Secondary prevention post-TIA or ischaemic stroke

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Starting 2 weeks post-ischaemic stroke or immediately post TIA

Days 1-14 post-ischaemic stroke see Protocol for acute treatment of ischaemic stroke.

Information for patients is available here

Antiplatelets

Clopidogrel 75mg once daily (monotherapy)  

Prescribing information

  • The efficacy of clopidogrel monotherapy is equivalent to a combination of aspirin and dipyridamole.
  • Clopidogrel may be associated with fewer side-effects, has once-daily dosing and is the preferred choice for better compliance.
  • Patients with documented hypersensitivity to clopidogrel should receive aspirin 75mg daily.
  • For patients at risk of gastro-intestinal complications with aspirin (known peptic ulcer or dyspepsia) co-prescribe gastroprotection (see Highland Formulary  Antiplatelets).
  • There is currently no evidence base for dual therapy with aspirin and clopidogrel or with dipyridamole and clopidogrel.

 

Antihypertensives

Perindopril erbumine 2mg daily titrating to 4mg

AND

Indapamide 2·5mg daily

Prescribing information

  • All stroke types, haemorrhagic, ischaemic and TIA, derive risk reduction in secondary events from tight blood pressure control, even in the normotensive patient though caution should be exercised in the frail elderly whose diastolic BP is below 70mmHg, and the combination  withheld if below 60mmHg.
  • Initiate treatment with the combination of perindopril 2mg daily and indapamide 2·5mg daily, then after 2 weeks, titrate perindopril to 4mg daily if tolerated, U&Es are stable and blood pressure is permissible.
  • Check U&Es prior to initiation and then within 4 to 7 days of initiation and at each dose titration.
  • If intolerant of perindopril, eg ACE-induced cough, stop both perindopril and indapamide and consider losartan monotherapy (there is no evidence base to support the combination of losartan and indapamide as a means to offset the risk of future stroke/TIA).
  • Once stabilised on treatment, recheck U&Es annually.
  • Once the above treatment has been maximised refer to Step up management of essential hypertension for further advice regarding blood pressure control and treat to target.

Blood pressure target post-stroke/TIA: 140/85mmHg (if diabetic,130/80mmHg or less)

 

Statins

Atorvastatin 80mg daily

Prescribing information

  • Prior to prescribing a statin, check non-fasting total cholesterol (TC), high-density lipoprotein (HDL) and triglyceride (TG) levels, as well as liver function tests (LFTs) and thyroid function tests (TFTs).
  • For further information refer to Statins for prevention of atherosclerosis.
  • Consider drug interactions; refer to table in above lipid-lowering guidance or to BNF.
  • Refer to BNF for common side-effects. If a person is not able to tolerate atorvastatin 80mg consider a lower dose or alternative statin.

Note: patients post-haemorrhagic stroke should not normally be prescribed a statin unless the risks of further vascular events outweigh the risk of further haemorrhage.

 

Anticoagulants

Oral anticoagulants

Prescribing information

  • Consider patients with ischaemic stroke or TIA in atrial fibrillation (AF) for anticoagulant treatment. Refer to Embolism prophylaxis in atrial fibrillation (AF).
  • There is no evidence of benefit in co-prescribing antiplatelets and anticoagulants for the prevention of further strokes.
  • In patients with atrial fibrillation assess stroke risk using CHA2DS2VASc and bleeding risk using HAS-BLED: see http://sparctool.com/.
  • In days following a TIA assess risk for stroke using ABCD2 score.

 

Editorial Information

Last reviewed: 31 March 2018

Next review: 31 March 2020

Author(s): Stroke Co-Ordinator

Approved By: Formulary Subgroup of ADTC

Reviewer Name(s): Linda Campbell

Document Id: TG0004