ALBERTA PROVINCIAL STROKE STRATEGY
Secondary Stroke Prevention
February 2009
TABLE OF CONTENTS
Page
1.0
INTRODUCTION ............................................................................................................. 5
2.0
ORGANIZING FOR SECONDARY STROKE PREVENTION ......................................... 5
Education of Health Care Providers.......................................................................... 6
3.0
SECONDARY STROKE PREVENTION – PATIENT FLOW........................................... 7
4.0
MINOR STROKE/TIA ALGORITHM................................................................................ 8
5.0
STROKE RISK................................................................................................................. 9
5.1 EVALUATION OF THE EVENT: STROKE RISK ASSESSMENT (Triage of TIA).... 9
5.2 IMPLEMENTATION OF INTERVENTIONS............................................................ 11
5.3 INITIATION OF MEDICATIONS ............................................................................. 11
5.4 MODIFICATION OF STROKE RISK FACTORS .................................................... 12
6.0
BEST PRACTICE GUIDELINES FOR SECONDARY STROKE PREVENTION .......... 13
6.1 DEVELOPMENT PROCESS .................................................................................. 13
6.2 GENERAL PRACTICE GUIDELINES FOR STROKE PREVENTION.................... 14
6.3 RECOMMENDATIONS BY STROKE TYPE........................................................... 14
Antithrombotic Therapy for Noncardioembolic Stroke or TIA............................... 14
Patients With Cardioembolic Stroke or TIA .......................................................... 14
- Atrial Fibrillation .................................................................................................. 14
- Prosthetic Heart Valves...................................................................................... 15
Interventional Approaches to Patients with Stroke or TIA Caused by Large-Artery
Atherosclerotic Disease........................................................................................ 15
- Extracranial Carotid Artery Disease .................................................................. 15
6.4 RECOMMENDATIONS BY TREATABLE VASCULAR RISK FACTORS............... 15
Hypertension......................................................................................................... 15
Diabetes................................................................................................................ 16
Cholesterol............................................................................................................ 16
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6.5 RECOMMENDATIONS BY MODIFIABLE BEHAVIOURAL RISK FACTORS ....... 17
Diet ....................................................................................................................... 17
Sodium.................................................................................................................. 17
Smoking................................................................................................................ 17
Alcohol .................................................................................................................. 17
Obesity.................................................................................................................. 17
Physical Activity .................................................................................................... 18
Hyperhomocysteinemia ........................................................................................ 18
6.6 BEST PRACTICE GUIDELINES REFERENCES ................................................... 18
7.0
SECONDARY STROKE PREVENTION CLINIC RESOURCES................................... 19
Minor Stroke / TIA Stroke Risk Assessment Pocket Card ...................................... 19
Secondary Prevention Clinic Referral Form............................................................ 20
Stroke Prevention Clinic RN Required Knowledge and Skills ................................ 21
Secondary Prevention of TIA/Stroke Initial Clinic Visit ........................................... 23
Secondary Prevention of TIA/Stroke Interdisciplinary Team Worksheet ................ 27
References .............................................................................................................. 31
8.0
PATIENT RESOURCES FOR SECONDARY STROKE PREVENTION....................... 32
ABC’s of Stroke Risk Reduction.............................................................................. 33
Taking Your Blood Pressure at Home .................................................................... 34
Ambulatory Blood Pressure Monitors ..................................................................... 36
Recommended Home Blood Pressure Monitors..................................................... 37
Hypertension Patient Internet Resources ............................................................... 39
Salt and High Blood Pressure ................................................................................. 40
Smoking Cessation ................................................................................................. 42
Education Resource List: Stroke and TIA ............................................................... 43
APPENDIX A – Stroke Prevention Continuum ........................................................................... 46
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We would like to acknowledge the contribution of the following groups:
Alberta Provincial Stroke Strategy Pillar 1
Pillar 1 Secondary Stroke Prevention Working Group
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1.0 INTRODUCTION
People with an ischemic stroke and a transient ischemic attack (TIA) have an increased risk of recurrent
strokes and other vascular events. Risk of stroke following TIA is high; 10-20% within 90 days. 50% of
these are within the first 2 days (48 hours)4. Recurrent strokes are more likely to result in disability and
death than initial strokes. Twenty to 40% of strokes are preceded by a TIA or non disabling stroke1.
Secondary stroke prevention is focused on this high risk population in order to prevent or delay future
disease events, achieve functional and clinical improvement, promote wellness and enhance quality of
life. Fortunately there is good evidence that we can significantly reduce the risk of future stroke by
lifestyle modification, treatment of vascular risk factors and appropriate pharmacotherapy. Early
identification, comprehensive diagnostic work-up, a case management approach and a team-based
approach to care are effective in reducing the incidence of recurrent strokes. The place of secondary
stroke prevention along the continuum of stroke prevention is described in Appendix A.
This document provides guidelines for the development of secondary stroke prevention services in each
region, appropriate referrals and flow of patients, best practice guidelines for the management of clinical,
vascular and lifestyle risk factors, and checklists for stroke prevention and patient resources.
2.0 ORGANIZING FOR SECONDARY STROKE PREVENTION
APSS Pillar 1 recommends that all regions offer stroke prevention services to individuals who are at high
risk for stroke. These individuals, whether identified in the Emergency Room or Family Physician office,
require urgent referral and assessment by an interdisciplinary team. These stroke prevention services
require a clinical physician lead with a special interest in stroke or vascular risk reduction as well as
nursing staff that are knowledgeable about stroke, risk factor management, case management, expediting
clinical investigations and patient/family education. Additional members of the team may include clinical
nutrition and rehabilitation.
RECOMMENDATION
Each region shall offer stroke prevention services to individuals at high risk for
stroke. These specialized services include assessment and short term follow-up
for optimum management of vascular risk factors. For long term follow up and
monitoring, these individuals should be referred back to their family physicians and
to other community health services, such as Chronic Disease Management
programs.
If there are insufficient TIA/stroke volumes in a region for a dedicated stroke
prevention clinic, stroke prevention services may be offered through another
appropriate specialized service within the region, such as a vascular risk reduction
clinic or other clinic (i.e., hypertension, diabetes, heart failure, other).
If regions have insufficient stroke volumes or resources for appropriate short-term
assessments and diagnostic interventions, individuals may be referred to Stroke
Prevention Services in larger regions for this component of care. Individuals may
be referred directly or receive services via telehealth. However, individuals should
receive long-term follow-up in their own regions for ongoing monitoring of vascular
risk factors, lifestyle counseling and compliance.
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Education of Health Care Providers
Patients at high risk for stroke are often detected in the family physician’s office or the emergency room.
Detection, referral and aggressive management of high risk patients are essential to prevent stroke or
recurrent stroke.
RECOMMENDATION
It is recommended that regions initiate education strategies to educate
regional / local primary physician groups and emergency physicians about
secondary stroke prevention practices and appropriate referral to stroke
prevention services.
The Secondary Stroke Prevention Patient Flow diagram (Section 3) describes the components of care
and flow for individuals at high risk of recurrent stroke. These services include assessment and short
term follow-up until the individuals’ risk factors are optimized. Individuals should be referred back to their
family physicians and to other community health services, such as Chronic Disease Management
programs, to ensure on-going management, surveillance and follow-up is undertaken. Family physicians
shall be kept informed of the patient’s progress and condition while attending the stroke prevention
services.
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3.0 SECONDARY STROKE PREVENTION - PATIENT FLOW
Patient presents with TIA or
Minor Stroke Event (see
Minor Stroke/TIA Algorithm)
Assess TIA Stroke Risk
NO
YES
Secondary Stroke Prevention Services
(Stroke Prevention Clinic, Cardiovascular
Risk Reduction Clinic)
Diagnostics
CT Scan of head
Carotid Investigations
Carotid Ultrasound
or CT Angiogram
ECG / Echocardiography / Holter
Case Management for:
Accelerated revascularization
Intensive management
Intensive lifestyle education and intervention
Monitoring of effectiveness of Rx and ongoing
follow-up (home health region vascular
clinic or FP)
Social Determinants Impacting Compliance
Links to:
Specialized Services for
Complex Patients (Diabetes,
Renal, Cardiology etc)
Outpatient Rehabilitation
Nutrition
Chronic Disease Management
Community programs
Ongoing Management by:
Family Physician
Primary Care Network
Chronic Disease Management
Program
Pharmacological Monitoring/
Intervention
Lifestyle
Social Determinants Impacting
Compliance
Carotid Revascularization
Procedure < 2 weeks
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4.0 MINOR STROKE / TIA ALGORITHM
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5.0 STROKE RISK
Approximately 20-40% of strokes are preceded by a Transient Ischemic Attack (TIA) or a non-disabling
stroke1. This identifies a window of opportunity for health care providers to institute risk reduction
strategies and evidence-based recommendations following a TIA or a minor stroke in order to prevent a
second event. In the past, there have been delays and a lack of immediate access to stroke prevention
clinics resulting in prolonged implementation of existing preventive strategies. Growing evidence
suggests that rapid assessment and early treatment following a TIA may dramatically reduce the risk of a
subsequent stroke2,3.
