What are the protocols following a cerebrovascular accident (CVA) or stroke?

From the Guidelines

Post-stroke protocols should prioritize immediate management and long-term prevention of recurrent strokes, with a focus on comprehensive evaluation, antiplatelet therapy, anticoagulation, blood pressure management, cholesterol management, and rehabilitation, as recommended by the most recent guidelines 1.

Key Components of Post-Stroke Protocols

• Comprehensive evaluation including brain imaging (CT or MRI), carotid ultrasound, echocardiogram, and blood tests to determine stroke type and cause
• Antiplatelet therapy with aspirin 325mg initially, followed by 81mg daily long-term, or alternative therapies such as clopidogrel 75mg daily or aspirin plus extended-release dipyridamole
• Anticoagulation with direct oral anticoagulants like apixaban 5mg twice daily or warfarin with a target INR of 2-3 for patients with atrial fibrillation
• Blood pressure management aiming for targets below 140/90 mmHg using medications like ACE inhibitors or ARBs
• Cholesterol management with high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) regardless of baseline levels
• Rehabilitation beginning within 24-48 hours of stroke onset, including physical, occupational, and speech therapy as needed

Lifestyle Modifications

• Smoking cessation
• Limiting alcohol consumption
• Maintaining a Mediterranean or DASH diet
• Regular physical activity
• Diabetes management if applicable

Evidence-Based Recommendations

The Canadian Stroke Best Practice Recommendations 1 provide evidence-based guidelines for the management of acute stroke, including the use of stroke units, interdisciplinary teams, and standardized assessment tools. The guidelines also recommend early mobilization, hydration, and nutrition, as well as the prevention of complications such as venous thromboembolism and pressure injuries. Additionally, the guidelines emphasize the importance of accurate and frequent neurological observation, as well as the use of validated scales such as the National Institutes of Health Stroke Scale to quantify stroke disability 1.

From the FDA Drug Label

The results for each endpoint separately, including an analysis of vascular death, are provided in the following table: TABLE 3 Event Warfarin Placebo RR % Risk Reduction (N=607) (N=607) (95% CI) (p- value) RR= Relative risk; Risk reduction = (I - RR); CI=Confidence interval; MI=Myocardial infarction; py = patient years Total Patient Years of Follow-up 2018 1944 Total Mortality 94 (4. 7/100 py) 123 (6.3/100 py) 0.76 (0.60,0.97) 24 (p=0.030) Vascular Death 82 (4.1/100 py) 105 (5.4/100 py) 0.78 (0.60,1.02) 22 (p=0.068) Recurrent MI 82 (4.1/100 py) 124 (6.4/100 py) 0.66 (0.51,0.85) 34 (p=0.001) Cerebrovascular Event 20 (1.0/100 py) 44 (2.3/100 py) 0.46 (0.28,0.75) 54 (p=0. 002)

The post-stroke protocol involves the use of warfarin to reduce the risk of cerebrovascular events, including stroke.

• The study results show that warfarin significantly reduced the risk of systemic thromboembolism, including stroke, in patients with non-rheumatic atrial fibrillation.
• The WARIS study found that warfarin reduced the risk of cerebrovascular events by 54% in patients post-myocardial infarction.
• The WARIS II study found that warfarin plus aspirin reduced the risk of thromboembolic stroke by 52% compared to aspirin alone. 2

From the Research

Post-Stroke Protocols

• The management of acute ischemic stroke in the first hours is critical to patient outcomes 3
• Secondary stroke prevention includes antiplatelet therapy, statins, and antihypertensives 4
• Aspirin, clopidogrel, or a combination of aspirin with dipyridamole are first-line options for secondary stroke prevention in the absence of atrial fibrillation 4
• Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time 4

Medications

• Anticoagulants are indicated if the patient has atrial fibrillation 4, 5, 6
• Patients should be started on statins after an ischemic stroke, with high doses recommended even if cholesterol concentrations are normal 4
• Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140/90 mmHg, with ACE inhibitors, calcium channel blockers, and diuretics as first-line options 4
• The combination of antiplatelets, ACE inhibitors, and statins may have additive protective effects in reducing ischemic stroke severity 7

Treatment Comparison

• Warfarin and the new anticoagulants (apixaban, dabigatran, edoxaban, and rivaroxaban) are similar in the reduction of stroke, vascular death, and mortality 5
• Oral anticoagulation is more efficacious than combined clopidogrel plus aspirin in preventing vascular events in patients with atrial fibrillation, but carries important bleeding complications 6
• The risk of major bleeding during oral anticoagulation is significantly lower among patients with a CHADS(2) score of 1 compared to those with a CHADS(2) score greater than 1 6