1. Canadian Best Practice Recommendations for Stroke Care:2008
Prevention of Stroke
The Canadian Stroke Strategy was initiated in 2003, under the leadership of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada with a common vision that:
“ All Canadians have optimal access to integrated, high quality and efficient services in stroke prevention, treatment, rehabilitation and community reintegration. The Canadian Stroke Strategy serves as a model for innovative and positive health system reform in Canada and internationally.”

2. Defining Prevention Primary Prevention Secondary Prevention
Individually based clinical approach to disease prevention
Usually occurs in the primary care setting
Focuses on the importance of screening and monitoring high risk individuals of a first event
Secondary Prevention
Individually based clinical approach to reducing the risk of further vascular events in individuals who have experienced a stroke or transient ischemic attack and those who have medical conditions or risk factors that place them at high risk of stroke.
For the purposes of the Canadian Best Practice Recommendations for Stroke Care (Update 2008) definitions of primary and secondary prevention were developed to provide context for all recommendations included in this section.
Primary prevention is an individually based clinical approach to disease prevention and is directed towards preventing the initial occurrence of a disease in a healthy individual.
Primary prevention is typically implemented in the primary care setting by a physician, advanced practice nurse and the patient.
Primary prevention and health promotion recommendations related to stroke include lifestyle and risk factor management, hypertension screening, dyslipidemia screening and diabetes.
The recommendations focus on the importance of screening and monitoring these patients at high risk for a first stroke event.
For the purpose of this document, primary prevention and risk factor management in the general population is not the focus. However, selected recommendations related to primary prevention have been included.
Secondary prevention is an individually based clinical approach to reducing the risk of further vascular events in persons who have had a stroke or transient ischemic attack and in those who have medical conditions or risk factors that would place them at higher risk of stroke.
Secondary prevention recommendations include lifestyle management, hypertension, dyslipidemia, antiplatelet therapy, anticoagulant therapy and carotid revascularization.
The target audience for this section are patients who have had a stroke or transient ischemic attack and those who are highest risk of an event.
The goal of this set of recommendations is to reduce the recurrence rates for stroke and TIA through rapid and comprehensive follow-up of patients and implementation of secondary prevention strategies.

3. 2.0 Prevention of Stroke 2.1 Lifestyle and Risk Factor Management
2.2 Blood Pressure Management
2.3 Lipid Management
2.4 Diabetes Management
2.5 Antiplatelet Therapy
2.6 Antithrombotic Therapy in Atrial Fibrillation
2.7 Carotid Intervention
Recommendation 2 focuses on the Prevention of Stroke and includes the following:
Lifestyle Management and Risk Factor Management
Blood Pressure Management
Lipid Management
Diabetes Management
Antiplatelet Therapy
Antithrombotic Therapy in Atrial Fibrillation
Carotid Intervention

4. Risk Factors Non-Modifiable Modifiable Hypertension Age Obesity Gender
Atrial Fibrillation
Diabetes
Cardiac Disease
Hyperlipidemia
Excessive Alcohol Intake
Physical Activity
Smoking
Stress
Hormone Replacement Therapy
Age
Gender
Family History
Ethnicity
Previous TIA or Stroke
Virtually all individuals have at least one risk factor and the prevalence of risk factors in the Canadian population is high. It is estimated that 75% of all Canadian adults have at least one life style-related risk factor.

5. 2.1 Lifestyle and Risk Factor Management
Persons at risk of stroke and patients who have had a stroke should be assessed for risk factors and lifestyle management issues including:
Diet
Sodium intake
Smoking
Exercise
Weight
Alcohol intake
They should receive information and counseling about possible strategies to modify their lifestyle and risk factors.
This recommendation addresses the need for reducing risk factors through a variety of lifestyle management strategies.
While hypertension is the single most important modifiable risk factor for stroke, recent research estimates that reducing sodium in foods would abolish high blood pressure for almost one in three Canadians.
Patients can be directed to the Heart and Stroke Foundation website to complete a simple online self assessment tool that will identify their risk of heart disease and stroke, provide tips, advice and support to help prevent or control high blood pressure and develop a personalized action plan.
The program is called the Blood Pressure Action Plan.
The website is

