This is the current release of the guideline.

This guideline updates a previous version: Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sep;126(3 Suppl):483S-512S.

The grades of recommendation (1A, 1B, 1C, 2A, 2B, 2C) are defined at the end of the "Major Recommendations" field.

Intravenous (IV) Tissue Plasminogen Activator for Acute Ischemic Stroke within 3 Hours of Symptom Onset

1. For eligible patients (see inclusion and exclusion criteria listed below) the guideline developers recommend administration of IV tissue plasminogen activator (tPA) in a dose of 0.9 mg/kg (maximum of 90 mg), with 10% of the total dose given as an initial bolus and the remainder infused over 60 min, provided that treatment is initiated within 3 hours of clearly defined symptom onset (Grade 1A).

   Underlying values and preferences: This recommendation places relatively more weight on overall prospects for long-term functional improvement despite the increased risk of symptomatic intracerebral hemorrhage in the immediate peristroke period.

2. The guideline developers recommend that patients who are eligible for tPA be treated as quickly as possible within the 3-hour time limit (Grade 1A).

   Remark: All unnecessary delays must be avoided as the benefits of tPA therapy diminish rapidly over time.

3. For patients with extensive (more than one third of the middle cerebral artery territory) and clearly identifiable hypodensity on CT, the guideline developers suggest not using of tPA (Grade 2B).

IV tPA for Acute Ischemic Stroke between 3 to 6 Hours of Symptom Onset

For patients with acute ischemic stroke of > 3 hours but < 4.5 hours, the guideline developers suggest clinicians do not use IV tPA (Grade 2A). For patients with acute stroke onset of > 4.5 hours, the guideline developers recommend against the use of IV tPA (Grade 1A).

Underlying values and preferences: This recommendation assumes a relatively low value on small increases in long-term functional improvement, a relatively high value on avoiding acute intra cranial hemorrhage and death, and a relatively high degree of risk aversion.

IV Streptokinase for Acute Ischemic Stroke Between 0 hours and 6 hours of Symptom Onset

For patients with acute ischemic stroke, the guideline developers recommend against streptokinase (Grade 1A).

Intra-arterial Thrombolysis for Acute Ischemic Stroke

1. For patients with angiographically demonstrated middle cerebral artery occlusion and without major early infarct signs on the baseline computed tomography (CT) or magnetic resonance imaging (MRI) scan, who can be treated within 6 hours of symptom onset, the guideline developers suggest intra-arterial thrombolytic therapy with tPA for selected patients in centers with the appropriate neurologic and interventional expertise (Grade 2C).
2. For patients with acute basilar artery thrombosis and without major CT/MRI evidence of infarction, the guideline developers suggest either intra-arterial or intravenous (IV) thrombolysis with tPA depending on available resources and capabilities (Grade 2C).

Anticoagulants for Altering Outcomes Among Acute Stroke in Patients Not Eligible for Thrombolysis

For patients with acute ischemic stroke, the guideline developers recommend against full-dose anticoagulation with IV, subcutaneous (SC), or low-molecular-weight heparins or heparinoids (Grade 1B).

Antiplatelet Agents for Altering Outcomes in Acute Stroke Patients Not Eligible for Thrombolysis

For patients with acute ischemic stroke who are not receiving thrombolysis, the guideline developers recommend early aspirin therapy (initial dose of 150 to 325 mg) (Grade 1A).

Antithrombotic Therapy for Prevention of Deep Vein Thrombosis and Pulmonary Embolism in Acute Ischemic Stroke

1. For acute stroke patients with restricted mobility, the guideline developers recommend prophylactic low-dose SC heparin or low-molecular-weight heparins (Grade 1A).
2. For patients who have contraindications to anticoagulants, the guideline developers recommend intermittent pneumatic compression (IPC) devices or elastic stockings (Grade 1B).

IPC for Deep Vein Thrombosis/Pulmonary Embolism Prophylaxis in Patients With Intracerebral Hematoma

In patients with an acute intracerebral hematoma (ICH), the guideline developers recommend the initial use of IPC devices (Grade 1B).

Heparin for Deep Vein Thrombosis/Pulmonary Embolism Prophylaxis in Patients With ICH

In stable patients, the guideline developers suggest low-dose SC heparin as soon as the second day after the onset of the hemorrhage (Grade 2C).

