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.

1. Lifestyle Advice

• low salt,
• low cholesterol,
• weight reducing diet,
• alcohol limits,
• moderate exercise
• smoking cessation (refer to smoking cessation clinic and consider NRT prescription)

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

2. Lower Blood Pressure

Do not commence treatment until the neurological deficit has fully resolved, or until two weeks after the stroke, whichever comes first.

• Treat with thiazide-like diuretic in first instance (see 2.2.1 Thiazides and related diuretics)
• Add ACE inhibitor if target BP is not achieved (see 2.5 Hypertension and heart failure)
• Use a long-acting calcium channel blocker as third-line if target BP is not achieved (see 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs)
• Aim to lower BP to less than 130 / 80 OR by 10% (whichever results in the lower BP level)

N.B. After stroke or TIA, 'normotensive' patients benefit as much as hypertensive patients from BP reduction.

See Management of Blood Pressure below

Continued monitoring

• Continue to monitor the patient at appropriate intervals.
• Follow-up should take place at 6 weeks, 6 months and annually thereafter, including BP, concordance, lifestyle and smoking advice.
• Maintaining long-term concordance with secondary vascular prevention is particularly important in preventing recurrence.

1. Lifestyle Advice

• low salt,
• low cholesterol,
• weight reducing diet,
• alcohol limits,
• moderate exercise
• smoking cessation (refer to smoking cessation clinic and consider NRT prescription)

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

2. Lower Blood Pressure

Do not commence treatment until the neurological deficit has fully resolved, or until two weeks after the stroke, whichever comes first.

• Treat with thiazide-like diuretic in first instance (see 2.2.1 Thiazides and related diuretics)
• Add ACE inhibitor if target BP is not achieved (see 2.5 Hypertension and heart failure)
• Use a long-acting calcium channel blocker as third-line if target BP is not achieved (see 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs)
• Aim to lower BP to less than 130 / 80 OR by 10% (whichever results in the lower BP level)

N.B. After stroke or TIA, 'normotensive' patients benefit as much as hypertensive patients from BP reduction.

See Management of Blood Pressure below

3. Lower cholesterol

Treat all patients with a low-cholesterol diet plus atorvastatin 20mg daily, increased as necessary to achieve target.

See Management of Cholesterol below

4. Use antiplatelet or anticoagulant treatment

Is atrial fibrillation present? (Including paroxysmal AF)

NO: Give Clopidogrel 75mg daily

• If intolerant of Clopidogrel, give Aspirin 75mg daily plus Dipyridamole MR 200mg twice daily
• See Antiplatelet treatment below

YES : Anticoagulate with warfarin or novel anticoagulant

• Also control rate with digoxin, verapamil, diltiazem or beta-blocker
• See Anticoagulant Treatment below

5. Consider carotid endarterectomy

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%

Continued monitoring

• Continue to monitor the patient at appropriate intervals.
• Follow-up should take place at 6 weeks, 6 months and annually thereafter, including BP, concordance, lifestyle and smoking advice.
• Maintaining long-term concordance with secondary vascular prevention is particularly important in preventing recurrence.

NICE Antiplatelet Guideline TA210, December 2010

• For the long-term prevention of ischaemic events after stroke or TIA, use clopidogrel monotherapy, 75mg daily. If intolerant of clopidogrel, then use the combination of aspirin 75mg daily plus dipyridamole MR 200mg twice daily, or dipyridamole monotherapy if also intolerant of aspirin.
• Stroke/TIA patients should avoid the long-term use of the combination of aspirin and clopidogrel, and the co-prescription of clopidogrel with omeprazole or esomeprazole (use lansoprazole instead).

• Anticoagulation is appropriate for the secondary prevention of stroke or TIA associated with atrial fibrillation (AF; permanent or paroxysmal), but should not be introduced until two weeks after the stroke unless neurological signs have fully resolved before then. In trials, Warfarin reduced the annual risk of recurrent stroke by approximately two thirds, from 12% to 4%. The target INR is 2.5, range 2.0-3.0. Warfarin is also appropriate where stroke or TIA is associated with a prosthetic heart valve, rheumatic mitral valve disease or within three months of a myocardial infarct (mural thrombus).
• In preventing thrombo-embolic events in patients over 65 years, a policy of rate control (with digoxin, verapamil or diltiazem, or a beta-blocker) combined with anticoagulation is superior to a policy of attempting to maintain sinus rhythm (with drugs or cardioversion) so as to avoid the need for anticoagulation.
• If anticoagulation is contraindicated or otherwise inappropriate, do not use antiplatelet treatment instead. Review ways to reduce the risk from anticoagulation (using the 'HAS-BLED' mnemonic), or discuss the patient with a stroke physician.

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:

• A 43% reduction in risk of further stroke or TIA;
• A 42% reduction in risk of myocardial infarction;
• A NNT (number needed to treat) of 11 to prevent one further vascular event.

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).

Monitoring of ACE Inhibitor therapy

Monitor BP, renal function and serum potassium:

• 1 week prior to treatment
• 1 week and 1 month after initiation
• 1 week after significant change in dosage or addition of an interacting drug e.g. diuretic
• When there is a significant change in the patient's condition or during severe concurrent illness.

If serum creatinine rises by ≥30%, discontinue / reduce dose to previously tolerated.

See Management of blood lipids guidance

• The 2016 National Clinical Guideline for Stroke is available at: https://www.strokeaudit.org/Guideline/Guideline-Home.aspx
• NICE technology appraisals of antiplatelet therapy after stroke (TA210), and the relevant NICE Lipid (CG181), AF (CG180) and Hypertension Guidelines (CG127) are available at guidance.nice.org.uk/.
• For clinical advice please contact the Consultant Stroke Physicians at the RD&E (Tel 01392 402552 or email: rde-tr.dailystrokeclinic@nhs.net).