What is the initial management for a patient with a stroke infarct, particularly in terms of secondary prevention and management of underlying conditions such as hyperlipidemia, hypertension, and atrial fibrillation?

Initial Management of Acute Ischemic Stroke

All patients with acute ischemic stroke should be admitted to a dedicated stroke unit for comprehensive monitoring and immediate initiation of secondary prevention measures, including antiplatelet therapy within 24-48 hours, high-intensity statin therapy regardless of baseline cholesterol, blood pressure management, and evaluation for cardioembolic sources requiring anticoagulation. 1, 2

Immediate Hospital Admission and Monitoring

• Admit all patients to a specialized stroke unit with cardiac and neurologic monitoring for at least the first 24 hours to detect arrhythmias (particularly atrial fibrillation), myocardial ischemia, and neurological deterioration 1, 3
• Patients with large hemispheric infarcts, right hemispheric strokes, or posterior fossa infarctions require particularly close observation for cerebral edema, which typically peaks at 3-5 days post-stroke 1
• Continue cardiac monitoring beyond 24 hours with Holter monitoring or event-loop recording for several days to detect occult atrial fibrillation that may not be apparent at presentation 1

Antiplatelet Therapy Initiation

• Start aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolytic therapy 2, 3
• For minor stroke or high-risk TIA, initiate dual antiplatelet therapy (aspirin 160-325 mg loading dose plus clopidogrel 300-600 mg loading dose, followed by aspirin 81 mg plus clopidogrel 75 mg daily) within 12-24 hours and continue for exactly 21 days, then switch to monotherapy 4
• After 21 days of dual therapy, transition to clopidogrel 75 mg daily as the preferred long-term antiplatelet agent 2, 4

High-Intensity Statin Therapy

• Initiate atorvastatin 80 mg daily immediately for all ischemic stroke patients, regardless of baseline cholesterol levels 2
• Target LDL-C <70 mg/dL (<1.8 mmol/L) or achieve ≥50% reduction from baseline for patients with atherosclerotic disease 2, 4
• Check lipid panel 4-12 weeks after statin initiation or dose adjustment, then every 3-12 months 2

Blood Pressure Management

• Allow permissive hypertension initially (do not aggressively lower BP in the hyperacute phase unless >220/120 mmHg or patient is receiving thrombolysis) 3
• Begin antihypertensive therapy within 24 hours after the acute phase with target BP <130/80 mmHg for most patients, or <120/80 mmHg for optimal secondary prevention 2, 5, 4
• Preferred agents include thiazide diuretics, ACE inhibitors (particularly perindopril), or angiotensin II receptor blockers (ARBs) 2, 6

Urgent Etiologic Evaluation

Vascular Imaging (perform within 24 hours)

• CT angiography, MR angiography, or carotid ultrasound to identify ipsilateral carotid stenosis requiring urgent intervention 4
• For symptomatic carotid stenosis 70-99% (NASCET criteria), perform carotid endarterectomy urgently, ideally within the first few days and no later than 2 weeks post-stroke 4

Cardiac Evaluation

• Transthoracic echocardiography to examine for cardioembolic sources including left ventricular thrombus, valvular disease, and reduced ejection fraction 1, 4
• Transesophageal echocardiography is reasonable when identification of left atrial thrombus, patent foramen ovale, or aortic arch atherosclerosis will alter management 1
• Extended cardiac monitoring (minimum 24 hours, consider up to 30 days with event monitors) to detect paroxysmal atrial fibrillation 1

Anticoagulation for Cardioembolic Stroke

• For atrial fibrillation identified as stroke mechanism, initiate oral anticoagulation with direct oral anticoagulants (DOACs) preferred over warfarin 2, 4
• DOAC options include dabigatran, apixaban, edoxaban, or rivaroxaban 4
• If using warfarin, target INR 2.0-3.0 2
• Timing of anticoagulation initiation depends on infarct size: small infarcts can begin anticoagulation at 3-4 days, moderate infarcts at 7-10 days, and large infarcts should wait 2 weeks to minimize hemorrhagic transformation risk 7

Prevention of Acute Complications

Deep Vein Thrombosis Prophylaxis

• Subcutaneous anticoagulants (unfractionated heparin 5000 IU twice daily or low-molecular-weight heparin such as enoxaparin 40 mg once daily) for immobilized patients 1
• For patients with contraindications to anticoagulation, use intermittent external compression devices or aspirin 1

Aspiration Prevention and Nutrition

• Perform bedside swallowing assessment (water swallow test) before allowing any oral intake 1, 3
• High NIHSS score, wet voice after swallowing, incomplete oral-labial closure, or cranial nerve palsies indicate high aspiration risk 1
• If swallowing is impaired, insert nasogastric or nasoduodenal tube for feeding; consider percutaneous endoscopic gastrostomy (PEG) if prolonged need is anticipated 1

Infection Prevention

• Monitor for pneumonia (most common cause of post-stroke death) and urinary tract infections 1
• Avoid indwelling bladder catheters when possible; use intermittent catheterization or acidification of urine to reduce infection risk 1
• Treat infections promptly with appropriate antibiotics 1

Glycemic Control

• Target HbA1c ≤7.0% for most diabetic patients 4
• Avoid hypoglycemia and extreme hyperglycemia in the acute phase 1

Lifestyle Modifications (Initiate During Hospitalization)

• Complete smoking cessation is non-negotiable: provide counseling and pharmacotherapy (nicotine replacement, bupropion, or varenicline) 2, 5
• Mediterranean-style diet: emphasize plant-based foods, healthy fats, reduce saturated fat to <7% of total calories, and limit sodium to <2000 mg daily 2, 5, 4
• Physical activity: prescribe at least 30 minutes of moderate-intensity aerobic exercise daily (or 10 minutes of low/moderate-intensity activity 4 days/week, or 20 minutes of vigorous activity twice weekly) 2, 5

Rehabilitation and Discharge Planning

• Initiate physical therapy, occupational therapy, and speech therapy during hospitalization 1, 5, 3
• Assess for post-stroke depression and provide treatment if indicated 1
• Provide comprehensive discharge planning with written action plans detailing medications, follow-up appointments, warning signs of recurrent stroke, and lifestyle modifications 1, 2, 5
• Schedule early follow-up with neurologist (within 2 weeks), internist, and primary care physician 1, 2

Common Pitfalls to Avoid

• Do not prolong dual antiplatelet therapy beyond 21-30 days unless there is a specific coronary indication, as bleeding risk increases without additional benefit 4
• Do not combine aspirin plus clopidogrel long-term for cerebrovascular prevention in patients without acute coronary disease 4
• Do not use anticoagulation routinely for presumed arterial (non-cardioembolic) stroke 4
• Do not initiate anticoagulation in TIA/stroke without first excluding intracranial hemorrhage with CT or MRI 4
• Do not delay carotid endarterectomy for symptomatic high-grade stenosis; benefit is greatest when performed within days of the index event 4

Quality Monitoring

• Implement hospital-based or outpatient quality monitoring programs to track adherence to secondary prevention guidelines, including antiplatelet/anticoagulation use, statin therapy, blood pressure control, and smoking cessation counseling 2, 5
• Approximately 12% of stroke patients are readmitted within 30 days; nurse-led transitional stroke clinics with follow-up phone calls can reduce readmission rates 1