Underlying values and preferences: Given the uncertainty about the risk of heparin in this setting, this recommendation places a relatively high value on reducing the consequences of thromboembolism and a relatively lower value on minimizing the risk of cerebral rebleeding.

Prevention of Cerebral Ischemic Events in Patients With Noncardioembolic Transient Ischemic Attack (TIA) or Stroke: Antiplatelet Drugs vs. Placebo or vs. an Alternative Antiplatelet Drug

1. In patients who have experienced a noncardioembolic stroke or TIA (i.e., atherothrombotic, lacunar, or cryptogenic), the guideline developers recommend treatment with an antiplatelet drug (Grade 1A). Aspirin, the combination of aspirin (25 mg) and extended-release dipyridamole (200 mg twice a day [bid]) and clopidogrel (75 mg once a day [qd]) are all acceptable options for initial therapy. The guideline developers recommend an aspirin dose of 50-100 mg/day over higher aspirin doses (Grade 1B).
2. In patients who have experienced a noncardioembolic stroke or TIA, the guideline developers recommend using the combination of aspirin and extended-release dipyridamole (25/200 mg bid) over aspirin (Grade 1A) and suggest clopidogrel over aspirin (Grade 2B).

   Underlying values and preferences: The implementation of the recommendation to use the combination of aspirin and extended-release dipyridamole over aspirin may vary based on cost, tolerability, availability, ease of use, and absolute risk.

3. In most patients with a noncardioembolic stroke or TIA, the guideline developers recommend avoiding long-term use of the combination of aspirin and clopidogrel (Grade 1B). In those with a recent acute myocardial infarction, other acute coronary syndrome, or a recently placed coronary stent, the guideline developers recommend clopidogrel plus aspirin (75-100 mg) (Grade 1A). The optimal duration of dual antiplatelet therapy depends on the specific cardiac indication (See other articles in the Chest journal supplement [see "Availability of Companion Documents" field]).
4. For patients who are allergic to aspirin, the guideline developers recommend clopidogrel (Grade 1A).

Prevention of Noncardioembolic Cerebral Ischemic Events: Oral Anticoagulants

For patients with noncardioembolic stroke or TIA, the guideline developers recommend antiplatelet agents over oral anticoagulation (Grade 1A).

Prevention of Cerebral Ischemic Events in Patients Undergoing Carotid Endarterectomy: Antiplatelet Agents

In patients undergoing carotid endarterectomy, the guideline developers recommend aspirin (50 to 100 mg/d) prior to and following the procedure (Grade 1A).

Prevention of Cardioembolic Cerebral Ischemic Events

1. In patients with atrial fibrillation (AF) who have suffered a recent stroke or transient ischemic attack, the guideline developers recommend long-term oral anticoagulation (target INR, 2.5; range, 2.0 to 3.0) (Grade 1A).
2. For patients with cardioembolic stroke who have contraindications to anticoagulant therapy, the guideline developers recommend aspirin at a dose of 75-325 mg/day (Grade 1B).
3. In patients with stroke associated with aortic atherosclerotic lesions, the guideline developers recommend antiplatelet therapy over no therapy (Grade 1A). For patients with cryptogenic stroke associated with mobile aortic arch thrombi, the guideline developers suggest either oral anticoagulation or antiplatelet agents (Grade 2C).
4. In patients with cryptogenic ischemic stroke and a patent foramen ovale, the guideline developers recommend antiplatelet therapy over no therapy (Grade 1A) and suggest antiplatelet agents over anticoagulation (Grade 2A).
5. In patients with mitral valve strands or prolapse, who have a history of TIA or stroke, the guideline developers recommend antiplatelet therapy (Grade 1A).

Anticoagulation for Cerebral Venous Sinus Thrombosis

In patients with venous sinus thrombosis, the guideline developers recommend that clinicians use UFH (Grade 1B) or LMWH (Grade 1B) over no anticoagulant therapy during the acute phase, even in the presence of hemorrhagic infarction. In these patients, the guideline developers recommend continued use of VKA therapy for up to 12 months (target INR, 2.5; range, 2.0-3.0) (Grade 1B).

