• Secondary prevention. In: National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne (Australia): National Stroke Foundation; 2007 Oct. p. 43-51.

This is the current release of the guideline.

The levels of evidence supporting the recommendations (I-IV) and grades of recommendations (A-D and clinical practice points [CPP]) are defined at the end of the "Major Recommendations" field.

The original guideline document also includes a consumer rating that identifies aspects of care considered to be critical from a patient perspective.

Behaviour Change

Every person with stroke should be assessed and informed of their risk factors for 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 therapy, nicotine receptor partial agonist therapy and/or behavioural therapy should be considered; (Grade A; Level I [Silagy et al., 2004; Hughes, Stead, & Lancaster, 2007; Cahill, Stead, & Lancaster, 2007; Sinclair, Bond, & Stead, 2004; Rice & Stead, 2004; Lancaster & Stead, 2005; Stead, Perera, & Lancaster, 2006])
• Improving diet: a diet that is low in fat (especially saturated fat) and sodium, but high in fruit and vegetables should be consumed; (Grade A; Level I [He & MacGregor, 2004; Hooper et al., 2004; Jurgens & Graudal, 2004; He, Nowson, & MacGregor, 2006; Hooper, et al., 2001] & Level II [Sacks et al., 2001; Appel et al., 1997; Barzi et al., 2003; de Lorgeril et al., 1999])
• Increasing regular exercise; (Grade C; metaanalysis of cohort studies in primary prevention demonstrate strong link between low exercise and stroke risk [Lee, Folsom, & Blair, 2003; Wendel-Vos et al., 2004; Oguma & Shinoda-Tagawa, 2004])
• Avoiding excessive alcohol. (Grade C; metaanalysis of cohort studies in primary prevention demonstrate link between high alcohol intake and stroke risk [Reynolds et al., 2003])

Interventions should be individualised and may be delivered using behavioural techniques (such as educational or motivational counselling). (Grade A; Level I [Stead & Lancaster, 2005; Sinclair, Bond, & Stead, 2004; Rice & Stead, 2004; Lancaster & Stead, 2005; Stead, Perera, & Lancaster, 2006; Rubak et al., 2005; Pignone & Mulrow, 2001)

Blood Pressure Lowering

All patients after stroke or transient ischaemic attack (TIA), whether normotensive or hypertensive, should receive blood pressure lowering therapy, unless contraindicated by symptomatic hypotension. (Grade A; Level I [Rashid, Leonardi-Bee, & Bath, 2003])

Commencement of new blood pressure lowering therapy may occur prior to discharge or within the first week after stroke or TIA. (Grade B; Level II [Nazir et al., 2004; Nazir et al., 2005] & Level III-3 [Ovbiagele et al., 2004])

Antiplatelet Therapy

Long term antiplatelet therapy should be prescribed to all people with ischaemic stroke or TIA who are not prescribed anticoagulation therapy. (Grade A; Level I [Antithrombotic Trialists Collaboration, 2003])

Low dose aspirin and modified release dipyridamole should be prescribed to all people with ischaemic stroke or TIA who do not have concomitant acute coronary disease. (CPP [ESPRIT Study Group et al., 2006; Diener et al., 1996])

Aspirin alone or clopidogrel alone may be used for people who do not tolerate aspirin plus dipyridamole therapy. Clopidogrel alone should be used for those who are intolerant of aspirin or in whom aspirin is contraindicated. (CPP [Antithrombotic Trialists Collaboration, 2003])

The combination of aspirin plus clopidogrel is not recommended in the secondary prevention of cerebrovascular disease in patients who do not have acute coronary disease or recent coronary stent. (Grade A; Level II [Diener et al., 2004; Bhatt et al., 2006])

