Secondary Prevention of Stroke and Transient Ischaemic Attack (TIA)

Drug therapy

Antiplatelets

Antiplatelets should be started as per the table below for patients with TIA or ischaemic stroke in sinus rhythm within 24 hours after a CT brain scan excludes haemorrhage and unless contraindicated.

Notes

1. For NIHSS, see here.
2. If clopidogrel is contraindicated prescribe aspirin at the same intended dose of clopidogrel, and if aspirin is contraindicated prescribe clopidogrel at the same intended dose as aspirin. If DAPT was intended, prescribe aspirin or clopidogrel 150mg daily for 21 days then continue on aspirin or clopidogrel 75mg daily thereafter.
3. Dual antiplatelet therapy (DAPT): DAPT consists of loading doses of clopidogrel oral 300mg plus aspirin oral 300mg, then both aspirin oral 75mg daily and clopidogrel oral 75mg daily for 21 days. After 21 days the patient would continue on only clopidogrel oral 75mg daily lifelong. The Immediate Discharge Letter (IDL) must contain information on intended duration of DAPT.

Proton pump inhibitors (PPI)

• Consider co-prescribing a proton pump inhibitor with antiplatelet therapy. If indicated lansoprazole oral 15mg daily should be prescribed with clopidogrel due to the interaction between clopidogrel and omeprazole/esomeprazole.
• For further information, refer to the acid inhibitors policy (link only active if accessing via NHS network) which is available via AthenA / Guidelines - Prescribing / Gastrointestinal.

Anticoagulants

• Patients admitted on anticoagulants should have them suspended until an emergency CT brain scan has been completed and haemorrhage excluded. While anticoagulants are suspended antiplatelets should be prescribed as detailed above.
• Discontinuation of anticoagulants may not be possible in some clinical situations e.g. metallic heart valves. Discuss with stroke consultant / cardiologist.
• Timing of initiation or re-introduction of anticoagulants in patients with TIA / ischaemic stroke and atrial fibrillation (AF) will always be at the discretion of the stroke consultant. After CT brain imaging rules out haemorrhage, initiation or re-introduction of anticoagulants if still indicated, usually depends on the infarct size.
• Anticoagulants are initiated or resumed broadly as follows:
  • TIA - immediately after CT brain excludes bleed
  • Minor stroke - earlier than 5 days after onset of stroke if the prescriber considers the benefits to outweigh the risk of early intracranial haemorrhage
  • Moderate to severe stroke - 5 to 14 days after onset of stroke
• Refer to non-valvular atrial fibrillation - oral anticoagulant choice guideline (link only active if accessing via NHS network) which is available via AthenA / Guidelines - Prescribing / Cardiovascular.
• Antiplatelets should never be co-prescribed with anticoagulants unless advised by consultant cardiologist or stroke consultant.

Antihypertensives

• After the acute stroke phase, all patients with a BP >130mmHg systolic should be considered for antihypertensive treatment.
• The exception is for people with severe bilateral carotid artery stenosis, for whom a systolic blood pressure target of 140–150mmHg is appropriate.
• Refer to the Management of Hypertension guideline for choice of drug treatment.

Cholesterol lowering

Ischaemic stroke

• Unless contraindicated, treat all patients who have had an ischaemic stroke with a statin regardless of baseline cholesterol concentration. Prescribe atorvastatin oral 40mg to 80mg at night.
• Patients with an ischaemic stroke admitted on a low or medium intensity statin should be switched to a high intensity statin irrespective of the serum cholesterol concentration. Refer to the BNF statin therapy intensity guidance.
• Lipid-lowering treatment for people with ischaemic stroke or TIA and evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol to below 1.8mmol/L (equivalent to a non-HDL-cholesterol of below 2.5mmol/L in a non-fasting sample).
• For further guidance, refer to the Management of Hyperlipidaemia guideline.

Haemorrhagic stroke

• Statins are generally not initiated after haemorrhagic stroke.

N.B. As with all aspects of secondary prevention it is important to be aware of the potential risks of polypharmacy and the lack of evidence for benefit in some patient groups. In very frail patients with limited life expectancy, some elements of secondary prevention may cause more harm than benefit. This may particularly be the case for lipid lowering therapy. In these circumstances, the stroke consultant may carry out an informed discussion with the patient regarding therapy and the outcome documented in case notes.

Oral contraception and hormone replacement therapy

• Premenopausal women with stroke and TIA should not be offered the combined oral contraceptive pill. Alternative hormonal (progestogen-only) and non-hormonal contraceptive methods should be considered instead.
• Post-menopausal women with ischaemic stroke or TIA who wish to start or continue hormone replacement therapy should receive advice based on the overall balance of risk and benefit, taking account of the woman’s preferences.
• Post-menopausal women with ischaemic stroke or TIA should not be offered hormone replacement therapy for secondary vascular prevention.