Dr Helen Hosker reviews the current guidelines on stroke and TIA, and summarises the interventions for secondary prevention

Stroke is the third largest cause of death in England with 110,000 individuals experiencing a new stroke each year.1 There are over 900,000 people who have had a stroke living in England.1 The launch of the National Stroke Strategy for England in December 2007, elevated stroke as a priority for service development and redesign. Three guidelines, published in 2008, provide the evidence base that support the strategy and clinical care:

  • the National clinical guideline for stroke, 3rd edition2
  • the NICE guideline on Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)3
  • the SIGN guideline on the management of patients with stroke or TIA.4

This personal view article summarises the key recommendations for primary care in the management of stroke and TIA.

Initial assessment of stroke

Rapid recognition of a stroke is key to enable patients to access acute stroke hospital care, including thrombolysis, faster. The right care in the acute stage will result in less brain damage, and therefore, fewer long-term disabilities. The Face Arm Speech Test (FAST) (see Figure 1) is actively promoted as a screening tool to identify those who may have had a stroke.3,4 It will identify around 78% of stroke presentations.4

It is important that healthcare professionals are aware that FAST is not a diagnostic test and that there are other presentations for stroke and TIA, such as:5

  • weakness of a leg
  • numbness of face, arm, or leg
  • difficulties in swallowing, causing coughing or choking
  • confusion
  • problems with walking, balance, or coordination
  • altered consciousness
  • headache with or without nausea and/or vomiting.

For primary care (both in-hours general practice and out-of-hours services), stroke must be viewed as a medical emergency in the same way as possible cardiac chest pain.1,4 Call handlers and receptionists must be aware of FAST and either encourage the caller to dial 999, or offer to do it on their behalf. A written protocol would be useful for these first-line contacts.

A patient with suspected stroke should always be admitted to hospital as a matter of emergency rather than waiting for a house visit, unless hospital admission is not in the patient’s best interests because of known circumstances or health problems.1 All patients in the acute stage of stroke can derive benefit from care on a specialist unit. Currently, only a small percentage of patients present within 3 hours of onset and can be considered for thrombolysis.6 New research has shown that thrombolytic agents can still be effective if given within 4.5 hours of onset of symptoms,7 and this is acknowledged in the SIGN guideline.4 Thrombolysis, or clot busting, can achieve revascularisation of the brain by restoring blood flow through the blocked artery. The recovery from symptoms of stroke can be rapid and sometimes complete. The main complication is haemorrhage.

Figure 1: Face Arm Speech Test for stroke4

Facial weakness

Can the person smile?

Has their mouth or eye drooped?

Arm weakness Can the person raise both arms?
Speech problems Can the person speak clearly and understand what you say?
Test all three symptoms

Stroke is a medical emergency

Call 999—early treatment can prevent further brain damage

National Institute for Health and Care Excellence (NICE) (2008) CG68. Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: NICE. Reproduced with kind permission. Available from www.nice.org.uk/CG68

Management of TIA

Transient ischaemic attack is a retrospective diagnosis2—a diagnosis of stroke is made if symptoms are present at the time that contact is made with a healthcare professional. A TIA is the only warning that indicates a stroke might be imminent. The major causes of early stroke after TIA or minor stroke are emboli from atrial fibrillation or severe internal carotid stenosis, both of which are eminently treatable. The ABCD2 scoring system (see Figure 2) is useful in identifying those patients at high risk of stroke after a TIA who require urgent specialist assessment.

Aspirin 300 mg should be given immediately to a patient following a TIA (unless there is a contraindication, such as proven aspirin intolerance) and continued for 2 weeks, or until seen in the clinic, as this has been shown to lead to a reduction in early strokes.4,8

The NICE guideline recommends giving aspirin within 24 hours while SIGN recommends within 48 hours,3,4 but in practice in primary care aspirin should be given at the time the diagnosis is first suspected. Administration of aspirin must not be delayed because the patient is waiting to be seen at a clinic—doctors should consider including aspirin in their emergency bag.

Patients who are at a high risk of stroke should undergo prompt specialist assessment and treatment within 24–48 hours of onset of symptoms of TIA. However, achieving this will require a redesign of TIA services with systems to directly book appointments both in hours and out of hours.1 It is essential that patients and carers be told that they must call 999 if further symptoms present before they are able attend the clinic.1

Figure 2: ABCD and ABCD24

Prognostic score to identify people at high risk of stroke after a transient ischaemic attack

It is calculated based on:

A — age (?60 years, 1 point)

B — blood pressure at presentation (?140/90 mmHg, 1 point)

C — clinical features (unilateral weakness, 2 points; speech disturbance without weakness, 1 point)

D — Duration of symptoms (?60 minutes, 2 points; 10–59 minutes, 1 point)

The calculation of ABCD2 also includes the presence of diabetes (1 point)