6. 2.1 Lifestyle and Risk Factor Management
Healthy balanced diet
High in fresh fruits and vegetables
Low fat dairy products
Dietary and soluble fibre
Whole grains
Proteins from plant foods
Low in saturated fats
Low cholesterol
Low sodium
Dietary Resources
Canada’s Food Guide to Healthy Eating
A healthy balanced diet high in fresh fruits and vegetables has been reported to contribute to the reduction of stroke risk.
This effect was independent of BMI, smoking, glucose tolerance, physical activity, blood pressure, serum cholesterol and intake of energy, ethanol and fat (Gillman et al, 1995).
Analysis of combined data from the Nurses Health Study and the Health Professionals Follow-up Study, researchers found that increasing the daily serving of fruits and vegetables by one serving contributed to the most reduction of stroke risk (Joshipura et al, 1999).
A strategy to assist in the implementation of the recommendations related to stroke prevention is to include the pharmacotherapy's and parameters into preprinted stroke admission orders.
The inclusion of risk factor management and secondary stroke prevention strategies should be included in the management plan across the continuum for the stroke survivor.
Access to education opportunities both online and didactic with case study inclusion help to increase the awareness and use of these recommendations.
Providing patients and families with referrals and information related to risk factor management is helpful and available both online, through information sessions and printed material.

7. 2.1 Lifestyle and Risk Factor Management
Sodium:
Recommended amounts of sodium per day from all sources is the Adequate Intake based on age.
Should not exceed an upper limit of 2300mg (1 teaspoon).
Sodium Resources:
Blood Pressure Canada suggests that the average Canadian diet contains about 3500 mg of sodium per day and approximately one million Canadians have hypertension due to excessive intake of sodium.
Blood Pressure Canada has released the following policy goal: Given that the Institute of Medicine of the National Academies has established a daily adequate intake for sodium of 1200 mg and a daily Tolerable Upper Intake Level of 2300 mg for healthy adults and that these values have been adopted by the Canadian and American governments for setting public healthy policy, the goal is to have Canadian adults reduce their sodium intake to within this range.

8. Recommendations for Adequate Sodium Intake by Age
Sodium Intake per Day (mg)
0-6 months
120
7-12 months
370
1-3 years
1000
4-8 years
1,200
9-50 years
1,500
50-70 years
1,300
> 70 years
This is a table defining the Adequate Intake amounts for all age groups.
Daily sodium intake should be targeted to these amounts.
Institute of Medicine,2004. Dietary Reference Intakes: Water, Potassium, Sodium Chloride, Sulfate.

9. Equivalent Measurements of Sodium and Salt
For example:
Two slices (292 grams total) of a Pepperoni Lover's large stuffed crust pizza at Pizza Hut contain 3,000 mg of sodium, double the recommended intake for a full day. .
Sodium (mg)
Sodium (mmol)
Salt (g)
500 22
1.25
1,500 65
3.75
2,000 87
5.0
2,300
100
5.8
2,400
104
6.0
3,000
130
7.5
4,000
174 10

10. 2.1 Lifestyle and Risk Factor Management
Physical Activity
Moderate exercise (accumulation of 30 to 60 minutes) four to seven days per week
Brisk walking
Jogging
Cycling
Swimming
Medically supervised programs are recommended for high risk patients.
A meta-analysis published by Lee et al (2003) reviewed 23 studies (18 cohort and 5 case control studies), examining the association between physical activity and stroke incidence and mortality.
When examined together, the studies revealed that highly active people were reported as having a 27% lower risk of stroke than people who were designated as low active.
People who were designated as moderately active also demonstrated a significantly reduced risk of stroke when compared to the low active group.
The benefits of both high and moderate levels of activity were reported for both ischemic and hemorrhagic strokes.
It should be noted that although this analysis demonstrates a risk reduction related to physical activity, there is a wide variation in the studies of the definitions of low, moderate and high levels of physical activity.

11. 2.1 Lifestyle and Risk Factor Management
Weight
Maintain goal of a body mass index (BMI) of 18.5 to 24.9 kg/m2 and a waist circumference of less than 88 cm for women and less than 102 cm for men.
Waist circumference should be measured annually and during secondary prevention assessments.

12. 2.1 Lifestyle and Risk Factor Management
Smoking
Smoking cessation and smoke free environment
Nicotine replacement therapy and behavioural therapy
Risk of stroke in relation to smoking acts in a dose-dependant fashion.
Heavy smokers are more at risk than light smokers.
Light smokers are more at risk that non- smokers.
Risk is greatest in the middle years and declines with age.

