Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014

Section 1: Initial risk stratification and management of nondisabling stroke and TIA

• 1.0 Patients with stroke and TIA who present to an ambulatory setting or a hospital should undergo clinical evaluation by a health-care professional with expertise in stroke care to determine risk for recurrent stroke and initiate appropriate investigations and management strategies.
• 1.1 Timing of initial assessment
  • 1.1.1 HIGHEST risk for stroke recurrence

    1. Patients who present within 48 h of a suspected TIA or ischemic stroke with transient, fluctuating or persistent unilateral weakness (face, arm and/or leg), or speech disturbance are considered at highest risk of recurrent stroke (Evidence Level B).

       1. These highest risk patients should be immediately sent to an emergency department with capacity for advanced stroke care (such as brain imaging on site, and ideally tPA capability on site) (Evidence Level C) (see section 1.2.i.a).

       2. Urgent brain imaging (CT or magnetic resonance imaging) and noninvasive vascular imaging should be completed without delay (Evidence Level B). Refer to section 1.2.i below for details.

       3. An ECG should also be completed without delay (Evidence Level B).

    2. Patients who present within 48 h of a suspected TIA or ischemic stroke with transient, fluctuating or persistent symptoms without motor weakness or speech disturbance (e.g. with symptoms such as hemibody sensory loss, or acute monocular visual loss, or binocular diplopia or hemivisual loss or dysmetria) may be considered at high risk of recurrent stroke (Evidence Level C).

       1. These patients should be referred for same-day assessment at the closest stroke prevention clinic or emergency department with capacity for advanced stroke care (Evidence Level B) (see section 1.3 for further details).

  • 1.1.2 INCREASED risk for recurrent stroke

    1. Patients who present between 48 h and two-weeks from onset with symptoms of transient, fluctuating or persistent unilateral weakness (face, arm and/or leg), or speech disturbance symptoms are considered at increased risk for recurrent stroke (Evidence Level B).

       1. These patients should receive a comprehensive clinical evaluation and investigations by a health-care professional with stroke expertise as soon as possible, at most within 24 h of first contact with the health-care system (Evidence Level B) (see section 2.1.2).

    2. Patients who present between 48 h and two-weeks of a suspected TIA or ischemic stroke with transient, fluctuating or persistent symptoms without motor weakness or speech disturbance (e.g. with symptoms such as hemibody sensory loss, or acute monocular visual loss, or binocular diplopia or hemivisual loss or dysmetria) may be considered at increased risk of recurrent stroke (Evidence Level C).

       1. These patients should receive a comprehensive clinical evaluation and investigations by a health-care professional with stroke expertise as soon as possible, at most within two-weeks of first contact with the health-care system (Evidence Level C). Refer to section 1.2 for more information on investigations.

  • 1.1.3 LOWER risk for recurrent stroke

    1. Patients presenting more than two-weeks following a suspected TIA or ischemic stroke may be considered as being less urgent and should be seen by a neurologist or stroke specialist for evaluation as soon as possible, generally within one-month of symptom onset (Evidence Level C).

    2. Patients experiencing atypical sensory symptoms (such as patchy numbness and/or tingling) may also be considered as less urgent and should be seen by a neurologist or stroke specialist for evaluation (Evidence Level C).

• 1.2 Clinical investigations

  1. All patients with suspected TIA or ischemic stroke should undergo an initial assessment that includes: brain imaging and noninvasive vascular imaging of the carotid arteries (Evidence Level B).

     1. This is most quickly and efficiently performed using CTA at the time of brain CT. Carotid ultrasound and MR angiography (MRA) are alternatives, and selection should be based on immediate availability and patient characteristics (Evidence Level C).

     2. The main evidence-based rationale for vascular imaging is to identify carotid stenosis (Evidence Level A). CTA may be considered to allow visualization of the intracranial circulation, posterior circulation and the aortic arch. A detailed understanding of this vasculature may guide management decisions (Evidence Level B).