Total scores range from 0 (low risk) to 7 (high risk)

National Institute for Health and Care Excellence (NICE) (2008) CG68. Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: NICE. Reproduced with kind permission. Available from www.nice.org.uk/CG68

Secondary prevention of stroke or TIA

Compliance with management of medical risk factors is more effective in the prevention of further vascular events than adherence to lifestyle risk-factor modification. Patients who have had a stroke are more likely to take tablets regularly than change their lifestyle.9 One paper has suggested that a combined strategy of aspirin, statins, antihypertensive drugs, diet, and exercise may reduce recurrence of vascular events, including ischaemic stroke by 80% over 5 years.10 It is, therefore, important that measures to modify all risk factors are offered to patients, and that there is no ‘cherry picking’.

Medical risk factors

In terms of secondary prevention of stroke and TIA, most advice in the management of medical risk factors has been derived from other vascular prevention studies, although recent studies are beginning to highlight specific recommendations for stroke.11 A summary of the recommendations on the secondary prevention of medical risk factors is shown in Table 1.

All patients should have their blood pressure checked, and should be treated in line with national guidelines.12 Patients with raised blood pressure should have their blood pressure lowered; the target values are extrapolated from other vascular diseases: <140/85 mmHg or <130/80 mmHg for patients with diabetes.4 Patients with normal blood pressure should be treated to reduce the risk of further strokes8,13so they should also be prescribed antihypertensive agents but there are no target values for this group. All stroke patients should receive antihypertensive therapy as secondary prevention regardless of initial blood pressure.

All patients who have had a stroke should be treated with a statin. However, the ideal dose and choice of statin therapy following ischaemic stroke is unclear—the SIGN recommendation for atorvastatin 80 mg is based on data from one trial with no comparison for dose or an alternative statin.14 Haemorrhagic strokes do not result from atherosclerotic disease, and statins have been linked to an increase in this type of stroke.4 The SIGN guideline does not recommend the routine use of statins for the prevention of further vascular events after a haemorrhagic stroke unless the risk of such events outweighs the risk of further haemorrhage.4 Determining the risk of these events is difficult, and the balance in favour of statin use may alter over time.

Following an ischaemic stroke, all patients should receive an antiplatelet agent or anticoagulant unless there are compelling contraindications. The addition of dipyridamole to aspirin is more effective in preventing strokes.11 The SIGN guideline recommends the use of clopidogrel as second-line monotherapy and other guidelines recommend aspirin as second-line therapy if unable to tolerate dipyridamole, or clopidogrel if there is true aspirin intolerance.2,4,11

Patients with stroke or TIA who are in atrial fibrillation are at a high risk of stroke and should be offered warfarin,4 but at present anticoagulant therapy is underused, particularly in the elderly. Older people are often not considered for anticoagulation on grounds of frailty, falls, or ageism—the substantial risk of a stroke should not be ignored. Patients not receiving warfarin should be reassessed on an individual basis.

Table 1: Summary of secondary prevention for stroke and TIA: intervention for medical risk factors2,4

