Secondary prevention

 

Recommendations 5.5.1

A. For patients with ischaemic stroke or TIA in sinus rhythm, clopidogrel should be the standard antithrombotic treatment:

• Clopidogrel should be used at a dose of 75mg daily
• For patients who are unable to tolerate clopidogrel, offer aspirin 75mg daily in combination with modified-release dipyridamole 200mg twice daily
• If both clopidogrel and modified-release dipyridamole are contraindicated or not tolerated, offer aspirin 75mg daily
• If both clopidogrel and aspirin are contraindicated or not tolerated offer modified-release dipyridamole 200mg twice daily
• The combination of aspirin and clopidogrel is not recommended for long-term prevention after TIA or stroke unless there is another indication such as acute coronary syndrome or recent coronary stent procedure

B. For patients with ischaemic stroke or TIA in paroxysmal, persistent or permanent atrial fibrillation (valvular or non-valvular) anticoagulation should be the standard treatment. Anticoagulation:

• Should not be given after stroke or TIA until brain imaging has excluded haemorrhage
• Should not be commenced in patients with uncontrolled hypertension
• Of patients with disabling ischaemic stroke should be deferred until at least 14 days have passed from the onset; aspirin 300mg daily should be used until this time
• Of patients with non-disabling ischaemic stroke should be deferred for an interval at the discretion of the prescriber, but no later than 14 days from the onset
• Should be commenced immediately following a TIA once brain imaging has ruled out haemorrhage, using an agent with a rapid onset such as low molecular weight heparin or an oral direct thrombin or factor Xa inhibitor.

C. Anticoagulation should not be used for patients in sinus rhythm unless there is another indication such as a major cardiac source of embolism, cerebral venous thrombosis or arterial dissection.

D. Anticoagulation therapy should be with adjusted-dose warfarin, target INR 2.5 (range 2.0 to 3.0), with a target time in the therapeutic range (TTR) of >72%. If rapid onset is required warfain should be preceded by full dose low molecular weight heparin, or an oral direct thrombin inhibitor or factor Xa inhibitor should be used.

E. For patients with cardioembolic stroke for whom treatment with warfarin is considered inappropriate one of the following three options should be considered:

• For patients with absolute contraindications to anticoagulation (eg undiagnosed bleeding) antiplatelet treatment should not be used as an alternative.
• For patients with relative contraindications to anticoagulation, measures should be taken to reduce bleeding risk, using a tool such as HAS-BLED to identify modifiable risk factors. If after intervention for relevant risk factors the bleeding risk is considered too high for anticoagulation, antiplatelet treatment should not be used as an alternative. In selected cases, a left atrial appendage occlusion device may be appropriate.
• For patients where treatment with warfarin has proved impractical or poorly controlled, or resulted in allergy or intolerance, a direct thrombin inhibitor or factor Xa inhibitor should be used.

F. Antithrombotic treatment for patients with recurrent TIA or stroke should be the same as for those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.

Sources 5.5.2

A. Diener et al. 2004; National Institute for Health and Clinical Excellence 2010a; consensus
B. EAFT (European Atrial Fibrillation Trial) Study Group 1993; Consensus
C. Mohr et al. 2001; Consensus
D. EAFT (European Atrial Fibrillation Trial) Study Group 1993; Consensus
E. EAFT (European Atrial Fibrillation Trial) Study Group 1993; Connolly et al. 2011; Olesen et al. 2011; Consensus; National Institute for Health and Clinical Excellence 2012a; National Institute for Health and Clinical Excellence 2012b
F. Algra et al. 2006; National Institute for Health and Clinical Excellence 2008b; Consensus