13. 2.1 Lifestyle and Risk Factor Management
Alcohol Consumption
Two or fewer standard drinks per day
Fewer than 14 drinks per week for men
Fewer than 9 drinks per week for women
A meta-analysis (Reynolds et al, 2003) revealed that individuals who consumed one to two drinks per day had the least risk of stroke and those that had more than five drinks per day had the most risk of stroke when compared to a group of abstainers.
Heavy drinking (more than five drinks per day) was associated with the risk of hemorrhagic stroke.
Irregular and binge drinking (more than five drinks at one time) have been associated with an increase risk of hemorrhagic stroke.
Data from the Copenhagen City Heart Study was reviewed to examine whether the type of alcohol consumed was related to the decreased risk of ischemic stroke with moderate alcohol consumption.
The overall benefit of moderate consumption was confirmed but the benefit was mostly seen in those that consumed wine.

14. System Implications
Health promotion efforts that contribute to the primary prevention of stroke in all communities and are integrated with existing chronic disease prevention initiatives.
Stroke prevention approaches are offered by primary care providers across the continuum at healthcare encounters.
National and international efforts to reduce sodium intake and increase public knowledge about the risks of sodium, directly targeting the food industry.
Access to risk factor management programs in all communities, primary healthcare settings, workplaces.
These next few slides present some of the system implications that may be considered in order to support implementation of the recommendation.
Groups may want to also consider system implications that relate more closely to their environment.
Linking with existing chronic disease prevention groups can further help to strengthen efforts targeted towards potential people at risk for stroke.
Potential stroke clients often have multiple risk factors that also are applicable to other chronic diseases.
Consider initiatives that increase the awareness of identifying and implementing stroke prevention strategies across the continuum.
It will be important to plan for ongoing monitoring, evaluation and communication of findings to contribute to quality improvement.

15. Selected Performance Measures
The proportion of the population with major risk factors for stroke, including hypertension, obesity, history of smoking, low physical activity, hyperlipidemia, diabetes, atrial fibrillation.
Percentage of the population who can identify the major risks of stroke.
The annual occurrence of stroke in each province and territory by stroke type.
Stroke mortality rates across provinces and territories, including in-hospital or 30 day and one year
These listed performance measures have been identified by the Canadian Stroke Strategy Information and Evaluation Working Group in consultation with the Best Practices Working Group.
Highlighted performance measures are the initial measures that should be put in place. Additional measures should also be adopted for more in-depth monitoring where possible.
Please refer to the Canadian Best Practice Recommendations for Stroke Care:2008 document and the CSS Performance Measurement Manual for more details.
Performance measures enable monitoring of patients at risk and the effectiveness of prevention strategies
Some performance measures are easier to collect or are currently being collected.
The Canadian Community Health Survey provides information on risk factors that can be presented at the regional level or even to the neighbourhood.
These are presented here to promote discussion and consideration of opportunities

16. 2.2 Blood Pressure Management
Hypertension is the single most important risk factor for stroke.
Blood pressure should be monitored in all persons at risk for stroke.
Numerous studies have found that elevated blood pressure is a powerful risk factor for primary and recurrent strokes. It is the most important modifiable risk factor for stroke.
Lewington, 2002 reported a meta-analysis of 61 studies with more than 1 million participants, an average 12 year follow-up and 120,000 recorded deaths, that showed that each 2mm Hg reduction in systolic blood pressure is associated with a 10% reduction in mortality from stroke.
Canadian Hypertension Education Program (CHEP) states that about 25% of adult Canadians are hypertensive and with current lifestyles, over 90% will develop hypertension.
It is important that all Canadians have their blood pressure checked at each encounter in the health care system. Blood pressure increases with age such that 50% of Canadians over 65 have hypertension.
Patients found to have hypertension need to have a more thorough assessment. This assessment should follow the CHEP guidelines so that a comprehensive treatment plan, that includes identification of other risk factors, lifestyle modifications, pharmacotherapy and ongoing monitoring.
The CHEP website is:
Patients can be directed to the Heart and Stroke Foundation website to complete a simple online self assessment tool that will identify their risk of heart disease and stroke, provide tips, advice and support to help prevent or control high blood pressure and develop a personalized action plan.
The program is called the Blood Pressure Action Plan.
The website is

