Primary prevention

The UK National Institute for Health and Care Excellence (NICE) recommends in its 2023 guideline to use the QRISK3 assessment tool to assess cardiovascular disease (CVD) risk within the next 10 years for the primary prevention of CVD in people aged between 25 and 84 years.[61]​​

Do not use a risk assessment tool for people who are at high risk of CVD, including people with:[61]

  • Type 1 diabetes

  • An estimated glomerular filtration rate less than 60 ml per minute per 1.73m2 and/or albuminuria

  • Familial hypercholesterolaemia or other inherited disorders of lipid metabolism.

Advise those at high risk of developing cardiovascular disease on lifestyle measures that reduce the risk of a stroke, including recommendations to:[61]​​

  • Exercise regularly

  • Maintain a cardioprotective diet

  • Manage weight

  • Reduce alcohol consumption

  • Stop smoking.

Manage underlying conditions that predispose a patient to stroke such as:[62]

  • Atrial fibrillation

  • Hypertension

  • Hypercholesterolaemia

  • Type 1 and type 2 diabetes

  • Transient ischaemic attacks.

Do not routinely offer aspirin for primary prevention of CVD.[61]

Secondary prevention

Start secondary prevention measures for all patients as soon as possible after the diagnosis is confirmed.[68]​ Secondary prevention is started in hospital and should be followed up in primary care.[68]​​[198]

  • Advise patients on lifestyle measures including recommendations to:[68]​​

    • Exercise regularly[199]

    • Maintain a healthy diet

    • Manage weight

    • Reduce alcohol consumption

    • Stop smoking

    • Reduce caffeine intake in people with hypertension.[67]

  • Review medications used in secondary prevention. Some patients may have been started on these drugs at diagnosis. See Subsequent acute management under Management recommendations. 

    • Antiplatelet therapy

      • For long-term secondary prevention in patients without paroxysmal or permanent atrial fibrillation, the National Clinical Guideline for Stroke for the UK and Ireland recommends single antiplatelet treatment with clopidogrel as standard treatment.[68]​ Aspirin should be used for those who are unable to tolerate clopidogrel.[68]

    • High-intensity statin therapy

      • Should be started (unless contraindicated or investigation confirms no evidence of atherosclerosis).​[68]

        • A lower dose should be used if there is the potential for medication interactions or a high risk of adverse effects.[68]

        • If the patient reports adverse effects, suggest stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin.[61]

        • Use an alternative statin at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated.[68]

        • The National Institute for Health and Care Excellence (NICE) in the UK recommends to offer ezetimibe instead of a statin to people for whom statins are contraindicated or, if the patient cannot tolerate statins of any intensity or dose.[61]

      • Lipid targets for secondary prevention vary according to guidelines:

        • The National Clinical Guideline for Stroke for the UK and Ireland recommends to aim to reduce fasting LDL-cholesterol to below 1.8 mmol/L (equivalent to a non-HDL-cholesterol below 2.5 mmol/L in a non-fasting sample) in patients with ischaemic stroke and evidence of atherosclerosis.[68]

        • NICE recommends to aim to reduce fasting LDL-cholesterol to 2.0 mmol/L (equivalent to a non-HDL cholesterol of 2.6 mmol/L or less) for secondary prevention in patients with cardiovascular disease (CVD).[61]

      • If target fasting LDL-cholesterol is not achieved at first review at 4-6 weeks, the National Clinical Guideline for Stroke for the UK and Ireland recommends to:[68]

      • Where there is no evidence of atherosclerosis on investigation you should base the decision for lipid-lowering therapy on the patient's overall cardiovascular risk.[68]

      • Consider a diagnosis of familial hypercholesterolaemia in people with ischaemic stroke below 60 years of age with very high cholesterol (below 30 years with total cholesterol above 7.5 mmol/L or 30 years or older with total cholesterol concentration above 9.0 mmol/L).[68]

      • Consider the measurement of lipoprotein(a), and if raised above 200 nmol/L specialist referral, in people with ischaemic stroke of presumed atherosclerotic cause below 60 years of age.[68]

