Canadian Best Practice Recommendations for Stroke Care

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Canadian Best Practice Recommendations for Stroke
Care Recommendation 2 Prevention of Stroke
(Updated 2008)
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Defining Prevention

• Primary Prevention
• Individually based clinical approach to disease
  prevention
• Usually occurs in the primary care setting
• Focuses on the importance of screening and
  monitoring high risk individuals of a first event

• Secondary Prevention
• Individually based clinical approach to reducing
  the risk of further vascular events in
  individuals who have experienced a stroke or
  transient ischemic attack and those who have
  medical conditions or risk factors that place
  them at high risk of stroke.

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2.0 Prevention of Stroke

• 2.1 Lifestyle and Risk Factor Management
• 2.2 Blood Pressure Management
• 2.3 Lipid Management
• 2.4 Diabetes Management
• 2.5 Antiplatelet Therapy
• 2.6 Antithrombotic Therapy in Atrial Fibrillation
• 2.7 Carotid Intervention

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Risk Factors

• Non-Modifiable

• 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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2.1 Lifestyle and Risk Factor Management

• Persons at risk of stroke and patients who have
  had a stroke should be assessed for risk factors
  and lifestyle management issues including
• Diet
• Sodium intake
• Smoking
• Exercise
• Weight
• Alcohol intake
• They should receive information and counseling
  about possible strategies to modify their
  lifestyle and risk factors.

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2.1 Lifestyle and Risk Factor Management

• Healthy balanced diet
• High in fresh fruits and vegetables
• Low fat dairy products
• Dietary and soluble fibre
• Whole grains
• Proteins from plant foods
• Low in saturated fats
• Low cholesterol
• Low sodium
• Dietary Resources
• Canadas Food Guide to Healthy Eating

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2.1 Lifestyle and Risk Factor Management

• Sodium
• Recommended amounts of sodium per day from all
  sources is the Adequate Intake based on age.
• Should not exceed an upper limit of 2300mg (1
  teaspoon).

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Recommendations for Adequate Sodium Intake by Age
Institute of Medicine,2004. Dietary Reference
Intakes Water, Potassium, Sodium Chloride,
Sulfate.
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Equivalent Measurements of Sodium and Salt

• For example
• Two slices (292 grams total) of a Pepperoni
  Lover's large stuffed crust pizza at Pizza Hut
  contain 3,000 mg of sodium, double the
  recommended intake for a full day.
• .
• http//www.marketwire.com/press-release/Canadian-
  Stroke-Network-944176.html

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2.1 Lifestyle and Risk Factor Management

• Physical Activity
• Moderate exercise (accumulation of 30 to 60
  minutes) four to seven days per week
• Brisk walking
• Jogging
• Cycling
• Swimming
• Medically supervised programs are recommended
  for high risk patients.

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2.1 Lifestyle and Risk Factor Management

• Weight
• Maintain goal of a body mass index (BMI) of 18.5
  to 24.9 kg/m2 and a waist circumference of less
  than 88 cm for women and less than 102 cm for men.

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2.1 Lifestyle and Risk Factor Management

• Smoking
• Smoking cessation and smoke free environment
• Nicotine replacement therapy and behavioural
  therapy

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2.1 Lifestyle and Risk Factor Management

• Alcohol Consumption
• Two or fewer standard drinks per day
• Fewer than 14 drinks per week for men
• Fewer than 9 drinks per week for women

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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 at
  healthcare encounters.
• National and international efforts to reduce
  sodium intake and increase public knowledge about
  the risks of sodium, directly targeting the food
  industry.
• Access to risk factor management programs in all
  communities, primary healthcare settings,
  workplaces.

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Selected Performance Measures

• The proportion of the population with major risk
  factors for stroke, including hypertension,
  obesity, history of smoking, low physical
  activity, hyperlipidemia, diabetes, atrial
  fibrillation.
• Percentage of the population who can identify the
  major risks of stroke.
• The annual occurrence of stroke in each province
  and territory by stroke type.

