canadian best practice recommendations for stroke care:2008 recommendation 2: prevention of stroke
TRANSCRIPT
Canadian Best Practice Recommendations for Stroke Care:2008
Recommendation 2:Prevention of Stroke
Defining Prevention
Primary Prevention Individually based
clinical approach to disease prevention
Usually occurs in the primary care setting
Focuses on the importance of screening and monitoring high risk individuals of a first event
Secondary Prevention Individually based
clinical approach to reducing the risk of further vascular events in individuals who have experienced a stroke or transient ischemic attack and those who have medical conditions or risk factors that place them at high risk of stroke.
2.0 Prevention of Stroke
2.1 Lifestyle and Risk Factor Management 2.2 Blood Pressure Management 2.3 Lipid Management 2.4 Diabetes Management 2.5 Antiplatelet Therapy 2.6 Antithrombotic Therapy in Atrial
Fibrillation 2.7 Carotid Intervention
Risk Factors
Modifiable Hypertension Obesity Atrial Fibrillation Diabetes Cardiac Disease Hyperlipidemia Excessive Alcohol Intake Physical Activity Smoking Stress Hormone Replacement
Therapy
Non-Modifiable
Age Gender Family History Ethnicity Previous TIA or Stroke
2.1 Lifestyle and Risk Factor Management Persons at risk of stroke and patients who have had a
stroke should be assessed for risk factors and lifestyle management issues including: Diet Sodium intake Smoking Exercise Weight Alcohol intake
They should receive information and counseling about possible strategies to modify their lifestyle and risk factors.
2.1 Lifestyle and Risk Factor Management Healthy balanced diet
High in fresh fruits and vegetables Low fat dairy products Dietary and soluble fibre Whole grains Proteins from plant foods Low in saturated fats Low cholesterol Low sodium
Dietary Resources Canada’s Food Guide to Healthy
Eating
2.1 Lifestyle and Risk Factor Management Sodium:
Recommended amounts of sodium per day from all sources is the Adequate Intake based on age.
Should not exceed an upper limit of 2300mg (1 teaspoon).
Sodium Resources: www.sodium101.ca
Recommendations for Adequate Sodium Intake by Age
Age Sodium Intake per Day (mg)
0-6 months 120
7-12 months 370
1-3 years 1000
4-8 years 1,200
9-50 years 1,500
50-70 years 1,300
> 70 years 1,200
Institute of Medicine,2004. Dietary Reference Intakes: Water, Potassium, Sodium Chloride, Sulfate.
Equivalent Measurements of Sodium and SaltSodium
(mg)Sodium (mmol)
Salt (g)
500 22 1.25
1,500 65 3.75
2,000 87 5.0
2,300 100 5.8
2,400 104 6.0
3,000 130 7.5
4,000 174 10
For example:•Two slices (292 grams total) of a Pepperoni Lover's large stuffed crust pizza at Pizza Hut contain 3,000 mg of sodium, double the recommended intake for a full day.. http://www.marketwire.com/press-release/Canadian-Stroke-Network-944176.html
2.1 Lifestyle and Risk Factor Management
Physical Activity Moderate exercise (accumulation of 30 to 60
minutes) four to seven days per weeko Brisk walkingo Joggingo Cyclingo Swimming
Medically supervised programs are recommended for high risk patients.
2.1 Lifestyle and Risk Factor Management
Weight Maintain goal of a body mass index (BMI) of
18.5 to 24.9 kg/m2 and a waist circumference of less than 88 cm for women and less than 102 cm for men.
2.1 Lifestyle and Risk Factor Management
Smoking Smoking cessation and smoke free
environment Nicotine replacement therapy and behavioural
therapy
2.1 Lifestyle and Risk Factor Management
Alcohol Consumption Two or fewer standard drinks per day Fewer than 14 drinks per week for men Fewer than 9 drinks per week for women
System Implications Health promotion efforts that contribute to the primary
prevention of stroke in all communities and are integrated with existing chronic disease prevention initiatives.
Stroke prevention approaches are offered by primary care providers across the continuum at healthcare encounters.
National and international efforts to reduce sodium intake and increase public knowledge about the risks of sodium, directly targeting the food industry.
Access to risk factor management programs in all communities, primary healthcare settings, workplaces.
Selected Performance Measures
The proportion of the population with major risk factors for stroke, including hypertension, obesity, history of smoking, low physical activity, hyperlipidemia, diabetes, atrial fibrillation.
Percentage of the population who can identify the major risks of stroke.
The annual occurrence of stroke in each province and territory by stroke type.
Stroke mortality rates across provinces and territories, including in-hospital or 30 day and one year
2.2 Blood Pressure Management
Hypertension is the single most important risk factor for stroke.
Blood pressure should be monitored in all persons at risk for stroke.
