 Implementation COR LOE New, Revised, or Unchanged A clinician-patient risk discussion is recommended before initiation of statin therapy to review net clinical benefit, weighing the potential for ASCVD risk reduction against the potential for statin-associated side effects, statin-drug interactions, and safety, while emphasizing that side effects can be addressed successfully. I A Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with indication for statin therapy, identification of potential predisposing factors for statin-associated side effects, including new-onset diabetes mellitus and statin-associated muscle symptoms, is recommended before initiation of treatment. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients with statin-associated side effects that are not severe, it is recommended to reassess and to rechallenge to achieve a maximal LDL-C lowering by modified dosing regimen, an alternate statin or in combination with nonstatin therapy. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines.


In patients with statin-associated side effects that are not severe, it is recommended to reassess and to rechallenge to achieve a maximal LDL-C lowering by modified dosing regimen, an alternate statin or in combination with nonstatin therapy. I B-R Recommendation unchanged from 2018 Cholesterol Guidelines. In patients at increased ASCVD risk with severe statin-associated muscle symptoms or recurrent statin-associated muscle symptoms despite appropriate statin rechallenge, it is reasonable to use RCT-proven nonstatin therapy that is likely to provide net clinical benefit.384 386 IIa B-R Recommendation unchanged from 2018 Cholesterol Guidelines. 6.8.4. Timing COR LOE New, Revised, or Unchanged Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable. IIa B-R Recommendation and COR unchanged from 2013 AIS Guidelines. LOE amended to conform with ACC/AHA 2015 Recommendation Classification System. For patients with AIS who qualify for statin treatment, in-hospital initiation of statin therapy is reasonable. IIa C-LD New recommendation. Statins have an established role in secondary stroke prevention and harbor promise in improving index stroke A retrospective cohort study that assessed 3-month treatment adherence rates after in-hospital initiation of statins in patients with ischemic stroke showed a high rate of adherence to statin therapy 3 months after hospital discharge.387 A meta-analysis of primarily observational studies found that in-hospital statin use was associated with good functional outcomes.388 Withdrawal of statins after ischemic stroke was associated with poor functional outcomes. There are limited published randomized trials examining the role of early statin use in AIS patients. FASTER (Fast Assessment of Stroke and Transient Ischemic Attack to Prevent Early Recurrence) evaluated simvastatin 40 mg versus placebo in patients with a TIA or minor stroke within Because of slow enrollment, this trial was terminated early.


FASTER (Fast Assessment of Stroke and Transient Ischemic Attack to Prevent Early Recurrence) evaluated simvastatin 40 mg versus placebo in patients with a TIA or minor stroke within Because of slow enrollment, this trial was terminated early. There were no significant differences in recurrent stroke or safety outcomes in the simvastatin versus placebo groups. FASTER was underpowered because of early termination, and the statin doses used in FASTER were of moderate intensity (not the high-intensity dose recommended for secondary stroke prevention). ASSORT (Administration of Statin on Acute Ischemic Stroke Patient) showed no difference in 90-day mRS score when statins were begun within 24 hours or on the seventh day.390 See Tables XCI and XCII in online Data Supplement 1. 6.8.5 Special Patient Groups COR LOE New, Revised, or Unchanged Women of childbearing age who are treated with statin therapy and are sexually active should be counseled to use a reliable form of contraception. I C-LD Recommendation unchanged from 2018 Cholesterol Guidelines. Women of childbearing age with hypercholesterolemia who plan to become pregnant should stop the statin 1 to 2 months before pregnancy is attempted or, if they become pregnant while on a statin, should have the statin stopped as soon as the pregnancy is discovered. I C-LD Recommendation unchanged from 2018 Cholesterol Guidelines. In adults with advanced kidney disease that requires dialysis treatment who are currently on LDL-lowering therapy with a statin, it may be reasonable to continue the statin. IIb C-LD Recommendation unchanged from 2018 Cholesterol Guidelines. In adults with advanced kidney disease who require dialysis treatment, initiation of a statin is not recommended. III: No Benefit B-R Recommendation unchanged from 2018 Cholesterol Guidelines. 6.9. Institution of Antihypertensive Medications 6.9.


