Key updates to ‘living’ stroke guidelines

Morgan Liotta

17/05/2022 2:50:40 PM

The first major update since 2018 contains several new strong recommendations for the management of stroke.

Letter blocks spelling out stroke
The guidelines refresh includes five new strong recommendations and three updated recommendations.

Australia and New Zealand’s Clinical guidelines for stroke management are the first and only living stroke guidelines worldwide, updated as new evidence emerges.
This week, the guidelines underwent the first refresh since 2018 to include new and updated ‘strong’ recommendations.
The new strong recommendations are:

  • For patients with potentially disabling ischaemic stroke who meet perfusion mismatch criteria in addition to standard clinical criteria, the recommended time window for safe administration of alteplase has been extended to nine hours post-stroke
  • For patients with potentially disabling ischaemic stroke due to large vessel occlusion who meet specific eligibility criteria, intravenous tenecteplase (0.25 mg/kg, maximum 25 mg) or alteplase (0.9 mg/kg, maximum of 90 mg), should be administered up to 4.5 hours after the time the patient was last known to be well
  • For patients with ischaemic stroke caused by a large vessel occlusion in the internal carotid artery, proximal middle cerebral artery (M1 segment), or with tandem occlusion of both the cervical carotid and intracranial large arteries, endovascular thrombectomy should be undertaken when the procedure can be commenced between six and 24 hours after they were last known to be well, if clinical and computed tomography perfusion or MRI features indicate the presence of salvageable brain tissue
  • In hospitals without onsite 24/7 stroke medical specialist availability, telestroke systems should be used to assist in patient assessment and decision-making regarding acute thrombolytic therapy and possible transfer for endovascular therapy
  • In patients with ischaemic stroke, cholesterol-lowering therapy should target low-density lipoprotein cholesterol <1.8 mmol/L for secondary prevention of atherosclerotic cardiovascular disease
To support healthcare professionals providing stroke management, the Medical Journal of Australia (MJA) has published a summary of the updated clinical guidelines, outlining the new and updated recommendations, as well as the associated challenges and benefits.
The authors of the MJA summary say the key benefit of having living guidelines is the ability to rapidly update recommendations in response to new evidence.
‘Rapid guideline updates as part of a living model are almost certain to have played a significant role by expediting local and state-wide system changes,’ they wrote.
‘Importantly, living guidelines provide currency of advice. The experience with stroke as well as other guidelines demonstrates that the rigour of the methods does not need to be compromised when living modes are adopted.’
Dr Gary Deed, RACGP Expert Committee – Quality Care member, told newsGP the summarised guideline updates should help GPs, but they should also acknowledge the full details, particularly of the five new recommendations.
‘The guidelines serve the purpose, whereby the [MJA] experts or peers have distilled a whole breadth of information into a succinct reference, so you don’t personally have to do all the hard yards reading multiple articles or journals,’ he said. 
‘A quick review of high-level recommendations and summaries can assist updating knowledge when you are tight on time, but remember there is so much more detail, so a practical way of using them is to keep them handy – especially in electronic form at the clinical practice, so you can refer back to content regularly.’
In 2017, the stroke guidelines moved from being published in a static format, to online as ‘living guidelines’.
A total of 35 new or updated recommendations have been made since, with 16 new recommendations (five strong, 10 weak, and one practice point), and updates to 19 recommendations.
There have been no cases in which a recommendation for an intervention has been downgraded from a ‘strong’ to a ‘weak’ recommendation, and no recommendation has been changed multiple times. In addition, important new recommendations have been made regarding lifesaving therapy, such as the administration of alteplase for thrombolysis.
Three updates graded as ‘strong’ recommendations are also included in the new guidelines:
  • Aspirin plus clopidogrel should be commenced within 24 hours and used in the short term (first three weeks) in patients with minor ischaemic stroke or high-risk transient ischaemic attack to prevent stroke recurrence
  • In patients with ischaemic stroke aged under 60 years in whom a patent foramen ovale is considered the likely cause of stroke after thorough exclusion of other aetiologies, percutaneous closure of the patent foramen ovale is recommended
  • For stroke survivors with reduced strength in their arms or legs, progressive resistance training should be provided to improve strength.
According to the MJA authors, the living guidelines model, along with the summary, not only ensures up-to-date clinical guidance, but an easily accessible reference which should be considered the way forward.
‘Our model of continual evidence surveillance and timely updates to recommendations is feasible, but sustainability remains a challenge,’ they wrote.
‘Now that we have started down this road, the message from guideline end users is that a return to the old model of static updates is no longer acceptable, and ongoing long-term investment in living guidelines must be prioritised.’
The full version of the updated living Clinical guidelines for stroke management is available on the Stroke Foundation website.
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