Taking Action for the Prevention of Stroke
September 20, 2012
Taking Action is an imperative within primary and secondary stroke prevention and applies to systems of care, healthcare providers, patients and the broader community. The primary underpinnings of ‘prevention’ require Taking Action to prevent first stroke or transient ischemic attack or recurrence of a cerebrovascular event. The actions required to prevent first and recurrent stroke include rapid access to specialized stroke prevention services; promotion of healthy lifestyles to minimize vascular risk; aggressive risk factor management, especially even the slightest elevation in blood pressure; appropriate prescription of medications for prevention; patient compliance with medication regimes and lifestyle changes such as diet and smoking cessation; timely access to interventions such as carotid endarterectomy; and, screening of appropriate patients for smoking status, mood, cognition and sleep difficulties.
Taking Action in stroke prevention involves healthcare providers, policy makers, patients and the public. A critical component of stroke prevention is access to specialized stroke prevention services, ideally provided by dedicated stroke prevention clinics. Stroke prevention clinics (or similar vascular prevention clinics) provide a comprehensive interdisciplinary approach to prevention of first or recurrent stroke, conduct detailed assessments by a range of healthcare disciplines, facilitate timely access to appropriate diagnostics and interventions, and provide education to patients and families. They also promote continuity of care between acute care facilities, the patient and their primary care providers.
Recent reports on the quality of stroke services across Canada and within specific provinces have shown that there is an insufficient number of stroke prevention clinics or similar services, even in urban areas where large volumes of stroke patients reside, and even fewer in rural settings. Establishing stroke prevention clinics and services within all regions of care is an imperative in Taking Action for stroke prevention.
Highlights of the Prevention of Stroke 2012 Update
The 2012 update of the Stroke Prevention Chapter of the Canadian Best Practice Recommendations for Stroke Care reinforces the growing and changing body of research evidence available to guide stroke prevention services. Aggressive risk factor management is emphasized throughout this chapter.
Highlights of the moderate and significant updates to stroke prevention recommendations for 2012 include:
- the potential stroke risk of oral contraceptives and hormone replacement therapy, especially in patients who also smoke;
- continued emphasis on the important role of blood pressure for stroke, and diligent monitoring and treatment to keep blood pressure levels well below 140 mm Hg systolic and 90 mm Hg diastolic;
- alignment of diabetes and stroke recommendations with updated guidelines by the Canadian Diabetes Association; revisions to the lipid management section to reflect ongoing analysis and interpretation of the SPARCL trial;
- the release of the findings from the ASA versus ASA + clopidogrel arm of the SPS3 study that reinforced recommendations advising against the use of dual-antiplatelet therapy;
- anticoagulant therapy recommendations for patients with atrial fibrillation and stroke have been significantly revised to reflect the release of the new classes of anticoagulants, based on the RE-LY (dabigatran), ROCKET (rivaroxaban) and ARISTOTLE (apixaban) trials;
- carotid interventions for asymptomatic patients incorporate the 10 year follow-up findings of the ACST trial;
- new recommendations on screening, identification and management of patients with obstructive sleep apnea, diagnosed both pre and post stroke;
- expansion of recommendations on smoking cessation assessment and management, including pharmacotherapy, in collaboration with the CAN-ADAPTE and C-CHANGE guideline groups; and,
- development of a Taking Action for Stroke Prevention quick response guide and pocket card.
Prevention of Stroke 2012 Update Resource Package Includes:
- Prevention of Stroke Best Practice Recommendations
- Prevention of Stroke Quick Reference Guide
- Prevention of Stroke Patient Order Set
- Prevention of Stroke Educational Slide Decks
- Assessment of a Patient with TIA or Non-Disabling Stroke
- Lifestyle and Risk Factor Management To Reduce Stroke (Non-pharmacological) (to come)
- Pharmacotherapy for the Prevention of Stroke (to come)
- Reference Materials from:
Development of the Canadian Best Practice Recommendations for Stroke Care
For detailed methodology on the development and dissemination of the Canadian Best Practice Recommendations for Stroke Care please refer to the stroke best practices website at http://www.strokebestpractices.ca/index.php/methods/.
The Canadian Stroke Network gratefully acknowledges the task group leaders and members, the external reviewers, all of who volunteered their time and expertise to this project. We thank the Canadian Stroke Information and Evaluation Working Group for its work in updating and confirming the performance measures that accompany each recommendation. We acknowledge Corrine Davies-Schinkel for work on the systematic reviews of the literature and meeting coordination; and, we thank Marie-France Saint-Cyr and Jan Carbon for their work on the French translations.
The development of these Canadian stroke care guidelines is funded in its entirety by the Canadian Stroke Network, which is in turn funded by the Networks of Centres of Excellence program. No funds for the development of these guidelines come from commercial interests, including pharmaceutical companies. All members of the recommendation writing groups and external reviewers are volunteers and do not receive any remuneration for participation in guideline development, updates and reviews.
Citing the Prevention of Stroke Update 2012
Coutts S, Kelloway L, on behalf of the Prevention of Stroke Writing Group. Chapter 2: Prevention of Stroke.
In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke Best Practices and Standards Working Group. Canadian Best Practice Recommendations for Stroke Care: 2012; Ottawa, Ontario Canada: Canadian Stroke Network.
We invite comments, suggestions, and inquiries on the development and application of the Canadian Best Practice Recommendations for Stroke Care and ongoing updates.
Please forward comments to the Canadian Stroke Network’s Performance and Standards office at firstname.lastname@example.org
- Prevention of Stroke Definitions
- Lifestyle And Risk Factor Management
- Blood Pressure Management
- Lipid Management
- Diabetes Management
- Antiplatelet Therapy
- Antithrombotic Therapy for Atrial Fibrillation
- Management of Extracranial Carotid Disease and Intracranial Atherosclerosis
- Assessment and Management of Obstructive Sleep Apnea
- Management of Smoking Cessation