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Secondary Prevention Of Stroke

Secondary Prevention Of Stroke

7th Edition – 2020 UPDATED

Module Sections and Resources
Secondary Prevention of Stroke Update 2020 Module Overview +-

This Secondary Prevention of Stroke module focuses on management of recurrent stroke risk reduction in patients who have experienced an initial stroke or transient ischemic attack.  In some cases, this module will also guide healthcare providers with guidance for individuals at high risk of a stroke or transient ischemic attack based on current health status and the significant presence of one or more vascular risk factors.

Primary prevention and the reduction of risk factor prevalence in the general population are not the main focus of the Canadian Stroke Best Practice Recommendations; therefore, only selected recommendations related to primary prevention are included. A comprehensive set of recommendations for primary prevention are available in existing high quality guidelines developed by other organizations (such as Canadian Cardiovascular Society, Hypertension Canada Blood Pressure guidelines, Canadian Task Force on Preventative Health Care, and the Canadian Physical Activity Guidelines). 

Notable Updates in CSBPR Secondary Prevention of Stroke 2020 +-

The 2020 update of the Canadian Stroke Best Practice Recommendations Secondary Prevention of Stroke module reinforces the growing and changing body of research evidence available to guide stroke prevention services. A coordinated and organized approach to assessment and aggressive risk factor management is emphasized throughout this module.  

The Canadian Stroke Best Practice Recommendations (CSBPR) Secondary Prevention of Stroke 2020 Seventh Edition module supersedes all recommendations contained in the CSBPR Secondary Prevention of Stroke 2017 Sixth Edition module.

Highlights of significant updates and new additions to the Secondary Prevention of Stroke best practice recommendations for 2020 that are based on new and emerging evidence include:

  • New simplified triage recommendations for patients with acute transient ischemic attack and minor strokes
  • Updated recommendations regarding the diagnostic workup of patients with ischemic stroke or transient ischemic attack (imaging, echocardiography for PFO detection, pulse palpation for opportunistic atrial fibrillation screening, and thrombophilia testing)
  • New section on perioperative management of anticoagulant and antiplatelet therapy
  • New recommendation regarding the ESUS treatment trials (embolic strokes of undetermined source)
  • Updated recommendation regarding the duration of dual antiplatelet therapy after transient ischemic attack or minor stroke
  • New recommendation regarding the THALES trial treatment regimen
  • New recommendation regarding permissive hypertension in patients experiencing hemodynamic ischemia related to critical stenosis of an extracranial or intracranial artery.
  • New recommendation regarding vertebral artery stenting
  • Updated recommendations regarding management of patients with atrial fibrillation 
  • Updated recommendations regarding management of patients with patent foramen ovale
  • Update recommendations regarding cervicocephalic artery dissection.
  • New recommendation on PCSK9 inhibitor therapy for lipid management 
  • New recommendation regarding patients with cancer-associated stroke
  • New recommendation regarding influenza vaccination and cautions related to air pollution.
  • Recommendations on virtual care for delivery of secondary stroke prevention

In addition, there are emerging trends in stroke prevention research that have been reviewed and discussed by the writing group.  These are areas that the group felt were important to monitor but the evidence is not sufficiently clear enough at the time of publication of these guidelines to make specific recommendation statements.  These areas include genetic prediSPoSition and biomarkers (e.g., ACE2), and Transcranial Doppler.

Guideline Development Methodology +-

The detailed methodology and explanations for each of these steps in the development and dissemination of the CSBPR is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website at

Management of Conflicts of Interest within CSBPR: All potential participants in the recommendation development and review process are required to sign confidentiality agreements and to declare all actual and potential conflicts of interest in writing prior to participation.  Any conflicts of interest that are declared are reviewed by the Chairs of the CSBPR Advisory Committee and appropriate Heart & Stroke staff members for their potential impact.  Potential members of any writing group who have conflicts that are considered to be significant with respect to the topics within the module of interest are not selected for writing group or reviewer roles.  Participants who have conflicts for one particular topic area are identified at the beginning of discussions for that topic and are recused from voting.  If the persons in conflict are one of the cochairs then they are recused from chair responsibilities for that discussion, and another non-conflicted participant assumes the chair role for that discussion and voting to ensure balanced and unbiased discussions.  Heart & Stroke senior staff members, who do not have any conflicts of interest, participate in all writing group discussions, and will intervene if there is any perceived untoward bias by a writing group member. Declarations of Conflict of interest for writing group members can be found in Appendix One.