Ischaemic stroke
Blood pressure
  • SIGN4
      • all patients with previous stroke or TIA should receive treatment, regardless of blood pressure, unless contraindicated
      • treatment target of <140/85 mmHg or <130/80 mmHg for patients with diabetes
      • one study has shown that a combination of ACE inhibitor and thiazide diuretic is effective in preventing further strokes
      • there is no evidence for the effectiveness of beta blockers
  • National clinical guideline for stroke2
      • the target for patients with established cardiovascular disease is <130/80 mmHg
      • beta blockers should not be used as first- or second-line option for the prevention of recurrent stroke unless specifically indicated
      • in patients with bilateral severe carotid artery stenosis a slightly higher target may be appropriate (e.g. systolic BP of 150 mmHg)
Cholesterol and statin therapy
  • SIGN4
      • statins should be prescribed to all patients following ischaemic stroke or TIA, irrespective of cholesterol level
      • the reduction in stroke risk is proportional to the lowering of LDL-C, irrespective of baseline value
      • target for cholesterol (TC and LDL-C) is not given
      • there is evidence for the use of atorvastatin 80 mg in preventing further ischaemic stroke; simvastatin 40 mg reduced the risk of further vascular events but not stroke
  • National clinical guideline for stroke2
      • treat with statin if TC >3.5 mmol/l or LDL-C >2.5 mmol/l to specified target values
Antiplatelet therapy
  • SIGN4
      • prescribe 75 mg aspirin and dipyridamole 200 mg modified release twice daily
      • the side-effect of headache as a result of therapy with dipyridamole can be reduced by starting
        with a low dose and up titrating
      • 75 mg clopidogrel is an alternative to combination aspirin and dipyridamole
      • the combination of aspirin and clopidogrel is not recommended for the prevention of ischaemic stroke
      • anticoagulant therapy is not recommended for secondary prevention in non-cardioembolic ischaemic stroke
  • National clinical guideline for stroke2
      • aspirin 50–300 mg daily plus dipyridamole 200 mg modified release twice daily should be the
        first-line treatment following ischaemic stroke or TIA
      • if the patient is intolerant to dipyridamole, aspirin (75 mg daily) or clopidogrel (75 mg daily) are alternatives
      • the addition of a proton-pump inhibitor should be considered if there is dyspepsia or significant
        risk of gastrointestinal bleeding with aspirin to allow aspirin medication to continue
Atrial fibrillation
  • SIGN4
      • patients in atrial fibrillation should be offered anticoagulation therapy (with warfarin)
      • warfarin should be routinely offered to elderly patients (>75 years) following ischaemic stroke or TIA who are in atrial fibrillation unless there are contraindications or patient preference
      • no evidence to support routine addition of aspirin to warfarin
  • National clinical guideline for stroke2
      • anticoagulation treatment is recommended in every patient with persistent or paroxysmal atrial fibrillation unless contraindicated and should not be usually started until 14 days after stroke
Haemorrhagic stroke (primary intracerebral haemorrhage)
Blood pressure
  • SIGN4
      • following haemorrhagic stroke, blood pressure should be lowered
      • there is evidence for the effectiveness of a combination of ACE inhibitor and thiazide diuretic in preventing further vascular events
  • National clinical guideline for stroke2
      • should be managed as in ischaemic stroke
Cholesterol and statin therapy
  • SIGN4
      • statin therapy after haemorrhagic stroke is not routinely recommended unless the risk of further vascular events outweighs the risk of further haemorrhage
  • National clinical guideline for stroke2
      • treatment with statin therapy should be avoided or used with caution in individuals with a history of haemorrhagic stroke, particular those with inadequately controlled hypertension

Antiplatelet therapy

  • SIGN4
      • use of aspirin to prevent further strokes is not recommended
      • aspirin may be considered if there is a high risk of cardiac ischaemic events
Anticoagulation
  • SIGN4
      • anticoagulants are not recommended following haemorrhagic stroke
TIA=transient ischaemic attack; SIGN=Scottish Intercollegiate Guidelines Network; ACE=angiotensin-converting enzyme; LDL-C=low-density lipoprotein cholesterol; TC=total cholesterol

Lifestyle modification

In addition to receiving advice and information, patients should be encouraged to take responsibility for their own health and they should be supported to make behavioural changes.2 A summary of the recommendations on lifestyle interventions is shown in Table 2. However, patients who have had a stroke may have difficulty in accessing services to support these changes by virtue of their disabilities, for example, mobility or dysphasia, and this should be considered during service redesign.

The following factors should be considered when issuing lifestyle advice:2,4

  • reduce the risk of diabetes and other vascular factors
  • reduction of body mass index in overweight patients is important for reducing the risk of diabetes and other vascular risk factors; it also reduces problems with manual handling and mobility linked to obesity
  • exercise opportunities can be difficult for patients who have had a stroke due to the nature of their disabilities. Aerobic exercise helps with vascular risk-factor reduction, but strength and balance training to reduce the risk of falls should also be considered
  • adherence to a five-a-day Mediterranean diet can be difficult for those unable to shop or cook for themselves, or who are reliant on frozen meals, or in residential care.
  • there can be cultural difficulties in modifying diets in some high-risk populations, for example, African, Caribbean, and South Asian.

Table 2: Summary of secondary prevention for stroke and TIA: lifestyle interventions2,4

Smoking
  • SIGN4
      • all patients who smoke should be advised to stop and offered support in order to minimise cardiovascular and general health risks
    • National clinical guideline for stroke2
        • all smokers should be advised to stop
        • cessation should be encouraged at every opportunity using tailored strategies, which may include pharmacological therapy and/or psychological support

