Clinical Guidelines for Acute Stroke Management - Living on the EDge

Section 7 Secondary Prevention
evidence on interventions to increase fitness. 389
Exercise has clear benefits <strong>for</strong> reducing
hypertension in at-risk people 390 and improving
glycemic control <strong>for</strong> those with type 2 diabetes. 391
Thus increasing exercise, particularly aerobic
exercise, could be expected to reduce the risk of
further stroke.
> Excessive alcohol consumption increases the risk of
stroke, 392 so reducing alcohol levels could be
expected to modify the risk of further strokes.
However, light alcohol intake was found to be
protective of stroke events. 392 The NHMRC Dietary
<strong>Guidelines</strong> <strong>for</strong> Australian Adults 2003 recommend
limiting alcohol consumption to a daily level of 2
standard drinks <strong>for</strong> men and 1 standard drink <strong>for</strong>
women. 384
> A multifactorial behavioural intervention strategy
may be required that targets several risk factors.
One study found a program of initiating tailored
secondary prevention, including lifestyle
interventions, while in hospital lead to improved
rates of adherence both prior to discharge and
3 months after discharge. 393, 394 Every stroke
survivor was given lifestyle advice and good
adherence was achieved regarding diet (78%),
exercise (70%) and smoking cessation (83% of
previous smokers had quit). 394 Other educational
interventions have also reported improved
adherence to dietary advice. 59, 60 Systematic
reviews have also found behaviour techniques,
<strong>for</strong> example dietary or motivational counseling,
provided by a specialist, trained clinician is effective
at changing behaviour in primary care setting.
395, 396
Lifescripts is a national initiative, which provides
tools <strong>for</strong> primary care clinicians promoting risk
factor management (see http://www.health.gov.au/
internet/wcms/Publishing.nsf/Content/healthpubhlth-strateg-lifescripts-index.htm).
7.1 BEHAVIOUR CHANGE GRADE LEVEL
a) Every person with stroke should be assessed and in<strong>for</strong>med of their risk factors
<strong>for</strong> a further stroke and possible strategies to modify identified risk factors.
The risk factors and interventions include:
• smoking cessation: nicotine replacement therapy, bupropion or nortriptyline A Level I
therapy, nicotine receptor partial agonist therapy and/or behavioural therapy
359-361, 363-366
should be considered;
• improving diet: a diet that is low in fat (especially saturated fat) and sodium, A Level I 367-369,
but high in fruit and vegetables should be consumed;
372, 376
&II
370, 373-375
• increasing regular exercise; (meta-analysis of cohort studies in primary) C
386-388
prevention demonstrate strong link between low exercise and stroke risk
• avoiding excessive alcohol. (meta-analysis of cohort studies in primary) C
392
prevention demonstrate link between high alcohol intake and stroke risk
b) Interventions should be individualised and may be delivered using behavioural A Level I 362-366,
techniques (such as educational or motivational counselling).
395, 396
7.2 Blood pressure lowering
High blood pressure is the major risk factor <strong>for</strong> both
first and subsequent stroke. In general effective blood
pressure management requires that blood pressure is
maintained below acceptable limits (i.e. lower than
140/90 mm Hg). 397 However, reduction in blood
pressure, irrespective of initial blood pressure, has
been shown to reduce the recurrence of stroke and
combined vascular events including myocardial
infarction. 398 Reducing blood pressure is particularly
important <strong>for</strong> patients who have diabetes where levels
should be below 130/85 mm Hg. 397 Currently the most
direct evidence available in secondary stroke
prevention is <strong>for</strong> the use of an ACE inhibitor or <strong>for</strong>
combination therapy with an ACE inhibitor and a
44