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

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therapy in this analysis was 0.8% per annum, suggesting that 125 individuals would need to be treated with the intensive regimen to prevent one major vascular event. It is estimated that about two-thirds of the gain from statin therapy is realised by the initial dose (National Institute for Health and Clinical Excellence 2008a). Whilst the relative risk reductions remain consistent as LDL cholesterol is lowered further, the absolute benefits become smaller. Modelling carried out for the NICE lipid-modification guideline suggests that it is not cost-effective to pursue an absolute LDL cholesterol target and instead recommends a simple two-step titration strategy of simvastatin 40 mg daily, intensified to 80 mg daily if total cholesterol remains ≥4.0 mmol/L or LDL cholesterol remains ≥2.0 mmol/L. In recognition of the fact that a minority of patients will achieve this target, a total cholesterol level of 5 mmol/L is suggested for audit purposes. In the HPS, 3,280 patients had a history of stroke, TIA or carotid revascularisation procedure and in this group there was a 91% (95% CI –8 to 395) increase in the risk of haemorrhagic stroke with statin therapy. The risk of haemorrhagic stroke in SPARCL was increased by 67% (95% CI 9 to 156) for those on a statin. No increased risk of haemorrhage has been identified in primary prevention studies involving statins and if there is indeed a genuine association, it may require the presence of pre-existing intracranial small vessel disease (Goldstein et al 2008). More prospective data are required to confirm any association between statin therapy and haemorrhagic stroke but in the meantime the working party suggests a precautionary approach to prescribing in patients with a history of primary intracerebral haemorrhage, consistent with other guidelines. 5.6.1 Recommendations A All patients who have had an ischaemic stroke or TIA should be offered treatment with a statin drug unless contraindicated. Treatment: ● should be initiated using a drug with low acquisition cost such as simvastatin 40 mg daily ● should be intensified if a total cholesterol of
National clinical guideline for stroke 5.7 Carotid stenosis Narrowing of the carotid arteries is commonly associated with stroke and TIA, and surgical intervention (including radiologically guided surgery and stenting) has been used in attempts to reduce both initial stroke and further stroke. The NICE guideline on acute stroke (National Institute for Health and Clinical Excellence 2008b) has specific recommendations and this guideline’s recommendations are consistent with those (see section 4.4). 5.7.1 Management of symptomatic carotid stenosis Evidence to recommendations Identifying individuals with symptomatic severe internal carotid stenosis and instituting appropriate management is a vital part of the management of ischaemic stroke and TIA. The principal evidence supporting carotid endarterectomy for symptomatic patients is derived from the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and particularly from the pooled analyses combining data from both trials (Rerkasem and Rothwell 2011). Only patients with non-disabling stroke or TIA were included in these trials and the benefits of surgery cannot be assumed to apply to those with more disabling strokes. Patients with possible cardioembolic source were also excluded. When allowances are made for the different methods used to measure stenosis from angiograms, the two studies report consistent findings. To avoid confusion when discussing levels of stenosis there is agreement that the technique used in NASCET should be used (the ratio of the diameter of the residual lumen at the point of maximum narrowing to that of the distal internal carotid artery, expressed as a percentage). All references to percentage stenosis in this guideline refer to the NASCET method of measurement. In a pooled analysis of individual patient data involving 6,092 patients, surgery reduced the 5-year absolute risk of ipsilateral ischaemic stroke by 16.0% (p
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National clinical guideline for str
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The Royal College of Physicians The
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The Intercollegiate Stroke Working
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Conflicts of interest All working p
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Key recommendations Number Recommen
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Acknowledgements The Intercollegiat
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Glossary ABCD2 score Prognostic sco
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2 Commissioning of stroke services
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2.1.2 Implications needed by patien
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2.4 Commissioning rehabilitation se
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3 Organisation of stroke services 3
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Page 60 and 61: 4 Acute phase care 4.0 Introduction
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7 Long-term management 7.0 Introduc
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● where appropriate refer the per
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experience appropriate to meet thei
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Profession-specific concise guideli
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● ensure that all relevant inform
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C People with stroke should be offe
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● avoiding the use of overhead ar
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Carers (informal, unpaid) (7.6.1) A
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● any continuing specialist treat
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Lipid-lowering therapy (5.6.1) B Al
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Occupational therapy concise guide
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C Bilateral arm training involving
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● be referred to a specialist in
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problems, such as using notebooks,
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Physiotherapy concise guide for str
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medically unstable, by an appropria
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numerical rating scale), the modifi
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Cognitive impairments - general (6.
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E Patients with suspected TIA who a
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Lipid-lowering therapy (5.6.1) A Al
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● ask about and identify any abso
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formal review at least every 6 mont
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Depression and anxiety (6.35.1) A A
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Perception (6.42.1) A Any person wh
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days per week, at a level that enab
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language function should be assesse
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● organising and supporting venue
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Appendix 1 Evidence table reviewers
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Appendix 2 Peer reviewers Commissio
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Dr Katerina Hilari City University
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QM7 Urgent response All patients wi
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References Abbott AL (2009) Medical
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Cirstea MC, Levin MF (2007) Improve
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Fung TT, Chiuve SE, McCullough ML,
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Koyuncu E, Nakipoglu YG, Dogan A, O
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Mitchell PH, Veith RC, Becker KJ, B
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Rothwell P, Eliasziw M, Gutnikov S,
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therapy for stroke inpatients. Clin
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