Secondary Stroke Prevention Checklist
Taking Steps to Prevent Another Stroke
|1. Has the patient had a stroke or TIA?
|Approximately 23% of strokes each year are recurrent. Risk of recurrent stroke or TIA is high (5% at 1 year) but can be mitigated with appropriate prevention strategies.
|2. Does the patient need to undergo diagnostic evaluation to determine the etiology of the stroke?
|Given the relatively high risk of recurrent stroke, a diagnostic evaluation is recommended for gaining insights into the etiology and planning optimal prevention strategies, with testing completed or underway within 48 hours of stroke symptom onset.
|3. Does the patient have blood pressure greater than 130/80 mm Hg?
|Treatment of hypertension is possibly the most important intervention for secondary prevention of ischemic stroke. An office blood pressure goal of <130/80 mm Hg is recommended for most patients. Antihypertensive medication is useful.
|4. Has the patient been screened for diabetes mellitus (DM)?
|DM is an independent risk factor for stroke recurrence. After a TIA or ischemic stroke, screening for DM is recommended as part of the basic laboratory evaluation. New cases of Type 2 DM have been detected in about DM is 11.5% of patients presenting with acute ischemic stroke and prediabetes in 36.2%. For most patients, achieving a goal of hemoglobin A1c ≤7% is recommended.
|5. Does the patient’s cholesterol level need to be lowered?
|Patients with ischemic stroke and no known coronary heart disease, no major cardiac sources of embolism, and LDL-C >100 mg/dL, should be treated with atorvastatin 80 mg daily to reduce risk of stroke recurrence. Patients with ischemic stroke or TIA and atherosclerotic disease should be treated with a statin and also ezetimibe, if needed, to a goal LDL-C of <70 mg/dL.
|6. Is the patient physically inactive?
|Regular physical activity reduces stroke risk, positively impacts stroke risk factors and aids in recovery. Patients who are able should engage in at least moderate-intensity aerobic activity for a minimum of 10 minutes 4 times a week or vigorous-intensity aerobic activity for a minimum of 20 minutes twice a week. For patients with deficits that impair their ability to exercise, a supervised exercise program can be beneficial.
|7. Does the patient smoke?
|Smoking approximately doubles the risk of stroke. Counseling with or without drug therapy should be recommended to help patients quit smoking.
|8. Does the patient need to make dietary changes?
|It is reasonable to recommend that patients follow a diet emphasizing vegetables, fruits, whole grains, low-fat dairy products, fish, legumes and nuts, and limits sodium, sweets and red meats.
|9. Does the patient drink large amounts of alcohol?
|Patients who are heavy drinkers should be counseled to eliminate or reduce their consumption of alcohol. Light to moderate amounts of alcohol consumption (up to 2 drinks per day for men and up to 1 drink per day for nonpregnant women) may be reasonable.
|10. Has the patient been screened for or diagnosed with atrial fibrillation (AF)?
|AF is a powerful risk factor for ischemic stroke, increasing the risk 4- to 5-fold. In patients with non-valvular AF or atrial flutter and stroke or TIA, oral anticoagulation is recommended.
|11. Is this an ischemic stroke or TIA patient who should be on aspirin or other antiplatelet therapy?
|In patients with noncardioembolic ischemic stroke or TIA, antiplatelet therapy is indicated in preference to oral anticoagulation. More specifically, Guidelines recommend aspirin 50-325mg daily, or clopidogrel 75mg, or the combination of aspirin 25mg and extended release dipyridamole 200mg twice daily. Dual antiplatelet therapy is only recommended short-term and in very specific patients.
|12. Does the patient have sleep apnea?
|Sleep apnea affects about 38%-40% of patients with stroke. Treatment with positive airway pressure can be beneficial.
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