Stroke
| Age | 0 - 9 | 10 - 14 | 15 - 19 | 20 - 24 | 25 - 29 | 30 - 34 | 35 - 39 | 40 - 44 | 45 - 49 | 50 - 54 | 55 - 59 | 60 - 64 | 65 - 69 | 70 - 79 | >80 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| X | X | X | X | X | X | X |
All patients over 45 years of age should be screened for hypertension, diabetes, smoking, obesity, dyslipidaemia, nonvalvular atrial fibrillation and physical inactivity, as modifying these risk factors reduces the risk of stroke. General practitioners should be alert to the symptoms of transient ischaemic attacks (TIAs) in this age group and assess early in order to prioritise those needing urgent investigation and management. Antihypertensive and lipid lowering therapy should be used for all patients with stroke and TIA unless contraindicated (B). Anticoagulation or antiplatelet therapy should also be considered for patients with TIAs and those with atrial fibrillation (AF) and a history of previous thrombotic stroke or myocardial infarction unless specific contraindications exist (A).
| Who is at higher risk of stroke? | What should be done? | How often? | Level of evidence and references |
|---|---|---|---|
Increased risk
|
Screen for and treat hypertension Screen for and treat other risk factors |
Every 12 months |
I A 330 |
| * Over 40 years of age for Aboriginal people and Torres Strait Islanders | * Those with a 5 year CV risk >15% should be started on low dose aspirin (75–150 mg/day) if there are no contraindications | ||
High risk
|
Manage other risk factors aggressively Stratify risk of stroke in all patients with symptoms of a TIA* (See ABCD2 tool below) |
Every 12 months |
|
| * Especially with co-existent AF or high grade (70–99%) symptomatic carotid stenosis | Question about symptoms of TIA and consider anticoagulation | ||
| Patients who have had a TIA or ischaemic stroke* | Anticoagulation with warfarin should be considered in patients with documented ischaemic stroke or TIAs due to AF Antiplatelet therapy should be used for noncardioembolic stroke or TIA Review or commence (unless contraindicated) antihypertensive and lipid lowering therapy for all patients |
Every 12 months | I A 333 |
| Auscultation for carotid bruit | Auscultating for carotid bruits in asymptomatic people is not recommended in the general adult population as a screening tool for stroke risk. Screening with duplex ultrasonography in this population is not cost effective (yields many false-positive results) coupled with the fact that the overall benefit of surgery is at best small. Therefore careful selection of patients is needed to justify surgery in those with severe (>60%) but asymptomatic stenosis.** However, the presence of a carotid bruit has been shown to be associated with increased risk of myocardial infarction and CV death, so may be a useful prognostic marker when assessing CV risk generally |
330,334-336 | |
| Screen patients with known asymptomatic carotid artery stenosis for other treatable causes of stroke and treat these intensively | 330 |
| Test | Technique | References |
|---|---|---|
Question about TIA |
Question patient or carer regarding symptoms of sudden onset of loss of focal neurological function such as weakness or numbness of arms or legs, speech disturbance, double vision or vertigo |
|
| ABCD2 tool | All patients with suspected TIA should have stroke risk assessment including the ABCD2 tool A = AGE >60 years (1 point) >4 = high risk: urgent CT brain (‘urgent’ is considered as soon as possible, but certainly within 24 hours). If carotid territory symptoms exist, consider duplex ultrasound for patients who are potential candidates for carotid revascularisation |
333 |
| * For further information about secondary prevention after stroke or TIA, go to www.strokefoundation.com.au ** See also Chapter 15 Screening tests of unproven benefit |
||
© The Royal Australian College of General Practitioners
Printed from www.racgp.org.au/redbook