Acute treatment of ischaemic stroke (day 1 to 14)

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Antiplatelets

Aspirin 300mg once daily started within 24 hours of the event for 14 days. 

  • If the patient is already on clopidogrel, eg for coronary artery stent, seek stroke specialist advice before switching to aspirin.
  • If already on aspirin 75mg daily then increase dose to 300mg daily for 14 days then refer to Secondary prevention post-TIA or ischaemic stroke.
  • If already on warfarin, see anticoagulant advice below.
  • If thrombolysed, initiate aspirin 24 hours after thrombolysis.

 Prescribing information

 
  • Only for use in confirmed non-haemorrhagic stroke after a CT scan.
  • For patients with dysphagia, aspirin 300mg once daily should be administered rectally as a suppository, or as the dispersible tablet via an enteral tube if this route is available.
  • In documented aspirin intolerance or allergy prescribe clopidogrel 75mg daily.
  • For patients at risk of gastro-intestinal complications with aspirin (known peptic ulcer or dyspepsia) co-prescribe gastroprotection (see Formulary).
  • Discontinue NSAIDs as they antagonise the antiplatelet effect of aspirin.
Antihypertensives

Withhold prescribing of NEW antihypertensives for 14 days post-ischaemic stroke.

 Prescribing information 

 
  • Consider patients with more than one event in seven days as high-risk and initiate antihypertensives immediately, as per Secondary prevention post-TIA and ischaemic stroke.
  • Regular antihypertensive medication should be continued as before in the post-stroke period if the blood pressure is permissible (refer to the table below). 
 Blood Pressure Action
 Consistently less than 120/80mmHg Withhold any regular antihypertensive medication.

Consistently 120/80mmHg or greater but less than 220 systolic BP

OR less than 130 mean arterial pressure

Continue regular antihypertensive medication if no other acute contra-indications.

Consistently 220 or greater systolic BP

OR greater than 130 mean arterial pressure
Continue regular antihypertensive medication if no other acute contra-indications. Seek specialist advice from a physician experienced in stroke.

 

Anticoagulants

Withhold for 3 days post-ischaemic stroke to decrease the risk of haemorrhagic transformation. 

Prescribing information

  • For patients presenting with stroke in atrial fibrillation (AF) while on oral anticoagulants, in most circumstances consider withholding the oral anticoagulant for 3 days and prescribe aspirin 300mg daily until Stroke Team review.
  • 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: Stroke prevention in atrial fibrillation risk tool: http://sparctool.com/ 

 

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 the prevention of atherosclerosis
  • Consider drug interactions; refer to table in above lipid-lowering guidance or to BNF.
  • If a person is not able to tolerate atorvastatin 80mg consider a lower dose or alternative statin. Refer to BNF for common side-effects.

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.

Further information

Patient information can be accessed here

The Stroke Nurse Referral Form for Chest Heart and Stroke Scotland can be accessed here

The Community Rehabilitation Teams Referral Form for North West Sutherland and East Highland can be accessed here

Editorial Information

Last reviewed: 31 March 2018

Next review: 31 March 2020

Author(s): Stroke Clinical Network

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Stroke consultant

Document Id: TG0003