22B. Secondary prevention of stroke

Antiplatelet therapy

Should be initiated in all patients after ischaemic stroke. Either aspirin or clopidogrel. Treatment should be initiated as soon as possible of ischaemic stroke onset, except if the patient receives thrombolysis, in which case it should be started 24 hours after.

Cholesterol management

High intensity statins should be initiated in all patients after ischaemic stroke. Statins are beneficial for all patients, possibly even if they don’t have dyslipidaemia, but most patients with ischaemic stroke have dyslipidaemia anyway. The target LDL is 1,4 mM (according to European guidelines. American guidelines target 1.8). If the target isn’t reached with high intensity statins alone and lifestyle changes alone, adjunctive cholesterol lowering drugs should be added.

Blood pressure management

For patients without diabetes, the target is < 140/90 mmHg. For patients with diabetes, the target is < 130/80 mmHg. Both non-pharmacological and pharmacological interventions should be used.

Anticoagulation

Anticoagulation is initiated in all patients with atrial fibrillation after ischaemic stroke. DOACs are preferred.

Carotid surgery

Carotid surgery is indicated for everyone with a 70 – 99% carotid stenosis (1A level recommendation) and suggested for those with 50 – 69% stenosis (2A level recommendation). This involves carotid endarterectomy or carotid artery stenting.

Blood glucose management

For patients with diabetes. Target is < 7% (53 mmol/mol)

Other interventions

• Smoking cessation
• Reduction of alcohol consumption
• Regular physical activity
• Mediterranean diet
• Salt intake < 2,4 g/day