     3. When performing CTA or MRA, we recommend including intracranial and extracranial vasculature (Evidence Level C).

  2. The following laboratory investigations should be undertaken routinely for patients with suspected TIA or ischemic stroke as part of the initial evaluation: hematology (complete blood count), electrolytes, coagulation (aPTT, INR), renal function (creatinine, e-glomerular filtration rate), fasting lipid profile, fasting glucose level and A1C, and ALT (Evidence Level C). Refer to box one for detailed list of recommended lab tests (available at www.strokebestpractices.ca).

  3. All patients with suspected TIA or ischemic stroke should undergo an ECG to assess baseline cardiac rhythm and to provide information regarding evidence of structural heart disease (i.e. previous myocardial infarction, left ventricular hypertrophy) (Evidence Level C).

  4. In cases where the ECG or initial cardiac rhythm (e.g. 24 or 48 h ECG monitoring) does not show atrial fibrillation but a cardioembolic mechanism is suspected, prolonged ECG monitoring is recommended in selected patients for the detection of paroxysmal atrial fibrillation (i.e. older patients with recent embolic stroke of undetermined source who are potential candidates for anticoagulant therapy) (Evidence Level B).

  5. Echocardiogram may be considered in cases where the stroke mechanism has not been identified (Evidence Level C).

  6. Selected patients with clinical evidence of ischemic stroke who are not admitted to hospital should be assessed for functional impairment when appropriate (e.g. cognitive evaluation, screening for depression, screening of fitness to drive, and functional assessments for potential rehabilitation treatment) (Evidence Level B).

Section 2: Lifestyle and risk factor management

• 2.0 Persons at risk of stroke and patients who have had a stroke should be assessed for vascular disease risk factors and lifestyle management issues (diet, sodium intake, exercise, weight, alcohol intake, and use of oral contraceptives and hormone replacement therapy) (Evidence Level B).

  1. They should receive information and counseling about possible strategies to modify their lifestyle and risk factors (Evidence Level B).

  2. Referrals to appropriate specialists should be made where required to provide more comprehensive assessments and structured programs to manage risk factors (Evidence Level B).

• 2.1 Healthy balanced diet: Counsel and educate individuals with stroke to eat a diet high in fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources and low in saturated and trans fats, low in cholesterol (<200 mg daily for patients at increased vascular risk) and low in sodium, in accordance with Canada's Food Guide (Evidence Level B).

  1. Counsel and educate individuals with stroke about following a Mediterranean-type diet, which is high in vegetables, fruits, whole grains, fish, nuts and olive oil (Evidence Level B).

• 2.2 Sodium Intake: Counsel and educate individuals with stroke and high blood pressure to have a daily sodium intake from all sources to less than 2000 mg per day (Evidence Level A).
• 2.3 Exercise: Participating in moderate dynamic exercise such as walking (ideally brisk walking), jogging, cycling, swimming or other dynamic exercise four- to seven-days each week in addition to routine activities of daily living (Evidence Level A).

  1. Patients should be counseled to achieve an accumulation of at least 150 mins of moderate to vigorous activity per week, in episodes of 10 mins or more (Refer to the CSEP Canadian Physical Activity Guidelines 2011 for additional information) (Evidence Level B).

  2. Most stroke patients should be encouraged to start a regular exercise program. Supervision by a health-care professional (such as a physiotherapist) at exercise initiation should be considered in individuals with stroke at risk of falls or injury, or in individuals with other comorbid disease (such as cardiac disease), which may place them at higher risk of medical complications (Evidence Level C).