III: No Benefit B-R Recommendation unchanged from 2018 Cholesterol Guidelines. 6.9. Institution of Antihypertensive Medications 6.9. Institution of Antihypertensive Medications COR LOE New, Revised, or Unchanged Starting or restarting antihypertensive therapy during hospitalization in patients with BP >140/90 mmHg who are neurologically stable is safe and is reasonable to improve long-term BP control unless contraindicated. IIa B-R New recommendation. Starting or restarting antihypertensive medications has been shown to be associated with improved control of the BP after discharge in 2 trials.247,248 Therefore, it is reasonable to start or restart antihypertensive medications in the hospital when the patient remains hypertensive and is neurologically stable. Studies evaluating this question included only patients with previous diagnosis of hypertension247 or enrolled mostly patients with previous hypertension.248 However, because hypertension is not uncommonly first diagnosed during the hospitalization for stroke, it is reasonable to apply this recommendation also to patients without preexistent hypertension. See Table LVI in online Data Supplement 1. 6.10. Smoking Cessation Intervention 6.10. Smoking Cessation Intervention COR LOE New, Revised, or Unchanged Smokers with AIS should receive in-hospital initiation of high-intensity behavioral interventions to promote smoking cessation. I A New recommendation. For smokers with an AIS, who receive in-hospital initiation of high-intensity behavioral interventions to promote smoking cessation, nicotine replacement therapy is recommended. I A New recommendation. A 2012 meta-analysis by the Cochrane group indicates that high-intensity behavioral interventions that begin during an index hospitalization and include at least 1 month of supportive contact after discharge increased smoking cessation rates after discharge (RR, 1.37 [95% CI, 1.27 1.48]; 25 trials). The estimate of the effect for each level of intervention intensity among patients with a cardiovascular diagnosis was very similar (RR, 1.42 [95% CI, 1.29 1.56]).


The estimate of the effect for each level of intervention intensity among patients with a cardiovascular diagnosis was very similar (RR, 1.42 [95% CI, 1.29 1.56]). Adding nicotine replacement therapy to an intensive counselling intervention increased smoking cessation rates A 2016 retrospective cohort study of Korean smokers with AIS assessed a timely intervention strategy versus historical controls who received Timely intervention comprised a certified nurse providing comprehensive education during admission and additional counseling after discharge. Timely intervention was associated with greater odds of sustained smoking cessation for 12 months. See Table XCIII and XCIV in online Data Supplement 1. Healthcare providers should strongly advise every patient with AIS who has smoked in the past year to quit. I C-EO Recommendation reworded for clarity from 2014 Secondary Prevention. COR unchanged. LOE amended to conform with ACC/AHA 2015 Recommendation Classification System. See Table XCV in online Data Supplement 1 for original wording. It is reasonable to advise patients after ischemic stroke to avoid secondhand (passive) tobacco smoke. IIa B-NR Recommendation reworded for clarity from 2014 Secondary Prevention. COR unchanged. LOE amended to conform with ACC/AHA 2015 Recommendation Classification System. See Table XCV in online Data Supplement 1 for original wording. For smokers with an AIS, in-hospital initiation of varenicline to promote smoking cessation might be considered. IIb B-R New recommendation. A 2012 meta-analysis by the Cochrane group indicates that high-intensity behavioral interventions that begin during an index hospitalization and include at least 1 month of supportive contact after discharge increased smoking cessation rates after discharge (RR, 1.37 [95% CI, 1.27 1.48]; 25 trials). The estimate of the effect for each level of intervention intensity among patients with a cardiovascular diagnosis was very similar (RR, 1.42 [95% CI, 1.29 1.56]).


The estimate of the effect for each level of intervention intensity among patients with a cardiovascular diagnosis was very similar (RR, 1.42 [95% CI, 1.29 1.56]). There was insufficient direct evidence to conclude that adding bupropion or varenicline to intensive counseling increases cessation rates over what is achieved by counseling alone.391 A subsequent 2016 multicenter, double-blind, randomized, placebo-controlled trial in which 302 smokers hospitalized with an acute coronary syndrome were randomized to varenicline or placebo for 12 weeks showed that at 24 weeks abstinence rates were 47.3% in the varenicline group versus 32.5% in the placebo group. Continuous abstinence rates were 35.8% in the varenicline group versus 25.8% in the placebo group.393 Patients in both groups received low- intensity counseling. See Tables XCIII and XCIV in online Data Supplement 1. Powers et al 2019 Guidelines for Management of AIS e399 6.11. Stroke Education 6.11. Stroke Education COR LOE New, Revised, or Unchanged Patient education about stroke is recommended. Patients should be provided with information, advice, and the opportunity to talk about the impact of the illness on their lives. I C-EO Recommendation and COR unchanged from 2016 Rehab Guidelines. LOE revised. Additional reference support for this guideline is provided in online Data Supplement 1.394 544 Writing Group Disclosures Writing Group Member Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ Advisory Board Other William J.


