Stroke Prevention

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Prevention of stroke may be classified as primary prevention, if there is no previous history of stroke or transient ischaemic attack (TIA), and secondary prevention if there has been such an event. See also other separate articles Primary Prevention of Cardiovascular Disease (CVD) and Cardiovascular Risk Assessment. For tertiary prevention, also see separate article Cerebrovascular Event Rehabilitation.

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  • Use an appropriate cardiovascular risk assessment tool (eg Joint British Societies' (JBS2) risk calculator) to assess CVD risk.[4]
  • The QRISK2 calculator is gaining acceptance and may be more relevant to UK populations.[5]
  • The ETHRISK calculator is more appropriate in British black and minority ethnic groups.[6]

Lifestyle factors[3]

  • Dietary advice:
    • Advise eating at least five portions of fruit and vegetables per day.
    • Advise eating at least two portions of fish per week, including a portion of oily fish.
    • Advise people to eat a diet in which the total fat intake is 30% or less of total energy intake, saturated fats are 10% or less of total energy intake, dietary cholesterol is less than 300 mg/day, and saturated fats are replaced by monounsaturated and polyunsaturated fats.
    • Advise pregnant women to limit their intake of oily fish to two portions a week.
    • Do not routinely recommend omega-3 fatty acid supplements or plant sterols and stanols for primary prevention.
  • Physical activity:
    • Advise people to take 30 minutes of at least moderate-intensity exercise a day at least five days a week.
    • Encourage people who cannot manage this to exercise at their maximum safe capacity.
    • Recommend exercise that can be incorporated into everyday life, such as brisk walking, using stairs and cycling.
    • Tell people that they can exercise in bouts of 10 minutes or more throughout the day.
    • Take into account the person's needs, preferences and circumstances.
    • Agree goals and provide written information about the benefits of activity and local opportunities to be active.
  • Weight management:
    • Offer people who are overweight or obese advice and support to work towards achieving and maintaining a healthy weight.
  • Alcohol consumption:
    • Advise men to limit their alcohol intake to 3-4 units a day.
    • Advise women to limit their alcohol intake to 2-3 units a day.
    • Advise everyone to avoid binge drinking.
  • Smoking cessation:
    • Advise all people who smoke to stop.
    • If people want to stop:
      • Offer support and advice.
      • In addition, provide medication to help with smoking cessation when indicated.

Drug treatment

See also the separate Atrial Fibrillation article - AF is responsible for 25% of all strokes.[7]

  • Hypertension:
    • Screen for hypertension and treat appropriately according to National Institute for Health and Clinical Excellence (NICE) guidelines.[8]
  • Antithrombotic treatment:
    • Following acute MI: anticoagulation is appropriate in those who are at increased risk of thromboembolism, including those with a large anterior MI, left ventricular aneurysm or thrombus, paroxysmal tachyarrhythmias, chronic heart failure or a history of thromboembolic events.[4]
    • Anticoagulation is indicated for other cardiovascular risk factors for thromboembolism, eg prosthetic valves, rheumatic heart disease and AF.
  • Aspirin:
    • Although use of aspirin is widely accepted for secondary prevention, results in primary prevention are inconclusive, and aspirin is not licensed for this indication.[9]
    • Aspirin produces a 12% proportional reduction in serious vascular events, mainly due to a 20% reduction in non-fatal MI. There was no net effect on stroke and vascular mortality.[10]
    • If low-dose aspirin is used in primary prevention, the balance of risk and benefits should be discussed with the patient.
    • The risk of gastrointestinal bleeding (0.1% per year with aspirin versus 0.07% per year without) probably outweighs the small benefit in stroke prevention (0.51% aspirin versus 0.57% control per year) unless the risk is particularly high.
  • Lipid-lowering drugs: NICE recommends statin therapy as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD.[3]
  • All patients should have an individualised strategy for stroke prevention that should be implemented within a maximum of seven days of acute stroke or TIA.
  • All patients should be given appropriate advice on lifestyle factors as described for primary prevention, including smoking cessation, physical activity, diet, weight control and avoiding excess alcohol.
  • All patients should receive regular review and treatment of risk factors for vascular disease for the rest of their lives after a stroke with inclusion on a stroke register and a minimum of annual follow-up.
  • Blood pressure: see separate article Management of Hypertension.
  • Antithrombotic treatment:
    • If there is a history of persistent or paroxysmal AF in a non-haemorrhagic stroke, consider anticoagulation first-line:
      • Anticoagulation should be started in every patient with persistent or paroxysmal AF (valvular or non-valvular) unless contra-indicated.[4]
      • Anticoagulants should not be used for patients without persistent or paroxysmal AF unless there is a major source of cardiac embolism.
      • Anticoagulation is indicated for other cardiovascular risk factors for thromboembolism, eg prosthetic valves.[12]
      • Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke.
    • Patients with TIAs not being anticoagulated should be on modified-release dipyridamole in combination with aspirin (modified-release dipyridamole alone if aspirin is not tolerated).[13]
    • Patients with ischaemic stroke (not due to AF) should be on clopidogrel (only use modified-release dipyridamole in combination with aspirin if clopidogrel is not tolerated). [14] Clopidogrel is also the preferred treatment option in patients with peripheral arterial disease or multivascular disease.[13]
    • For patients post-MI, an option including aspirin is preferred (use clopidogrel only, if aspirin is not tolerated).
  • Anti-lipid agents:
    • Treatment with a statin should be given to all patients with ischaemic stroke or TIA unless contra-indicated.[3]