After a TIA, the 90-day risk of stroke is approximately 10-20% with half of these strokes occurring within
the first 48 hours4. Implementation of early secondary stroke prevention strategies is essential.
Components of Secondary Stroke Prevention
The approach to secondary stroke prevention is dependent upon the underlying cause, or mechanism, of
the initial event and existing stroke risk factors. Secondary stroke prevention services should include
prompt access to the following four components of secondary stroke prevention: evaluation of the event,
implementation of interventions, initiation of medications, and modification of stroke risk factors.
5.1 EVALUATION OF THE EVENT
Stroke Risk Assessment (Triage of TIA)
Not all patients diagnosed with TIA are at risk of early stroke. Some TIA patients have a significantly
higher stroke risk than others. The ability to identify those individuals at high risk of subsequent stroke is
of utmost importance. Recent studies suggest that early risk of stroke after a TIA can be predicted by
using a scoring system based on clinical features. A unified ABCD2 Score was recently validated by
Johnston, Rothwell, and colleagues demonstrating it to be highly predictive of stroke risk.
ABCD2 SCORING CHART
Yes
1
1
No
0
0
2
0
1
0
Duration
> 10 min < 59 min
≥ 60 min
1
2
0
0
Diabetes
1
0
Age ≥ 60 yrs
≥ 140/90
BP
Clinical Features
•
Unilateral weakness
(with or without speech disturbance)
• Speech deficit without weakness
Score ≥ 4 = High Risk
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Brain imaging is also useful in predicting the prognosis of TIA patients although sensitivity of detecting
acute infarction on brain CT is low. If infarction is seen, this is associated with a high risk of stroke
recurrence and reduced survival. One study identified 10% of TIA patients without an acute infarct on CT
experienced a stroke within 90 days. In contrast, if a new infarct was identified on CT, 38% of patients
experienced a stroke7.
Diffusion weighted imaging (DWI) may be more sensitive in detecting infarction than CT. It has been
noted that 40-60% of TIA patients have evidence of ischemic injury on DWI. If a DWI lesion is evident
with a TIA, there is a higher risk of subsequent stroke. The 90-day risk of stroke is 4.3% without ischemia
on DWI and 10.8% with ischemia on DWI among patients with minor stroke and TIA.8,9,10.
Presence of DWI lesions and their association with clinical predictors of early stroke risk after a TIA was
published in May 2005. This study describes several clinical characteristics to be associated with proven
prognostic significance associated with DWI lesions after the TIA.
Factors predicting positive DWI lesions are as follows:
•
Symptoms lasting > 1 hour
•
Motor deficits
• Aphasia
If there is no access to MRI, or a MRI has not been completed, stroke risk may still be assessed utilizing
these predictive clinical features.
The recommended risk assessment tool described below considers the ABCD2 score, time from stroke
symptom onset and the predictive clinical features described.
TIA STROKE RISK ASSESSMENT
HIGH RISK:
• Symptom onset within the last 48 hours with any one of the following:
9 Motor deficit lasting more than 5 minutes
9 Speech deficit lasting more than 5 minutes
9 ABCD2 score > 4
• Atrial fibrillation with TIA
MEDIUM RISK:
• Symptom onset between 48 hrs and 7 days with any one of the following:
9 Motor deficit lasting more than 5 minutes
9 Speech deficit lasting more than 5 minutes
9 ABCD2 score > 4
LOW RISK:
• Symptom onset > 7 days
• Symptom onset < 7 days without the presence of high risk symptoms (speech deficit or motor
deficit or ABCD2 score > 4 or atrial fibrillation with TIA )
Note: Isolated syncope or dizziness is rarely a TIA and may not require Stroke Prevention Clinic
referral
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Investigations
Once “stroke risk” is identified, the following investigations should be completed in order to determine the
cause, or mechanism, of the event.
Investigations:
o
o
o
o
o
o
CT scan of head
Carotid investigations: carotid ultrasound or CT angiogram
ECG: if atrial fibrillation strongly consider anticoagulation
Echocardiogram: only if suspicion of cardiac cause
Holter Monitor: if suspect atrial fibrillation
CBC, electrolytes, creatinine, glucose, PTT, INR, fasting glucose and lipid profile
All suspected TIA patients should receive a CT scan of the head as soon as possible. Due to limited
access and availability of some diagnostic services, the urgency of investigations has been identified
according to stroke risk.
HIGH RISK: Contact TIA HOTLINE: 1-888-282-4825 (Northern Alberta, including Red Deer)
1-800-661-1700 (South of Red Deer)
Complete investigations within 24 hours
*May require referral to Primary or Comprehensive Stroke Centre to ensure timely completion of
investigations
Stroke Prevention Clinic Referral (seen within 24 hours)
MEDIUM RISK: Complete investigations within 3 days
Stroke Prevention Clinic Referral (seen within 3 days)
LOW RISK: Complete investigations within 2 weeks
Stroke Prevention Clinic Referral (seen within 2 weeks)
5.2 IMPLEMENTATION OF INTERVENTIONS
Carotid Endarterectomy
Carotid artery disease detected following carotid imaging is related to high risk of early stroke after TIA5.
Carotid endarterectomy performed within 2 weeks of the event for patients with TIA and >50 %
symptomatic carotid stenosis has been shown to significantly decrease the occurrence of second strokes.
Evidence exists that this benefit declines rapidly with delay in surgery6.
Patients with symptomatic carotid disease should be offered carotid intervention within 2 weeks of their
event.
5.3 INITIATION OF MEDICATIONS
Antithrombotic Therapy
Thrombotic mechanisms are present in ischemic strokes and TIA’s. Anti-thrombotic therapy is the only
treatment which immediately reduces stroke risk.
All patients with ischemic strokes or TIA’s should be on anti-platelet therapy for secondary stroke
prevention unless there is an indication for anti-coagulation.
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Anti-platelet therapy should be initiated as soon as possible. If unable to complete a CT scan prior to
initiation of anti-platelet therapy, only aspirin should be administered at the following dose. Once a CT
scan is completed and evaluated, other anti-platelet agents may be used.
The following is recommended:
Aspirin 160 - 325 mg (immediately loading dose) then 81 mg once daily
Other options:
-
Aspirin /extended release dipyridamole (Aggrenox)
o 25mg/200 mg BID
Clopidogrel (Plavix)
o 300 mg (immediate loading dose) then 75 mg once daily
If a cardioembolic source is suspected, long-term anti-coagulation with adjusted dose Warfarin (Target
INR 2.5: range 2.0-3.0) is recommended.
Additional medications are also recommended such as:
- anti-hypertensive medications if BP>140/90 mmHg
- Statins to achieve target LDL of less than 2.0 mmol/L
These are described further in Section 6.0 Best Practice Guidelines for Secondary Stroke Prevention.
5.4 MODIFICATION OF STROKE RISK FACTORS
Modifiable stroke risk factors and lifestyle behaviors should be evaluated and addressed when providing
secondary stroke prevention services. These include:
1.
2.
3.
4.
5.
6.
7.
8.
Hypertension
Diabetes
Dyslipidemia
Cardiac Disease
ƒ Atrial fibrillation
ƒ Coronary Artery Disease
Smoking
Alcohol consumption and drug use
Obesity
Physical inactivity
Section 6.0 provides Best Practice Guidelines for management of these common risk factors for stroke.
These guidelines are targeted to health care providers in the primary care setting and secondary stroke
prevention clinic/services.