2.2a. Blood Pressure Assessment All persons at risk for stroke should have their blood
pressure measured at each healthcare encounter but no less than once annually.
Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement <www. hypertension.ca>.
Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Program.
Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications.
2.2b. Blood Pressure Management Target blood pressure levels as defined by CHEP
guidelines for prevention of first stroke, recurrent stroke and other vascular events.
RCTs have not defined the optimal time to initiate blood pressure lowering therapy after stroke or transient ischemic attack.
For patients with non-disabling stroke or transient ischemic attack not requiring hospitalization, it is recommended that blood pressure lowering treatment be initiated or modified at the time of the first medical assessment.
CHEP 2008 Recommendations for the Management of Blood Pressure
Condition Recommendation
Prevention of first stroke in general population
Target: 140/90mmHg
Patients who have had a stroke/TIA
Target: <140/90mmHg
Patient with diabetes for prevention of first stroke/TIA
Target: 130/80mmHg
Non-diabetic chronic kidney disease
Target: <130/80mmHg
www.hypertension.ca/chep
System Implications
Coordinated hypertension awareness programs at provincial and community levels that involve community groups, pharmacists, primary care and other relevant partners.
Stroke prevention including routine blood pressure monitoring, offered by primary care providers in the community as part of comprehensive patient management.
Selected Performance Measures
Proportion of the population who have diagnosed elevated blood pressure.
Percentage of the population with known hypertension who are on blood pressure lowering therapy.
Proportion of stroke/TIA patients prescribed blood pressure lowering agents on discharge from acute care.
2.3 Lipid Management
Lipid levels should be monitored in all persons at risk for stroke.
2.3a. Lipid Assessment Fasting lipid levels (TC,TG,LDL-C,HDL-C) should be
measured every 1-3 years for all men 40 years or older and post menopausal women and/or 50 years or older.
More frequent testing should be done for patients with abnormal values or if treatment is initiated.
Adults at any age should have their blood lipid levels measured if they have a history of diabetes, smoking, hypertension, obesity, ischemic heart disease, renal vascular disease, peripheral vascular disease, ischemic stroke, TIA or symptomatic carotid stenosis.
2.3b. Lipid Management
Ischemic stroke patients with LDL-C >2.0mmol/L should be managed with lifestyle modification, dietary guidelines.
Statin agents should be prescribed for most patients who have had an ischemic stroke or transient ischemic attack to achieve current recommended lipid levels.
System Implications
Coordinated dyslipidemia awareness programs at the provincial and community levels that involve community groups, pharmacists, primary care and other relevant partners.
Stroke prevention, including lipid level monitoring offered by primary care providers in the community as part of comprehensive patient management.
Performance Measures Proportion of the population who report that they
have elevated lipid levels, especially LDL. Proportion of stroke patients prescribed lipid-
lowering agents for secondary prevention of stroke: At discharge from acute care Through secondary prevention clinic By primary care
Proportion of stroke patients with an LDL-C between 1.8-2.5 mmol/L at 3 months post stroke.
2.4 Diabetes Management 2.4a. Diabetes Assessment
All individuals in the general population should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria.
A fasting plasma glucose (FPG) should be performed every three years in individuals >40 years of age to screen for diabetes.
Risk factors include:o Family historyo High risk populationo Vascular diseaseo History of gestational diabeteso Hypertensiono Dyslipidemia
o Polyvystic ovary syndromeo Overweighto Abdominal obesity
2.4 Diabetes Management
2.4a. Diabetes Assessment In adults, fasting lipid levels (TC, HDL-C, TG,
calculated LDL-C) should be measured at the time of diagnosis of diabetes and then every one to three years as clinically indicated.
More frequent testing should be done if treatment for dyslipidemia is initiated.
Blood pressure should be measured at every diabetes visit.
2.4 Diabetes Management 2.4b. Diabetes Management
Glycemic targets must be individualized To achieve an HbA1c <7.0%, patients with type 1
or type 2 diabetes should aim for a fasting plasma glucose or preprandial plasma glucose targets of 4.0 to 7.0 mmol/L.
The 2-hour postprandial plasma glucose target is 5.0–10.0 mmol/L [Evidence Level B]. If HbA1c targets cannot be achieved with a postprandial target of 5.0–10.0 mmol/L, further postprandial blood glucose lowering, to 5.0–8.0 mmol/L, can be considered.
2.4 Diabetes Management
2.4b Diabetes Management Adults at high risk of a vascular event should
be treated with a statin to achieve an LDL-Cholesterol ≤2.0 mmol/l.
Unless contraindicated, low dose ASA therapy (80-325mg/day) is recommended in all patients with diabetes with evidence of cardiovascular disease and those with atherosclerotic risk factors.
System Implications
Coordinated diabetes awareness programs at the provincial and community levels that involve community groups, pharmacists, primary care and other relevant partners.
