What is the best course of action for a patient who has had two strokes and needs a new provider?

Immediate Actions for a Patient with Two Prior Strokes Needing a New Provider

As a nurse practitioner, your first priority is to conduct an urgent comprehensive stroke evaluation within 24 hours of first contact, including obtaining complete hospital records from both prior strokes, performing a focused neurological assessment, and ensuring the patient is immediately connected to a neurologist or stroke specialist while you initiate aggressive secondary prevention strategies. 1

First Steps: Immediate Assessment and Documentation

Obtain Critical Historical Information

• Secure and review all hospital records from both previous strokes to understand the technical details of each acute event, including pre-stroke risk factors, symptoms at onset, diagnostic evaluation results (imaging, vascular studies), anatomic locations of infarcts, emergency therapies received, hospital courses, and presumed pathogenetic mechanisms 1, 2
• Document a comprehensive stroke narrative that includes dates of both strokes, stroke subtypes (ischemic vs hemorrhagic), vascular territories affected, degree of recovery between events, and any incompletely treated risk factors that may have contributed to recurrence 1, 2
• Classify the pathogenesis of each stroke (large artery atherosclerosis, cardioembolism, small vessel disease, other determined cause, or cryptogenic) as this directly guides secondary prevention strategies 1, 2

Perform Urgent Clinical Evaluation

• Complete a focused neurological examination documenting current deficits including motor weakness, sensory changes, speech/language function, visual fields, coordination, and gait to establish baseline functional status 1
• Screen for acute or subacute symptoms suggesting a third stroke or TIA, particularly unilateral weakness, speech disturbance, sensory symptoms, vision changes, or ataxia—any such symptoms within the past 48 hours require immediate emergency department transfer 1, 3
• Assess current functional status including activities of daily living, instrumental activities of daily living, mobility, communication capacity, and cognitive function to identify rehabilitation needs 1

Second Priority: Risk Stratification and Urgent Referrals

Determine Urgency of Specialist Evaluation

• If the patient has had any stroke-like symptoms within the past 2 weeks, they are at high or moderate risk for recurrent stroke and require evaluation by a stroke specialist within 24 hours to 2 weeks depending on symptom type 1, 3
• If both strokes occurred more than 2 weeks ago with no recent symptoms, arrange evaluation by a neurologist or stroke specialist ideally within one month, though sooner is preferable given the two-stroke history 1
• Recognize that patients with two prior strokes have approximately 30% risk of another stroke, making aggressive secondary prevention urgent 4

Initiate Immediate Specialist Referrals

• Refer to a neurologist or stroke specialist as the primary ongoing specialist, as they possess the diagnostic skills and stroke-specific knowledge essential for optimal management 1, 5, 6
• Consider referral to a stroke prevention clinic if available in your area, as these specialized services optimize risk factor management and coordinate multidisciplinary care 1
• Arrange for stroke unit follow-up if the patient was previously admitted to a stroke unit, as organized stroke care reduces mortality and dependency 1

Third Priority: Comprehensive Screening and Investigation

Screen for Post-Stroke Complications

• Systematically assess for common complications including depression (affects up to 25% at 2 years), cognitive impairment, anxiety, fatigue, pain, spasticity, falls, contractures, and thromboembolism risk 1, 2
• Screen for depression using a validated tool (such as PHQ-9), as depression is highly prevalent after stroke and requires treatment identical to depression in non-stroke patients 1
• Evaluate cognitive function using validated screening instruments, as cognitive deficits may not be immediately apparent and can emerge over time 1, 2
• Assess for dysphagia, nutrition, hydration, continence, and pain, as these physical issues commonly persist and affect quality of life 1

Verify Completion of Stroke Workup

• Confirm that comprehensive vascular imaging was completed for both strokes, including extracranial and intracranial vessels from aortic arch to vertex (CTA or MRA preferred) 1
• Ensure cardiac evaluation was adequate, including 12-lead ECG at minimum, and extended cardiac monitoring or echocardiography if cardioembolic source was suspected 1
• Review laboratory investigations including complete blood count, metabolic panel, lipid profile, hemoglobin A1c, and coagulation studies to identify modifiable risk factors 1