• 2.4 Weight: Counsel and educate individuals with stroke to achieve a body mass index (BMI) of 18·5 to 24·9 kg/m²; or a waist circumference of <88 centimeters for women and <102 centimeters for men (Evidence Level B). (Note: these numbers are reflective of current research based mostly on Caucasian patients. Refer to the Reference list for waist circumference values for other ethnic groups.)
• 2.5 Alcohol consumption: Excessive alcohol intake increases the risk of ischemic stroke and intracranial hemorrhage. Counsel and educate individuals with stroke to avoid heavy alcohol use (Evidence Level B). Following Canada's Low-Risk Alcohol Drinking Guidelines is recommended: for women, no more than 10 drinks per week, with no more than 2 drinks per day most days and no more than 3 drinks on any single occasion; for men, no more than 15 drinks per week, with no more than 3 drinks per day most days and no more than 4 drinks on any single occasion (Evidence Level C).
• 2.6 Oral Contraceptives and Hormone Replacement Therapy: Individuals with stroke who are taking estrogen-containing oral contraceptives or hormone replacement therapy should have the risks and benefits of these treatments discussed with them (Evidence Level C).

  1. Estrogen-containing oral contraceptives or hormone replacement therapy should be discontinued in patients with stroke. Management alternatives should be considered in these patients (Evidence Level B).

• 2.7 Recreational Drug Use: Individuals with stroke and known recreational drug use should be counseled to discontinue use (Evidence Level C), and should be provided with appropriate support and referrals to services and resources for drug addiction (Evidence Level B).

Section 3: Blood pressure and stroke prevention

• 3.0 Hypertension is the single most important modifiable risk factor for stroke. Blood pressure should be monitored and managed in all persons at risk for stroke (Evidence Level A).
• 3.1 Blood pressure assessmentAll persons at risk of stroke should have their blood pressure measured routinely, ideally at each health-care encounter, but no less than once annually (Evidence Level C).

  1. Proper standardized techniques should be followed for initial and subsequent blood pressure measurement including office, home, and community testing (Evidence Level B) as outlined by the Canadian Hypertension Education Program.

  2. Patients found to have elevated blood pressure (systolic greater than 130 mmHg and/or diastolic greater than 85 mmHg) should undergo thorough assessment for the diagnosis of hypertension (Evidence Level C).

     1. A specific follow-up visit should be scheduled and completed for the assessment and diagnosis of hypertension following an initial elevated blood pressure measurement (Evidence Level C).

     2. The specific visit for assessment of hypertension should include three measurements and be conducted in accordance with the current guidelines of the Canadian Hypertension Education Program (Evidence Level C).

  3. Patients with refractory hypertension should have comprehensive investigations for secondary causes of hypertension (Evidence Level B).

  4. Patients with hypertension or at risk for hypertension (in prehypertension state or other risk factors) should receive aggressive risk factor modification counseling and interventions (Evidence Level B). Refer to the recommendations in section 2 on Lifestyle Management for additional information.

• 3.2 Blood pressure managementBlood pressure should be managed in all patients to reach optimal control as follows:

  1. For patients who have had a stroke or TIA, blood pressure lowering treatment is recommended to achieve a target of consistently lower than 140/90 mmHg (Evidence Level B).

  2. In patients with diabetes, blood pressure–lowering treatment is recommended for the prevention of first or recurrent stroke to attain systolic blood pressure targets consistently lower than 130 mmHg (Evidence Level C) and diastolic blood pressure targets consistently lower than 80 mmHg (Evidence Level B).

  3. In patients with nondiabetic chronic kidney disease, blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke to attain a blood pressure consistently lower than 140/90 mmHg (Evidence Level C).

  4. For recommendations on specific agents and sequence of agents for the secondary prevention of ischemic stroke, refer to the Canadian Hypertension Education Program treatment guidelines [14].

  5. Randomized controlled trials have not defined the optimal time to initiate blood pressure–lowering therapy after stroke or TIA. Blood pressure–lowering treatment should be initiated or modified before discharge from hospital (Evidence Level B).

  6. Patients who are not started on hypertensive therapy in acute care should have arrangements made for follow-up with primary care for ongoing evaluation and management (Evidence Level C).

  7. For children, blood pressure should be targeted below the 95 percentile for age, height and gender (Evidence Level B).

