Stroke Prevention Flashcards
What is the classification of stroke prevention?
Primary prevention, if there is no previous history of stroke or transient ischaemic attack (TIA).
Secondary prevention, if there has been such an event.
What is the risk assessment tool used for the primary prevention of stroke?
The QRISK®3 calculator has been developed specifically for the UK population. QRISK®3 includes more factors than QRISK®2 to help enable the identification of those at most risk of heart disease and stroke.
QRISK®3 includes weighting for ethnicity.
What is the lifestyle advice given to people for the primary prevention of strokes?
Dietary advice
Advise people to take 30 minutes of at least moderate-intensity exercise a day at least five days a week.
Encourage people who cannot manage this to exercise at their maximum safe capacity.
Recommend exercise that can be incorporated into everyday life, such as brisk walking, using stairs and cycling.
Weight management
Advise men and women to limit alcohol intake to no more than 14 units a week.
Advise everyone to avoid binge drinking.
Advise all people who smoke, to stop.
If people want to stop:
-Offer support and advice.
-In addition, provide medication to help with smoking cessation when indicated.
What is the drug treatment for the primary prevention of strokes?
Before starting statin therapy, offer people the opportunity to change their lifestyle and reassess their risk
-NICE recommends statin therapy as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD .
Screen for hypertension and treat appropriately according to NICE guidelines
If low-dose aspirin is used in primary prevention, the balance of risk and benefits should be discussed with the patient.
- All patients with AF should be assessed for their risk of stroke and the need for thromboprophylaxis balanced with the patient’s risk of bleeding.
What is the risk assessment tool used for stroke risk in patients with AF?
NICE recommends using the CHA2DS2-VASc assessment tool for stroke risk and the HAS-BLED tool for bleeding risk prior to and during anticoagulation.
What is included in the CHA2DS2-VASc score?
Risk factors for stroke included in CHA2DS2-VASc include prior ischaemic stroke, TIAs or thromboembolic events, heart failure, left ventricular systolic dysfunction, vascular disease, diabetes, hypertension, females and patients over 65 years.
What is the treatment to prevent stroke in patients with AF?
Patients with a very low risk of stroke (CHA2DS2-VASc score of 0 for men or 1 for women) do not require any antithrombotic therapy for stroke prevention.
Oral anticoagulation should be offered to patients with confirmed diagnosis of AF in whom sinus rhythm has not been successfully restored within 48 hours of onset, patients who have had or are at high risk of recurrence of AF (e.g., structural heart disease, prolonged history of AF longer than 12 months), a history of failed attempts at cardioversion, and patients with a greater risk of stroke than risk of bleeding.
Oral anticoagulation is with a vitamin K antagonist (eg, warfarin or, in non-valvular AF, with apixaban, dabigatran etexilate, rivaroxaban or edoxaban.
Anticoagulants are also indicated during cardioversion procedures.
If anticoagulant treatment is contra-indicated or not tolerated, left atrial appendage occlusion can be considered.
What is the treatment to prevent stroke if anticoagulants are contra-indicated in AF patients?
If anticoagulant treatment is contraindicated or not tolerated, left atrial appendage occlusion can be considered.
What is the treatment for the secondary prevention of stroke after a TIA?
People with a suspected TIA should be offered aspirin 300 mg a day, to be started immediately.
All people who have a suspected TIA should be referred immediately for specialist assessment and seen within 24 hours.
All patients should be given appropriate advice on lifestyle factors as described for primary prevention, including smoking cessation, physical activity, diet, weight control and avoiding excess alcohol.
All patients should receive regular review and treatment of risk factors for vascular disease for the rest of their lives after a stroke with inclusion on a stroke register and a minimum of annual follow-up.
Patients with TIA or ischaemic stroke (not due to AF) should be on clopidogrel (only use modified-release dipyridamole in combination with aspirin if clopidogrel is not tolerated). Clopidogrel is also the preferred treatment option in patients with peripheral arterial disease or multivascular disease.
Dual therapy with aspirin and clopidogrel may be initiated in secondary care for the first three months following ischaemic stroke or TIA due to severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.
Treatment with a statin should be given to all patients with ischaemic stroke or TIA unless contra-indicated.
All people who have a TIA should have consideration given at their specialist assessment of their suitability for carotid endarterectomy. If they are considered as a possible candidate, they should have urgent carotid imaging.
What is the treatment for the secondary prevention of stroke after a stroke?
People with acute stroke should be started on 300 mg aspirin daily for two weeks once intracerebral haemorrhage has been excluded. At this time a definitive longer antithrombotic treatment plan should be implemented.
An alternative antiplatelet should be offered to anyone who is allergic to or genuinely intolerant of aspirin
Anticoagulation should be stopped for one week following diagnosis of cerebral infarction in people with prosthetic valves if there is a significant risk of haemorrhagic transformation. During this week, 300 mg aspirin should be substituted.
When should anticoagulation should be started in AF patients after a stroke?
If there is a history of persistent or paroxysmal AF in a non-haemorrhagic stroke, consider anticoagulation first-line
Anticoagulation should be started in every patient with persistent or paroxysmal AF (valvular or non-valvular) unless contra-indicated, following an initial two-week course of aspirin 300 mg daily.
Anticoagulants should not be started until brain imaging has excluded haemorrhage and usually not until 14 days have passed from the onset of an ischaemic stroke.
When is carotid endarterectomy recommended?
Carotid endarterectomy is of some benefit for patients with 50-69% symptomatic stenosis and is very beneficial for 70-99% stenosis.
Carotid endarterectomy for asymptomatic carotid stenosis reduces the risk of any stroke by approximately 30% over three years. However, the absolute risk reduction is small and there is a 3% perioperative stroke or death rate
