Secondary prevention of stroke / TIA in primary care

For information on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms, see NICE guideline NG128: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.

The guidance below 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 is intended 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.

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

This will usually have been initiated by the stroke team during admission.

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. Frail, elderly patients may not require blood pressure 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 blood lipids guidance

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. 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.
  • Cardiac arrhythmias may warrant further investigation

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 long-term use of the combination of aspirin and clopidogrel, and ideally avoid the co-prescription of clopidogrel with omeprazole or esomeprazole (use ranitidine, or lansoprazole instead). The BNF states that omeprazole is predicted to decrease the efficacy of clopidogrel
  • For patients at high risk of a repeat event the stroke team may use aspirin 75mg plus clopidogrel 75mg once daily for one month. Patients should then be converted to just clopidogrel 75mg once daily

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 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 (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 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

Refer to: Monitoring requirements of drugs acting on the renin-angiotensin system

Further advice


 

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