EBRSR [Evidence-Based Review of Stroke Rehabilitation] 8 Secondary Prevention of Stroke Katherine Salter PhD (cand.), Robert Teasell MD, Norine Foley MSc, Adam Hopfgartner MSc (cand.), Jennifer Mandzia MD, Shannon Janzen MSc, Danielle Rice BA, Mark Speechley PhD Last Updated: September 2016 Abstract The Heart and Stroke Foundation of Canada has estimated that there are approximately 400,000 individuals living with the effects of stroke (Statistics Canada, 2011). While there is disagreement among studies assessing the relative cost associated with secondary compared to first-ever stroke, recurrent strokes appear to contribute a disproportionate share to the overall national burden of stroke, principally due to costs associated with long-term disability (e.g. nursing home care and re-hospitalization). The secondary prevention of stroke includes strategies used to reduce the risk of stroke recurrence among patients who had previously presented with a stroke or TIA. Management strategies, which should be specific to the underlying etiology, include risk factor modification, the use of antithrombotic or anticoagulant drugs, carotid surgery, endovascular treatments. The present review provides information on risk factor management programs, management of hypertension, diabetes, hyperlipidemia, the role of infection, lifestyle modification (diet, smoking, use of alcohol, physical activity) as well as treatment for atherosclerosis and cardiac abnormalities (e.g. atrial fibrillation) and reperfusion techniques. The review may be downloaded in a single document or in single sections corresponding to the topic areas listed above. 8. Secondary Prevention of Stroke pg. 1 of 344 www.ebrsr.com Table of Contents Abstract .............................................................................................................................................1 Table of Contents ...............................................................................................................................2 Key Points ..........................................................................................................................................6 8.1 The Importance of Preventing Recurrent Strokes ..........................................................................7 8.2 Stroke Risk Factors and Risk Factor Management ..........................................................................8 8.2.1 Stroke and TIA as Risk Factors ................................................................................................9 8.2.1.1 Urgent Assessment and Intervention Post-TIA ....................................................................... 10 8.2.1.2 Prediction of Risk for Recurrent Stroke Following TIA ............................................................ 15 8.2.2 Risk Factor Management ...................................................................................................... 17 8.2.2.1 Programs for Risk Management Following Stroke ................................................................. 19 Summary ......................................................................................................................................... 24 References ....................................................................................................................................... 25 Key Points ........................................................................................................................................ 38 8.3 Hypertension ............................................................................................................................. 39 8.3.1 Significance of Hypertension ................................................................................................ 39 8.3.2 Treatment of Hypertension .................................................................................................. 39 8.3.3 Treatment Recommendations .............................................................................................. 50 Summary ......................................................................................................................................... 52 References ....................................................................................................................................... 54 Key Points ........................................................................................................................................ 63 8.4 Managing Diabetes ..................................................................................................................... 64 8.4.1 Significance of Diabetes ....................................................................................................... 64 8.4.2 Management of Diabetes and Associated Macrovascular Complications ............................... 64 8.4.2.1 Glycemic Control ..................................................................................................................... 64 8.4.2.2 Hypertension Control .............................................................................................................. 69 8.4.2.3 Treatment of Dyslipidemia ..................................................................................................... 71 8.4.2.4 Fibrates and Stroke Prevention in Patients with Diabetes ..................................................... 74 8.4.3 Treatment Recommendations .............................................................................................. 76 Summary ......................................................................................................................................... 78 References ....................................................................................................................................... 80 Key Points ........................................................................................................................................ 89 8.5 Hyperlipidemia ........................................................................................................................... 90 8.5.1 The Significance of Elevated Cholesterol Levels ..................................................................... 90 8.5.2 Treatment of Hyperlipidemia and the Risk of Stroke ............................................................. 91 8.5.2.1 Statins and Functional Outcome ............................................................................................. 96 8.5.3 Treatment Recommendations .............................................................................................. 98 Summary ....................................................................................................................................... 100 References ..................................................................................................................................... 101 Key Points ...................................................................................................................................... 108 8.6 Infection .................................................................................................................................. 109 8.6.1 Pneumonia ........................................................................................................................ 109 8.6.2 Other Conditions ............................................................................................................... 111 Summary ....................................................................................................................................... 113 8. Secondary Prevention of Stroke pg. 2 of 344 www.ebrsr.com References ..................................................................................................................................... 114 Key Points ...................................................................................................................................... 118 8.7 Lifestyle Modification ............................................................................................................... 120 8.7.1 Physical Activity ................................................................................................................. 120 8.7.1.1 Stroke Risk ............................................................................................................................. 120 8.7.1.2 Functional Outcomes ............................................................................................................ 124 8.7.1.3 Mortality ............................................................................................................................... 125 8.7.1.4 Interventions to Promote Physical Activity Following Stroke ............................................... 125 8.7.1.5 Physical Activity Recommendations ..................................................................................... 126 8.7.2 Diet ................................................................................................................................... 127 8.7.2.1 Vitamins/Antioxidants .......................................................................................................... 133 8.7.2.2 Homocysteine ....................................................................................................................... 136 8.7.2.3 Treatment Recommendations .............................................................................................