8. Stroke Recommendations

BP lowering

  • Optimal BP levels on treatment for patients with established cerebrovascular disease are unclear, but levels of <130/80 mmHg are recommended. Care should be taken not to reduce rapidly BP in those with significant carotid/vertebrobasilar stenosis. Treatment should usually be started within 1–2 weeks of the acute event.

Lipid lowering

  • Statin therapy is recommended for patients with ischaemic stroke. Its introduction should be delayed for 2 weeks post stroke but there is no need to discontinue statins in patients already on therapy.
  • Statin therapy should be avoided in individuals with a history of haemorrhagic stroke, particularly in those with inadequately controlled hypertension unless there is a compelling indication, such as concomitant coronary artery disease.

Antithrombotic therapy
In the absence of atrial fibrillation, recommendations for patients who have had an ischaemic stroke follow the current NICE guidelines:[2]

  • After acute ischaemic stroke, patients should initially receive 300 mg of aspirin daily for 2 weeks, then be changed to long-term clopidogrel 75 mg daily. For patients who have a contraindication or intolerance to clopidogrel, modified-release dipyridamole plus aspirin is an alternative. For people who have a contraindication or intolerance to both clopidogrel and aspirin, modified-release dipyridamole alone is recommended.
  • For patients with transient ischaemic attacks (TIAs), modified-release dipyridamole 200 mg BD plus aspirin 75–150 mg daily is an alternative treatment option to clopidogrel. For people who have a contraindication or intolerance to aspirin, modified-release dipyridamole alone is an alternative treatment option.

In the presence of atrial fibrillation (valvular or non-valvular) patients with a TIA or ischaemic stroke:

  • Should be anticoagulated with warfarin to achieve a target INR on warfarin of 2.5 (range 2.0–3.0) or with one of the new oral anticoagulant agents.
  • Anticoagulation should not be started until brain imaging has excluded haemorrhage, and not usually until 14 days have passed from the onset of a disabling ischaemic stroke.
  • Anticoagulation should not be used for patients in sinus rhythm unless a cardiac source of embolism has been identified.