Coordinated education and support programs for persons with diabetes to increase compliance and reduce ongoing risks for cardiovascular complications.
Performance Measures
Proportion of the population with a confirmed diagnosis of diabetes (Type l and Type ll).
Proportion of persons with diabetes presenting to hospital with a new stroke event.
2.5 Antiplatelet Therapy
All patients with ischemic stroke or transient ischemic attack should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for anticoagulation.
2.5 Antiplatelet Therapy
Aspirin (ASA), combined ASA and extended release dypyridamole, or clopidogrel may be used depending in the clinical circumstances.
For adult patients on ASA, the usual maintenance dosage is 80-325 mg/day.
For children with stroke, the usual maintenance dosage for ASA is 3-5 mg/kg per day.
Long term combinations of aspirin and clopidogrel are not recommended.
System Implications
Stroke Prevention Clinics in place to improve secondary stroke prevention care.
Optimization of strategies at local, regional and provincial levels to prevent recurrence of stroke.
Stroke prevention awareness and education of secondary prevention for primary care practitioners and specialists who manage stroke patients during the acute phase and post-discharge from acute care.
Performance Measures
Proportion of stroke/TIA patients prescribed antiplatelet therapy on discharge from acute care.
Proportion of stroke/TIA patients prescribed antiplatelet therapy on discharge from secondary prevention clinic
2.6 Antithrombotic Therapy in Atrial Fibrillation
Patients with stroke and atrial fibrillation should be treated with warfarin at a target INR of 2.5, range 2.0 to 3.0 (target INR of 3.0 for mechanical cardiac valves, range 2.5 to 3.5).
These patients should be likely to be compliant with the required monitoring and are not at high-risk for bleeding complications.
System Implications Stroke Prevention Clinics to improve secondary stroke
prevention including management of atrial fibrillation in patients with stroke and TIA.
A process for appropriate outpatient monitoring of patient INR levels and follow-up communication with patients taking anticoagulants.
Optimization of strategies at local, regional and provincial levels to prevent recurrence of stroke.
Stroke prevention awareness and education of secondary prevention for primary care practitioners and specialists who manage stroke patients during the acute phase and post-discharge from acute care.
Performance Measures Proportion of eligible stroke/TIA patients with
atrial fibrillation prescribed anticoagulant therapy on discharge from acute care.
Proportion of stroke/TIA patients with atrial fibrillation prescribed anticoagulant therapy after a visit to a secondary stroke prevention clinic.
Proportion of patients with stroke and atrial fibrillation on aspirin and not prescribed anticoagulant agents.
Proportion of patients on warfarin with INR in therapeutic range at 3 months and 1 year following index of stroke event.
2.7 Carotid Intervention 2.7a. Symptomatic Carotid Stenosis
Patients with transient ischemic attack or nondisabling stroke and ipsilateral 70-99% internal carotid artery stenosis should be offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke unless contraindicated.
o Carotid endarterectomy recommended for selected patients with moderate (50 to 69% symptomatic stenosis , should be evaluated by a physician with expertise in stroke management).
o Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity and mortality of <6%.
2.7 Carotid Intervention
2.7a. Symptomatic Carotid Stenosis Carotid stenting may be considered for
patients who are not operative candidates for technical, anatomical or medical reasons.
Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis.
2.7 Carotid Intervention
2.7b. Asymptomatic Carotid Stenosis Carotid endarterectomy may be considered for
selected patients with asymptomatic 60-99% carotid stenosis.
o Patients should be less than 75 years old with a surgical risk <3%, a life expectancy >5 years, and be evaluated by a physician with expertise in stroke management.
System Implications
Initial assessment performed by clinicians experienced in stroke that are able to determine carotid territory involvement.
Timely access to diagnostic services for evaluating carotid arteries.
Timely access to surgical consults, including a mechanism in place for expedited referrals as required.
Selected Performance Measures Proportion of stroke patients with moderate to
severe (70-99%) carotid artery stenosis who undergo a carotid intervention procedure following the index stroke.
Median time from stroke symptom onset to carotid endarterectomy surgery.
Proportion of stroke patients requiring carotid intervention, who undergo the procedure within two weeks of the index stroke event.
Proportion of moderate (50-69%) carotid stenosis who undergo carotid intervention procedure following the index stroke event.
Stroke Prevention: Example
A Best Practice Example
Implementation Tips Form a working group, consider both local and
regional representation. Complete a gap analysis to compare current
practices using the Canadian Best Practice Recommendations for Stroke Care Update: 2008 Gap Analysis Tool.
Identify strengths, challenges, opportunities Identify 2-3 priorities for action Identify local and regional champions
Implementation Tips
Identify professional education needs and develop a professional education learning plan.
Consider local or regional workshops to focus on stroke prevention.
Access resources such as Heart and Stroke Foundation, provincial contacts
Consult with other strategies for lessons learned, resources.