References
1. Rothwell PM, Buchan A, Johnston SC. Recent advances in management of transient ischaemic
attacks and minor ischaemic stroke. Lancet Neurol 2006; 5:323-31
2. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic
attack and minor stroke on early recurrent stroke (EXPRESS study): a Prospective population –based
sequential comparison study. Lancet 2007; 370:1432-1442
3. Amarenco P, et al. A TIA clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet
Neurol 2007;6:953-60
4. Johnston SC, Gress DR, Browner WS, Sidnet S. Short term prognosis after emergency department
diagnosis of TIA. JAMA 2000; 284:2901-06
5. Eliasziw M, Kennedy J, et al. Early risk of stroke after a TIA in patients with internal carotid artery
disease. CMAJ. 2004; 170(7): 1105-9
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6. Rothwell PM, Eliasziw M, et al. Sex difference in the effect of time from symptom to surgery on
benefit from carotid endarterectomy for transient ischemic attack and non-disabling stroke. Stroke
2004; 35:2855-2861
7. Douglas et al. Head Computed Tomography Findings Predict Short-Term Stroke Risk after Transient
Ischemic Attack. Stroke 2003; 34: 2894-2898
8. Kidwell C et al. Diffusion MRI in patients with Transient Ischemic Attack. Stroke 1999; 6:1174-1180
9. Coutts SB et al. Triaging TIA and minor stroke patients using acute magnetic resonance imaging.
Annals of Neurology 2005;57:848-854
10. Krol A et al. Perfusion MRI Abnormalities in Speech or Motor Transient Ischemic Attack Patients.
Stroke 2005
6.0 BEST PRACTICE GUIDELINES FOR SECONDARY STROKE PREVENTION
6.1 DEVELOPMENT PROCESS
The Alberta Provincial Stroke Strategy (APSS) consists of stakeholders, partners and stroke care
specialists with a goal to improve the prevention and management of stroke throughout Alberta. This
is a progressive program which will ensure that present and future advances in stroke care are
integrated across all regions in this province. The strategy is founded upon the following four key
pillars of stroke care:
•
•
•
•
Pillar 1:
Pillar 2:
Pillar 3:
Pillar 4:
Stroke Prevention and Health Promotion
Acute Stroke Care
Stroke Rehabilitation and Community Integration
Network Evaluation and Quality Improvement
A sub-committee of Pillar I, the ‘Secondary Stroke Prevention Working Group’, was established to
articulate “Best Practice Guidelines for Secondary Prevention”. The goal of this working group is to
review, synthesize, and recommend best practices in secondary stroke prevention and assist with the
implementation of the evidence-based guidelines into clinical practice.
The best practices/action plans for managing risk factors for stroke are based on Canadian Stroke
Strategy Best Practice Guidelines and other accepted standards of practice. Canadian Stroke
Strategy (CSS) Best Practices recommendations document is now complete for 2008 and has been
posted on the CSS Website at: www.canadianstrokestrategy.ca. These best practice guidelines are
endorsed by APSS Pillar 1 – Health Promotion and Disease Prevention. The methodology for the
development of these standards is available on the web-site. The standards are a result of an
extensive review of the national and international evidence-based stroke best practices in stroke
prevention and management. Canadian targets and guidelines are referenced for the management
of blood pressure, dyslipidemia and diabetes.
Definitions of classes and levels of evidence used in these guidelines are described below:
• Class I - Conditions for which there is evidence for and/or general agreement that the procedure or
treatment is useful and effective.
• Class II – Conditions for which there is conflicting evidence and/or a divergence of opinion about
the usefulness/efficacy of a procedure or treatment.
o Class IIa – Weight of evidence or opinion is in favor of the procedure or treatment.
o Class IIb – Usefulness/efficacy is less well established by evidence or opinion.
• Class III – Conditions for which there is evidence and/or general agreement that the procedure or
treatment is not useful / effective and in some cases may be harmful.
• Level of Evidence A – Data derived from multiple randomized clinical trials
• Level of Evidence B – Data derived from a single randomized trial or nonrandomized studies
• Level of Evidence C – Expert opinion or case studies
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6.2 GENERAL PRACTICE GUIDELINES FOR STROKE PREVENTION
Patients with a prior stroke / transient ischemic attack (TIA) are at risk for a subsequent stroke or
other vascular event.
1. All individuals who are at high risk for stroke and all patients with prior stroke/TIA should be
assessed for and given information about vascular risk factors, lifestyle management issues (diet,
sodium intake, weight, smoking, alcohol, exercise, stress management) and be counseled about
possible strategies to modify their lifestyle and risk factors. 2
* Although evidence is not clear regarding the direct impact of stress on stroke risk, stress
management does have an effect on reducing hypertension.
2. Stroke or TIA patients, family members, and health care providers should be educated about
stroke prevention, given relevant information resources and how to gain access to them. 1
3. Patients should be referred to community services and Chronic Disease Management Programs
as required.
6.3 RECOMMENDATIONS BY STROKE TYPE
Antithrombotic Therapy for Noncardioembolic Stroke or TIA
1. All patients with ischemic stroke or TIA should be prescribed antiplatelet therapy for secondary
prevention of recurrent stroke unless there is an indication for anticoagulation.2 (Evidence Level
A)
2. Aspirin (50 to 325 mg/day) monotherapy, the combination of aspirin (25mg) and extended-release
dipyridamole (200mg) (Aggrenox), or clopidogrel (Plavix) monotherapy are all acceptable options
for initial therapy.2,7 (Evidence Level A / I)
3. For patients with noncardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral
anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular
events.7 (Evidence Level A / I)
4. Long-term combinations of aspirin and clopidogrel are not recommended for secondary stroke
prevention.2 (Evidence Level A)
5. For patients who have an ischemic cerebrovascular event while taking aspirin, there is no
evidence that increasing the dose of aspirin provides additional benefit. Although alternative
antiplatelet agents are often considered for noncardioembolic patients, no single agent or
combination has been well studied in patients who have had an event while receiving aspirin.3
(Evidence Level B / II)
6.
The addition of aspirin to clopidogrel increases the risk of hemorrhage. Combination therapy of
aspirin and clopidogrel is not routinely recommended for ischemic stroke or TIA patients unless
they have a specific indication for this therapy (ie, coronary stent or scute coronary syndrome). 7
Patients with Cardioembolic Stroke or TIA
Atrial Fibrillation
1. For patients with ischemic stroke or TIA and persistent or paroxysmal (Intermittent) atrial
fibrillation, anticoagulation with adjusted-dose warfarin (target INR 2.5; range, 2.0-3.0) is
recommended unless contraindicated.2,3 (Evidence Level A / I)
2. In patients unable to take oral anticoagulants, aspirin 81- 325 mg/day is recommended.3,10
(Evidence Level A / I)
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Prosthetic Heart Valves
1. For patients with ischemic stroke or TIA who have modern mechanical prosthetic heart valves,
oral anticoagulants are recommended, with an INR target of 3.0 (range, 2.5-3.5).2,3 (Evidence
Level B / I)
Other causes of cardioembolic strokes can exist (ie. Cardiomyopathy, valvular heart disease, PFO).
For detailed management consult an available expert in this area.
Interventional Approaches to Patients with Stroke or TIA Caused by Large-Artery
Atherosclerotic Disease
Extracranial Carotid Artery Disease
1. Patients with TIA or nondisabling stroke and ipsilateral 70% - 99% internal carotid artery stenosis
(measured on a catheter angiogram by 2 concordant non-invasive imaging modalities) should be
offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke
2
unless contraindicated). (Evidence Level A)
2. Carotid endarterectomy is recommended for selected patients with moderate (50 to 69%)
symptomatic stenosis. These patients should be evaluated by a physician with expertise in
stroke management. 2 (Evidence Level A).
3. Carotid stenting may be considered for patients who are not operative candidates for technical,
anatomical or medical reasons. 2(Evidence Level C)
4. Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity
and mortality of <6%.2 (Evidence Level A)
5. Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis. (Evidence Level
A)
6. Asymptomatic carotid stenosis should be referred to a specialized stroke prevention clinic. Risk
factors should be aggressively managed.
