Canadian Stroke Strategy Best Practice Recommendations for Stroke Care: 2006 Recommendation 3 Preven

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Canadian Stroke Strategy Best Practice
Recommendations for Stroke Care
2006Recommendation 3Prevention of Stroke
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Canadian Best Practice Recommendations 2006

• 24 recommendations
• Public Awareness (1)
• Patient and Caregiver Education (1)
• Stroke Prevention (7)
• Acute Stroke Management (8)
• Stroke Rehabilitation (6)
• Follow-up and Community Re-engagement (1)

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Cross Continuum Recommendations

• 1.0 Public Awareness
• 1.1 Public Awareness and Responsiveness
• 2.0 Patient and Family
• 2.1 Patient and Caregiver Education

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Prevention

• 3.0 Prevention of Stroke
• 3.1 Lifestyle Management
• 3.2 Blood Pressure Management
• 3.3 Lipid Management
• 3.4 Diabetes Management
• 3.5 Antiplatelet Therapy
• 3.6 Anticoagulation in Atrial Fibrillation
• 3.7 Carotid Intervention

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Acute Stroke

• 4.0 Acute Stroke Management
• 4.1 Acute Stroke Unit Care
• 4.2 Brain Imaging
• 4.3 Blood Glucose
• 4.4 Acute Thrombolytic Treatment
• 4.5 Carotid Artery Imaging
• 4.6 Dysphagia Assessment
• 4.7 Acute Aspirin Therapy
• 4.8 Management of Subarachnoid and
  Intracerebral Hemorrhage

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Rehabilitation

• 5.0 Stroke Rehabilitation
• 5.1 Initial Stroke Rehabilitation Assessment
• 5.2 Provision of Inpatient Rehabilitation
• 5.3 Components of Inpatient Stroke
  Rehabilitation
• 5.4 Identification and Management of Post Stroke
  Depression
• 5.5 Shoulder Pain Assessment and Treatment
• 5.6 Community Based Rehabilitation

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Community

• 6.0 Follow-Up and Community Reintegration
• 6.1 Follow-up and Evaluation in the Community

This section will be further developed in 2008
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Recommendation Format
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Recommendation 3

• Prevention of Stroke

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3.0 Prevention of Stroke

• 3.1 Lifestyle Management
• 3.2 Blood Pressure Management
• 3.3 Lipid Management
• 3.4 Diabetes Management
• 3. 5 Antiplatelet Therapy
• 3.6 Anticoagulation in Atrial Fibrillation
• 3.7 Carotid Intervention

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3.1 Lifestyle and Risk Factor Management

• Components of stroke prevention
• Primary prevention focus on importance of
  screening and monitoring those patients at high
  risk of having a first event
• Includes lifestyle and risk factor management,
  hypertension screening, dyslipidemia and diabetes

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3.1 Lifestyle and Risk Factor Management

• Components of Stroke Prevention
• Secondary Prevention focus on the management of
  patients who have experienced a stroke/TIA event
  and are at risk for subsequent events
• Includes lifestyle management, hypertension,
  dyslipidemia, antiplatelet therapy,
  antithrombotic therapy, carotid revascularization

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3.1 Lifestyle and Risk Factor Management

• Persons at risk of stroke and patients who have
  had a stroke should be assessed for and given
  information about risk factors, lifestyle
  management issues and be counselled about
  possible strategies to modify their lifestyle and
  risk factors.

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Risk Factors

• Modifiable

• Non-Modifiable

• Hypertension
• Obesity
• Atrial Fibrillation
• Diabetes
• Cardiac Disease
• Hyperlipidemia
• Excessive Alcohol Intake
• Physical Activity
• Smoking
• Stress
• Hormone Replacement Therapy

• Age
• Gender
• Family History
• Ethnicity
• Previous TIA or Stroke

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3.2 Blood Pressure Management

• 3.2 a. Blood Pressure Assessment
• All persons at risk of stroke should have their
  blood pressure measured at each healthcare
  encounter.
• 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.

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3.2 Blood Pressure Management

• 3.2 b. Blood Pressure Management
• Patients with ischemic stroke who are past the
  hyper acute period should be prescribed
  antihypertensive treatment to target normal blood
  pressure
• Target blood pressure levels as per the Canadian
  Hypertension Education Program (CHEP) guidelines.

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CHEP Guidelines

• CHEP 2006
• For prevention of first stroke in general
  population lt140mmHg Systolic and lt90 mmHg
  diastolic (minimal target).
• For prevention of first stroke or recurrent
  stroke in patients with diabetes or chronic
  kidney disease lt 130mmHg systolic and lt80mmHg
  diastolic.
• Blood pressure lowering is recommended in
  patients with blood pressure lt 140/90 who have
  had a stroke.