Carotid endarterectomy has been the standard in atherosclerotic stroke prevention but carotid artery stenting has emerged as a less invasive alternative for revascularisation.[15]

  • Carotid endarterectomy:
    • Carotid endarterectomy is of some benefit for patients with 50-69% symptomatic stenosis and is very beneficial for 70-99% stenosis without near-occlusion.[16]
    • Benefit in patients with carotid near-occlusion is marginal in the short term and uncertain in the long term.[16]
    • Carotid endarterectomy should be performed as soon as the patient is fit for surgery, preferably within two weeks of a TIA.[11]
    • Carotid endarterectomy for asymptomatic carotid stenosis reduces the risk of any stroke by approximately 30% over three years. However, the absolute risk reduction is small and there is a 3% peri-operative stroke or death rate.[17]
  • Carotid angioplasty and stenting:
    • Stenting with the use of an embolic protection device is a less invasive revascularisation strategy than endarterectomy in carotid artery disease. For patients with severe carotid artery stenosis and co-existing conditions, carotid stenting with the use of an embolic protection device appears to be as safe and as effective as carotid endarterectomy.[18]
    • Endovascular treatment and carotid endarterectomy appear to have similar early risks of death or stroke and similar long-term benefits in the treatment of carotid artery stenosis.[17]
    • The efficacy of carotid artery stenting compared with endarterectomy has not yet been fully established.[19]
  • NICE recommendations following acute stroke or TIA:[11]
    • People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50-99% according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, or 70-99% according to the European Carotid Surgery Trialists' (ECST) Collaborative Group criteria, should:
      • Be assessed and referred for carotid endarterectomy within one week of onset of stroke or TIA symptoms.
      • Undergo surgery within a maximum of two weeks of onset of stroke or TIA symptoms.
      • Receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).
    • People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the ECST criteria, should:
      • Not undergo surgery.
      • Receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).
  • The Scottish Intercollegiate Guidelines Network (SIGN) recommends that all patients with carotid artery territory stroke (without severe disability) or TIA should be considered for carotid endarterectomy as soon as possible after the index event. Carotid endarterectomy should be considered in all male patients with a carotid artery stenosis of 50-99% (by NASCET method) and all female patients with a carotid artery stenosis of 70-99%. Carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within two weeks of event.[20]

Further reading & references

  1. 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 Jun 20;113(24):e873-923.
  2. Sudlow C; Preventing further vascular events after a stroke or transient ischaemic attack: an update on medical management. Pract Neurol. 2008 Jun;8(3):141-57.
  3. Lipid modification - cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease; NICE Clinical Guideline (May 2008, amended May 2010)
  4. No authors listed; JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart. 2005 Dec;91 Suppl 5:v1-52
  5. QRISK®2-2011 Cardiovascular Risk Assessment Calculator; QRISK®2-2011 Cardiovascular Risk Assessment Calculator
  6. ETHRISK® - Ethnic Group CHD Risk Calculator; ETHRISK® - Ethnic Group CHD Risk Calculator (modified Framingham); A modified Framingham CHD and CVD risk calculator for British black and minority ethnic groups
  7. Ahmad Y, Lip GY; Stroke Prevention in Atrial Fibrillation: Where are We Now? Clin Med Insights Cardiol. 2012;6:65-78. Epub 2012 Feb 23.
  8. Hypertension: management of hypertension in adults in primary care; NICE Clinical Guideline (August 2011)
  9. Aspirin: not licensed for primary prevention of thrombotic vascular disease, Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update 3(3), 10-11. (2009)
  10. Baigent C, Blackwell L, Collins R, et al; Aspirin in the primary and secondary prevention of vascular disease: Lancet. 2009 May 30;373(9678):1849-60.
  11. Stroke: The diagnosis and acute management of stroke and transient ischaemic attack (TIA); NICE Clinical Guideline (July 2008)
  12. Furie KL, Kasner SE, Adams RJ, et al; Guidelines for the prevention of stroke in patients with stroke or transient Stroke. 2011 Jan;42(1):227-76. Epub 2010 Oct 21.
  13. Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events; NICE Technology Appraisals, December 2010
  14. National clinical guidelines for stroke (fourth edition); Royal College of Physicians (2012)
  15. Skerritt MR, Block RC, Pearson TA, et al; Carotid endarterectomy and carotid artery stenting utilization trends over time. BMC Neurol. 2012 Mar 29;12(1):17.
  16. Rerkasem K, Rothwell PM; Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD001081.
  17. Chambers BR, Donnan GA; Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001923.
  18. Hopkins LN, Myla S, Grube E, et al; Carotid artery revascularization in high surgical risk patients with the NexStent Catheter Cardiovasc Interv. 2008 Jun 1;71(7):950-60.
  19. Ederle J, Dobson J, Featherstone RL, et al; Carotid artery stenting compared with endarterectomy in patients with symptomatic Lancet. 2010 Mar 20;375(9719):985-97. Epub 2010 Feb 25.
  20. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention; Scottish Intercollegiate Guidelines Network - SIGN (December 2008)

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Peer Reviewer:
Dr John Cox
Document ID:
2808 (v24)
Last Checked:
19/07/2012
Next Review:
18/07/2017