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2.2 Blood Pressure Management

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

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2.2a. Blood Pressure Assessment

• All persons at risk for stroke should have their
  blood pressure measured at each healthcare
  encounter but no less than once annually.
• Proper standardized techniques, as described by
  the Canadian Hypertension Education Program,
  should be followed for blood pressure measurement
  ltwww. hypertension.cagt.
• Patients found to have elevated blood pressure
  should undergo thorough assessment for the
  diagnosis of hypertension following the current
  guidelines of the Canadian Hypertension Program.
• Patients with hypertension or at risk for
  hypertension should be advised on lifestyle
  modifications.

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2.2b. Blood Pressure Management

• Target blood pressure levels as defined by CHEP
  guidelines for prevention of first stroke,
  recurrent stroke and other vascular events.
• RCTs have not defined the optimal time to
  initiate blood pressure lowering therapy after
  stroke or transient ischemic attack.
• For patients with non-disabling stroke or
  transient ischemic attack not requiring
  hospitalization, it is recommended that blood
  pressure lowering treatment be initiated or
  modified at the time of the first medical
  assessment.

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CHEP 2008 Recommendations for the Management of
Blood Pressure
www.hypertension.ca/chep
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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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Selected Performance Measures

• Proportion of the population who have diagnosed
  elevated blood pressure.
• 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.

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2.3 Lipid Management

• Lipid levels should be monitored in all persons
  at risk for stroke.

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2.3a. Lipid Assessment

• Fasting lipid levels (TC,TG,LDL-C,HDL-C) should
  be measured every 1-3 years for all men 40 years
  or older and post menopausal women and/or 50
  years or older.
• More frequent testing should be done for patients
  with abnormal values or if treatment is
  initiated.
• Adults at any age should have their blood lipid
  levels measured if they have a history of
  diabetes, smoking, hypertension, obesity,
  ischemic heart disease, renal vascular disease,
  peripheral vascular disease, ischemic stroke, TIA
  or symptomatic carotid stenosis.

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2.3b. Lipid Management

• Ischemic stroke patients with LDL-C gt2.0mmol/L
  should be managed with lifestyle modification,
  dietary guidelines.
• Statin agents should be prescribed for most
  patients who have had an ischemic stroke or
  transient ischemic attack to achieve current
  recommended lipid levels.

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System Implications

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

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Selected Performance Measures

• Proportion of the population who report that they
  have elevated lipid levels, especially LDL.
• Proportion of stroke patients prescribed
  lipid-lowering agents for secondary prevention of
  stroke
• At discharge from acute care
• Through secondary prevention clinic
• By primary care
• Proportion of stroke patients with an LDL-C
  between 1.8-2.5 mmol/L at 3 months post stroke.

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2.4 Diabetes Management

• 2.4a. Diabetes Assessment
• All individuals in the general population should
  be evaluated annually for type 2 diabetes risk on
  the basis of demographic and clinical criteria.
• A fasting plasma glucose (FPG) should be
  performed every three years in individuals gt40
  years of age to screen for diabetes.
• Risk factors include
• Family history
• High risk population
• Vascular disease
• History of gestational diabetes
• Hypertension
• Dyslipidemia

• Polyvystic
• ovary syndrome
• Overweight
• Abdominal
• obesity

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2.4 Diabetes Management

• 2.4a. Diabetes Assessment
• In adults, fasting lipid levels (TC, HDL-C, TG,
  calculated LDL-C) should be measured at the time
  of diagnosis of diabetes and then every one to
  three years as clinically indicated.
• More frequent testing should be done if treatment
  for dyslipidemia is initiated.
• Blood pressure should be measured at every
  diabetes visit.

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2.4 Diabetes Management

• 2.4b. Diabetes Management
• Glycemic targets must be individualized
• To achieve an HbA1c lt7.0, patients with type 1
  or type 2 diabetes should aim for a fasting
  plasma glucose or preprandial plasma glucose
  targets of 4.0 to 7.0 mmol/L.
• The 2-hour postprandial plasma glucose target is
  5.010.0 mmol/L Evidence Level B. If HbA1c
  targets cannot be achieved with a postprandial
  target of 5.010.0 mmol/L, further postprandial
  blood glucose lowering, to 5.08.0 mmol/L, can be
  considered.