Section 4: Lipid management

• 4.0 Patients who have had an ischemic stroke or TIA should have their serum lipid levels assessed and aggressively managed (Evidence level A).
• 4.1 Lipid assessment

  1. Fasting lipid levels [total cholesterol, total triglycerides, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol] should be measured on all patients presenting with stroke or TIA (Evidence Level B).

• 4.2 Lipid management

  1. Patients with ischemic stroke or TIA should be managed with aggressive therapeutic lifestyle changes to lower lipid levels, including dietary modification, as part of a comprehensive approach to lower risk of first or recurrent stroke (Evidence Level B).

  2. A statin should be prescribed as secondary prevention to most patients who have had an ischemic stroke or TIA in order to achieve an LDL cholesterol of less than 2·0 mmol/l, or a 50% reduction in LDL cholesterol from baseline (Evidence Level B) [15].

  3. Statin therapy is not indicated for prevention of intracerebral hemorrhage (Evidence Level B).

Section 5: Diabetes and stroke

• 5.0 Patients with diabetes who have had an ischemic stroke or TIA should have their diabetes assessed and optimally managed (Evidence level A).
• 5.1 Diabetes assessment

  1. Patients with ischemic stroke or TIA should be screened for diabetes with a fasting plasma glucose, glycated hemoglobin (A1C) or 75 g oral glucose tolerance test soon after admission to hospital (Evidence Level C) [16].

  2. For patients with diabetes and either ischemic stroke or TIA, glycated hemoglobin (A1C) should be measured as part of a comprehensive stroke assessment (Evidence Level B).

• 5.2 Diabetes management

  1. Glycemic targets must be individualized; however, therapy in most patients with type 1 or type 2 diabetes and stroke or TIA should be treated to achieve a glycated hemoglobin (A1C) level ≤7·0% to reduce the risk of microvascular complications (Evidence Level A) and, in individuals with type 1 diabetes, macrovascular complications (Evidence Level C).

  2. To achieve an A1C ≤7·0%, patients with type 1 or type 2 diabetes should aim for a fasting plasma glucose or preprandial plasma glucose target of 4·0 to 7·0 mmol/l (Evidence Level B).

  3. The two-hour postprandial plasma glucose target is 5·0 to 10·0 mmol/l (Evidence Level B). If A1C targets cannot be achieved with a postprandial target of 5·0 to 10·0 mmol/l, further postprandial blood glucose lowering, to 5·0 to 8·0 mmol/l, can be considered (Evidence Level C).

  4. Adults with diabetes and ischemic stroke are at high risk of further vascular events and should also be treated with a statin to achieve a low-density lipoprotein cholesterol ≤2·0 mmol/l (Evidence Level A).

  5. Unless contraindicated, low-dose acetylsalicylic acid (ASA) therapy (80 to 325 mg/day) is recommended in all patients with diabetes with evidence of stroke or cardiovascular disease (Evidence Level A).

Section 6: Antiplatelet therapy in ischemic stroke and TIA

• 6.0 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 (Evidence Level A).

  1. Acetylsalicylic acid (80 mg to 325 mg), combined ASA (25 mg) and extended-release dipyridamole (200 mg), or clopidogrel (75 mg) are all appropriate options, and selection should depend on the clinical circumstances (Evidence Level A).

  2. Short-term concurrent use of ASA and clopidogrel (up to 90 days) has not shown an increased risk of bleeding (Evidence Level A); however, longer-term use is not recommended for secondary stroke prevention, unless there is an alternate indication (e.g. drug-eluting stent requiring dual antiplatelet therapy), due to an increased risk of bleeding and mortality (Evidence Level A).

  3. The combination of ASA (81 mg) and clopidogrel 75 mg is still of uncertain benefit in the Canadian setting for early prevention of recurrent stroke when used within 90 days, and should not be routinely used in all patients (Evidence Level C). Although the CHANCE clinical trial has demonstrated the efficacy of 21 days ASA and clopidogrel therapy in a Chinese population, the generalization of these findings to the Canadian population and North America standards of care remains unclear. These findings will be further investigated in the POINT trial.