Acknowledgements +-

Heart &Stroke gratefully acknowledges the Secondary Prevention of Stroke writing group leaders and members all of whom have volunteered their time and expertise to the update of these recommendations. Members of the Canadian Stroke Consortium were involved in all aspects of the development of these recommendations. These recommendations underwent external review by: Jason Andrade, Rohit Bhatia, Margie Burns, Elena Adela Cora, Roxanne Cournoyer, Laurent Derex, Paul Dorian, Charles Duffy, Eric Ehrensperger, Yuriy Flomin, Kirsten George-Phillips, Sarah Grant, Milan Gupta, Rahul Jain, Shirin Jalani, Glen Jickling, Hooman Kamel, Hong Kao, Lisa Keon, Lisa Korec, Catherine Legault, Gerald MacDonald, GB John Mancini, Michael MacDonald, Kaylee Murphy, Kelvin Kuan Huei Ng, Darlene Peacock, Andre Roussin, Joanna D Schaafsma, Peter Senior, Aleksander Tkach, Sean Virani, and Janice Williams. We thank the Canadian Stroke Best Practices and Quality Advisory Committee members, including Eric Smith (Co-Chair), Anita Mountain (Co-Chair), Leanne Casaubon, Gord Gubitz, Dar Dowlatshahi, Dylan Blacquiere, Louise Clement, Thalia Field, Farrell Leibovitch, Christine Papoushek, Jeffrey Habert, Barbara Campbell, Joyce Fung, Michael Hill, Tim Hillier, Thomas Jeerakathil, Eddy Lang, Pascale Lavoie, Beth Linkewich, Colleen O’Connell, Melanie Penn, Jai Shankar, Debbie Timpson, Theodore Wein, and Katie White.  We acknowledge and thank Norine Foley and the evidence analysis team at workHORSE; Laurie Charest of Heart & Stroke for her coordination of the CSBPR teams and processes; Andrea deJong, Francine Forget Marin and the Heart & Stroke internal teams who contributed to the development of these recommendations and publication: Communications, Translation, Knowledge Translation, Engagement, Health Policy and Digital Solutions.  

Community Consultation and Review Panel (CCRP) Members

Heart & Stroke is especially grateful to the members of the Community Consultation and Review Panel who reviewed all sections of this module, shared their personal experiences and insights on what did or would have made their journey optimal.  The members of the Secondary Prevention of Stroke CCRP included: Cheryl Beattie, Jennifer Bogart, Dan Dobbin, Glen Hilton, Judy Hilton, Allan Morrison and additional volunteers who provided input.

Citing the Prevention of Stroke 2020 Module +-

SECONDARY PREVENTION of STROKE Scientific Writing Group: David J. Gladstone (Co-Chair), Alexandre Y. Poppe (Co-Chair), James Douketis, William Semchuk, Aline Bourgoin, Jafna Cox, John B. Falconer, Brett R. Graham, Marilyn Labrie, Lena McDonald, Jennifer Mandzia, Daniel Ngui, Paul Pageau, Amanda Rodgerson, Tammy Tebbutt, Carmen Tuchak, Jacob A Udell, Stephen van Gaal, Karina Villaluna, Dar Dowlatshahi, Shelagh Coutts, Theodore Wein, Manraj K.S. Heran, Pascale Lavoie, Rebecca McGuff and M. Patrice Lindsay; on Behalf of the Canadian Stroke Best Practice Recommendations Advisory Committee, in collaboration with the Canadian Stroke Consortium.  Secondary Prevention of Stroke Module, 7th Edition, 2020. In M. Patrice Lindsay, Anita Mountain, Gord Gubitz, Dariush Dowlatshahi, Leanne K Casaubon, Rebecca McGuff and Eric E Smith (Editors), on behalf of the Canadian Stroke Best Practices and Quality Advisory Committee in collaboration with the Canadian Stroke Consortium and the Canadian Partnership for Stroke Recovery. Canadian Stroke Best Practice Recommendations Seventh Edition, 2020; Toronto, Ontario Canada: Heart and Stroke Foundation.


We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations.  Please forward comments to the Heart and Stroke Foundation’s Stroke Team at

Secondary Prevention of Stroke Module Contents +-

1. Triage and Initial Diagnostic Evaluation of Transient Ischemic Attack and Non-Disabling Stroke

2. Lifestyle And Risk Factor Management

3. Blood Pressure and Stroke Prevention

4. Lipid Management

5. Diabetes Management in Stroke

6. Antiplatelet Therapy for Ischemic Stroke and TIA

7. Anticoagulation Therappy for Atrial Fibrillation

8. Perioperative Management of Anticoagulant and Antiplatelet Therapy Recommendations  

9. Management of Extracranial Carotid Artery Disease and Intracranial Atherosclerosis

10. Other Cardiac Issues in Individuals with Stroke

11. Cancer-Associated Ischemic Stroke

Stroke Resources