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SECONDARY PREVENTION of STROKE

Rationale

Patients who have had a stroke are at increased risk for a further stroke (about 7% per year).The risk is highest early after stroke or TIA.

Such patients are also at risk from other vascular events such as myocardial infarct.

Secondary preventive treatment is therefore a priority for this group.

Most evidence is based on primary prevention of stroke, but the evidence for secondary prevention is now accumulating.

Guidelines:

  1. All patients should have their blood pressure checked, and hypertension persisting over 1 month should be treated. The British Hypertension Society Guidelines state: optimal treated target BPs are <140mmHg systolic, <85mmHg diastolic
  2. Further reduction of BP should be considered using perindopril & indapamide. (PROGRESS study 2001)
  3. Patients with ischaemic stroke who do not need anticoagulation should be on aspirin 75-325mg daily, or clopidogrel, or a combination of low dose aspirin and modified release dipyridamole.
  4. Anticoagulation is only indicated if cardiac embolism is suspected.
  5. Warfarin should not be started until scan has excluded haemorragic stroke, & at least 2 weeks has passed since the onset of stroke.
  6. Anticoagulation should be started in every patient with atrial fibrillation, unless there is some contraindication.
  7. Other cardiac indications for anticoagulation after ischaemic stroke are;
  • mitral valve disease
  • prosthetic heart valves
  • within 3 months of myocardial infarct

8. Any patient with carotid territory stroke & minor/absent disability should be considered for carotid endarterectomy.

9.All patients should be given appropriate lifestyle advice, including:

  • Not smoking
  • Regular exercise
  • Acheiving satisfactory weight
  • Avoiding excessive alcohol
  • Reducing salt in diet

10. Statin therapy should be considered for those with a history of ischaemic heart disease & serum cholesterol >5mm/l following stroke.

More detail can be found in Section 11.3 of the Royal College of Physicians National Clinical Guidelines for Stroke, with grading of the approproate evidence sources.

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Copyright ©Nikki Devitt 2002, on behalf of the WAHT Stroke Pathway Group

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Date of last review: 25th April 2002

Date of next review:25th October 2002