Additional reference support for this guideline is provided in online Data Supplement 1.394 544 Writing Group Disclosures Writing Group Member Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ Advisory Board Other William J. Powers University of North Carolina, Chapel Hill None None None Wake Forest University Baptist Medical Center* None None None Alejandro A. Rabinstein Mayo Clinic None None None None None None None Teri Ackerson Saint Luke s Health System, AHA/ASA None None None None None None None Opeolu M. Adeoye University of Cincinnati None None None None None None None Nicholas C. Bambakidis University Hospitals, Cleveland Medical Center None None None None None None None Kyra Becker University of Washington School of Medicine, Harborview Medical Center None None None Defense and prosecution* None None None Jos Biller Loyola University Chicago None None None None None None None Michael Brown Michigan State University College of Human Medicine, Emergency Medicine None None None 2018 Defense, Sandberg, Phoenix & Von Gontard*; Kamykowski, Gavin & Smith* None None Cochrane (senior editor) Bart M. Demaerschalk Mayo Clinic, Mayo Clinic Hospital None None None None None None None Brian Hoh University of Florida None None None None None None None Edward C. Jauch Mission Health System Research Institute NINDS (StrokeNet coinvestigator)*; Diffusion Pharmaceuticals (PHAST-TSC DSMB member)* None None Plaintiff and defense* None Biogen* None Chelsea S. Kidwell University of Arizona None None None None None None None Thabele M. Leslie-Mazwi Massachusetts General Hospital None None None None None None None Bruce Ovbiagele UCSF None None None None None None None Disclosures (Continued) Phillip A. Scott University of Michigan Department of Emergency Medicine NIH (principal investigator) University of Michigan (co-medical director, Clinical Trials Support Unit)* None Expert testimony None None University of Michigan (associate chair, Research Department of Emergency Medicine) Kevin N. Sheth Yale University School of Medicine Astrocyte (advisory)*; Bard (PI, Stroke Trial) ; Biogen (PI Stroke Trial) ; Hyperfine (PI, Imaging Trial including stroke patients) ; Zoll (DSMB chair)* None None None Alva Health* Biogen* None Andrew M. Southerland University of Virginia Diffusion Pharmaceuticals, Inc (Prehospital Administration of Acute Stroke Therapy with Trans-sodium Crocetinate [PHAST- TSC]) ; NINDS UO1 Trial)*; NHLBI-NINDS (Cardiothoracic Surgical Trials Network) ; Coulter Translational Research Foundation (Brain and Neurological Deficit Identification Tool [BANDIT] Study)* None None Plaintiff and defense cases focused on questions related to stroke* iTREAT Project, US Patent Application No.


BANDIT Project, US Provisional Patent Application No. None None Deborah V. Summers Saint Luke s Health System None None None None None None None David L. Tirschwell Harborview Medical Center NIH None None None None None None This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity or owns $10000 or more of the fair market value of the entity. A relationship is considered to be modest if it is less than significant under the preceding definition. *Modest. Significant.


A relationship is considered to be modest if it is less than significant under the preceding definition. *Modest. Significant. Writing Group Disclosures Continued Writing Group Member Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ Advisory Board Other Reviewer Disclosures Reviewer Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ Advisory Board Other Mark J. Alberts Hartford HealthCare None None Genentech (speakers bureau) None None None None Joseph P. Broderick University of Cincinnati NIH (trial) ; NIH (investigator) Genentech (PRISMS) ; Genentech (TNK) None None None None None (Continued) Powers et al 2019 Guidelines for Management of AIS e401 Colin P. Derdeyn University of Iowa None None None None Pulse therapeutics* Penumbra* None Marc Fisher Beth Israel Deaconess Medical Center None None None None None None American Heart Association Karen L. Furie Rhode Island Hospital None None None None None None None Philip B. Gorelick Michigan State University None None None Employer received compensation for expert witness work None IMPACT clinical trial*; NeuroSpring* None Walter N. Kernan Yale University None None None None None None None Steven J. Kittner Veterans Affairs Maryland Health Care System; University of Maryland School of Medicine None None None None None None None Patrick D. Lyden Cedars-Sinai Medical Center NIH* None None None None None None Philip M. Meyers Columbia University None None None None None None None Jeffrey L. Saver UCLA None None None None Rapid Medical* Medtronic*; Stryker*; Neuravi/ Ceronovus*; Boehringer Ingelheim*; St. Jude Medical* University of California (employer)* Steven Warach University of Texas at Austin State of Texas None None Private law firm* Stock holdings in various pharma companies in a managed investment portfolio (myself)*; stock holdings in various pharma companies in a managed investment portfolio (family)* Genentech* None Lawrence R. Wechsler University of Pittsburgh None None None None None None None Babu G. Welch UT Southwestern Medical Center None None Stryker Neurovascular (speakers bureau)*; Stryker Neurovascular (honoraria)* None None Stryker Neurovascular* None This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit.


A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. A relationship is considered to be modest if it is less than significant under the preceding definition. *Modest. Significant. Reviewer Disclosures Continued Reviewer Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ Advisory Board Other References 1. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, QureshiAI, Rosenfield K, etal;onbehalfoftheAmericanHeartAssociationStrokeCouncil;Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare profession- als from the American Heart Association/American Stroke Association. 2. Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M, deVeber G, Ferro JM, Tsai FY; on behalf of the American Heart Association Stroke Council and the Council on Epidemiology and Prevention. Diagnosis and management of cere- bral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2a. 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. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association [published corrections appear in Stroke. 2018;49:e138 and Stroke. 2018;49:e233-234]. Stroke.


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