Anticoagulation Therapy

Anticoagulation therapy for long-term secondary prevention should be used in all people with ischaemic stroke or TIA who have atrial fibrillation, cardioembolic stroke from valvular heart disease, or recent myocardial infarction, unless a contraindication exists. (Grade A; Level I [Saxena & Koudstaal, "Anticoagulants for preventing stroke," 2004; Saxena & Koudstaal, "Anticoagulants versus antiplatelet therapy," 2004])

Anticoagulation therapy for secondary prevention for those people with ischaemic stroke or TIA from presumed arterial origin should not be routinely used as there is no evidence of additional benefits over antiplatelet therapy. (Grade A; Level I [Algra et al., 2006])

The decision to commence anticoagulation therapy should be made prior to discharge. (Grade C; Level III-3 [Ovbiagele et al., 2004])

In patients with TIA, commencement of anticoagulation therapy should occur once CT or MRI has excluded intracranial haemorrhage as the cause of the current event. (CPP)

Cholesterol Lowering

Therapy with a statin should be used for all patients with ischaemic stroke or TIA. (Grade B; Level II [Collins et al., 2004; Amarenco et al., 2006])

Patients with high cholesterol levels should receive dietary review and counselling by a specialist, trained clinician. (Grade B; Level I [Ruback et al., 2005; Pignone & Mulrow, 2001])

Diabetes Management

All acute stroke patients should have their glucose monitored. Patients with glucose intolerance or diabetes should be managed in line with national guidelines for diabetes. (CPP)

Carotid Surgery

Carotid endarterectomy should be undertaken in patients with nondisabling carotid artery territory ischaemic stroke or TIA with ipsilateral carotid stenosis measured at 70-99% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) if surgery can be performed by a specialist surgeon with low rates of perioperative mortality/morbidity. (Grade A; Level I [Cina, Clase, & Haynes, 1999; Rothwell et al., 2003])

Carotid endarterectomy should be undertaken in select patients (considering age, gender and comorbidities) with nondisabling carotid artery territory ischaemic stroke or TIA with ipsilateral carotid stenosis measured at 50-69% (NASCET criteria) if surgery can be performed by a specialist surgeon with very low rates of perioperative mortality/morbidity. (Grade A; Level I [Cina, Clase, & Haynes, 1999; Rothwell et al., 2003])

Carotid endarterectomy may be undertaken in highly select patients (considering age, gender and comorbidities) with asymptomatic carotid stenosis of 60-99% if it can be performed by a specialist surgeon with very low rates of perioperative mortality/morbidity. (Grade A; Level I [Cina, Clase, & Haynes, 1999; Rothwell et al., 2003])

Eligible patients should undergo carotid endarterectomy as soon as possible after the event (ideally within 2 weeks). (Grade A; Level I [Rothwell et al., 2004])

Carotid endarterectomy should only be performed by a specialist surgeon at centres where outcomes of carotid surgery are routinely audited. (Grade B; Level I [Cina, Clase, & Haynes, 1999])

Carotid endarterectomy is not recommended for those with <50% symptomatic stenosis or those with <60% asymptomatic stenosis. (Grade A; Level I [Cina, Clase, & Haynes, 1999; Chambers, 2005])

Carotid angioplasty and stenting should not routinely be considered for patients with symptomatic stenosis. However, it may be considered as an alternative in certain circumstances, that is in patients who meet criteria for carotid endarterectomy but are deemed unfit due to medical comorbidities (e.g., significant heart/lung disease, age >80 yrs), or conditions that make them unfit for open surgery (e.g., high or low carotid bifurcation, carotid re-stenosis). (Grade B; Level I [Coward, Featherstone, & Brown, 2004] & Level II [SPACE Collaborative Group, 2006; Mas et al., 2006])

Patent Foramen Ovale (PFO)

All patients with an ischaemic stroke or TIA, and a PFO, should receive antiplatelet therapy as first choice. (Grade C; Level II [Homma et al., 2002])

Anticoagulation may also be considered taking into account other risk factors and the increased risk of harm. (Grade C; Level II [Homma et al., 2002])