      • Note that although the National Clinical Guideline for Stroke for the UK and Ireland recommend to consider ezetimibe only if target fasting LDL-cholesterol is not achieved at first review at 4-6 weeks, NICE recommends to consider ezetimibe in addition to the maximum tolerated intensity and dose of statin to reduce CVD risk further, even if the lipid target for secondary prevention of CVD is met.[61]

    • Antihypertensives

      • Give a thiazide-like diuretic, long-acting calcium-channel blocker, or ACE inhibitor to treat hypertension.[68]

        • For people with stroke aged 55 years 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 antagonist 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 antagonist.

      • Monitor blood pressure lowering treatment frequently and adjust treatment as tolerated to achieve a target systolic blood pressure below 130 mmHg (equivalent to a home systolic blood pressure below 125 mmHg).[68]

        • In people with severe bilateral carotid artery stenosis, a target blood pressure of 140-150 mmHg is appropriate.

      • Consider home or ambulatory blood pressure monitoring to guide management to improve treatment compliance and blood pressure control.[68]

        • 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.[68]

    • Anticoagulants

      • Should be considered in people with stroke and paroxysmal, persistent, or permanent atrial fibrillation or atrial flutter once intracranial bleeding and other contraindications (such as severe hypertension - clinic blood pressure of 180/120 mmHg or higher, which should be treated first) are excluded. Cerebral microbleeds (regardless of number or distribution) need not preclude the use of such treatment.​[68]

        • Disabling stroke: the National Institute for Health and Care Excellence (NICE) in the UK recommends to defer anticoagulation until at least 2 weeks from onset of symptoms.[67]​ However, the National Clinical Guideline for Stroke for the UK and Ireland recommends that patients with moderate to severe ischaemic stroke and atrial fibrillation or flutter may be considered for anticoagulation from 5-14 days of onset for moderate to severe stroke. Aspirin 300 mg daily should be used in the meantime.[68] Wherever possible, these patients should be offered participation in a trial of the timing of initiation of anticoagulation after stroke.[68] 

        • Non-disabling ischaemic stroke: NICE recommends to defer anticoagulation for an interval at the discretion of the prescriber, but no later than 2 weeks from the onset of symptoms.[67] The National Clinical Guideline for Stroke for the UK and Ireland recommends that patients with ischaemic stroke and atrial fibrillation or flutter should be considered for anticoagulation within 5 days of onset for mild stroke, if the prescriber considers the benefits to outweigh the risk of early intracranial haemorrhage.[68] Aspirin 300 mg daily should be used in the meantime.[68] 

      • Anticoagulation should include measures to reduce bleeding risk, using a validated tool to identify modifiable risk factors.[68] 

      • First-line treatment for people with ischaemic stroke due to non-valvular atrial fibrillation should be anticoagulation with a direct oral anticoagulant (DOAC).[68]

      • People with ischaemic stroke due to valvular/rheumatic atrial fibrillation or with mechanical heart valve replacement, and those with contraindications or intolerance to DOAC treatment, should receive anticoagulation with adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0) with a target time in the therapeutic range of greater than 72%.[68]

      • For people with cardioembolic stroke for whom treatment with anticoagulation is considered inappropriate because of a high risk of bleeding:[68]

        • Antiplatelet treatment should not be used as an alternative when there are absolute contraindications to anticoagulation (e.g., undiagnosed bleeding)

        • A left atrial appendage occlusion device may be considered as an alternative, provided the short-term peri-procedural use of antiplatelet therapy is an acceptable risk.

      • For people with cardioembolic stroke for whom treatment with anticoagulation is considered inappropriate for reasons other than the risk of bleeding:[68] 

        • Antiplatelet treatment may be considered to reduce the risk of recurrent vaso-occlusive disease.

      • People who initially present with recurrent transient ischaemic attack or stroke should receive the same antithrombotic treatment as those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.[68] 

  • Optimise management of other comorbidities and risk factors such as diabetes mellitus, obstructive sleep apnoea, heart failure, contraception, menopause, and influenza.

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