What is the recommended management for stroke patients in an outpatient setting?

From the Guidelines

The recommended management for stroke patients in an outpatient setting involves a comprehensive approach focusing on secondary prevention and rehabilitation, as outlined in the most recent guidelines from 2018 1.

Key Components of Outpatient Management

• Antiplatelet therapy, typically aspirin 81-325mg daily, clopidogrel 75mg daily, or aspirin/dipyridamole extended-release 25/200mg twice daily, based on stroke etiology and patient factors
• For those with atrial fibrillation, anticoagulation with direct oral anticoagulants (DOACs) like apixaban 5mg twice daily or warfarin (target INR 2-3) is indicated
• Blood pressure control is crucial, aiming for targets below 130/80 mmHg using medications such as ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics
• Lipid management with high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) is recommended regardless of baseline cholesterol levels
• Diabetes management should target HbA1c below 7%
• Lifestyle modifications include smoking cessation, limiting alcohol consumption, maintaining a Mediterranean or DASH diet, regular physical activity, and weight management

Rehabilitation and Follow-up

• Rehabilitation services should be coordinated based on deficits, including physical, occupational, and speech therapy
• Regular follow-up appointments should monitor medication adherence, risk factor control, and functional status This comprehensive approach addresses the underlying pathophysiology of stroke by reducing thrombotic risk, controlling vascular risk factors, and promoting neural recovery through targeted rehabilitation, as supported by the guidelines from 2018 1.

From the FDA Drug Label

For patients with non-valvular AF that is persistent or paroxysmal and at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, or 2 of the following risk factors: age greater than 75 years, moderately or severely impaired left ventricular systolic function and/or heart failure, history of hypertension, or diabetes mellitus), long-term anticoagulation with warfarin is recommended In patients with non-valvular AF, anticoagulate with warfarin to target INR of 2.5 (range, 2.0 to 3.0)

The recommended management for stroke patients in an outpatient setting includes long-term anticoagulation with warfarin for patients with non-valvular atrial fibrillation (AF) who are at high risk of stroke. The target INR range is 2.0 to 3.0, with a target INR of 2.5. Key factors to consider when managing stroke patients in an outpatient setting include:

• Prior ischemic stroke or transient ischemic attack
• Age greater than 75 years
• Moderately or severely impaired left ventricular systolic function and/or heart failure
• History of hypertension or diabetes mellitus 2

From the Research

Stroke Management Outpatient

Overview of Recommended Management

The management of stroke patients in an outpatient setting involves several strategies to prevent stroke recurrence, including risk factor control and antithrombotic medication 3.

Risk Factor Control

Risk factors such as hypertension, dyslipidaemia, and diabetes mellitus can be modified by pharmacotherapy and lifestyle modification 3.

• Antihypertensive treatment is recommended for secondary stroke prevention for both hypertensive and normotensive patients.
• HMG-CoA reductase inhibitor (statin) therapy is highly recommended to obtain an intensive lipid-lowering effect.
• Treatment with pioglitazone is effective for patients with type 2 diabetes.

Antithrombotic Therapy

Antithrombotic therapy is essential for preventing stroke recurrence, and the choice of therapy depends on the stroke mechanism and patient's condition 3, 4.

• For patients with noncardioembolic ischaemic stroke or TIA, antiplatelet therapy rather than anticoagulation is recommended.
• Aspirin monotherapy, the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy are recommended as the major choices.
• The combination of aspirin and clopidogrel is not routinely recommended due to an increased risk of bleeding.
• Adjusted-dose warfarin with a target international normalized ratio range between 2.0 and 3.0 is recommended after an ischaemic stroke or TIA associated with nonvalvular atrial fibrillation.

Antiplatelet Therapy

Antiplatelet therapy has an essential role in the management of ischemic stroke, and the specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications 4, 5, 6, 7.

• Aspirin is the most commonly used antiplatelet agent, and its efficacy in reducing stroke severity and preventing recurrent stroke has been established.
• Short-term dual antiplatelet therapy with aspirin and clopidogrel may be superior to antiplatelet monotherapy in secondary stroke prevention for patients with mild noncardioembolic stroke or high-risk transient ischemic attack.
• However, dual therapy is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days.