national-clinical-guidelines-for-stroke-fourth-edition

Primary care concise guide for stroke 2012
National clinical guideline for stroke
personal preference and compatibility with
safety in the home environment
● be aware of how to obtain further supplies
of medication
● have a regular review of their medication
● have their capacity (eg cognition, manual
dexterity, ability to swallow) to take full
responsibility for self-medication assessed
by the multidisciplinary team prior to
discharge as part of their rehabilitation.
Blood pressure (5.4.1)
A All patients with stroke or TIA should have
their blood pressure checked. Treatment should
be initiated and/or increased as is necessary or
tolerated to consistently achieve a clinic blood
pressure below 130/80, except for patients with
severe bilateral carotid stenosis, for whom a
systolic blood pressure target of 130–150 is
appropriate.
Antithrombotic treatment (5.5.1)
A recent NICE technology appraisal recommends
generic clopidogrel as the most cost-effective
antiplatelet therapy for secondary prevention
following ischaemic stroke (National Institute for
Health and Clinical Excellence 2010a). Aspirin
plus modified-release dipyridamole is
recommended for those unable to take
clopidogrel, although this combination may be
more difficult to tolerate, with a 29%
discontinuation rate compared with 23% for
clopidogrel in the PRoFESS study.
Clopidogrel is not licensed for the management of
TIA and therefore NICE recommends aspirin plus
modified-release dipyridamole for this indication.
Clinicians have tended to treat TIA and ischaemic
stroke as different manifestations of the same
disease and therefore it is illogical to have different
treatment strategies for the two presentations. In
producing this guideline, the members of the
working party felt that a unified approach to the
treatment of TIA and ischaemic stroke would be
appropriate. Whilst clopidogrel does not have a
licence for use after TIA, as the more cost-effective
and better tolerated option, it was felt that the
benefits of recommending this drug as first-line
outweighed any disadvantages.
A For patients with ischaemic stroke or TIA in
sinus rhythm, clopidogrel should be the
standard antithrombotic treatment:
● Clopidogrel should be used at a dose of 75
mg daily.
● For patients who are unable to tolerate
clopidogrel, offer aspirin 75 mg daily in
combination with modified-release
dipyridamole 200 mg twice daily.
● If both clopidogrel and modified-release
dipyridamole are contraindicated or not
tolerated, offer aspirin 75 mg daily.
● If both clopidogrel and aspirin are
contraindicated or not tolerated, offer
modified-release dipyridamole 200 mg
twice daily.
● The combination of aspirin and clopidogrel
is not recommended for long-term
prevention after TIA or stroke unless there
is another indication such as acute coronary
syndrome or recent coronary stent
procedure.
B For patients with ischaemic stroke or TIA in
paroxysmal, persistent or permanent atrial
fibrillation (valvular or non-valvular)
anticoagulation should be the standard
treatment. Anticoagulation:
● should not be given after stroke or TIA until
brain imaging has excluded haemorrhage
● should not be commenced in patients with
uncontrolled hypertension
● of patients with disabling ischaemic stroke
should be deferred until at least 14 days
have passed from the onset; aspirin 300 mg
daily should be used until this time
● of patients with non-disabling ischaemic
stroke should be deferred for an interval at
the discretion of the prescriber, but no later
than 14 days from the onset
● should be commenced immediately
following a TIA once brain imaging has
ruled out haemorrhage, using an agent with
a rapid onset such as low molecular weight
heparin or an oral direct thrombin or factor
Xa inhibitor.
162 © Royal College of Physicians 2012