6.4 RECOMMENDATIONS BY TREATABLE VASCULAR RISK FACTORS
Hypertension
1. Antihypertensive treatment is recommended for both prevention of recurrent stroke and
prevention of other vascular events in persons who have had an ischemic stroke or TIA and are
beyond the hyperacute period.2,3
(Evidence Level A / I)
2. Blood pressure lowering treatment is recommended for patients who have had a stroke or
transient ischemic attack to a target of less than 140/90 mm Hg (135/85 mm Hg for home or
ambulatory measurements).2 (Evidence Level C)
3. In patients who have had a stroke, treatment with an angiotensin-converting enzyme (ACE)
inhibitor/diuretic combination is preferred. The choice of blood pressure lowering agent and the
target blood pressure will also depend upon other associated comorbidities (eg coronary artery
disease, congestive heart failure, renal impairment, diabetes etc.). 2,3 (Evidence Level B / I)
Please refer to Canadian Hypertension Education Program (CHEP) guidelines for the appropriate
measuring, frequency of blood pressure measurement and recommendations on specific agents.
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4. Several lifestyle modifications have been associated with blood pressure reductions. Patients with
hypertension or at risk for hypertension should be advised of lifestyle modifications.2,3 (Evidence
Level C / II)
Please refer to the Resource List for additional information.
Diabetes
1. Rigorous blood pressure control should be considered in patients with diabetes. (Evidence Level
B / II) The recommended target blood pressure in these individuals should be < 130/80 mm Hg.
Although all major classes of antihypertensives are suitable for blood pressure control, ACE
inhibitors and angiotensin receptor blockers (ARBs) are more effective in reducing the
progression of renal disease and are recommended as first-choice medications for diabetic
patients with established renal disease. In this group most patients will require more than one
3
agent to achieve the target blood pressure.
(Evidence Level A / I)
2. Glycemic targets must be individualized; however, therapy in most patients with type 1 or type 2
diabetes should be targeted to achieve a glycolated hemoglobin (HbAlc) level < 7.0% in order to
reduce the risk of microvascular complications. 3 (Evidence Level A / I)
According to the Canadian Diabetes Association, the target blood sugar is 4.0 to –7.0 mmol/L fasting
and 5.0 to 10.0 mmol/L 2 hours after meals. Target HB A1C ≤ 7.0%.2 (Evidence Level B / II)
Refer to the Canadian Diabetes Association (CDA) guidelines for frequency of monitoring
(www.diabetes.ca)
Cholesterol
1. Ischemic stroke or TIA patients with LDL-C of >2.0 mmol/L, should be managed with lifestyle
modification and dietary guidelines. 2 (Evidence Level A)
2. Administration of statin therapy with intensive lipid-lowering effects is recommended for patients
with atherosclerotic ischemic stroke or TIA to reduce the risk of stroke and cardiovascular events.
Target goal of an LDL-C of <2.0 mmol/L and TC/HCL-C <4.0 mmol/L 2 (Evidence Level A / I ) 2,7.
Refer to resource list for additional information
3. Statins are the first line agents to achieve the target cholesterol levels. Ezetimibe should be
considered in patients who are intolerant to statin therapy.
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6.5 RECOMMENDATIONS BY MODIFIABLE BEHAVIOURAL RISK FACTORS
Diet
1. A healthy balanced diet is a diet high in fresh fruits, vegetables, low-fat dairy products, dietary
and soluble fibre, whole grains and protein from plant sources and low in saturated fat,
cholesterol and sodium in accordance with Canada’s Food Guide to Health Eating. 3 (Evidence
Level B / I)
Sodium
1. The recommended daily sodium intake from all sources is the Adequate Intake by age. For
persons 9-50 years, the Adequate Intake is 1500 mg. Adequate Intake decreases to 1300 mg for
persons 50-70 years and to 1200 mg for person > 70 years. A daily upper consumption limit of
2300 mg should not be exceeded by any age group.3 (Evidence Level B / I)
Smoking
1. All ischemic stroke or TIA patients who have smoked in the past year should be strongly
encouraged not to smoke.3 (Evidence Level C / I)
2. Interventions to promote smoking cessation may include nicotine replacement therapy and
behavioral therapy. 2 (Evidence Level B / II)
Alcohol
1. Patients with prior ischemic stroke or TIA who are heavy drinkers should eliminate or reduce their
consumption of alcohol.3 (Evidence Level A / I)
(a) A safe level may consist of:
•
1-2 drinks per day
Men: less than 14 drinks per week; Women: less than 9 drinks per week2 (Evidence Level
C / III)
(b) For some people, 2 drinks may be considered too much (eg. Low body weight or elderly).
One standard drink is equivalent to:
•
•
1 bottle (350 ml) of beer (5% alcohol)
•
5 oz. (150 ml) of wine (12% alcohol)
• 1 1/2 oz. (50 ml) of liquor (40% alcohol)
(www.heartandstroke.ca)
For more information on alcohol with diabetes, please refer to the following website:
www.diabetes.ca/files/CDAAlcoholFinal.pdf
Obesity
1. Weight reduction should be advised for all overweight ischemic stroke or TIA patients to maintain
the goal of a BMI of 18.5 to 24.9 kg/m2 and a waist circumference of < 88 cm for women and <
102 cm for men. 2,4 (Evidence Level B / II). Clinicians should encourage weight management
through an appropriate balance of caloric intake, physical activity, and behavioral counseling.3
(Evidence Level C / II)
2. A diet that is low in fat (especially saturated fat) and sodium, and high in fruit and vegetables is
recommended.2 (Evidence Level II/B)
Please refer to the National Obesity Guidelines:
(www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm)
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Physical Activity
1. For those with ischemic stroke or TIA who are capable of engaging in physical activity, an
accumulation of 30 to 60 minutes of moderate-intensity physical exercise (ie. brisk walking,
jogging, cycling or other dynamic exercise) 4 to 7 days each week should be advised to reduce
risk factors and comorbid conditions that increase the likelihood or recurrence of stroke. For
those with disability after ischemic stroke, a supervised therapeutic exercise regimen is
recommended.2,3 (Evidence Level C / II)
Hyperhomocysteinemia
1. For patients with ischemic stroke or TIA and hyperhomocysteinemia, daily standard multivitamin
preparations are reasonable to reduce the level of homocysteine. There is no evidence that
reducing homocysteine levels will lead to a reduction of stroke occurrence.3 (Evidence Level A / I)
6.6 REFERENCES
1. Heart and Stroke Foundation of Ontario. Best practice guidelines for stroke care: A resource for
implementing optimal stroke care: 2003. Available at:
http://209.5.25.171/Page.asp?PageID=399&SubcategoryID=110&CategoryID=7
2. Canadian Stroke Strategy Best Practices and Standards. Canadian Best Practice
Recommendations for Stroke Care: 2008. Canadian Stroke Strategy Best Practices and
Standards Working Group. December 2008. Available at: http://canadianstrokestrategy.ca
3. Sacco et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient
ischemic attack: A statement for healthcare professionals from the American Heart Association /
American Stroke Association council on stroke. American Heart Association, 2006. Available at:
http://stroke.ahajournals.org/cgi/content/full/37/2/577
4. Canadian Hypertension Education Program. Canadian hypertension education program
recommendations: 2008. Available at:
http://www.stacommunications.com/journals/cardiology/2005/January/PDF/030.pdf
5. Canadian Diabetes Association. Canadian diabetes association guidelines. Available at:
http://www.diabetes.ca
6. Heart and Stroke Foundation of Canada. Available at: http://www.heartandstroke.ca
7. Adams et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients
with stroke and transient ischemic attack. Stroke, 2008, 39; 1647-1652. Available at:
http://stroke.ahajournals.org/cgi/content/full/39/5/1647
8. Diener et al. Rational, design and baseline data of a randomized, double-blind, controlled trial
comparing two antithrombotic rejimens (a fixed-dose combination of extended-release
dipyridamol plus ASA with clopidogrel) and telmisartin versus placebo on patients with strokes:
The prevention regimen for effectively avoiding second strokes trial (PRoFESS). Cerebrovasc
Dis, 2007; 23: 368-380.
9. Fuster et al. Circulation ACC/AHA/ESC 2006 Guidelines for the Management of Patients with
Atrial Fibrillation; Circulation 2006;114;257-354.
10. Amarenco et al. High-Dose Atorvastatin after Stroke of Transient Ischemic Attack. N Engl J Med
2006;355:549-559.