Fourth Priority: Aggressive Secondary Prevention

Implement Evidence-Based Risk Factor Management

• Aggressively manage blood pressure with target <140/90 mmHg for most patients, as hypertension control is the most important modifiable risk factor for stroke prevention 1, 2
• Initiate or optimize high-intensity statin therapy for ischemic stroke patients to reduce LDL-C by ≥50%, regardless of baseline cholesterol levels 2
• Target hemoglobin A1c ≤7% for patients with diabetes through medication optimization and lifestyle modification 2
• Prescribe antiplatelet therapy (aspirin, clopidogrel, or combination based on stroke mechanism) unless anticoagulation is indicated for atrial fibrillation or other cardioembolic source 1
• Address smoking cessation if applicable, as this is a critical modifiable risk factor 4

Perform Medication Reconciliation

• Conduct a comprehensive medication review to ensure the patient is on appropriate secondary prevention medications, identify any gaps in therapy, assess for drug interactions, and evaluate adherence 1, 2
• Verify anticoagulation management if indicated for atrial fibrillation or other conditions, ensuring appropriate dosing and monitoring 1

Fifth Priority: Rehabilitation and Functional Support

Assess Rehabilitation Needs

• Evaluate for ongoing or new rehabilitation needs including physical therapy, occupational therapy, speech-language pathology, and recreation therapy 1, 7
• Establish processes for re-accessing rehabilitation services if functional decline occurs, even months or years post-stroke 1, 7
• Monitor communication capacity and refer to speech-language services for persistent communication impairments 1

Support Community Reintegration

• Ask about vocational interests (work, school, volunteering) and assess potential for return to these activities 1
• Inquire about pre-stroke leisure pursuits and assess rehabilitative needs to resume these activities, as participation improves quality of life 1
• Screen for driving safety if relevant, ideally by an occupational therapist using valid methods to assess residual sensory, motor, or cognitive deficits 1

Sixth Priority: Patient and Caregiver Support

Establish Patient-Centered Care

• Create a welcoming environment where the patient can express values, aspirations, questions, fears, and needs regarding their stroke history and future care 1, 2
• Solicit the patient's experience of both strokes, including their understanding of what happened, early questions, fears, and psychological consequences 1
• Update social history to understand how the strokes have affected the patient's roles, family circumstances, and social support 1

Engage and Support Caregivers

• Involve caregivers with patient consent to help identify patient and family needs and improve care satisfaction 1, 2
• Assess caregiver needs and burden, as increased caregiver burden is associated with poorer outcomes for both patient and caregiver 1, 7
• Provide information about support groups, home help options, and rehabilitation resources for both patient and caregivers 7

Ongoing Management: Establish Continuity of Care

Schedule Follow-Up

• Arrange initial primary care follow-up within 2-4 weeks if not already established, to address ongoing physical issues, medication management, and stroke prevention 1, 7
• Schedule specialist follow-up with neurology or stroke specialist based on urgency determined above 1, 6
• Plan for periodic reassessment at 1,4,6, and 12 months to monitor for complications, functional decline, and emerging needs 7

Coordinate Transitions of Care

• Ensure bidirectional communication with all providers involved in the patient's care, including written documentation of clinical data, medication lists, care plans, and patient education 7
• Establish clear protocols for when the patient should seek emergency care, including warning signs of another stroke (sudden weakness, speech difficulty, vision changes, severe headache) 3, 7

Critical Pitfalls to Avoid

• Do not delay specialist referral assuming you can manage everything in primary care—patients with two strokes require stroke specialist expertise for optimal secondary prevention 1, 6
• Do not assume the stroke workup was complete at prior hospitalizations—verify that comprehensive vascular imaging, cardiac evaluation, and laboratory studies were performed 1
• Do not overlook depression and cognitive screening—these complications are common, treatable, and significantly impact quality of life if missed 1, 2
• Do not fail to involve caregivers—their participation improves outcomes and their own needs must be addressed to prevent burnout 1, 7
• Do not wait for symptoms to develop before implementing aggressive secondary prevention—the 30% recurrence risk demands immediate action 4