17. 2.2a. Blood Pressure Assessment
All persons at risk for stroke should have their blood pressure measured at each healthcare encounter but no less than once annually.
Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement <www. hypertension.ca>.
Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Program.
Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications.
Most patients with stroke or TIA will benefit from treatment with a blood pressure lowering agent, regardless of the presence of hypertension.
For secondary prevention, ACE inhibitors, angiotensin receptor blockers and thiazide diuretics have all shown to reduce recurrent stroke and other vascular events.
There is less evidence on the role of beta blockers and calcium channel blockers in the secondary prevention of stroke but there may be some benefit.
Aggressive treatment of blood pressure is of greater benefit than more modest reductions.
Angio tension receptor blockers (ARB) have also demonstrated efficacy for the prevention of stroke in both primary and secondary settings.
CHEP has identified target blood pressure levels based upon evidence and can be obtained from the CHEP website:
CHEP has placed a major emphasis on proper home blood pressure techniques and these should be shared with patients.

18. 2.2b. Blood Pressure Management
Target blood pressure levels as defined by CHEP guidelines for prevention of first stroke, recurrent stroke and other vascular events.
RCTs have not defined the optimal time to initiate blood pressure lowering therapy after stroke or transient ischemic attack.
For patients with non-disabling stroke or transient ischemic attack not requiring hospitalization, it is recommended that blood pressure lowering treatment be initiated or modified at the time of the first medical assessment.
Target blood pressure should be less than 140/90 for all patients with stroke or at high risk of stroke.

19. CHEP 2008 Recommendations for the Management of Blood Pressure
Condition
Recommendation
Prevention of first stroke in general population
Target: 140/90mmHg
Patients who have had a stroke/TIA
Target: <140/90mmHg
Patient with diabetes for prevention of first stroke/TIA
Target: 130/80mmHg
Non-diabetic chronic kidney disease
Target: <130/80mmHg
Ideally the targets should be even lower and studies are underway to better define the appropriate lower target rate for stroke patients.

20. System Implications
Coordinated hypertension awareness programs at provincial and community levels that involve community groups, pharmacists, primary care and other relevant partners.
Stroke prevention including routine blood pressure monitoring, offered by primary care providers in the community as part of comprehensive patient management.
These next few slides present some of the system implications that may be considered in order to support implementation of the recommendation.
Groups may want to also consider system implications that relate more closely to their environment.
Linking with existing chronic disease prevention groups can further help to strengthen efforts targeted towards potential people at risk for stroke.
Potential stroke clients often have multiple risk factors that also are applicable to other chronic diseases.

21. Selected Performance Measures
Proportion of the population who have diagnosed elevated blood pressure.
Percentage of the population with known hypertension who are on blood pressure lowering therapy.
Proportion of stroke/TIA patients prescribed blood pressure lowering agents on discharge from acute care.
There are several performance measures for monitoring hypertension and related prevention strategies.
The highlighted measures are higher priorities for measurement.
Generally the data on stroke unit admissions and duration of stay is not available in administrative datasets and will need to be collected through chart audit or other local tracking systems.

22. 2.3 Lipid Management
Lipid levels should be monitored in all persons at risk for stroke.
Assessment and management of dyslipidemia is an important aspect of stroke prevention.
Fasting lipid levels include: TC,TG,LDL-C,HDL-C
Major cardiovascular risk factors include: diabetes, smoking, hypertension, obesity, cardiovascular disease, lupus, exertional chest discomfort, evidence of atherosclerosis.
The Heart Protection Study (HPS, 2004) showed that Simvastatin 40mg once a day rapidly produced a definite and substantial reduction in ischemic stroke, irrespective of patient age, gender or blood lipid levels. It also showed that statin therapy reduced the risk of major vascular events among people who had previously had a stroke or other cerebrovascular event, even if they did not manifest coronary disease.

23. 2.3a. Lipid Assessment
Fasting lipid levels (TC,TG,LDL-C,HDL-C) should be measured every 1-3 years for all men 40 years or older and post menopausal women and/or 50 years or older.
More frequent testing should be done for patients with abnormal values or if treatment is initiated.
Adults at any age should have their blood lipid levels measured if they have a history of diabetes, smoking, hypertension, obesity, ischemic heart disease, renal vascular disease, peripheral vascular disease, ischemic stroke, TIA or symptomatic carotid stenosis.
Most patients with TIA or stroke will benefit from statin therapy.
A large meta-analysis of the use of various lipid-lowering agents found that only statins reduce the risk of stroke, with a risk reduction of 26% for secondary prevention (Corvol, 2003).
Other possible effects of statins include the following:
Anti-inflammatory properties may help to stabilize the lining of the blood vessels.
Statins may help relax blood vessels thus contributing to lower blood pressure.
Statins may have a blood thinning effect thus reducing the risk of blood clots.

