Stroke (Read code G66) and TIA management (Read code G65)



Stroke and TIA management (2017/18)

Primary prevention of Stroke or TIA

1. Maintain a normal BP.

2. If CVD 10 year QRisk2 score ≥ 10% consider a statin using a ‘fire and forget’ approach (Atorvastatin 20mg OD).

3. If known IHD then lipid management decreases the risk of stroke. ‘Treat to target’ as per hyperlipidaemia guidelines.

4. All patients with valvular heart disease and AF should be considered for anticoagulation. Use the CHA2DS2-VASc score to determine anticoagulation use in patients with non valvular AF. If score more than 1 should be considered for anticoagulation. At present this is usually with warfarin, although NOAC may be an option for some groups. (See appendix A)

5. Healthy diet, alcohol in moderation, exercise and smoking cessation advice and treatment.

Managing a Suspected stroke or TIA

1. All patients with a suspected stroke should be admitted to hospital (999). Use the FAST screening tool. Time is of the essence.

2. All patients with a TIA should be discussed with the Stroke Team to arrange immediate assessment. Do this while the patient is with you. (Via CRH switchboard on 01422 357171.)High risk will be seen within 24 hrs. No paper referrals

3. If 2 or more TIA’s within a week, arrange urgent admission.

4. Patients with a suspected TIA but presenting after 1 week should be assessed in a TIA clinic within 1 week, consider starting statin and treating BP acutely to target 130/80.

5. Consider possible posterior circulation stroke ( may present with ataxia, nystagmus, diplopia etc) These account for 20-25% ischaemic strokes.

The FAST screening tool for identify patients with stroke

Facial weakness - can the person smile? Has their mouth or eye drooped?

Arm weakness - can the person raise both arms?

Speech problems - can the person speak clearly and understand what you say?

Time to call 999 if they fail any of these tests.

(NICE recommends thrombolysis within 4.5 hours of onset of symptoms. Elderly patients should not be excluded from thrombolysis purely on the basis of their age.)

Assessing the risk of stroke post TIA using the ABCD2 score:

• A (age; 1 point for age >60 years)

• B (blood pressure; 1 point for hypertension (>140 systolic or 90 diastolic)

• C (clinical features; 2 points for focal weakness (with or without speech impairment), 1 for speech disturbance without weakness

• D (symptom duration; 1 point for 10–59 minutes, 2 points for ≥60 minutes).

• Diabetic; 1 point

NICE guidance 2017; Refer anyone with suspected TIA urgently without risk stratification. The stroke team may still ask about the ABCD score to assess urgency.

People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.

All patients with TIA (symptoms resolved already) should be given Aspirin 300mg immediately and then daily until reviewed in TIA clinic. Normally they are then switched to Clopidogrel 75mg a day.

Patient should be advised not to drive for 28 days after the event – see DVLA guidance.

Arrange to check FBC, CRP, electrolytes, HbA1c, Non-fasting lipids, TSH & LFT prior to attendance at clinic if possible.

Secondary prevention

1. BP control target is ................
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