  4. At the present time, there is not enough evidence to guide management if a patient has a stroke while on a specific antiplatelet agent (Evidence Level C). In all cases of recurrent stroke while on antiplatelet therapy, all other vascular risk factors should be reassessed and aggressively managed. Refer to Prevention of Stroke section 2 on Lifestyle and Risk Factor Management for additional recommendations.

  5. In children with stroke the usual maintenance dosage of ASA is 1 to 5 mg/kg per day for the prevention of recurrent stroke (Evidence Level B). The usual maximum dose is 81 mg/day.

  6. The evidence for clopidogrel use in children is sparse at this time. Clopidogrel may be considered an alternative for adolescents at a dose of 1 mg/kg/day up to a maximum of 75 mg/day. Younger children may have higher anti-platelet effects of clopidogrel, and the suggested doses should be considered within the range of 0·2–0·5 mg/kg/day (Evidence Level C).

Refer to Prevention of Stroke section 7 on Stroke and Atrial Fibrillation for additional recommendations on anticoagulant therapy.

Section 7: Anticoagulation for individuals with stroke and atrial fibrillation

• 7.1 Detection of Atrial Fibrillation

  1. All patients with suspected TIA or ischemic stroke should undergo a 12-lead ECG to assess baseline cardiac rhythm and identify atrial fibrillation or flutter, and to provide information regarding evidence of structural heart disease (i.e. previous myocardial infarction, left ventricular hypertrophy) (Evidence Level C).

  2. In cases where the ECG or initial cardiac rhythm monitoring (e.g. 24 or 48 h ECG monitoring) does not show atrial fibrillation but a cardioembolic mechanism is suspected, prolonged ECG monitoring is recommended in selected patients for detection of paroxysmal atrial fibrillation (Evidence Level B) [17].

• 7.2 Prevention of recurrent stroke in patients with nonvalvular atrial fibrillation

  1. Patients with TIA or ischemic stroke and atrial fibrillation should receive oral anticoagulation (Evidence Level A).

     1. In most patients, direct oral anticoagulants (DOAC) such as apixaban, dabigatran, rivaroxaban, or edoxaban (when available in Canada), should be prescribed in preference over warfarin (Evidence Level B).

     2. When selecting oral anticoagulants, patient-specific criteria should be considered (Evidence level C). Refer to table 7 for additional information on anticoagulant medications, available at www.strokebestpractices.ca.

  2. The time to start oral anticoagulation following TIA or ischemic stroke is unclear and therapy should be started as soon as it is thought to be safe for the patient (Evidence Level C).

  3. For patients with acute ischemic stroke and atrial fibrillation, routine use of bridging with heparin is not recommended (Evidence Level B). Physicians should use antiplatelet agents until the patient is anticoagulated (Evidence Level C). Refer to Prevention of Stroke section 6 on Antiplatelet Therapy for Ischemic Stroke and TIA for additional recommendations on antithrombotic therapy.

• 7.3 Enhancing anticoagulation therapy and minimizing bleeding complications

  1. Medication adherence is important for patients on all oral anticoagulants. For patients with atrial fibrillation that are taking warfarin, careful dosing and consistent international normalized ratio monitoring is recommended to minimize adverse events; warfarin efficacy is dependent on maintaining therapeutic international normalized ratio control, and declines significantly when the international normalized ratio falls below 2·0 (Evidence Level A).

  2. For patients prescribed apixaban, dabigatran, rivaroxaban, or edoxaban (when available in Canada), renal function should be routinely monitored, and measured at least once annually or when there is a change in health status (Evidence Level C). Dose adjustments may be required based on changes in renal function if detected.

  3. Concomitant antiplatelet therapy with oral anticoagulation is not recommended in patients with atrial fibrillation unless there is a specific medical indication (Evidence Level B).