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3.3 Lipid Management

• 3.3a Lipid Assessment
• Fasting lipid levels should be measured every 1-3
  years and assessment of other cardiovascular risk
  factors for all men 40 years of age and post
  menopausal women and/or 50 years of age.
• More frequent testing should be done for patients
  with abnormal values or if treatment is
  initiated.
• Screen at any age, adults with major CAD risk
  factors.

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3.3 Lipid Management

• 3.3b. Lipid Management
• Ischemic stroke patients with LDL-C of 2.0mmol/L
  should be managed with lifestyle modification,
  dietary guidelines and medication
  recommendations.
• Statin agents should be prescribed for all
  patients who have had an ischemic stroke/TIA
  event in order to achieve a target goal of an
  LDL-C of lt 2.0mmol/l and TC/HDL-C lt 4.0mmol/l.

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3.4 Diabetes Management

• 3.4a Diabetes Assessment
• All individuals should be evaluated annually for
  type 2 diabetes risk on the basis of demographic
  and clinical criteria.
• A fasting plasma glucose (FPG) for screening
  should be performed every 3 years in individuals
  gt40 years of age.
• More frequent and/or earlier testing with either
  a FPG or plasma glucose drawn 2 hours after a 75G
  oral glucose load should be considered in people
  with additional risk factors.
• Fasting lipid levels should be assessed in all
  adults at the time of diagnosis of diabetes and
  every 1-3 years as clinically indicated
• Blood pressure should be measured at every
  diabetes visit.

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3.4 Diabetes Management

• 3.4b Diabetes Management
• Glycemic targets should be individualized,
  however, therapy in most patients with type 1 or
  type 2 diabetes should be targeted to achieve an
  A1C7.0
• To achieve an A1C7.0, FPG or preprandial PG
  targets of 4.0-7.0mmol/l and 2 hour postprandial
  PG targets of 5.0-10.0mmol/l are recommended.
• If possible, lowering PG targets toward normal
  range should be considered.
• Adults at high risk of a vascular event should be
  treated with a statin to achieve an LDL-C lt
  2.0mmol/l.
• Unless contraindicated, low dose ASA (80-325mg)
  is recommended in all diabetic patients with
  evidence of CVD and atherosclerotic risk factors.

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3.5. Antiplatelet Therapy

• All patients with ischemic stroke or transient
  ischemic attack should be on antiplatelet therapy
  (ASA) for secondary prevention of recurrent
  stroke unless there is a contraindication for
  anticoagulation or a contraindication to ASA.
• Usual maintenance dose is 81-325mg per day.

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3.6 Antithrombotic Therapy in Atrial Fibrillation

• 3.6a For primary prevention of stroke in
  patients with atrial fibrillation, ASA or
  anticoagulation with warfarin should be
  considered based upon clinical circumstances.
• 3.6b Patients with stroke and atrial
  fibrillation should be treated with warfarin at a
  target INR of 2.5, range 2.0-3.0 (target INR of
  3.0 for mechanical cardiac valves, range 2.5-3.5)

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3.7 Carotid Intervention

• Patients with symptomatic carotid artery disease
  of 70-99 stenosis should be offered carotid
  intervention (carotid endarterectomy) within 2
  weeks of the incident of stroke or TIA.

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Life Style and Risk Factor Management System
Implications

• Health promotion efforts that contribute to the
  primary prevention of stroke in all communities
  and are integrated with existing chronic disease
  prevention initiatives.
• Stroke prevention approaches are offered by
  primary care providers across the continuum.
• Mechanisms for ongoing monitoring, evaluation and
  feedback loop for communication of findings to
  contribute to quality improvement .

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Life Style and Risk Factor Management
Performance Measures

• The proportion of population who has identified
  risk factors for stroke including hypertension,
  obesity, smoking history, low physical activity,
  hyperlipidemia, diabetes and atrial fibrillation.
• Percentage of population who can identify major
  risks of stroke.
• Percentage of population who know what to do to
  prevent/reduce stroke risk.

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Life Style and Risk Factor Management
Performance Measures

• Percentage of people who are aware of the healthy
  targets for each stroke risk factor.
• The annual occurrence of stroke in each province
  and territory by stroke type.
• Stroke mortality rates across provinces and
  territories, including in-hospital or 30 day and
  one year.

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Blood Pressure Management System Implications

• Coordinated hypertension awareness programs at
  provincial and community levels, that involve
  community groups, pharmacists, primary care and
  other relevant partners.
• Stroke prevention including routine blood
  pressure monitoring, offered by primary care
  providers in the community as part of
  comprehensive patient management.

