Primary prevention

Use the QRISK3 assessment tool to assess cardiovascular disease (CVD) risk for the primary prevention of CVD (including intracerebral haemorrhage [ICH]) in people aged ≤84 years.[53]​ Hypertension and heavy alcohol use are the strongest risk factors for ICH.

Advise those at high risk of developing cardiovascular disease on lifestyle measures that reduce the risk of a stroke, including recommendations to:[53]

  • Exercise regularly

  • Maintain a cardioprotective diet

  • Manage weight

  • Reduce alcohol consumption

  • Stop smoking.

Manage underlying conditions that predispose a patient to stroke such as:[54]

  • Hypertension

  • Hypercholesterolaemia

  • Type 1 and type 2 diabetes

  • Atrial fibrillation

  • Transient ischaemic attacks.

Do not routinely offer aspirin for primary prevention of CVD.[53]

Secondary prevention

Start secondary prevention measures for all patients as soon as possible after the diagnosis is confirmed.[30]​ Secondary prevention is started in hospital and should be followed up in primary care, particularly blood pressure monitoring and treatment.[30][115]

  • Advise patients on lifestyle measures including recommendations to:[30]

    • Exercise regularly

    • Maintain a healthy diet

    • Manage weight

    • Reduce alcohol consumption

    • Stop smoking

    • Reduce caffeine intake in people with hypertension.[116]

  • Review medications used in secondary prevention. In particular, monitor blood pressure lowering treatment frequently and adjust treatment as tolerated to achieve and maintain a smooth target systolic blood pressure below 130 mmHg, equivalent to a home systolic blood pressure below 125 mmHg.[30]

    • Give a thiazide-like diuretic, long-acting calcium-channel blocker, or ACE inhibitor to treat hypertension.[30]

      • For people with stroke aged 55 or over, or of African or Caribbean origin at any age, start a long-acting dihydropyridine calcium-channel blocker or a thiazide-like diuretic. If target blood pressure is not achieved, an ACE inhibitor or angiotensin II receptor blocker should be added.

      • For people with stroke not of African or Caribbean origin and younger than 55 years, start an ACE inhibitor or an angiotensin II receptor blocker.

  • Consider home or ambulatory blood pressure monitoring to guide management to improve treatment compliance and blood pressure control.[30]

    • Ensure that patients with stroke who are monitoring their blood pressure at home use a validated device with an appropriate measurement cuff and a standardised method, and that they (or where appropriate, their family/carer) receive education and support on how to use the device and the implications of readings for management.[30]

  • Patients with lobar ICH associated with probable cerebral amyloid angiopathy (CAA) may be considered for antiplatelet therapy for the secondary prevention of vaso-occlusive events, but wherever possible patients should be offered participation in a randomised trial.[30] If participation in a randomised trial is not possible then clinicians should make an individualised decision based on estimates of the future risks of recurrent ICH and vaso-occlusive events.[30]

  • Optimise management of other comorbidities and risk factors such as diabetes mellitus; cerebral amyloid angiopathy; heavy alcohol, amphetamine drugs, or cocaine use; antiplatelet, anticoagulant, and statin use.

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