What is the secondary management for stroke?

Secondary Management for Stroke

Secondary stroke prevention requires aggressive management of vascular risk factors, appropriate antithrombotic therapy, and surgical interventions when indicated to significantly reduce the risk of recurrent stroke.

Core Components of Secondary Stroke Prevention

Risk Factor Management

• Blood Pressure Control

  • Target blood pressure should be consistently <120/80 mmHg through medication and lifestyle modifications 1
  • Aggressive management of hypertension is essential as it is the most important modifiable risk factor for stroke 1

• Lipid Management

  • Statins should be prescribed for all patients with ischemic stroke or TIA to achieve LDL cholesterol <2.0 mmol/L or >50% reduction from baseline 2
  • For patients with stroke and coronary disease, more aggressive targets (LDL-C <1.8 mmol/L) should be considered 2
  • Atorvastatin 80mg daily has been shown to reduce the risk of stroke by 25% compared to 10mg daily dosing 3

• Diabetes Management

  • Target A1C levels should be ≤7.0% for most patients with diabetes 2
  • If A1C targets cannot be achieved with a postprandial target of 5.0-10.0 mmol/L, further lowering to 5.0-8.0 mmol/L should be considered 2

• Lifestyle Modifications

  • Complete smoking cessation is essential 1
  • Regular moderate-intensity aerobic exercise (at least 30 minutes daily) 1
  • Mediterranean diet pattern with reduced salt intake 1
  • Increased plant-based food intake and reduced saturated fat, cholesterol, and sodium 1

Antithrombotic Therapy

• For Non-Cardioembolic Stroke

  • Antiplatelet therapy should be prescribed for all patients with ischemic stroke or TIA unless anticoagulation is indicated 2

  • Options include:

    • Acetylsalicylic acid (80-325 mg daily) 2
    • Combined acetylsalicylic acid (25 mg) and extended-release dipyridamole (200 mg twice daily) 2
    • Clopidogrel (75 mg daily) 2

  • Short-term dual antiplatelet therapy (DAPT):

    • For minor stroke or high-risk TIA, short-term DAPT with aspirin and clopidogrel for up to 21 days has not shown increased bleeding risk and may be protective 2
    • Longer-term use of DAPT is not recommended due to increased bleeding risk 2, 4

  • For intracranial stenosis:

    • Dual antiplatelet therapy with ASA 325 mg and Clopidogrel 75 mg for up to 90 days may be considered 2
    • Aggressive management of all vascular risk factors is essential 2

• For Cardioembolic Stroke (Atrial Fibrillation)

  • Appropriate anticoagulation therapy is recommended 1
  • Direct oral anticoagulants (DOACs) may be preferred over warfarin due to decreased bleeding risks 4

Carotid Artery Disease Management

• For Symptomatic Carotid Stenosis (70-99%)

  • Carotid endarterectomy should be performed urgently, ideally within the first days following non-disabling stroke or TIA 2
  • For patients not clinically stable in the first few days, surgery should be performed within 14 days of the ischemic event 2
  • Carotid endarterectomy is generally more appropriate than carotid stenting for patients over 70 years 2

• For Asymptomatic Carotid Stenosis (60-99%)

  • Aggressive medical management of risk factors (blood pressure, cholesterol, antiplatelet therapy, lifestyle changes) 2
  • Carotid endarterectomy may be considered for selected patients with life expectancy >5 years and acceptable surgical risk 2
  • Should be performed by a surgeon with <3% risk of perioperative complications 2

Intracranial Stenosis Management

• For 70-99% Intracranial Stenosis
  • Intracranial stenting is not recommended for recently symptomatic stenosis 2
  • Medical management includes dual antiplatelet therapy for up to 90 days and aggressive management of vascular risk factors 2
  • For recurrent stroke despite maximal medical therapy, intracranial angioplasty may be considered in carefully selected patients 2

Cervical Artery Dissection Management

• Diagnosis and Treatment
  • Diagnosis can be established by CTA, MRA, or DSA 2
  • Antithrombotic therapy (antiplatelet or anticoagulation) is recommended 2
  • Either antiplatelet therapy or anticoagulation with heparin/warfarin is reasonable based on individual risk/benefit analysis 2

Health Systems Approach to Secondary Prevention

• Hospital-based or outpatient-focused quality monitoring programs are recommended to improve adherence to secondary prevention guidelines 2
• A multidisciplinary outpatient team-based approach is effective for controlling BP, lipids, and other vascular risk factors 2
• Patients with TIA or minor stroke should be evaluated by a physician with stroke expertise 2

Common Pitfalls to Avoid

• Medication Adherence Issues: Up to 40% of stroke patients don't take medications as prescribed, increasing recurrence risk 1
• Single Risk Factor Focus: Addressing multiple risk factors simultaneously is more effective than focusing on individual factors 1
• Delayed Carotid Intervention: Delaying carotid endarterectomy beyond the recommended timeframe increases recurrence risk 2
• Prolonged Dual Antiplatelet Use: Extended DAPT beyond recommended duration increases bleeding risk without additional benefit 4, 2
• Inadequate Risk Factor Control: Simply providing health information without behavioral interventions is ineffective 1