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7.0 SECONDARY STROKE PREVENTION CLINIC RESOURCES
Minor Stroke / TIA Stroke Risk Assessment Pocket Card
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Stroke Prevention Clinic RN Required Knowledge and Skills
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Identification of High Risk, Medium Risk and Low Risk stroke/TIA patients from referrals
o Triage care appropriately
Basic neurological assessment
Basic CPR competence
NIHSS (National Institute of Health Stroke Scale) Assessment
o Assess stroke/TIA signs and symptoms
o Identify worsening of symptoms and communicate this to Physician
Carotid artery assessment
o Auscultation and identification of carotid bruit(s)
Assessment of Body Mass Index (BMI)
o Identify healthy/unhealthy values
Assessment of hip/waist ratio (Hip/Waist Circumference)
o Identify healthy/unhealthy values
Knowledge of normal and abnormal blood/lab evaluations and the requirement for continued
monitoring
o Screen blood/lab values and implement appropriate actions for abnormal results
Knowledge of current guidelines for identification and management of the following:
o hypertension, diabetes and dyslipidemia
Hypertension assessment strategies
o Blood pressure monitoring techniques (i.e. home blood pressure monitoring)
o 24 hour ambulatory blood pressure monitor application, data retrieval and patient education
Identify factors contributing to increased stroke risk
Knowledge of risk factor modification strategies, medications used for treatment/prevention of stroke,
diagnostic tests and treatment interventions
Assessment of patient learning needs and educational requirements
Provide patient education related to:
o Pathophysiology of stroke/TIA
o Signs and symptoms of stroke/TIA
o Diagnostic tests and possible treatment interventions
o CT (CTA), MR (MRA), Carotid Doppler Ultrasound, Transcranial doppler (TCD), Holter
monitor, Echocardiogram (TTE, TEE), Carotid endarterectomy.
o Medications used for treatment/prevention of stroke and stroke risk factors (indications, actions,
administration)
o Antiplatelets/anticoagulants, antihypertensives (ie. ACE-I, ARB, diuretics) statins, hypoglycemic
agents, etc.)
o Stroke Risk factor identification and recommended lifestyle modification
o Hypertension management strategies, diet, exercise, stress management, smoking cessation
strategies, diabetes management, hypercholesterolemia management
Organizes, coordinates and arranges referral to, or consultation with, appropriate healthcare
professionals, hospital or community programs:
o Neurologist, vascular surgeon
o Chronic Disease Management Programs
o Healthy lifestyle programs/classes, dietician, diabetes and lipid programs, AADAC smokers help
line, etc.
Provide telephone consultation and appropriate referral as required.
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SECONDARY STROKE PREVENTION OF TIA / STROKE ASSESSMENT AND FOLLOW-UP
CHECKLISTS
The following checklists are for use in stroke prevention clinic or service to ensure that the appropriate
assessments and interventions are implemented. These checklists incorporate what is known about best
practice for high risk patients and is intended to standardize and unify practice across the province.
While health facilities may adopt their own forms and add additional elements, all of the following
checklist components should be incorporated in practice in stroke prevention services. Certain
elements will also be required for evaluation purposes.
Family physicians, Chronic Disease Management program and Primary Care Networks involved in longer
term follow-up of TIA and post-stroke patients are encouraged to use these resources as well.
Initial Clinic Visit Checklist
This checklist is an interdisciplinary form designed for use in Secondary Stroke Prevention Clinics or
vascular risk reduction clinics and should be completed at the first visit. The form summarizes the
patient’s clinical history, social and family history, clinical and investigational findings and current vascular
risk factors. The results are intended to inform the development of an Action Plan for the patient to
address risk factors.
Interdisciplinary Team Follow-up Worksheet
The Interdisciplinary Team Follow-up Worksheet is intended for use at follow-up visits and as a teaching
tool for patients. The checklist describes the patients’ risk factors, goals and action plans and written
progress towards targets and goals. While targeted to the TIA/Stroke patient the form is holistic and
incorporates risk factors for many chronic conditions. As a result, this checklist would be appropriate for
use in family physicians offices, chronic disease management programs and other vascular risk reduction
clinics. Electronic versions of the form could automatically link the patient/health care provider to
resources (eg. DASH diet), and patient education websites. Individuals who are actively engaged in the
care process and involved in goal setting are more likely to comply with care plans. Copies of the
worksheet should be available to all individuals so they can document and monitor their own progress
towards health goals. The form can be used as a communication tool for others involved in the patients
care such as family physician, home care, and community care.
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SECONDARY PREVENTION OF TIA/STROKE
INITIAL CLINIC VISIT
Clinic Appointment Date: _______________________________
Name: _________________________________ DOB: _____/____/____
Male
Female
PHN: _______________________________
Referred from:
Doctor’s office
Emergency Department
In-patient
Specify site: _________________________________________________________________________
Referring health care provider: ____________________
Family MD: ___________________________
Referral Diagnosis: __________________________________________________________________
STROKE HISTORY
Past stroke syndrome history: No
Stroke
TIA
Possible stroke/TIA
Date of most recent event: _____________________________
Stroke
Non-specific
TIA
Presenting signs & symptoms as described by patient:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PAST MEDICAL HISTORY
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
MEDICATION HISTORY/ALLERGIES
Allergies:
No
Yes
If yes, specify:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Currently taking/prescribed:
Antiplatelet agent
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Antihypertensive agent
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Current Medications
Dosage
Frequency
Current Medications
Dosage
Frequency
FAMILY HISTORY:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SOCIAL & FUNCTIONAL HISTORY:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Home environment (Type of dwelling): _____________________________________________________
Lives:
Alone
With spouse/partner
With family
Assisted living
Nursing home/LTC
Occupation: ______________________________________________ Retired
Able to drive: No
Yes
Comments: ______________________________________________
ADLs: Performs own care independently (bathing, shaving, dressing etc)
Requires assistance
Identify needs:
____________________________________________________________________________________
____________________________________________________________________________________
Mobility: Independent (without aid)
Cane
Walker
Wheelchair
Caregiver: ____________________________________________________________________
PHYSICAL EXAM:
Blood Pressure:
Pulse:
Respirations:
Height:
Weight:
BMI:
Waist Circumference:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
______________________________________________________________________________
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INVESTIGATIONS:
Investigation
Not
Done
Not
Required
Date
Requested
Date
completed
Results/Comments
CBC
Lytes/BUN
Creatinine
PT INR
Fasting lipids
Fasting
homocysteine
Fasting blood
glucose
Glycosylated
hemoglobin A1C
ECG
Carotid Doppler
Echocardiogram
CT head
MRI
MRA
Angiogram
Holter/event
monitor
Other:
IMPRESSION /DIAGNOSIS:
TIA
STROKE
OTHER
Specify:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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IDENTIFIED VASCULAR RISK FACTORS:
Please check off all applicable risk factors and corresponding target or indicate if already at target.
Hypertension
Diabetes mellitus
Type I
Type II
Dyslipidemia
Overweight
Waist circumference
Previous Stroke or TIA
Carotid Artery Disease
Coronary Artery Disease
Atrial fibrillation
Peripheral Artery Disease
Smoker
Alcohol
Inactivity
Target:
Target:
BP < 140/90 or
< 130/80
FBS (4-7)
A1C (< 7)
Target:
LDL (< 2.0) Tc/HDL (< 4)
Target: Body Mass Index (BMI) 18.5-24.9 kg/m2
Target:
Female (< 88cm) Male (<102cm)
At target
At target
At target
At target
At target
Degree of Stenosis:
Target:
Target:
Alcohol consumption ≤ 1-2 drinks/day
Active at least 30 min 4 days / week
At target
At target
ACTION PLAN: (Refer to Multidisciplinary Team Worksheet for more detailed action plan)
Education regarding lifestyle modifications
Diet Exercise Weight Smoking
Education regarding medication compliance
Instruction re: home BP monitoring where applicable
Identify patient targets and provide appropriate education
Referrals made:
Vascular Surgeon
Date of appointment __________________
Other:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
New medications: Antiplatelet agent Statin
(Identify all new prescriptions given)
Antihypertensive agent
New investigations (specify):
Follow up required (specify):
Consider referring to chronic disease management programs
Consider referring to outpatient rehabilitation services
Signature: _________________________________________________________
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SECONDARY PREVENTION OF TIA/STROKE
INTERDISCIPLINARY TEAM WORKSHEET
ASSESSMENT
VISIT DATE:
CURRENT MEDICATIONS:
Allergies: No
GOAL/ACTION PLAN
Yes
If yes, specify:
Aspirin
Plavix
Aggrenox
Warfarin
RISK FACTORS:
Height: __________cm Weight ___________kg
BMI ____________ (target 18.5-24.9kg/m2)
Waist circumference ____________ cm
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Compliance:
Excellent (takes meds 99% of time)
Good (misses a dose weekly)
Poor (misses 2 or more doses of 1 or more
meds weekly)
Uncertain
Not currently taking pills
What factors would make it easier for you to take
your medications (meds) regularly?