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2.4 Diabetes Management

• 2.4b Diabetes Management
• Adults at high risk of a vascular event should be
  treated with a statin to achieve an
  LDL-Cholesterol 2.0 mmol/l.
• Unless contraindicated, low dose ASA therapy
  (80-325mg/day) is recommended in all patients
  with diabetes with evidence of cardiovascular
  disease and those with atherosclerotic risk
  factors.

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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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Selected Performance Measures

• Proportion of the population with a confirmed
  diagnosis of diabetes (Type l and Type ll).
• Proportion of persons with diabetes presenting to
  hospital with a new stroke event.

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2.5 Antiplatelet Therapy

• All patients with ischemic stroke or transient
  ischemic attack should be prescribed antiplatelet
  therapy for secondary prevention of recurrent
  stroke unless there is an indication for
  anticoagulation.

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2.5 Antiplatelet Therapy

• Aspirin (ASA), combined ASA and extended release
  dypyridamole, or clopidogrel may be used
  depending in the clinical circumstances.
• For adult patients on ASA, the usual maintenance
  dosage is 80-325 mg/day.
• For children with stroke, the usual maintenance
  dosage for ASA is 3-5 mg/kg per day.
• Long term combinations of aspirin and clopidogrel
  are not recommended.

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System Implications

• Stroke Prevention Clinics in place to improve
  secondary stroke prevention care.
• Optimization of strategies at local, regional and
  provincial levels to prevent 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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Selected 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.

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2.6 Antithrombotic Therapy in Atrial Fibrillation

• Patients with stroke and atrial fibrillation
  should be treated with warfarin at a target INR
  of 2.5, range 2.0 to 3.0 (target INR of 3.0 for
  mechanical cardiac valves, range 2.5 to 3.5).
• These patients should be likely to be compliant
  with the required monitoring and are not at
  high-risk for bleeding complications.

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System Implications

• Stroke Prevention Clinics to improve secondary
  stroke prevention including management of atrial
  fibrillation in patients with stroke and TIA.
• A process for appropriate outpatient monitoring
  of patient INR levels and follow-up communication
  with patients taking anticoagulants.
• Optimization of strategies at local, regional and
  provincial levels to prevent 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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Selected 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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2.7 Carotid Intervention

• 2.7a. Symptomatic Carotid Stenosis
• Patients with transient ischemic attack or
  nondisabling stroke and ipsilateral 70-99
  internal carotid artery stenosis should be
  offered carotid endarterectomy within 2 weeks of
  the incident transient ischemic attack or stroke
  unless contraindicated.
• Carotid endarterectomy recommended for selected
  patients with moderate (50 to 69 symptomatic
  stenosis , should be evaluated by a physician
  with expertise in stroke management).
• Carotid endarterectomy should be performed by a
  surgeon with a known perioperative morbidity and
  mortality of lt6.

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2.7 Carotid Intervention

• 2.7a. Symptomatic Carotid Stenosis
• Carotid stenting may be considered for patients
  who are not operative candidates for technical,
  anatomical or medical reasons.
• Carotid endarterectomy is contraindicated for
  patients with mild (lt50) stenosis.

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2.7 Carotid Intervention

• 2.7b. Asymptomatic Carotid Stenosis
• Carotid endarterectomy may be considered for
  selected patients with asymptomatic 60-99
  carotid stenosis.
• Patients should be less than 75 years old with a
  surgical risk lt3, a life expectancy gt5 years,
  and be evaluated by a physician with expertise in
  stroke management.

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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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Selected 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.
• Median time from stroke symptom onset to carotid
  endarterectomy surgery.
• Proportion of stroke patients requiring carotid
  intervention, who undergo the procedure within
  two weeks of the index stroke event.
• Proportion of moderate (50-69) carotid stenosis
  who undergo carotid intervention procedure
  following the index stroke event.

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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 Best Practice
  Recommendations for Stroke Care Update 2008 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, resources.

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