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This guidance is intended for use as an aid to decision-making, to assist with the cost-effective care of stroke patients and thus to achieve a uniformly high standard of long-term stroke prevention in primary care. It isintended to provide guidance that both clinicians and patients may need at the key decision points in the prevention of recurrent stroke or TIA. Advice is based on NICE Guidance where this is available, but is not intended to provide 'rules' for every possible eventuality in stroke management and should be used pragmatically.
Stroke: The sudden onset of focal neurological loss of presumed vascular origin lasting more than 24 hours.
Transient Ischaemic Attack (TIA): The sudden onset of focal neurological loss of presumed vascular origin lasting less than 24 hours Includes: retinal ischaemia/transient monocular blindness
In most cases, particularly if the stroke was not recent, did not lead to hospitalisation or if there are vascular risk factors present, it is reasonable to base secondary prevention on the assumption it was ischaemic.
Issue supporting written material and contact numbers for the Stroke Association Peer Support, Information and Advice Service (Tel: 01392 447362). Record on practice Stroke Register
Do not commence treatment until the neurological deficit has fully resolved, or until two weeks after the stroke, whichever comes first.
N.B. After stroke or TIA, 'normotensive' patients benefit as much as hypertensive patients from BP reduction.
See Management of Blood Pressure below
Issue supporting written material and contact numbers for the Stroke Association Peer Support, Information and Advice Service (Tel: 01392 447362). Record on practice Stroke Register
Do not commence treatment until the neurological deficit has fully resolved, or until two weeks after the stroke, whichever comes first.
N.B. After stroke or TIA, 'normotensive' patients benefit as much as hypertensive patients from BP reduction.
See Management of Blood Pressure below
Treat all patients with a low-cholesterol diet plus atorvastatin 20mg daily, increased as necessary to achieve target.
See Management of Cholesterol below
NO: Give Clopidogrel 75mg daily
YES : Anticoagulate with warfarin or novel anticoagulant
Refer for carotid duplex study (via Daily Stroke Clinic at RD&E on 01392 402552). Surgery is recommended for an ipsilateral symptomatic internal carotid artery stenosis of greater than 50%
NICE Antiplatelet Guideline TA210, December 2010
Refer to: Management of atrial fibrillation, Anticoagulation in AF, for further guidance.
NICE Guidance on the novel oral anticoagulants (edoxaban TA355, dabigatran TA249, rivaroxaban TA256, apixaban TA275) recommends these agents as an option for preventing stroke in non-valvular AF.
The main trial of BP lowering after a stroke or TIA (the PROGRESS trial) showed that with an ACE inhibitor / thiazide-like combination there was a 12/5 mmHg reduction in BP resulting in, over an average of 4 years:
Similar risk reductions were seen among both the hypertensive and normotensive subjects in the trial, because all patients were at relatively high risk of vascular events, even if they were normotensive (20% risk of a major vascular event within 4 years).
Monitor BP, renal function and serum potassium:
If serum creatinine rises by ≥30%, discontinue / reduce dose to previously tolerated.