Not applicable
Finances
Education
Other (specify):
Other:
Currently on special diet (i.e. CDA) No
Specify:
COMMENTS
Yes
Goal:
Take meds regularly
and as prescribed
Understands why is
taking meds
Action plan:
Review meds &
rationale
Ensure patient has
current list of meds
Dosette/bubble pack
Other:
Goal:
BMI (18.5-24.9kg/m2)
Action plan:
Set weight loss goal
Canada Food Guide
Dash diet
Refer to nutrition
classes
Refer to dietician
Waist circumference
< 88cm (female)
< 102cm (male)
Regular exercise
Other:
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Hypertension (Target < 140/90): No
(3 readings 2 minutes apart)
Yes
BP #1 _______ BP #2 ________
Goal:
Maintain BP <140/90
If diabetic, maintain
BP < 130/80
Action plan:
Review home BP
monitoring
Review “Taking Your
Blood Pressure at
Home”
Consider 24 hr BP
monitoring
Education on
medication compliance
Goal:
Maintain LDL < 2.0
Maintain Tc/HDL < 4
Action plan:
Healthy eating info
Refer to dietician
Initiate medication
Goal:
Maintain fasting blood
glucose and A1C within
target
Action plan:
Weight reduction
Regular exercise
BP #3 _________ Standing __________
Home monitoring: No
Yes
Results:
Dyslipidemia (Target LDL < 2.5 Tc/HDL < 4):
No
Yes
LDL _________ Tc/HDL ______________
Remarks:
Diabetes Mellitus: No
Type 1 Type 2
Yes
Home monitoring: No Yes
Results:
___________________________________
Fasting Blood Glucose (target 4-7) _____________
Glycosylated hemoglobin A1C (target < 7) _______
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Pamphlets re:
diabetes
Home blood sugar
monitoring
Refer to Diabetes
education program
Initiate medication
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Atrial Fibrillation: No
New
Chronic
Yes
Paroxysmal
Unknown
Warfarin (INR 2-3) No Yes
Other: __________________________
Cardiac History: No
Chest pain: No
Goal:
Minimize risk of
cardioembolic event in
the presence of atrial
fibrillation
Yes
Yes
At rest
On exertion
Carotid Artery Disease:
Action plan:
Referral for
endarterectomy where
appropriate
Degree of stenosis: L _________ R _________
Peripheral Artery Disease: No
Intermittent claudication No
Yes
Yes
Smoking (cigarette/chewing tobacco): Never
Quit
Date: __________
Yes
Amount/day: __________________
Goal:
To be smoke free
within _____ months
Limit exposure to
second hand smoke
Other:
# of pack years: ____________
Alcohol:
Never
Rare/never
Limit alcohol
consumption to 1-2
drinks/day
Yes
< 2 drinks/day
> 2 drinks/day
Drug use (amphetamine/cocaine): No
Exercise: No
Action plan:
Education re: Warfarin
& routine INR checks
Education re: dietary
factors that influence
INR/meds
Yes
Current activity (type/frequency):
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Yes
Eliminate drug use
Goal:
Active at least 30 min
daily
Other:
Action plan:
Quit by ___________
Smoking cessation
pamphlets
Use patch/gum/drug
assist
Refer to smoking
cessation program
Provide info regarding
AADAC programs
Other_____________
Action plan:
Activity guidelines
given
Community programs
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Mental Wellness:
If individual identifies any issues/behaviours
indicative of anxiety, stress or depression - consider
screening for depression and referring for
appropriate followup.
Goal:
Identify appropriate
strategies/resources to
help manage/eliminate
stressful issues
Action plan:
Referral to Stroke
Recovery Association
Local support groups
Social worker
Refer to community
mental health
Functional status:
Home environment (Type of dwelling): __________________________
Lives:
Alone
Able to drive: No
With spouse/partner
Yes
With family
Assisted living
Nursing home/LTC
ADLs: Performs own care independently (bathing, shaving, dressing etc)
Mobility: Independent (without aid)
Cane
Walker
Requires assistance
Wheelchair
Identify Needs/Comments:
Summary & Recommendations:
Signature: ___________________________________________
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REFERENCES:
DASH diet: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
Canadian Diabetes Association: http://www.diabetes.ca
Canadian Hypertension Education Guidelines: http://www.hypertension.ca/index2.html
Canadian Stroke Strategy: http://www.canadianstrokestrategy.ca
Alberta Provincial Stroke Strategy (APSS):
Heart & Stroke Foundation: http://ww2.heartandstroke.ca
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8.0 PATIENT RESOURCES FOR SECONDARY STROKE PREVENTION
The following patient resource tools may be useful in family physician offices, stroke prevention clinics or
vascular risk reduction services, targeted for stroke.
ABCs of Stroke Risk Reduction
The ABCs of Stroke Risk Reduction is a simple tool that summarizes the key risk factors for stroke.
This may be given to patients after their first visit and can be placed in a key site (eg. fridge) as a
reminder to individuals about lifestyle behaviours.
Taking Your Blood Pressure at Home
Hypertension is the number one risk factor for stroke. Accurate, regular blood pressure readings are
important for monitoring progress and efficacy of interventions. The Taking Your Blood Pressure at
Home is a self-management tool for patients to allow them to take and monitor their own blood pressure.
It provides guidance on how to take their blood pressure, what to do if BP readings are consistently high,
and how to choose a blood pressure monitor. This information is based on 2008 Canadian Hypertension
Education Program Recommendations.
The following resources assist clinicians to educate patients regarding home blood pressure monitoring
and ambulatory blood pressure monitoring
• Instruction Tips for Teaching a Patient how to perform home Blood Pressure Monitoring
• Ambulatory Blood Pressure Monitors
Home Blood Pressure Monitors
Choosing a home blood pressure monitor can be challenging. The Home Blood Pressure Monitors
patient handout provides a description and picture of blood pressure monitors recommended by the
Canadian Hypertension Society.
Hypertension: Patient Internet Resources
Additional patient information can be accessed via the internet. This patient handout identifies suggested
web sites.
Salt and High Blood Pressure
Sodium intake has a significant impact on blood pressure. The Salt and High Blood Pressure handout
assists patients to identify sources of sodium in their diet and strategies to reduce their sodium intake.
Smoking Cessation
The Smoking Cessation handout identifies resources and strategies available to assist efforts to stop
smoking.
Health Care Provider/Patient Education Resource List
The attached is a list of education resources that are commonly used by health care providers and
patients/clients for stroke prevention and risk factor management.
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Instruction Tips for Teaching
a Patient How to Perform Home Blood Pressure (BP)
Monitoring
1. Choosing a monitor:
- give patient copy of recommended monitors handout.
- instruct patient to ask the Pharmacist to demonstrate/review the product being
purchased.
- a wrist monitor is not recommended
2. Review patient instruction sheet making use of the clinic’s home BP monitor. Fill in
target BP space (<140/90 OR if diabetes or has renal impairment then <130/80).
3. The cuff should not be placed on any clothing. It is best that a patient has a bare
arm. If that is not possible a loose short sleeve shirt will be acceptable.
4. Arm should be on a firm surface and may be supported by a pillow if necessary to
keep upper arm at heart level.
5. Preparation for BP reading
- patient should choose a comfortable chair with a straight back which is near the
table/desk that will hold the BP equipment.
- place the BP monitoring equipment and documentation record on the table/desk
- remind patient to go to the bathroom (so that quiet time will not be interrupted).
- the patient should sit quietly for at least 5 minutes. Have the patient refrain from
talking, moving or watching TV while taking a blood pressure reading (moving
and talking can affect the reading).
6. Documentation
- show patient how and where to record the readings.
- recording options:
a) show the patient how to record on the instruction sheet.
b) if the patient brings in their own BP machine, use the booklet that comes with it.
c) if using the Stroke Survivors Companion booklet, turn to page 108.
7. BP should be taken everyday (no exceptions). If possible, BP should be taken first
thing in the morning before medications. Same time everyday (within 30 min).
8. If the BP is elevated for 3-4 readings at anytime within a seven day period, the
patient should see his/her family physician. Remind the patient to bring along the BP
record and the home BP monitor.
Remind the patient
that home
BP monitoring
is not a substitute for
Ambulatory
Blood
Pressure Monitors
seeing their health care provider for follow-up care.
