• Advise lifestyle measures that reduce the risk of stroke and other cardiovascular disease events, including:
• Stopping smoking.
• Adopting a cardioprotective diet, including reducing salt intake.
• Regular exercise.
• Prudent use of alcohol.
• Achieving and maintaining a satisfactory body weight.
• Because lifestyle changes can be a major challenge, consider measures to support behaviour change.
• For more information, see the section on Advice on lifestyle interventions in the CKS topic on CVD risk assessment and management.

• Antithrombotic, antihypertensive, and lipid modifying treatments are recommended, and will need to be started by the GP if this has not already been done in secondary care.
• For full management details, see the CKS topics on:
• Antiplatelet treatment, or Atrial fibrillation for people with this condition.
• Hypertension - not diabetic.
• Lipid modification - CVD prevention.
• Diabetes type 2, for people with this condition.
• All people should be followed up 1 month after the event, either in primary or secondary care, so that medication and other interventions to modify risk factors (for example diabetes, hypertension, hyperlipidaemia, or ischaemic heart disease) can be assessed [DH, 2007].

For the management of acute stroke or TIA, see Acute stroke/TIA.

For the management of someone presenting with a suspected completed TIA , see TIA, completed.

Secondary prevention of TIA

• For people who have had a TIA, long-term antiplatelet treatment should usually be started in primary care as soon as the diagnosis is confirmed.
• A combination of modified-release dipyridamole (200 mg twice daily) and aspirin (50 mg to 300 mg daily) is recommended.
• Consider also prescribing a proton pump inhibitor to reduce the risk of gastrointestinal bleeding in people at high risk of gastrointestinal bleeding or to relieve aspirin-induced dyspepsia.
• If aspirin is contraindicated or not tolerated, give modified-release dipyridamole alone.
• Clopidogrel (75 mg daily) alone is an alternative (off-label use).
• If modified-release dipyridamole is not tolerated, give aspirin alone.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.

Secondary prevention of ischaemic stroke

• For people who have had an ischaemic stroke, high-dose aspirin is usually continued for about 2 weeks after the event, and then low–dose long–term antiplatelet treatment is started.
• Clopidogrel (75 mg daily) is the preferred antiplatelet for secondary prevention of ischaemic stroke.
• If clopidogrel is contraindicated or not tolerated, give a combination of modified-release dipyridamole (200 mg twice daily) and aspirin (50 mg to 300 mg daily).
• Consider also prescribing a proton pump inhibitor to reduce the risk of gastrointestinal bleeding in people at high risk of gastrointestinal bleeding or to relieve aspirin-induced dyspepsia.
• If both clopidogrel and modified-release dipyridamole are contraindicated or not tolerated, give aspirin alone.
• If both clopidogrel and aspirin are contraindicated or not tolerated, give modified-release dipyridamole alone.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.

Recurrent stroke or TIA

• People who have recurrent strokes or TIAs should not be given more intensive antiplatelet treatment or anticoagulation unless there are exceptional circumstances or as part of a clinical trial. Seek specialist advice regarding management of these people.

People with persistent or paroxysmal atrial fibrillation or with cerebral venous sinus thrombosis

• Anticoagulation is recommended for people with persistent or paroxysmal atrial fibrillation, and is usually recommended for people with cerebral venous sinus thrombosis.
• Anticoagulation is normally initiated in secondary care, and should not be started until intracerebral haemorrhage has been excluded by brain imaging.
• For more information on managing anticoagulation in people with atrial fibrillation, see the CKS topic on Atrial fibrillation and the CKS topic on Anticoagulation - oral.

In depth

• All people with stroke or transient ischaemic attack (TIA) should have their blood pressure checked and be offered antihypertensive treatment in line with national guidelines:
• For people with a TIA: consider starting antihypertensive treatment as soon as possible.
• For people with an acute stroke: treatment will usually be initiated in secondary care about 2 weeks after the event (unless a hypertensive emergency requires urgent reduction in blood pressure).
• Optimal target blood pressure:
• For people with established cardiovascular disease: aim to reduce blood pressure to 140/90 mmHg or less, and preferably to 130/80 mmHg.
• For people with bilateral, severe (more than 70%) stenosis of the internal carotid arteries: a slightly higher target blood pressure (e.g. systolic blood pressure 150 mmHg) may be appropriate.
• For information and prescription details, see the CKS topic on Hypertension - not diabetic for people without Type 2 diabetes; otherwise, see the CKS topic on Diabetes type 2.

In depth

The following recommendations apply to most people. They do not apply to people with lipid disorders such as familial hypercholesterolaemia:

• A statin should be started:
• As soon as possible for people with a transient ischaemic attack (TIA).
• 48 hours after the event for people with an acute stroke.
• People with an acute stroke or TIA who are already receiving statins should continue their statin treatment.
• Seek specialist advice before initiating a statin in people with a history of haemorrhagic stroke, particularly those with inadequately controlled hypertension.
• Before starting treatment:
• Consider whether treatment is appropriate, taking into account comorbidities and life expectancy.
• Perform baseline blood tests (for more information, see the section on Tests before drug treatment in the CKS topic on Lipid modification - CVD prevention).
• Investigate for (and if found, manage) any conditions, such as diabetes, that are suggested by the baseline tests.
• If dyslipidaemia is present, investigate for, and manage, secondary causes.
• Consider higher-intensity statin therapy if the total cholesterol level does not decrease to below 4 mmol/L or the low-density lipoprotein cholesterol level does not decrease to below 2 mmol/L.
• Optimize, as far as possible, the management of comorbidities and implementation of lifestyle interventions.
• For more information (including options when simvastatin is not suitable), see the CKS topic on Lipid modification - CVD prevention and the appropriate sections in the CKS topic on Diabetes type 2.

In depth