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Blood Pressure Management Performance Measures

• Proportion of persons at risk for stroke who have
  their blood pressure measured at each healthcare
  encounter.
• Proportion of population who report having
  hypertension.
• Proportion of the population who have diagnosed
  elevated blood pressure (hypertension).

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Blood Pressure Management Performance Measures

• Percentage of the population with known
  hypertension who are on blood pressure lowering
  therapy.
• Proportion of stroke/TIA patients prescribed
  blood pressure lowering agents on discharge from
  acute care.
• Proportion of stroke/TIA patients prescribed
  blood pressure lowering agents after assessment
  in a secondary prevention clinic.

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Diabetes Management System Implications

• Coordinated diabetes awareness programs at the
  provincial and community levels that involve
  community groups, pharmacists, primary care and
  other relevant partners.
• Coordinated education and support programs for
  persons with diabetes to increase compliance and
  reduce ongoing risks for cardiovascular
  complications.

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Diabetes Management Performance Measures

• Proportion of the population with a confirmed
  diagnosis of diabetes (type 1 and type 2).
• Proportion of persons with diabetes presenting to
  hospital with a new stroke event.

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Antiplatelet Therapy System Implications

• Stroke Prevention Clinics in place to improve
  secondary stroke prevention care.
• Optimization of strategies at the local, regional
  and provincial levels to prevent the recurrence
  of stroke.
• Stroke prevention awareness and education of
  secondary prevention for primary care
  practitioners and specialists who manage stroke
  patients during the acute phase and
  post-discharge from acute care.

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Antiplatelet Therapy Performance Measures

• Proportion of stroke/TIA patients prescribed
  antiplatelet therapy on discharge from acute
  care.
• Proportion of stroke/TIA patients prescribed
  antiplatelet therapy on discharge from secondary
  prevention clinic care.

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Antithrombotic Therapy in Atrial Fibrillation
System Implications

• Stroke prevention clinics in place to improve
  secondary stroke prevention.
• Optimization of strategies at the local, regional
  and provincial levels to prevent the recurrence
  of stroke.
• Stroke prevention awareness and education of
  secondary prevention for primary care
  practitioners and specialists who manage stroke
  patients during the acute phase and
  post-discharge from acute care.

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Antithrombotic Therapy in Atrial Fibrillation
Performance Measures

• Proportion of eligible stroke/TIA patients with
  atrial fibrillation prescribed anticoagulant
  therapy on discharge from acute care.
• Proportion of stroke/TIA patients with atrial
  fibrillation prescribed anticoagulant therapy
  after a visit to a secondary stroke prevention
  clinic.
• Proportion of patients with stroke and atrial
  fibrillation on aspirin and not prescribed
  anticoagulant agents
• Proportion of patients on warfarin with INR in
  therapeutic range at 3 months and 1 year
  following index of stroke event.

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Carotid Intervention System Implications

• Initial assessment performed by clinicians
  experienced in stroke that are able to determine
  carotid territory involvement.
• Timely access to diagnostic services for
  evaluating carotid arteries.
• Timely access to surgical consults, including a
  mechanism in place for expedited referrals as
  required.

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Carotid Intervention Performance Measures

• Proportion of stroke patients with moderate to
  severe (70-99) carotid artery stenosis who
  undergo a carotid intervention procedure
  following the index stroke.
• Proportion of moderate (50-69) carotid stenosis
  who undergo carotid intervention procedure
  following the index stroke event.
• Proportion of mild (lt50) carotid stenosis who
  undergo carotid intervention following the index
  stroke event.
• Median time from stroke symptom onset to carotid
  endarterectomy (CEA) surgery.

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Stroke Prevention Example

• A Best Practice Example

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Implementation Tips

• Form a working group, consider both local and
  regional representation.
• Complete a gap analysis to compare current
  practices using the Canadian Stroke Strategy Best
  Practices Recommendations 2006 Gap Analysis
  Tool.
• Identify strengths, challenges, opportunities.
• Identify 2-3 priorities for action.
• Identify local and regional champions.

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Implementation Tips

• Identify professional education needs and develop
  a professional education learning plan.
• Consider local or regional workshops to focus on
  stroke prevention.
• Access resources such as Heart and Stroke
  Foundation, provincial contacts.
• Consult with other strategies for lessons learned
  and resources.

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Stroke Prevention Resources

• Consumer Resources
• Heart and Stroke Foundation
• Blood Pressure Action Plan www.heartandstroke.ca/b
  p
• Living with Cholesterol
• Get Your Blood Pressure Under Control
• Professional Resources
• Canadian Diabetes Association
• Canadian Hypertension Education Program
• www.hypertension.ca
• Health Nexus Santé www.healthnexus.ca

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