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Ambulatory Blood Pressure Monitors (ABPM)
•
An Ambulatory Blood Pressure Monitor (ABPM) is a portable blood pressure
monitor that a patient wears for a 24 hour period. This monitor measures and
records blood pressure at regular intervals.
•
This monitor should be considered with patients:
- to expedite the diagnosis of hypertension and masked hypertension
- to rule out white coat syndrome
- with symptoms suggestive of hypotension
- with fluctuating clinic-based pressure readings
- that are untreated and have mild to moderate ( 140-179/90-109) clinic –
based hypertension, in the absence of target organ damage.
•
Consider therapy adjustment in patients with the 24 hour ABPM:
- SBP ≥ 130 mmHg and/or DBP ≥ 80 mmHg
- And / or awake SBP ≥ 135 mmHg and /or DBP ≥ 85 mmHg.
•
While ABPM is usually lower during the night, a decrease in nocturnal blood
pressure of less than 10% is associated with increased risk of cardiovascular
events (CHEP 2004)
Recommended Blood Pressure Monitors for Use in Clinics
•
•
•
•
BP TRU machine
Use a mercury manometer or a recently calibrated aneroid or a validated
automated device.
Aneroid devices should not be used unless they are known to be in calibration
and are checked regularly (minimally every 12 months).
If the needle on an aneroid device does not zero it is inaccurate however the
converse is not true.
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Recommended Home Blood Pressure Monitors
Buying a home blood pressure monitor
Devices used to measure blood pressure at home can be purchased from most
pharmacies and from other stores that sell health-care equipment. The retail staff
should be able to provide training in the use of the blood pressure monitor and should
assist in selecting the proper cuff size and features for you. This statement should
appear on the box and/or in material supplied with the device:
“Recommended by the Canadian Hypertension Society.”
Blood pressure measuring devices that have a memory or printout for storing readings
are recommended as this allows your doctor to see all readings that have been taken.
Ask your doctor or pharmacist to check the monitor to make sure it measures your
blood pressure accurately.
Automated blood pressure recording devices may not work properly in all individuals
such as persons with an irregular heart rhythm. Some models may perform better than
others when an irregular heartbeat is present. If you have this condition, mention it to
the sales staff and make certain that the device takes proper readings before making a
purchase.
Recommended Models Endorsed by the Canadian Hypertension Society
A&D® or LifeSource® monitors Models: 705, 767, 767PAC, 767Plus, 774, 774AC,
779, 787EJ, 787AC, 787W
Omron® monitorsModels: HEM-705CPCAN, HEM-741CAN, HEM-711DLXCAN, HEM773ACCAN, HEM-775CAN, HEM-790ITCAN
Microlife® or Thermor BIOS Diagnostics ® monitors (also sold as ‘private label
brands’)Model: BP 3BTO-A, BP 3AC1-1, BP 3AC1-1 PC, BP 3AC1-2, BP 3AG1, BP
3BTO-1, BP 3BTO-A (2), BP 3BTO-AP, RM 100, BP A100 Plus, BP A 100.
Note: WRIST blood pressure monitors of any kind are not recommended for use.
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Recommended Models Endorsed by the Canadian Hypertension Society
LifeSource
Omron HEM-
787EJ
711DLX
Omron HEM-790IT w
A&D
Cuff
Model
Omron HEM-775
LifeSource
Model
787W
BP 3BTO-
Omron HEM-773 W ComFit
A
Cuff
Additional information regarding home blood pressure recording devices can be found at:
http://hypertension.ca/chep/approved-home-bp-devices
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Hypertension
Patient Internet Resources
Resource
2007 Public
Hypertension
Recommendations
On-line Personalized
blood pressure plan
DASH diet
Canada’s Food
Guide
Dietitians of Canada
On-line health and
fitness calculations
Diabetes and
Hypertension
Heart Disease and
Stroke
Description
General Information on
prevention
and treatment of
hypertension
Create a personalized
action plan for healthy
living
The DASH diet and
healthy eating to
improve blood pressure
control
Canada’s official guide
to healthy eating and
lifestyle choices
Tips for eating well and
living well
Learn about your risk
factors using different
tools to calculate your
personal factors
Information on
hypertension for people
with diabetes
Controlling your blood
pressure can reduce
your chance of
developing heart
disease or having a
stroke
Source
www.hypertension.ca
www.heartandstroke.ca/bp
www.nhlbi.nih.gov/health/public/
heart/hbp/dash/how_plan.html
www.hc-sc.gc.ca/fn-an/food-guidealiment/index_e.html
www.dietitians.ca
www.healthtoolsonline.com/healthfit.html
www.diabetes.ca
www.heartandstroke.ca
Used with permission of Blood Pressure Canada
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Salt and High Blood Pressure
Salt and Sodium
Table salt is made up of two minerals – sodium and chloride, therefore if you use the
salt shaker at the table or when cooking you are getting some sodium. Most of our
dietary sodium is obtained from the salt and sodium additives used in the processed
foods we buy. If you look at the ingredient list of packaged foods, even those that don’t
taste salty, you will often see several sodium additives. Most people consume two or
even three times the recommended amount of sodium without even realizing it.
Adequate Sodium Intake
Experts agree that an adequate sodium intake for most adults is 1500 mg per day or
approximately 2/3 teaspoon of table salt. We need small amounts of sodium for healthy
functioning, such as maintaining a proper fluid balance in the body.
Maximum Sodium Intake
The maximum amount of sodium we should consume a day is 2300 mg which is equal
to approximately 1 teaspoon of table salt. This is not a goal, but rather a limit and, in
fact, the lower your salt intake the better. Excess dietary sodium can increase the
amount of blood in your arteries, raising blood pressure and increasing the risk of heart
disease and stroke.
Following a low-sodium diet could reduce the risk of heart attack or stroke by 2530%.
Foods High in Sodium Content
The salt shaker contributes only about 10% of total sodium consumption. Most sodium
is obtained from processed foods, including fast foods, prepared meals, processed
meats such as hot dogs and lunchmeats, canned soups, bottled dressings, packaged
sauces, condiments such as ketchup and pickles, and salty snacks like potato chips.
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How to Reduce Sodium Intake
Check the Nutrition Facts table on food products for sodium or salt. If the daily value of
sodium listed in the table is 10% or less per serving, or the amount of sodium is 200 mg
or less per serving, the product is considered low in salt. To help reduce added,
unnecessary salt:
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Cut down on prepared and processed foods
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Eat more fresh vegetables and fruit
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Reduce the amount of salt used in cooking, baking and at the table (this includes
sea salt)
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Use condiments sparingly and experiment with other seasonings, such as garlic,
lemon juice and fresh or dried herbs
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Avoid using commercially softened water for drinking or cooking
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Limit how often you eat in restaurants.
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Restrict fast foods and take-out meals.
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Use oil, rather than butter or margarine for cooking.
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Limit “instant” foods or convenience foods (ie. canned soups, TV dinners, etc)
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Buy pre-prepared foods that are low in sodium such as frozen vegetables and
pre-cut salad.
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Plan meals at least a day in advance. Find quick meal ideas in cookbooks and
on-line.
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Read food labels. Look for foods labeled salt-free, no added salt, low in sodium,
or reduced in sodium.
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Look for unsalted snack foods such as chips, pretzels, nuts, seeds and crackers.
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Use herbs and spices on popcorn instead of butter and salt.
For more tips on how to reduce salt from your diet, visit the following web sites:
www.heartandstroke.ab.ca
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Smoking Cessation
Self Help Resources
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Canadian Cancer Society's One Step at a Time http://www.cancer.ca
Public Health Agency of Canada http://www.phac-aspc.gc.ca/chn-rcs/index-eng.php
Physicians for a Smoke-Free Canada http://www.smoke-free.ca
Quitnet http://www.quitnet.com/
Alberta Quits http://alberta.quitnet.com/
Health Canada http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/index-eng.php
AADAC http://www.aadac.com
Telephone Advice
•
AADAC Smokers’ Helpline 1-866-332-2322
Some Resources for Health Professionals
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Health Canada resources for health professionals http://www.hc-sc.gc.ca/hl-vs/tobactabac/index-eng.php
Physicians for a Smoke-Free Canada http://www.smoke-free.ca
Campaign for a Smoke Free Alberta http://www.smokefreealberta.com
Smoking Cessation: Pharmacotherapy
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Effective pharmacotherapies exist for smoking cessation.
