Secondary Stroke Prevention

Recommendations

Secondary prevention recommendations are directed to those risk factors most relevant to stroke, including lifestyle (diet, sodium intake, exercise, weight, smoking, and alcohol intake), hypertension, dyslipidemia, previous stroke or transient ischemic attack, atrial fibrillation and stroke, and carotid stenosis. Secondary prevention recommendations can be addressed in a variety of settings—acute care, stroke prevention clinics, and community-based care settings. They pertain to patients initially seen in primary care, those who are treated in an emergency department and then released and those who are hospitalized because of stroke or transient ischemic attack.
Recommendations for secondary prevention of stroke should be implemented throughout the recovery phase, including during inpatient and outpatient rehabilitation, reintegration into the community and ongoing follow-up by primary care practitioners.
Secondary prevention should be addressed at all appropriate healthcare encounters on an ongoing basis following a stroke or transient ischemic attack.

Persons at risk of stroke and patients who have had a stroke should be assessed for vascular disease risk factors and lifestyle management issues (diet, sodium intake, exercise, weight, smoking and alcohol intake). They should receive information and counseling about possible strategies to modify their lifestyle and risk factors [Evidence Level B].
Lifestyle and risk factor interventions should include:

2.1.1 Healthy balanced diet: Eating a diet high in fresh fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources and low in saturated fat, cholesterol and sodium, in accordance with Canada's Food Guide to Healthy Eating [Evidence Level B].

2.1.2 Sodium: Following the recommended daily sodium intake from all sources, known as the Adequate Intake. For persons 9 to 50 years, the Adequate Intake is 1500 mg. Adequate Intake decreases to 1300 mg for persons 50 to 70 years and to 1200 mg for persons over 70 years. A daily upper consumption limit of 2300 mg should not be exceeded by any age group [Evidence Level B].78

2.1.3 Exercise: Participating in moderate exercise (an accumulation of 30 to 60 minutes) such as walking (ideally brisk walking), jogging, cycling, swimming or other dynamic exercise four to seven days each week in addition to routine activities of daily living. High-risk patients (e.g., those with cardiac disease) should engage in medically supervised exercise programs [Evidence Level A].

2.1.4 Weight: Maintaining a body mass index (BMI) of 18.5 to 24.9 kg/m2 or a waist circumference of <80 centimetres for women and <94 centimetres for men [Evidence Level B].49

2.1.5 Smoking: Addressing smoking cessation and a smoke-free environment every healthcare encounter for active smokers.48

i.  In all healthcare settings along the stroke continuum, patient smoking status should be assessed and documented [Evidence Level A].

ii. Provide unambiguous, non-judgmental, and personally relevant advice regarding the importance of cessation to all smokers, and offer assistance with the initiation of a smoking cessation attempt–either directly or through referral to appropriate resources [Evidence Level A].

iii.  A combination of pharmacological therapy and behavioural therapy should be considered [Evidence Level A].

iv.  The three classes of pharmacological agents that should be considered as first- line therapy for smoking cessation are nicotine replacement therapy, bupropion, and varenicline [Evidence Level A].

2.1.6 Alcohol consumption: Limiting consumption to two or fewer standard drinks per day; fewer than 14 drinks per week for men; and fewer than nine drinks per week for women [Evidence Level C].

Hypertension management
Hypertension is the single most important modifiable risk factor for stroke. Blood pressure should be monitored and managed in all persons at risk for stroke.

2.2.1 Blood pressure assessment
All persons at risk of stroke should have their blood pressure measured routinely, ideally at each healthcare encounter, but no less than once annually [Evidence Level C].

i.  Proper standardized techniques as described by the Canadian Hypertension Education Program should be followed for blood pressure measurement including office, home, and community testing.50 Details regarding proper blood pressure monitoring techniques for clinicians and patients can be found athttp://hypertension.ca/chep/wp- content/uploads/2008/03/bpposterenglish.jpg50

ii.  Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Education Program [Evidence Level A].

iii.  Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications [Evidence Level C].
Refer to recommendation 2.1 for additional information.

Source

1. Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, and Phillips S. Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010; Ottawa, Ontario Canada: Canadian Stroke Network.