Definitions:

*The guideline developers use the wording recommend for strong (Grade 1) recommendations and suggest for weak (Grade 2) recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2001 Jan (revised 2008 Jun)

American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians (ACCP) Expert Panel on Antithrombotic and Thrombolytic Therapy

Primary Authors: Gregory W. Albers, MD, Chair; Pierre Amarenco, MD; J. Donald Easton, MD; Ralph L. Sacco, MD and Philip Teal, MD

Committee Co-Chairs: Jack Hirsh, MD, FCCP (Chair); Gordon H. Guyatt, MD, FCCP; Gregory W. Albers, MD; Robert A. Harrington, MD, FCCP; Holger J. Schünemann, MD, PhD, FCCP

Participants: Giancarlo Agnelli, MD; Pierre Amarenco, MD; Jack E. Ansell, MD; Collin Baigent; Shannon M. Bates, MD; Kenneth A. Bauer, MD; Richard C. Becker, MD; Peter B. Berger, MD; David Bergqvist, MD, PhD; Rebecca J. Beyth, MD; Christopher P. Cannon, MD; Elizabeth A. Chalmers, MB, ChB, MD; Anthony K.C. Chan, MBBS; Clifford W. Colwell, Jr., MD; Anthony J. Comerota, MD; Deborah Cook, MD; Mark A. Crowther, MD; James E. Dalen, MD; Gabrielle deVeber, MD, MHSc; Maria Benedetta Donati, MD, PhD; James D. Douketis, MD; Andrew Dunn, MD; J. Donald Easton, MD; Michael Ezekowitz, MD; Margaret Fang; William H. Geerts, MD, FCCP; Alan S. Go, MD; Samuel Z. Goldhaber, MD, FCCP; Shaun D. Goodman, MD; Michael Gould, MD, FCCP; Ian A. Greer, MD; Andreas Greinacher, MD; David Gutterman, MD, FCCP, HSP; Jonathan L. Halperin, MD; John A. Heit, MD; Elaine M. Hylek, MD; Alan Jacobson, MD; Roman Jaeschke, MD, PhD; Amir K. Jaffer, MD; Susan Kahn; Clive Kearon, MBBCh, PhD; Fenella Kirkham, MBBC; Andreas Koster, MD, PhD; Michael R. Lassen, MD; Mark N. Levine, MD, MSc; Sandra Zelman Lewis, PhD; A. Michael Lincoff, MD; Gregory YH Lip, MD; Christopher Madias, MD; Warren J. Manning, MD; Daniel B. Mark, MD; M. Patricia Massicotte, MD, MSc; David Matchar, MD; Thomas W. Meade, DM, FCCP; Venu Menon, MD; Tracy Minichiello, MD; Paul Monagle, MBBS, MSc, MD, FCCP; Christopher M. O'Connor, MD; Patrick O'Gara, MD; E. Magnus Ohman, MD; Ingrid Pabinger, MD; Gualtiero Palareti, MD; Carlo Patrono, MD; Stephen G. Pauker, MD; Graham F. Pineo, MD; Jeffrey J. Popma, MD; Gary Raskob, PhD; Gerald Roth, MD; Ralph L. Sacco, MD; Deeb N. Salem, MD, FCCP; Charles-Marc Samama, MD, FCCP; Meyer Michel Samama, MD; Sam Schulman, MD, PhD; Daniel Singer, MD; Michael Sobel, MD; Shoshanna Sofaer, DrPH; Alex C. Spyropoulos, MD FCCP; Ph. Gabriel Steg, MD; Philip Teal, MD; Raymond Verhaeghe, MD; David A. Vorchheimer, MD; Theodore E. Warkentin, MD; Jeffrey Weitz, MD

Not stated

American College of Clinical Pharmacy - Medical Specialty Society
American Society of Health-System Pharmacists - Professional Association

This is the current release of the guideline.

This guideline updates a previous version: Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sep;126(3 Suppl):483S-512S.

This NGC summary was completed by ECRI on November 19, 2004. The information was verified by the guideline developer on January 12, 2005. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This summary was updated by ECRI Institute on March 14, 2008 following the updated FDA advisory on heparin sodium injection. This NGC summary was updated by ECRI Institute on December 1, 2008. The updated information was verified by the guideline developer on January 7, 2009. This summary was updated by ECRI Institute on January 5, 2010 following the U.S. Food and Drug Administration advisory on Plavix (Clopidogrel).

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.