Currently there is insufficient evidence to recommend PFO closure. (CPP)

Concordance with Medication

Interventions to promote adherence to medication regimes are often complex and should include one or more of the following:

• Information, reminders, self-monitoring, reinforcement, counselling, family therapy. (Grade B; Level I [Schroeder, Fahey, & Ebrahim, 2004; Schedlbauer et al., 2004; Haynes et al., 2005])
• Reduction in the number of daily doses. (Grade B; Level I [Schroeder, Fahey, & Ebrahim, 2004; Schedlbauer et al., 2004])
• Multi-compartment medication compliance device. (Grade C; Level I [McGraw, 2004; Heneghan, Glasziou, & Perera, 2006])

Definitions:

Levels of Evidence

Grading of Recommendations

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Secondary prevention. In: National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne (Australia): National Stroke Foundation; 2007 Oct. p. 43-51.

Not applicable: The guideline was not adapted from another source.

2007 Oct

National Stroke Foundation (Australia) - Private Nonprofit Organization

Australian Government Department of Health and Ageing

Expert Working Group

Group Members: Dr Alan Barber, Neurologist, Auckland City Hospital; Dr Christopher Beer, Senior Lecturer, University of Western Australia and Geriatrician/Clinical Pharmacologist Royal Perth and Mercy Hospitals and Swan Health Service; Prof Justin Beilby, Executive Dean, Faculty of Health Sciences and Professor of General Practice, University of Adelaide; Assoc Prof Julie Bernhardt, Physiotherapist, National Stroke Research Institute; Prof Christopher Bladin, Neurologist, Box Hill Hospital; Ms Brenda Booth, Consumer, Working Aged Group with Stroke, NSW; Dr Julie Cichero, Speech Pathologist, Private Practice & University of Queensland; Ms Louise Corben, Occupational Therapy, Monash Medical Centre & Bruce Lefroy Centre Murdoch Children's Research Institute; Dr Denis Crimmins (Chair) Neurologist, Gosford Hospital; Dr Richard Gerraty, Neurologist, Alfred Hospital and Monash University; Mr Kelvin Hill, Manager, Guidelines Program, National Stroke Foundation; Dr Erin Lalor, Chief Executive Officer, National Stroke Foundation; Assoc Prof Christopher Levi, Neurologist, John Hunter Hospital; Prof Richard Lindley, Professor of Geriatric Medicine, University of Sydney and Westmead Hospital; Prof Sandy Middleton, School of Nursing (NSW & ACT), Australian Catholic University; Ms Fiona Simpson, Dietitian and Senior Research Fellow, Royal North Shore Hospital Sydney

All members of the working group completed and signed a declaration of potential conflicts of interest with development of these guidelines. Most had no perceived conflicts. The reasons provided for potential conflicts primarily involved receiving money from non commercial and commercial organisations specifically for undertaking clinical research. This was expected given the expertise of members of the working group in clinical research. Only a small number of members had received financial support from commercial companies for providing consultancy or lecturing.

Australian and New Zealand Society for Geriatric Medicine - Medical Specialty Society
Australian College of Rural and Remote Medicine - Professional Association
Australian Physiotherapy Association - Medical Specialty Society
BeyondBlue: The National Depression Initiative - National Government Agency [Non-U.S.]
Council of Ambulance Authorities (Australia) - Professional Association
Dietitians Association of Australia - Professional Association
Occupational Therapy Australia - Professional Association
Royal Australian and New Zealand College of Radiologists - Professional Association
Speech Pathology Australia - Medical Specialty Society
Stroke Society of Australasia - Disease Specific Society

This is the current release of the guideline.

This NGC summary was completed by ECRI Institute on December 1, 2008. The information was verified by the guideline developer on December 4, 2008. This summary was updated by ECRI Institute on July 20, 2009 following the U.S. Food and Drug Administration advisory on Varenicline and Bupropion.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.