Section 8: Management of extracranial carotid disease and intracranial atherosclerosis

• 8.1 Symptomatic carotid stenosisPatients with TIA or nondisabling stroke and ipsilateral 50% to 99% internal carotid artery stenosis should have an evaluation by an individual with stroke expertise and selected patients should be offered carotid endarterectomy as soon as possible (Evidence Level B).

  1. Carotid stenosis should be measured by CTA alone or two concordant noninvasive imaging modalities such as MRA and carotid ultrasound or digital subtraction angiography (DSA) [Evidence Level C].

  2. Individuals with mild stroke or TIA should have carotid endarterectomy performed within 48 h of symptom onset (NASCET Trial, NNT = 3) [18], and within 14 days for patients who are not clinically stable within the first 48 h (Evidence Level B).

     1. Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity and mortality of less than 6% (Evidence Level A).

  3. Carotid stenting may be considered for patients who are not operative candidates for technical, anatomic or medical reasons (Evidence Level A).

     1. Interventionalists should have expertise in carotid procedures and an expected risk of peri-procedural morbidity and mortality rate of less than 5%.

  4. Carotid endarterectomy is more appropriate than carotid stenting for patients over age 70 who are otherwise fit for surgery because stenting carries a higher peri-procedural risk of stroke and death (Evidence Level A).

• 8.2 Asymptomatic and remotely symptomatic carotid stenosisCarotid endarterectomy may be considered for selected patients with 60% to 99% carotid stenosis who are asymptomatic or were remotely symptomatic (i.e. greater than six-months) (Evidence Level A).

  1. Stroke patients with asymptomatic carotid stenosis should receive aggressive medical management of risk factors as defined throughout the Prevention of Stroke Module (e.g. blood pressure, cholesterol, antiplatelet therapy) (Evidence Level B).

  2. Patients with asymptomatic carotid disease should be evaluated by a physician with expertise in stroke management (Evidence Level C).

  3. Patients should be evaluated to determine eligibility for carotid endarterectomy, such as a life expectancy of more than five-years, and an acceptable risk of surgical complications (Evidence Level A).

  4. In carefully selected patients, carotid endarterectomy should be performed by a surgeon with a less than 3% risk of perioperative morbidity and mortality (Evidence Level A).

  5. Carotid stenting may be considered in patients who are not operative candidates for technical, anatomic or medical reasons provided there is a less than 3% risk of peri-procedural morbidity and mortality (Evidence Level A).

• 8.3 Intracranial stenosis

  1. Intracranial stenting is not recommended for the treatment of recently symptomatic intracranial 70% to 99% stenosis (Evidence Level B).

  2. In the SAMMPRIS trial the medical management arm included dual antiplatelet therapy with ASA 325 mg and Clopidogrel 75 mg started within 30 days of stroke or TIA and treated for up to 90 days (Evidence Level B) [19]. This should be considered for each patient on an individual basis. In addition, there should be aggressive management of all vascular risk factors including blood pressure, lipids, diabetes mellitus, and other at-risk lifestyle patterns (Evidence Level A).

  3. In patients who have been managed with maximal medical therapy in the presence of intracranial stenosis and experience a recurrent stroke, there is lack of clear evidence to guide further management decisions; intracranial stenting may be reasonable in carefully selected patients (Evidence Level C).

Section 9: Smoking cessation for individuals with stroke

Note: The term ‘Smoking’ in these recommendations refers to tobacco and other inhaled substances.

• 9.0 All members of the interdisciplinary team should address smoking cessation and a smoke-free environment at every health-care encounter for active smokers.

  1. In all health-care settings along the stroke continuum (inpatient, ambulatory, and community), patient smoking status should be identified, assessed and documented (Evidence Level A).

  2. Provide unambiguous, nonjudgmental, and patient-specific advice regarding the importance of cessation to all smokers (Evidence Level B) and others who reside with the patient.

  3. Offer assistance with the initiation of a smoking cessation attempt – either directly or through referral to appropriate resources (Evidence Level A).

