Secondary prevention of stroke and Transient Ischaemic Attack (TIA)

Introduction

Secondary prevention of stroke should be considered in all patients as soon as possible after their stroke or TIA. Initiation of secondary prevention investigations and treatment should be guided by the stroke team, therefore, ensure that all new stroke or TIA patients are referred to the local stroke service via the TrakCare referral form.

Drug therapy

Antithrombotics

Patients in sinus rhythm:

• First choice is aspirin oral 300mg daily for 14 days then clopidogrel oral 75mg each day (N.B. clopidogrel is unlicensed in TIA). Some patients may be given dual antiplatelet therapy (DAPT) but this would be a consultant decision. DAPT (aspirin and clopidogrel) can be used in people with non-cardioembolic minor ischaemic stroke (NIHSS score of 3 or less) or high-risk TIA (ABCD score of 4 or more) in the past 24 hours, if diagnosis is confirmed by a stroke specialist and brain imaging has excluded intracerebral haemorrhage (ICH). DAPT is usually used for 21 days, then the patient continues on clopidogrel 75mg daily for long-term treatment.
• If the patient is allergic or intolerant to clopidogrel, then prescribe combination therapy:
  • Aspirin oral 300mg each day for 14 days or until hospital discharge, then reduce to aspirin oral 75 mg each day 
  • Dipyridamole MR oral 200mg, starting with 200mg each night and increasing to 200mg twice daily if tolerated (severe ischaemic heart disease is one possible contraindication).

Patients in atrial fibrillation (AF):

• Patients will usually start oral anticoagulants 10 to 14 days after the acute stroke but advice from a stroke consultant should be sought about this. Where patients are already on anticoagulation and have an ischaemic stroke, seek advice from a stroke consultant before resuming anticoagulation. Ensure stroke team advise before prescribing warfarin or other oral anticoagulant (refer to AF guideline for general management). If discharging patient home on warfarin ensure follow up arrangements are in place (see Referral of Patients to Anticoagulation Clinic guideline).
• If contraindications to warfarin or any of the other oral anticoagulants, seek advice from the stroke consultant.

Patients with haemorrhagic stroke:

• Antiplatelet drugs are contraindicated unless cause of intracerebral bleed resolves and patients also have concomitant ischaemic heart or stroke disease. This is a risk / benefit balance and advice should be sought from the stroke team.

Blood Pressure (BP)

After the acute phase, all patients with a BP >130mmHg systolic or >80mmHg diastolic should be considered for:

• A long-acting angiotensin-converting enzyme inhibitor (ACEI) and a diuretic (e.g. bendroflumethiazide), if tolerated and not contraindicated.
• Additional antihypertensives if BP remains above target level. Even ‘normotensive’ patients (<130mmHg systolic or <80mmHg diastolic) may benefit from antihypertensive treatment, especially with ACEIs. See NHSGGC guideline, 'Hypertension Management, Heart MCN' on StaffNet / Clinical Info / Clinical Guideline Directory (link only active if connected to GGC network) for details. 

Cholesterol

Unless contraindicated, treat all patients who have had an ischaemic stroke with a statin regardless of baseline cholesterol concentration. Give atorvastatin oral 80mg daily. For further guidance see NHSGGC StaffNet / Clinical Info / Clinical Guidelines Directory (link only active if connected to GGC network) and search for 'Coronary heart disease and stroke, primary and secondary prevention guidelines (cholesterol)'.

Diabetes

If initial blood sugar is elevated, investigate for diabetes including checking fasting blood sugar and HbA1c. If already diabetic, check HbA1c and aim for good control. This may be difficult to achieve for many patients, but this is an important, modifiable risk factor.

Carotid disease

All stroke or TIA patients with symptoms potentially related to their carotid artery circulation territory should have carotid imaging requested immediately and the results discussed with the Stroke Consultant. No carotid investigation is required for patients with primary intracerebral haemorrhage.

In a patient with moderate to severe (>50% stenosis) carotid disease, discuss immediately with the local stroke team to assess need for further imaging, suitability for surgery and the need for any alteration in secondary prevention medication.

Cardiac disease

All stroke or TIA patients who do not have already known AF should be investigated for possible AF with a request made for 72 hour ambulatory ECG monitoring (local protocols vary with availability). Echocardiography (echo) is used in selected patients e.g. with multiple cerebrovascular events or with otherwise unexplained stroke but the decision to request echo usually will be made by the stroke consultants.

Health Promotion

• Smoking – Record tobacco consumption, advise smoking cessation and offer referral to Smoking Cessation Service (see Appendix 1).
• Exercise – Provide general supportive advice for healthy active lifestyle within functional limits.
• Weight – Record height and weight. Aim for improved BMI (gold standard is <25).
• Nutrition – Offer supportive advice for healthy eating, particularly for patients with diabetes or high cholesterol.
• Driving – Offer advice as per DVLA guidance – driving is prohibited for 1 month after event and longer if recurrent events or presence of a disability impairing driving, or if PSV/HGV driver.
• Alcohol – Advise on safe limits and refer to Addiction Team if appropriate.