What is the best approach to manage a patient with a past history of stroke, considering their risk of recurrent stroke and potential cardiovascular risk factors such as hypertension (high blood pressure), hyperlipidemia (elevated lipid profile), and hyperglycemia (elevated blood glucose levels)?

Management of Patients with Prior Stroke

All patients with a history of stroke require aggressive blood pressure control with a target of <130/80 mmHg using diuretics, ACE inhibitors, or ARBs as first-line agents, combined with high-intensity statin therapy (atorvastatin 80 mg daily) targeting LDL-cholesterol <2.0 mmol/L (<77 mg/dL) to reduce recurrent stroke risk by approximately 30%. 1

Blood Pressure Management Algorithm

For Patients with Previously Diagnosed Hypertension

• Restart antihypertensive treatment immediately if the stroke occurred ≥72 hours ago and neurological status is stable 1
• Target BP <130/80 mmHg (Class IIb recommendation) 1
• Use diuretics, ACE inhibitors, or ARBs as first-line agents, as these have demonstrated benefit in dedicated RCTs 1
• Add calcium channel blockers or mineralocorticoid receptor antagonists if target BP is not achieved with initial agents 1

For Patients Without Prior Hypertension Diagnosis

If BP ≥140/90 mmHg:

• Initiate antihypertensive treatment (Class I recommendation) 1
• Target BP <130/80 mmHg 1

If BP <140/90 mmHg:

• The benefit of initiating antihypertensive treatment is not well established (Class IIb) 1
• Consider treatment on a case-by-case basis, particularly if other high-risk features are present 1

Special Considerations for Lacunar Stroke

• Target SBP <130 mmHg may be reasonable, as this may reduce future intracerebral hemorrhage risk compared to targets of 130-140 mmHg 1

Critical BP Management Pitfalls

• Do not target SBP <120 mmHg - observational studies show no benefit and potential harm at these levels 1
• Larger BP reductions correlate with greater stroke risk reduction, but the relationship plateaus below 130 mmHg 1
• The magnitude of BP reduction appears more important than the specific agent used 1

Lipid Management Protocol

Statin Therapy Requirements

• Prescribe atorvastatin 80 mg daily for all patients with ischemic stroke or TIA to reduce recurrent stroke risk by 22% and all vascular events 1
• Target LDL-cholesterol consistently <2.0 mmol/L (<77 mg/dL) or achieve >50% reduction from baseline 1
• For patients with concurrent acute coronary syndrome or established coronary disease, target LDL-C <1.8 mmol/L (<70 mg/dL) 1

Lipid Assessment

• Measure total cholesterol, triglycerides, LDL-cholesterol, and HDL-cholesterol on all stroke patients 1
• Calculate triglyceride/HDL-cholesterol ratio, as elevated ratios independently predict recurrent stroke risk (highest quintile has 56% increased risk) 2

Additional Lipid Management

• For patients with low HDL-cholesterol, implement weight reduction, increased physical activity, and smoking cessation 1
• Consider niacin or fibrates for persistently low HDL-cholesterol (Class IIb recommendation) 1
• Do not prescribe statins for intracerebral hemorrhage prevention - they are not indicated 1

Diabetes Management

Glycemic Control Targets

• Treat hyperglycemia >180 mg/dL with insulin to maintain glucose 140-180 mg/dL 3
• For severe hyperglycemia (>1000 mg/dL), initiate continuous IV insulin infusion at 0.5 units/hour using regular insulin 3
• Monitor blood glucose every 1-2 hours initially in acute settings 3
• Measure hemoglobin A1c to distinguish chronic diabetes from acute stress hyperglycemia 3

Critical Glucose Management Pitfalls

• Do not target glucose <140 mg/dL - this increases hypoglycemia risk without proven benefit 3
• Correct hypoglycemia (<60 mg/dL) immediately with 25 mL of 50% dextrose IV as it can cause permanent brain damage 3, 4
• Avoid glucose-containing IV fluids; use normal saline for volume resuscitation 3, 4
• Hyperglycemia worsens stroke outcomes and increases hemorrhagic transformation risk 3, 4

Diabetes-Specific Statin Therapy

• All diabetic patients with ischemic stroke require statin therapy targeting LDL-cholesterol <2.0 mmol/L, as they are at particularly high risk for recurrent vascular events 1

Comprehensive Risk Factor Assessment

Essential Evaluations

• Cardiac monitoring for ≥24 hours to detect atrial fibrillation requiring anticoagulation 3, 5
• ECG and cardiac biomarkers 5
• Complete blood count, electrolytes, renal function, coagulation studies 5
• Brain MRI with diffusion-weighted imaging to definitively assess for acute infarction 3
• Carotid ultrasound to evaluate for significant stenosis 1

Functional and Cognitive Assessment

• Swallow evaluation before allowing oral intake to prevent aspiration 3, 5
• Mental status examination focusing on vascular cognitive impairment patterns (executive dysfunction, slowed processing, working memory deficits) 1
• Functional assessment using validated scales (Barthel Index or Pfeffer Functional Assessment Questionnaire) 1
• Depression screening with CES-D or Geriatric Depression Scale 1

Antiplatelet Therapy

• Administer full-dose aspirin (325 mg) for acute ischemic stroke 3
• Consider advanced antiplatelet regimens (clopidogrel, aspirin-dipyridamole combination) for long-term secondary prevention 6

Monitoring and Follow-Up Strategy

Acute Phase (First 24-48 Hours)

• Admit to intensive care unit or dedicated stroke unit with continuous cardiac monitoring 3, 5
• Perform frequent neurological assessments using standardized scales (NIHSS), as approximately 25% of patients deteriorate during this period 5
• Maintain oxygen saturation >94% 5

Infection Surveillance

• Monitor for fever, which should prompt immediate evaluation for pneumonia - a leading cause of post-stroke mortality 5
• Administer appropriate antibiotics early when infection is identified 5

DVT Prophylaxis

• Administer subcutaneous anticoagulants or use intermittent external compression stockings for immobilized patients 5

Common Management Failures

The evidence demonstrates marked deficiencies in real-world stroke secondary prevention: 7, 8

• 18.7% of stroke survivors have unrecognized hypertension 8
• Only 17% of stroke patients with hyperlipidemia receive adequate management at baseline 7
• 33.3% of treated stroke survivors still have uncontrolled hypertension 8
• Predictors of inadequate risk factor control include higher body mass index, Black race, and lower education 8

These data underscore the critical need for aggressive, protocol-driven management rather than passive observation of risk factors in stroke survivors.