Alcohol

  • SIGN4
      • recommends no more than 3–4 units per day for men and 2–3 units for women with at least two
        drink-free days per week for both men and women
  • National clinical guideline for stroke2
      • alcohol intake should be kept within safe drinking limits (?3 units per day for men and ?2 units per day for women)
Weight (BMI)
  • SIGN4
      • individuals who are overweight should be advised to reduce weight and maintain any weight reduction
    • National clinical guideline for stroke2
      • offer advice and support to encourage weight loss
      • advice to lose weight should include diet and exercise
      • medication to lose weight should be offered only after dietary advice and exercise has been started and evaluated, and should be in line with national guidelines
Exercise
  • SIGN4
      • encourage lifelong participation in programmes of exercise after stroke
      • exercise programmes should ideally be delivered or supervised by someone with knowledge and training in exercise and stroke
  • National clinical guideline for stroke2
      • patients should take daily regular exercise accumulating to 20–30 minutes of moderate activity, sufficient to become slightly breathless, unless there are contraindications
      • exercise should be tailored to the individual following appropriate assessment and any disability should be taken into consideration
      • patients with mobility problems should be encouraged to practise as much as possible any activity considered within their safe capability
Diet
  • SIGN4
      • reduce total and saturated fat intake
      • consume two portions of fish per week (including one portion oily fish)
      • salt intake should be reduced as much as possible, particularly in individuals with hypertension
      • increase fruit and vegetable consumption to reduce risk of stroke or TIA
      • vitamin supplementation is not recommended following stroke
  • National clinical guideline for stroke2
      • reduce and replace total and saturated fat intake by:
          • using low-fat dairy products
          • replacing butter and lard with vegetable and plant oils
          • reducing meat intake
      • eat five or more portions of fruit or vegetables per day
      • eat two portions of fish per week (including one portion of oily fish)
      • no evidence to support the use of vitamin supplements in preventing stroke or other vascular events and it is, therefore, not recommended
TIA=transient ischaemic attack; SIGN=Scottish Intercollegiate Guidelines Network; BMI=body mass index

Provision of information

Information in a variety of formats should be provided for patients who have had a stroke, their family, and/or carers, taking into account communication difficulties, educational status, and first language.2–4 Patients should be given information about the secondary prevention of stroke and TIA to improve compliance, and this should be reiterated at review. Patients and their carers should be made aware of the symptoms of an acute stroke, and that an emergency response is required in the event of a further acute event.

Summary

General practitioners have a key role in making a diagnosis of acute stroke and ensuring that patients are seen and referred as a medical emergency for a new stroke event or high-risk TIA. They should also ensure that patients with low-risk TIAs are seen in a clinic within 1 week. Implementing comprehensive secondary prevention and taking note of the specific recommendations for ischaemic stroke will reduce the risk of further strokes and other acute vascular events.

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guidelines on stroke
  • Increased urgent referrals and hospital admissions for stroke will lead to greater costs
  • Investments in specialist acute stroke units should result in reduced disability and reduced lengths of stay
  • Investment in services for TIA should be offset by prevention of strokes
  • Local payment by result tariffs may need to be negotiated to realise savings (e.g. reduced lengths of stay)
  • There will be an increase in prescribing costs associated with full implementation of the recommendations for secondary prevention
  • Investment in primary and secondary prevention is difficult to prove, and not realised in the short term
  • Social care may benefit more from savings than healthcare from investments in acute care
  • Local stroke networks should be worked with to influence and implement service redesign
  • Local authorities should be worked with in the use of their stroke development monies allocated by Department of Health (England only)
  1. Department of Health. National Stroke Strategy. London: DH, 2007. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062
  2. Intercollegiate Stroke Working Party. National clinical guideline for stroke, 3rd edition. London: Royal College of Physicians, 2008. Available at: www.rcplondon.ac.uk/pubs/brochure.aspx?e=250
  3. National Institute for Health and Care Excellence. Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). Clinical Guideline 68. London: NICE, 2008. Available at: www.nice.org.uk/Guidance/CG68
  4. Scottish Intercollegiate Guidelines Network. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention. SIGN 108. Edinburgh: SIGN, 2008. Available at: www.sign.ac.uk/guidelines/fulltext/108/index.html
  5. Mohd Nor A, Davis J, Sen B et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet 2005; 4 (11): 727–734.
  6. National Institute for Health and Care Excellence. Alteplase for the treatment of acute ischaemic stroke.Technology Appraisal 122. London: NICE, 2007. Available at: www.nice.org.uk/TA122
  7. Hacke W, Kaste M, Bluhmki E et al.Thrombolysis with alteplase 3 to 4.5 hours after acute ischaemic stroke. N Engl J Med 2008; 359 (13): 1317–1329.
  8. Rothwell P, Giles M, Chandratheva A et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early stroke recurrence (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007; 370 (9596): 1432–1442.
  9. Ovbiagele B, Saver J, Fredieu A et al. In-hospital initiation of secondary stroke prevention therapies yields high rates of adherence at follow-up. Stroke 2004; 35 (12): 2879–2883.
  10. Hackham D, Spence J. Combining multiple approaches for the secondary prevention of vascular events after a stroke—a quantitative modelling study. Stroke 2007: 38 (6): 1881–1885.
  11. National Institute for Health and Care Excellence. Clopidogrel and modified release dipyridamole in the prevention of occlusive vascular events. Technology Appraisal 90. London: NICE, 2005.
  12. British Hypertension Society, National Collaborating Centre for Chronic Conditions. Hypertension: management of hypertension in adults in primary care: partial update. London: Royal College of Physicians, 2006.
  13. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358 (9287): 1033–1041.
  14. Amarenco P, Bogousslavsky J, Callahan A 3rd et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006; 355 (6): 549–559.G