{ "_meta": { "endpoint": "recommendations", "schemaVersion": "1.0.0", "appVersion": "6.11.6", "checksum": "sha256:a136fba348ce3218e822e73a3c82c768", "count": 11, "source": "Evidence atlas recommendations bundle", "license": "Synthetic educational reference content for qualified review. No warranty.", "disclaimer": "Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action." }, "data": [ { "id": "rec-ich-bp-smooth-control", "topic": "ich-bp-management", "setting": "inpatient", "text": "In acute spontaneous ICH, continuous smooth, sustained BP control with timely treatment can be beneficial when BP lowering is indicated.", "classOfRecommendation": "IIa", "levelOfEvidence": "B-NR", "guidelineSource": "AHA/ASA 2022 ICH Guideline; INTERACT3 (2023)", "supportingClaimIds": [ "cl-ich-bp-bundle" ], "caveats": [ "Smooth, sustained BP control and timely treatment are Class IIa process recommendations.", "Do not present INTERACT3 as BP-only class evidence; it tested a bundle including BP, glucose, temperature, and anticoagulation reversal.", "Avoid abrupt large drops in BP (>60 mmHg) which may worsen outcomes.", "Do not pursue a numeric BP target in isolation from neurologic status and the full care bundle." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-ich-bp-target", "topic": "ich-bp-management", "setting": "inpatient", "text": "In mild-to-moderate acute spontaneous ICH with presenting SBP 150-220 mmHg, targeting SBP 140 mmHg and maintaining 130-150 mmHg when appropriate is safe and may be reasonable.", "classOfRecommendation": "IIb", "levelOfEvidence": "B-R", "guidelineSource": "AHA/ASA 2022 ICH Guideline", "supportingClaimIds": [], "caveats": [ "The SBP 140/range 130-150 target is Class IIb.", "In patients with SBP >220 mmHg, the safety of aggressive lowering to 140 is less certain; use clinical judgment and continuous monitoring.", "Use with the separate Class IIa process recommendation for smooth, sustained control and timely treatment.", "Do not pursue a numeric BP target in isolation from neurologic status, hematoma severity, and neurosurgical planning." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-ich-bp-avoid-low", "topic": "ich-bp-management", "setting": "inpatient", "text": "Avoid acute SBP <130 mmHg in mild-to-moderate spontaneous ICH because it is potentially harmful.", "classOfRecommendation": "III-harm", "levelOfEvidence": "B-R", "guidelineSource": "AHA/ASA 2022 ICH Guideline; ATACH-2", "supportingClaimIds": [], "caveats": [ "Acute SBP <130 mmHg is Class III-harm.", "This lower-bound harm guard is separate from the Class IIb SBP 140/range 130-150 target." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-ich-anticoag-reversal-fxa", "topic": "ich-anticoag-reversal", "setting": "inpatient", "text": "In factor Xa inhibitor-associated ICH within 15 hours of last dose, andexanet alfa is reasonable to achieve hemostatic efficacy when available; 4F-PCC is an alternative when andexanet is unavailable or contraindicated. Monitor for thrombotic complications.", "classOfRecommendation": "IIa", "levelOfEvidence": "B-R", "guidelineSource": "AHA/ASA 2022 ICH Guideline; ANNEXA-I (2024)", "supportingClaimIds": [ "cl-ich-andexanet-fxa" ], "caveats": [ "ANNEXA-I demonstrated higher hemostatic efficacy with andexanet but more thrombotic complications vs usual care.", "Andexanet alfa is not indicated for edoxaban; for edoxaban, 4F-PCC remains primary.", "Reversal should not delay neurosurgical evaluation." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-ich-anticoag-reversal-warfarin", "topic": "ich-anticoag-reversal", "setting": "inpatient", "text": "In warfarin-associated ICH, give vitamin K 10 mg IV plus 4F-PCC dosed by INR/weight to rapidly reverse anticoagulation; FFP is an inferior alternative.", "classOfRecommendation": "I", "levelOfEvidence": "B-R", "guidelineSource": "AHA/ASA 2022 ICH Guideline", "supportingClaimIds": [ "cl-ich-warfarin-reversal-pcc-vk" ], "caveats": [ "Vitamin K is required for sustained reversal; PCC alone is short-acting.", "FFP carries volume-overload risk and slower correction." ], "lastReviewed": "2026-07-18", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-late-window-ivt", "topic": "extended-window-ivt", "setting": "inpatient", "text": "In patients presenting 4.5-9 h from LKW or with wake-up stroke, IV thrombolysis (alteplase or tenecteplase 0.25 mg/kg) selected by perfusion or DWI-FLAIR mismatch is reasonable when EVT is not indicated or available.", "classOfRecommendation": "IIa", "levelOfEvidence": "B-R", "guidelineSource": "AHA/ASA 2026 AIS Guideline; ESO 2023", "supportingClaimIds": [ "cl-late-window-ivt-non-lvo", "cl-tnk-late-window-non-lvo" ], "caveats": [ "Imaging-based selection is required; unselected late-window thrombolysis is not supported (TWIST).", "Time from LKW remains a key safety determinant; TIMELESS extended TNK to 24 h with mismatch selection but the overall primary endpoint did not reach significance." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-tnk-first-line", "topic": "tnk-vs-alteplase", "setting": "inpatient", "text": "Tenecteplase 0.25 mg/kg (max 25 mg) is a reasonable alternative to alteplase 0.9 mg/kg for IV thrombolysis in eligible AIS within 4.5 h, particularly for patients with anticipated EVT.", "classOfRecommendation": "IIa", "levelOfEvidence": "B-R", "guidelineSource": "ESO 2023; AHA/ASA 2026", "supportingClaimIds": [ "cl-tnk-noninferior-alteplase" ], "caveats": [ "Use TNK 0.25 mg/kg only; the 0.4 mg/kg dose was not non-inferior in EXTEND-IA TNK part 2.", "Local protocols may continue to favor alteplase; both are acceptable." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-evt-large-core", "topic": "evt-large-core", "setting": "inpatient", "text": "In patients with anterior-circulation LVO and ASPECTS 3-5 (or core 50-100 mL) within 24 h of LKW, EVT is recommended to improve functional outcome.", "classOfRecommendation": "I", "levelOfEvidence": "A", "guidelineSource": "AHA/ASA 2026 AIS Guideline", "supportingClaimIds": [ "cl-evt-large-core" ], "caveats": [ "Pre-stroke mRS, life expectancy, and goals of care still inform shared decision-making.", "ASPECTS <3 was not adequately enrolled in the seminal RCTs and is a Class IIb area." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-dapt-minor-stroke", "topic": "dapt-minor-stroke", "setting": "inpatient", "text": "In patients with minor non-cardioembolic ischemic stroke (NIHSS ≤3 or ≤5 with disabling deficit) or high-risk TIA (ABCD² ≥4 or DWI+), dual antiplatelet therapy (aspirin plus clopidogrel for 21 days, or aspirin plus ticagrelor for 30 days) started within 24 h is recommended to reduce recurrent ischemic stroke at 90 days.", "classOfRecommendation": "I", "levelOfEvidence": "A", "guidelineSource": "AHA/ASA 2021 Secondary Prevention; CHANCE / POINT / THALES / INSPIRES", "supportingClaimIds": [ "cl-dapt-minor-stroke" ], "caveats": [ "Bleeding risk increases with duration; do not extend DAPT beyond 21-30 days for this indication.", "INSPIRES extended the window to 72 h in eligible mild stroke / high-risk TIA.", "For CYP2C19 loss-of-function carriers, ticagrelor (CHANCE-2) is preferred over clopidogrel." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-af-early-anticoag", "topic": "af-anticoag-timing", "setting": "inpatient", "text": "In patients with AIS and atrial fibrillation, early DOAC initiation within ~4 days is reasonable across stroke severities (OPTIMAS: non-inferior across infarct sizes) and was superior to delayed start at 30 days in pooled individual-patient data (CATALYST IPDMA: OR 0.70, 95% CI 0.50-0.98, no sICH excess), excepting very severe stroke or extensive hemorrhagic transformation.", "classOfRecommendation": "IIa", "levelOfEvidence": "B-R", "guidelineSource": "AHA/ASA 2021 Secondary Prevention; OPTIMAS (2024); CATALYST IPDMA (2025); ELAN (2023); TIMING (2022)", "supportingClaimIds": [ "cl-af-early-anticoag" ], "caveats": [ "Reserve longer delay for very severe stroke or extensive hemorrhagic transformation; confirm absence of significant hemorrhagic transformation on follow-up imaging before starting in moderate-large stroke.", "Early initiation (≤4 d) is non-inferior across severities (OPTIMAS) and superior at 30 d in pooled IPD (CATALYST); individualize for the highest-risk presentations." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" }, { "id": "rec-evt-late-window", "topic": "evt-late-window", "setting": "inpatient", "text": "In patients with anterior-circulation LVO presenting 6-24 h from LKW, EVT is recommended for those meeting DAWN or DEFUSE-3 imaging-selection criteria.", "classOfRecommendation": "I", "levelOfEvidence": "A", "guidelineSource": "AHA/ASA 2026 AIS Guideline; DAWN; DEFUSE-3", "supportingClaimIds": [ "cl-evt-late-window" ], "caveats": [ "Outside trial-selection criteria, EVT is reasonable on a case-by-case basis with shared decision-making." ], "lastReviewed": "2026-04-25", "verificationStatus": "verified-guideline", "verificationNotes": "" } ] }