Except in the presence of contraindications these should be considered part of the quit plan
for all patients attempting to quit smoking.
Nicotine Replacement Therapy
• Nicotine patch (Habitrol™, Nicoderm™, Nicotrol™)
• Nicotine gum (Nicorette™)
• Nicotine inhaler (Nicorette, Nicotrol)
Bupropion SR (Zyban™)
Varenicline (Champix)
Level 1 evidence that combination of Nicotine patch and Bupropion SR are more effective
than either alone.
The nicotine patch and gum/lozenge/inhaler maybe used at the same time and/or in
combination with Bupropion (OMA Position Paper: Rethinking Stop Smoking Medications:
Treatment Myths and Medical Realities January 2008)
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EDUCATION RESOURCE LIST: STROKE & TIA
AB Heart & Stroke Foundation:
http://www.heartandstroke.ab.ca
Aphasia: Beyond Words-Helping Stroke Survivors with Aphasia Improve Communication
Blood Pressure Record Wallet Card
Dietary Fat and Cholesterol
Do You Know The Five Main Warning Signs of Stroke?
How Stroke Affects Behavior
Know Your Blood Pressure
Let’s Talk About Stroke –An Information Guide for Stroke Survivors and Their Families- binder
Lowering Your Blood Cholesterol the Stroke Help Book
Memory Loss after Stroke
Second-hand Smoke and Your Heart
Stroke Book Mark – Be Stroke Smart
Stroke Fact Sheets: Preventing Stroke, What is Stroke?
Stroke: Medical Tests and Treatments
The Active Heart
Understanding Transient Ischemic Attack (TIA) * 78 pg PDF document
What is Stroke?
Women and Tobacco
AB Egg Producers Board:
http://www.eggs.ab.ca/
Bringing Fats into Focus
American Stroke Association:
http://www.strokeassociation.org
Let’s Talk About Stroke Factsheets (from the STROKE: Patient Education Tool Kit)
Pamplets:
Being a Stroke Family Caregiver
Caring for Someone with Aphasia
How Stroke affects Behavior
Sex After Stroke
Stroke: Are You at Risk?
Articles:
A caregiver’s resource guide
Auditory overload: tempest in a teapot
Caregiver Tips
Caring for a Person with Aphasia
Communicating Despite Aphasia
Communicating Without Words
Defeating Silence
Emotional Recover: Dealing with Depression
Exercise After Stroke
Home Resources for Communication Impairments
Let’s Talk About Driving After Stroke
Let’s Talk About Feeling Tire after Stroke
Limb Contractures
Post-Stroke Communication: It Just Takes Time
Practice Your Memory
Reflex Crying
Guides:
Living with Disability after Stroke –Our guide of practical tips for daily living
Bookmarks:
People who read books are at risk for heart disease and stroke
This is the Face of a Person Affected by Stroke
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Beef Information Centre:
http://www.beefinfo.org/enindex.cfm
A Matter of Fat
Boehringer Ingelheim:
http://www.boehringer-ingelheim.com/corporate/home/home.asp
Recurrent Stroke: How to Protect Yourself
The Path to Stroke Prevention
Bristol-Myers Squibb:
http://www.bms.com/landing/data/index.html
Healthy Living through Controlling High Blood Pressure
Canadian Cancer Society:
http://www.cancer.ca/ccs/internet/niw_splash/0%2C%2C3172%2C00.html
For Smokers Who Want to Quit
2008 Canadian Hypertension Education Program Recommendations:
http://www.cfpc.ca/cfp/2004/Oct/vol50-oct-fpwatch-1.asp
http://www.hypertension.ca
http://www.bpcommunityexchange.net
http://hypertension.ca/chep/information-dissemination-form
Recommended Electronic Blood Pressure Monitors for Home Measurement Sheet
http://hypertension.ca/chep/approved-home-bp-devices/
http://www.hypertension.ca/bpc/resource-center/educational-tools-for-health-care-professionals
2008 Dietary Sodium and Blood Pressure slide presentation
High Blood Pressure The Silent Killer 2008 Public Education slide kit
Canadian Stroke Network, News Release:
http://www.canadianstrokenetwork.ca/
StrokEngine to deliver latest evidence on rehabilitation research
Chinook Health Region:
http://www.chr.ab.ca/
Building Healthy Lifestyles: Blood Pressure Self Management
Building Healthy Lifestyles: Eating for a Healthy U
Building Healthy Lifestyles: Vascular Protection Hypertension Clinical GuideNo Added Salt
Personal Risk Factor Worksheet
Progress Notes
Heart and Stroke Foundation (see AB Heart & Stroke)
http://www.heartandstroke.ca
http://www.hsf.ca/bp
National Stroke Association: (see Free Resources for Members Order Form)
http://www.stroke.org
Are You at Risk for Stroke?
Check Your Pulse – Atrial Fibrillation
Explaining Stroke
Home Exercises for Stroke Survivors
Living at Home after a Stroke
Mobility: Issues Facing Stroke Survivors and Their Families
Recovery after a Stroke (see Recovery Fact Sheet Series list)
Recurrent Stroke Prevention
Reducing Risk & Recognizing Symptoms
Transient Ischemic Attack – Prevention
Royal Alexandra Hospital:
http://www.capitalhealth.ca/HospitalsandHealthFacilities/Hospitals/RoyalAlexandraHospital/default.htm
Instruction Tips for Teaching a Patient How to Perform Home BP Monitoring sheet
Taking Your Blood Pressure (BP) at Home sheet
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The ABC’s of Stroke Risk Reduction sheet
Self-Help Resource Centre-Empowering Stroke Prevention Project
www.selfhelp.on.ca
Guides:
Healthy Ways to Prevent Stroke- A Guide for You
Healthy Ways to Prevent Stroke in Your Community- a Facilitator’s Guide
University of Ottawa Heart Institute:
http://www.ottawaheart.ca/UOHI/Welcome.do
Coping With Cholesterol
Alberta Healthy Living Network:
http://www.ahln.ca
Dietitians of Canada:
http://www.dietitians.ca
Health Canada:
http://www.hc-sc.gc.ca
Healthy Alberta:
http://www.healthyalberta.com
Physicians for a Smoke-free Canada:
http://www.smoke-free.ca
5 to 10 a Day:
http://www.5to10aday.com
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APPENDIX A
ALBERTA PROVINCIAL STROKE STRATEGY
Stroke Prevention Continuum
Well
y No illness
y No risk factors
Goal
y Health maintenance, health promotion,
prevention, screening
Model:
y Primary prevention, population health,
community development, partners,
some health region involvement, selfmanagement
Focus:
y Education, awareness
y Avoid unhealthy lifestyle practices
y Self-management focus
HCP:
y Less specialized
y HCP, lay, facilitator
APSS Documents:
y Planning for Primary Stroke
Prevention
y Public Awareness – Risk Factors for
Stroke
Latent
y No illness
y Risk factors present
Goal
y Control of risk factors, early detection
through screening, case finding,
surveillance
y Health maintenance, health promotion.
Model:
y Long term, ongoing follow-up
y Cohort management, some one-on-one,
community based, community partners,
self-management
Focus:
y Control of risk factors, lifestyle
y Avoid unhealthy lifestyle change,
medication as needed, self-management
focus
HCP:
y Family Physicians, Primary health care
providers, primary care networks
APSS Documents
y Planning for Primary Prevention
y Public Awareness – Risk Factors
Chronic (Established
disease/controlled chronic)
y Post-acute stroke event - stroke or TIA
Goal
y Secondary prevention to prevent or delay
future disease events, clinical &
functional improvement, health
promotion, Q of Life
Model:
y Intensive, mainly one-on-one,
specialist/facility or hospital-based service
y Stroke Specific Clinics – Stroke prevention,
Stroke Follow-up
y Other Specialist Clinics – Vascular risk
reduction, cardiology, neurology, heart
failure etc
y Chronic Disease Clinics – Hypertension,
dyslipidemia, diabetes, cardiac rehab etc.
Focus:
y Symptom control through medication,
lifestyle change, self-management
HCP:
y Specialists, sub-specialists, family
physicians with focused interest in stroke
APSS Documents
y Primary / Secondary Prevention Guidelines
y Secondary Stroke Prevention Clinic
Resources (Section 7.0)
y Patient Resources for Secondary Stroke
Prevention (Section 8.0)