Stroke

Stroke risk

The risk of recurrent stroke in people who have had an ischaemic stroke or transient ischaemic attack (TIA) is high (10% at one week, 14% at one month and 18% at three months). To reduce the relative risk of further vascular events:

Get blood pressure down to 120-130/70, but wait a week or two after a disabling stroke
Don't lower blood pressure too low or too fast if there is bilateral carotid stenosis
Start a statin if untreated cholesterol level is >3.5 or if there is a history of ischaemic stroke or TIA
Give aspirin 75 mg a day, or clopidrogel 75 mg a day if the the patient can't take aspirin
Dipyridamole 200 mg twice a day, in addition to aspirin, further reduces the risk of recurrence. The headache it causes tends to settle down in time.
Don't forget the importance of lifestyle modification (such as stopping smoking) and tight diabetes control.

Source: Practical Neurology 2008;8:141-157.

A summary of national recommendations for secondary prevention of further vascular events in patients who have already experienced a stroke or TIA. Most of these recommendations are also applicable to patients with established CHD.

Antiplatelet therapy

ALL patients not on anticoagulation should be prescribed an antiplatelet agent after an ischaemic stroke (or other vascular event) to prevent further stroke or vascular events.

Hypertension

Initiate drug therapy in ALL stroke patients with sustained SBPs >140mmHg or DBPs >90mmHg despite non-pharmacological measures.

Treatment targets

	Clinic BP (mmHg)		Mean day-time ABPM or home BP
	No diabetes	Diabetes	No diabetes	Diabetes
Optimal BP	<140/85	<140/80	<130/80	<130/75
Audit standard	<150/90	<140/85	<140/85	<140/85

The audit standard reflects the minimum recommended level of BP control. Despite best practice, it may not be achievable in all hypertensives. SBP = systolic blood pressure DBP = diastolic blood pressure ABPM = ambulatory blood pressure monitor.

Hyperlipidaemia

Therapy with a statin should be considered for all patients with a past history of Ml and a cholesterol >5.0 mmol/L following stroke. Statins and dietary advice should be given to lower serum cholesterol concentrations EITHER to <5.0 mmol/l (LDL-cholesterol to <3.0 mmol/l) OR by 30% (whichever is greater).

Diabetes

Ensure meticulous control of glucose and blood pressure in patients with diabetes.

Anticoagulation

Anticoagulation should be - started in every patient in atrial fibrillation (valvular or non-valvular) unless contraindicated - considered for all patients who have ischaemic stroke associated with mitral valve disease, prosthetic heart valves, or within 3 months of Ml An INR of 2.5 + 0.5 is considered optimal

Lifestyle

ALL patients should be offered information and personalised advice about how they can reduce their modifiable risk factors.

Smoking
- ALL smokers should be offered advice about how to stop smoking, including advice on the use of nicotine replacement therapy and other therapy.
- Smoking doubles the risk of stroke and CHD. After smoking cessation, risk of stroke and CHD returns to that of people who have never smoked.
Diet
- Patients should be advised to:
  - reduce weight, if appropriate
  - reduce total and saturated fat intake, replace with some increase in polyunsaturated and monounsaturated fat and oily fish consumption
  - reduce salt intake (max 5g/day)
  - increase fruit and vegetable consumption (5 portions/day)
Exercise
- If appropriate, patients should be advised to take dynamic exercise (e.g. brisk walking for 20 minutes/day)
Alcohol
- Patients should be advised to limit alcohol consumption (e.g. <21 u/week for men; <14u/week for women)

References

Department of Health. Notional Service Framework for Coronary Heart Disease. Department of Health: London, March 2000
Department of Health. Saving Lives: Our Healthier Nation. HMSO, Cm4386, July 1999
The Royal College of Physicians. Natianal Clinical Guidelines for Stroke. London, 2000
Wood 0 eta1. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1 998;80 ISuppi 2):S1 -S26
Ramsay LE eta1. Guidelines for management of h pertension: report of the third working party of the British Hypertension Society. J Hum Hypertension 1 999;1 3:569-92
Wolf PA et al. Cigarette smoking as a risk factor for stroke: the Framingham study. JAMA 1 988;259: 1025-29
Stroke Management (Northumberland guidelines - NHSnet only)

Guidelines for management of risk factors in stroke patients