Your browser has 'Cookies' disabled, alert boxes will continue to appear without this feature.

RACGP EGM Tuesday 30 May 2017 

Proxy voting closes 8.00 pm (AEST), Sunday 28 May. 

Cast your vote n​o​w

Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

8.5 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

GPs should be alert to symptoms of transient ischaemic attacks (TIAs) in those aged 45 years and they should assess these patients early in order to prioritise those needing urgent investigation and management. People at high risk should be questioned about symptoms of TIA to determine appropriate action. Adults with AF should have their absolute CVD risk assessed and the cause of their AF determined and treated according to cardiovascular and thromboembolic risk (II, B).

Table 8.5.1. Stroke: Identifying risk
Who is at risk?What should be done?How often?
High absolute risk
  • Calculated >15% absolute risk, clinically determined high risk or pre-existing cardiovascular disease (CVD)
  • Previous stroke (especially with co-existent atrial fibrillation [AF] or high grade [70–99%] symptomatic carotid stenosis)
  • Previous transient ischaemic attack (TIA)
Question about symptoms of TIA. If TIA, stratify risk of stroke and consider anticoagulation* (I, A) 34, 51 66–68

If AF, determine cause of AF and treat according to cardiovascular and thromboembolic risk (II, B)

Manage behavioural and physiological risk factors actively. Treat with antihypertensive and lipid-lowering medications unless contraindicated or clinically inappropriate (II, B)
Every 12 months (IV, C)
Auscultation for carotid bruit Auscultating for carotid bruit 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). In addition, the overall benefit of surgery is, at best, small; hence, very careful selection of patients is needed to justify surgery in those with severe (>60%) but asymptomatic stenosis† 67, 69–71

However, the presence of a carotid bruit has been shown to be associated with increased risk of myocardial infarction and cardiovascular death, so may be a useful prognostic marker when assessing cardiovascular risk generally67

Screen patients with known asymptomatic carotid artery stenosis for other treatable causes of stroke and treat these intensively
* Anticoagulation therapy for long-term secondary prevention should be used in people with ischaemic stroke or TIA who have documented atrial fibrillation or cardio-embolic stroke

† Antiplatelet therapy should be considered for non-cardio-embolic stroke or TIA

AF, atrial fibrillation; CVD, cardiovascular disease; TIA, transient ischaemic attack
Table 8.5.2. Tests to detect stroke risk
TestTechnique
Question about transient ischaemic attack (TIA)

ABCD2 tool
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 vertigo68, 72

All patients with suspected TIA should have stroke risk assessment, which may include the ABCD2 tool:
  • Age: >60 years (1 point)
  • BP: >140/90 mmHg (1 point)
  • Clinical features: Unilateral weakness (2 points), speech impairment without weakness (1 point)
  • Duration: >60 minutes (2 points), 10–59 minutes (1 point)
  • Diabetes (1 point)
Important additional information required:
  • presence of atrial fibrillation (AF)
  • signs that might indicate carotid disease (eg anterior circulation signs), in people who are candidates for carotid surgery
  • ≥2 TIAs within the previous seven days (crescendo TIA)
For those deemed high risk (ABCD2 tool = 4–7 and/or AF, potential carotid disease or crescendo TIA): Urgent brain and carotid imaging (‘urgent’ is considered immediately, but certainly within 24 hours). If carotid territory symptoms, consider duplex ultrasound for patients who are potential candidates for carotid revascularisation

For those deemed low risk (ABCD2 tool = 0–3 without AF, potential carotid disease or crescendo TIA): Refer for computed tomography (CT) of brain (and carotid ultrasound where indicated) as soon as possible (ie within 48–72 hours)
Assess the need for anticoagulation A decision to anticoagulate someone with AF can be assisted by stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) scores73, 74
AF, atrial fibrillation; CT, computed tomography; TIA, transient ischaemic attack

For further information about secondary prevention after stroke or TIA refer to the Stroke Foundation

Also refer to Chapter 15. Screening tests of unproven benefit.

References

  1. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: National Stroke Foundation, 2012.
  2. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Reducing risk in heart disease: An expert guide to clinical practice for secondary prevention of coronary heart disease. Melbourne: National Heart Foundation of Australia, 2012.
  3. National Heart Foundation of Australia. National Heart Foundation position statement on non-valvular atrial fibrillation and stroke prevention. Med J Aust 2001;174:234–348.
  4. Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2006;113(24):e873–923.
  5. Alberts MJ, Eikelboom JW, Hankey GJ. Antithrombotic therapy for stroke prevention in non-valvular atrial fibrillation. Lancet Neurol 2012;11(12):1066–81.
  6. Sauve J, Thorpe KE, Sackett DL, Taylor W. Can bruits distinguish high-grade from moderate symptomatic carotid stenosis? The North American Symptomatic Carotid Endarterectomy Trial. Ann Intern Med 1994;120(8):633–37.
  7. Pickett CA, Jackson JL, Hemann BA, Atwood JE. Carotid bruit as a prognostic indicator of cardiovascular death and myocardial infarction: A meta-analysis. Lancet 2008;371:1587–94.
  8. Floriani M, Giulini SM, Bonardelli S, Portolani N. Value and limites of ‘critical auscultation’ of neck bruits. Angiology 1988;39:967–72.
  9. National Stroke Foundation. Clinical guidelines for stroke management. Melbourne: NSF, 2010.
  10. Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012;126(7):860–65.
  11. Wolf PA, Abbot RD, Kannel WB. Atrial fibrillation as an independent risk facor for stroke: The Framingham study. Stroke 1991;22:983–88.
Advertisement loading...

Advertisement

The Royal Australian College of General Practitioners

Contact Us

General Inquiries

General Enquiries

Opening hours 8:00 am-8:00 pm AEST

1800 4RACGP

1800 472 247 | +61 (3) 8699 0300 (international)

Payments

Payments

Pay invoices online

RACGP automated payment service: 1800 198 586

Follow us on

Follow RACGP on Twitter Follow RACGP on Facebook Follow RACGP on LinkedIn


Healthy Profession. Healthy Australia Logo

The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807
RACGP House, 100 Wellington Parade, East Melbourne, Victoria 3002 Australia

Terms and conditions | Privacy statement
Sponsor conditions | Delegate conditions