Stroke and TIA management (2015/16)

Primary prevention of Stroke or TIA

  1. Maintain a normal BP.
  1. If CVD 10 year QRisk2 score≥10% consider a statin using a ‘fire and forget’ approach (Atorvastatin20mgOD).
  1. If known IHD then lipid management decreases the risk of stroke. ‘Treat to target’ as per hyperlipidaemia guidelines.
  1. 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)
  1. 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.
  1. All patients with a TIA and ABCD2 score of >3 should be discussed with the Stroke Team to arrange immediate assessment. (Via CRH switchboard on 01422 357171.)
  1. If 2 or more TIA’s within a week,arrange urgent admission.
  1. All patients with a TIA and ABCD2 score of = to or < 3 should be assessed in a TIA clinic within 1 week. (Fax referral to Stroke Team.)
  1. 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.

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

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 <150/<90- Aspirational <130/<80 (unless they have bilateral carotid artery stenosis, when target is systolic < 150). Theminimum (QOF) standard is <150/<90. If this requires 2 or more agents one should be a diuretic. (SIGN guidance suggests ACE-Inhibitors and Thiazide diuretic for all, even if normotensive.)
  1. All patients with a history of ischaemic stroke should be onClopidogrel in preference to low dose aspirin, as this reduces CVS mortality and recurrent stroke (NICE Dec 2010). Patients with stroke associated with AF should be assessed for long-term treatment with warfarin or NOAC.
  1. Patients with TIA should receiveClopidogrel 75mg in preference to Aspirin 75mg daily & Dipyridamole M/R200mg BD(RCP guideline 2012). High risk patients may be on dual antiplatelet therapy ( Aspirin and Clopidogrel) for 21 days.If intolerant to Aspirin and Clopidogrel then Dipyridamole MR 200mg BD may be given on its own.
  1. If patients suffer from multi-vascular disease ie have vascular problems in more than one place e.g. heart and stroke give Clopidogrel 75mg OD. If intolerant to it then give Aspirin 75mg OD.
  1. Statins – All patients with a history of TIA/ischaemic stroke irrespective of age, sex or cholesterol level should commence a statin ( e.g. Atorvastatin 80mg. Use 40mg with CCBs) . Warn the patient about common side or serious side effects e.g. myalgia. Check non fasting lipids and ALT at 4 weeks.

Statins are not recommended after intracerebral haemorrhage unless indicated for other vascular disease.

  1. Smoking cessation and healthy lifestyle advice should be given and documented.
  1. All patients with non disabling stroke or TIA should be considered for urgent specialist assessment – patients with high grade ipsilateral stenosis benefit from carotid endarterectomy.
  1. Ensure they have an appropriate Read code in the Summary Page
  1. Amaurosis Fugax is an anterior circulation stroke but not flagged in the QOF. Recall is required.

The patient pathway

Patients, as a result of remembering their annual review date or having a reminder on their prescription will ring to book their annual review. The reception team will book an appointment with the practice nurse +/- appointment with HCA according to the icons on patients notes .

The Practice nurses on completing the annual review, where no action is deemed to be necessary, will also document and inform the patient of their next planned review date and task the appropriate GP to code the medication review and reauthorise the prescriptions. Patients requiring bloods will have appointment with HCA. Patients requiring further assessment or a change in medication will be referred to the GP.

QOF 2015/16

QOF indicator / Description / Points in 2015/16 / Threshold / Any changes from last year?
STIA001 / Register of patients with stroke or TIA / 2 / - / No change
STIA008 / The percentage of patients with a stroke or TIA (diagnosed on or after 1 April 2015) who have a record of a referral for further investigation between 3 months before or 1 month after the date of the latest recorded stroke or the first TIA / 2 / 45-80 / No change
STIA003 / The percentage of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less / 5 / 40-75 / No change
STIA009 / The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 August to 31 March / 2 / 55-95 / No change
STIA007 / The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken / 4 / 57-97 / No change

Appendix ADabigatran, Apixaban and Rivoraxaban all three are licensed for prevention of stroke in presence of non-valvular Atrial Fibrillation. There is no clear evidence of superiority of one over another in trials as no major head to head ones exist.Rivoraxaban (Xarelto) has once daily dosing and is the cheapest !

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