  4. People who are not ready to quit should be offered a motivational intervention to help enhance their readiness to quit (Evidence Level B).

  5. A combination of pharmacological therapy and behavioral therapy should be considered in all smoking cessation programs and interventions (Evidence Level A).

  6. The three classes of pharmacological agents that should be considered as first-line therapy for smoking cessation are nicotine replacement therapy, bupropion, and varenicline (Evidence Level A).

     1. The choice of appropriate pharmacotherapy should take into account the patient's medical stability, clinical needs, other medical factors, and patient preferences (Evidence Level C).

  7. For admitted stroke patients who are current smokers, protocols should be in place to manage nicotine withdrawal during hospitalization (Evidence Level B).

  8. There is a lack of clear evidence regarding the timing to initiate nicotine withdrawal/replacement therapy in patients following a stroke. Expert opinion suggests this should begin as soon as possible (Evidence Level C).

  9. Interdisciplinary team members should counsel patients, family members, and caregivers about the harmful effects of exposure to second-hand smoke (Evidence Level B).

Section 10: Sleep apnea and stroke

• 10.0 Obstructive sleep apnea (OSA) should be considered a risk factor for stroke and has also been shown to be present in many patients following a stroke (Evidence Level B). Preventative strategies should be in place for people with OSA or in stroke patients who develop sleep disturbances following a stroke (Evidence Level B).
• 10.1 Screening and assessment for sleep apnea

  1. Patients who have experienced a stroke or TIA should be screened for the presence of sleep apnea symptoms (Evidence level B).

     1. Screening for the presence of sleep apnea should occur during follow-up visits (Evidence level C), using a validated sleep apnea screening tool.

  2. Patients with symptoms suggestive of sleep apnea on initial screening should be referred to a sleep specialist (Evidence level C).

• 10.2 Management of OSA in patients with strokeStroke prevention strategies, including specific targeted management strategies for sleep apnea should be initiated for patients with confirmed sleep apnea post stroke or TIA, based on objective clinical assessment and investigations (Evidence Level B).

  1. The management of all treatable vascular disease risk factors should be optimized in patients with confirmed sleep apnea post stroke (Evidence Level B). Refer to other sections in this Secondary Prevention of Stroke Module for additional recommendations.

  2. First line therapies for the treatment of sleep apnea include:

     1. Avoidance of hypnotic and sedative medications and alcohol (Evidence Level B);

     2. Positional therapy (Evidence Level B);

     3. Weight loss (Evidence Level B);

     4. Continuous positive airway pressure (C-PAP) (Evidence Level B);

     5. Dental appliances (Evidence level B) in consultation with dental specialists.

  3. Long-term management plans should be developed in consultation with a sleep specialist (Evidence Level C).

  4. Refer to available comprehensive Sleep Apnea Guidelines for additional information on the management of sleep apnea [20].

• 10.3 Pediatric considerations: There is no direct evidence available to demonstrate a connection in children regarding sleep apnea and stroke. However, it is recommended that children with stroke be screened for signs and symptoms suggesting sleep apnea (Evidence Level C), or conditions predisposing them to sleep apnea, such as obesity, sickle cell disease, severe strokes, or structural airway problems (e.g. enlarged tonsils) (Evidence Level C).

  1. Any child with suspected sleep apnea should be referred to a pediatric sleep specialist (Evidence Level C).

Section 11: Patent foramen ovale and aortic arch atheroma in individuals with stroke

1. The current research evidence does not support closure of patent foramen ovale in individuals with stroke (Evidence Level A).
2. Stroke presumably related to a Patent Foramen Ovale should be managed following the stroke prevention recommendations included in this Heart and Stroke Foundation (HSF) Secondary Prevention of Stroke Module (Evidence Level C).
3. Aortic arch atheroma should be managed following the stroke prevention recommendations included in this HSF Secondary Prevention of Stroke Module (Evidence Level C).