Stroke Prevention and Recurrence

Stroke Prevention and Management

• A stroke survivor has a 25-35% risk of having a secondary (recurrent) stroke, but this risk can be mitigated with appropriate secondary stroke prevention measures.
• Research has shown that the annual stroke recurrence rate has decreased from 8.7% in the 1960s to 5% in the 2000s, largely due to improved blood pressure control and use of antiplatelet therapy.

Risk Factors and Prevention

• The American Heart Association/American Stroke Association states that the majority of strokes can be prevented through blood pressure control, a healthy diet, regular physical activity, and smoking cessation.
• Five factors - blood pressure, diet, physical inactivity, smoking, and abdominal obesity - account for 82% and 90% of the population-attributable risk for ischemic and hemorrhagic stroke, respectively.
• Targeting multiple risk factors is critical to secondary prevention, and studies have shown that using aspirin or clopidogrel, along with dietary changes and increased physical activity, can lead to a cumulative risk reduction of 80% for recurrent vascular events.

Diagnostic Evaluation

• In patients who have had an ischemic stroke or TIA, a diagnostic evaluation is recommended to understand the etiology and to optimize the care plan to prevent recurrent stroke.
• Testing should be initiated and ideally completed within 48 hours of symptom onset.
• Diagnostic evaluation options include:
  • CT or MRI of the brain to confirm the diagnosis of symptomatic ischemic cerebral vascular disease
  • ECG to screen for atrial fibrillation and other concomitant cardiac conditions
  • Blood tests to gain insight into risk factors for stroke and to inform therapeutic goals
  • Non-invasive imaging of the intracranial large arteries and imaging of the extracranial vertebrobasilar arterial system
  • Radiology to screen for stenosis

Treatment and Management

• Patients with a TIA or minor (non-disabling) ischemic stroke should be initiated on dual antiplatelets, then continued on clopidogrel alone thereafter.
• Patients with a disabling acute ischemic stroke should be treated with aspirin 300mg for 2 weeks initially.
• Patients with atrial fibrillation should be commenced on a direct oral anticoagulant (DOAC) as soon as it is safe to do so.
• All patients with an acute ischemic stroke should be commenced on a high-intensity statin.
• Carotid endarterectomy may be suitable for patients with severe carotid stenosis of 50-99% on the same side as the part of the brain affected.

Lifestyle Modifications

• Patients who have had a stroke or TIA should be advised to follow a Mediterranean-type diet.
• Reducing sodium intake by at least 1g/d sodium (2.5g/d salt) can reduce the risk of cardiovascular disease events including stroke.
• Exercise can lower the risk of recurrent stroke and the composite cardiovascular end point of recurrent stroke, myocardial infarction, or vascular death.
• Smoking cessation should be encouraged with referral to specialist help if required.
• Men who drink > 2 alcoholic drinks a day or women who drink > 1 alcoholic drink a day should be counseled to eliminate or reduce their consumption of alcohol to reduce stroke risk.

Quality Measures and Follow-up

• Enrolment in quality monitoring and improvement programs is recommended for patients with ischemic stroke or TIA upon discharge.
• A multidisciplinary outpatient team-based approach can be effective in controlling blood pressure, lipids, and other vascular risk factors.
• Stroke quality measures have been developed to standardize stroke care among hospitals, and using these performance metrics can help improve stroke care and ultimately lead to improved outcomes for patients.