Secondary prevention of stroke / TIA

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.

Eastern locality: for further information see the Exeter Secondary Prevention Guidelines v7 (2014)

Definitions

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

Stroke of unknown pathology

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.

Haemorrhagic stroke

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.

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.

Ischaemic stroke and TIA

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.

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 endaterectomy

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.

Antiplatelet treatment

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 combination of Aspirin and Clopidogrel, and the co-prescription of Clopidogrel with omeprazole or esomeprazole (if necessary, use ranitidine, or if a PPI is essential, lansoprazole).

Anticoagulant Treatment

  • 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 event unless neurological signs have fully resolved before then. It 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). Warfarin reduces 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.
  • 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, consider antiplatelet treatment instead. Aspirin reduces the annual risk of recurrent cardioembolic stroke from 12% to 10%.

Refer to: Management of atrial fibrillation, Anticoagulation in AF, for further guidance.

NICE Guidance on the novel oral anticoagulants (dabigatran TA249; rivaroxaban TA256; apixaban TA275) recommends these agents as an option for preventing stroke in non-valvular AF.

Management of Blood Pressure

The main trial of BP lowering after a stroke or TIA (the PROGRESS trial) showed that with a 12/5 mmHg reduction in BP with an ACE inhibitor / thiazide combination (perindopril 4mg daily + indapamide 2.5mg daily), there was, 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:

  • 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.

Management of Cholesterol

Further advice

 

Home > Formulary > Chapters > 2. Cardiovascular > Secondary prevention of stroke / TIA

 

  • First line
  • Second line
  • Specialist
  • Hospital