24. 2.3b. Lipid Management
Ischemic stroke patients with LDL-C >2.0mmol/L should be managed with lifestyle modification, dietary guidelines.
Statin agents should be prescribed for most patients who have had an ischemic stroke or transient ischemic attack to achieve current recommended lipid levels.
The target lipid levels provided in these recommendations align with the Canadian Dyslipidemia organization rates published in 2006.

25. System Implications
Coordinated dyslipidemia awareness programs at the provincial and community levels that involve community groups, pharmacists, primary care and other relevant partners.
Stroke prevention, including lipid level monitoring offered by primary care providers in the community as part of comprehensive patient management.
In order for stroke prevention recommendations to be successfully implemented, several structural pieces and supports from management need to be in place.

26. Performance Measures
Proportion of the population who report that they have elevated lipid levels, especially LDL.
Proportion of stroke patients prescribed lipid-lowering agents for secondary prevention of stroke:
At discharge from acute care
Through secondary prevention clinic
By primary care
Proportion of stroke patients with an LDL-C between mmol/L at 3 months post stroke.
There are several performance measures for monitoring lipid levels and related prevention strategies.
The highlighted measures are higher priorities for measurement.

27. 2.4 Diabetes Management 2.4a. Diabetes Assessment
All individuals in the general population should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria.
A fasting plasma glucose (FPG) should be performed every three years in individuals >40 years of age to screen for diabetes.
Risk factors include:
Family history
High risk population
Vascular disease
History of gestational diabetes
Hypertension
Dyslipidemia
Polyvystic
ovary syndrome
Overweight
Abdominal
obesity
Diabetes is a major risk factor for stroke and most adults with type 1 or 2 diabetes should be considered at high risk for vascular disease.
Diabetes is a particularly strong risk factor in younger patients with studies suggesting an increased stroke risk as high as 10 fold in some younger subgroups.
Some of these risk factors include: family history, high risk population, vascular disease, history of gestational diabetes, hypertension, dyslipidemia, overweight, abdominal obesity, polycystic ovary syndrome.
Diabetes increases the risk of ischemic stroke more than hemorrhagic stroke.
Studies have also shown that patients with diabetes that experience a stroke may have a worse outcome, however, there is no evidence that diabetes induces a larger area of infarction.
Many patients may exhibit metabolic syndrome and additional risk factors such as hypertension, hyperdyslipidemia which further increase the risk of TIA/Stroke.
Reducing risk factors to target levels is essential and involves a multi-issue approach including lifestyle modifications, tight glycemic control, antiplatelet drugs (aspirin), control of lipid levels and blood pressure control.
If patients are receiving treatment for dyslipidemia, more frequent testing should be done.

28. 2.4 Diabetes Management 2.4a. Diabetes Assessment
In adults, fasting lipid levels (TC, HDL-C, TG, calculated LDL-C) should be measured at the time of diagnosis of diabetes and then every one to three years as clinically indicated.
More frequent testing should be done if treatment for dyslipidemia is initiated.
Blood pressure should be measured at every diabetes visit.
These recommendations for managing diabetes in stroke patients align with the newest recommendations from the Canadian Diabetes Association, published in October 2008.
The Canadian Diabetes Clinical Practice Guidelines 2008 are available at:

29. 2.4 Diabetes Management 2.4b. Diabetes Management
Glycemic targets must be individualized
To achieve an HbA1c <7.0%, patients with type 1 or type 2 diabetes should aim for a fasting plasma glucose or preprandial plasma glucose targets of 4.0 to 7.0 mmol/L.
The 2-hour postprandial plasma glucose target is 5.0–10.0 mmol/L [Evidence Level B]. If HbA1c targets cannot be achieved with a postprandial target of 5.0–10.0 mmol/L, further postprandial blood glucose lowering, to 5.0–8.0 mmol/L, can be considered.
To achieve an A1C≤ 7.0mmol/l FPG or preprandial PG, targets are identified as:
mmol/l
2 hour postprandial PG targets mmol/l
PG targets toward normal range include:
A1C≤6.0%
FPG/preprandial PG mmol/l
2 hour postprandial PG mmol/l

30. 2.4 Diabetes Management 2.4b Diabetes Management
Adults at high risk of a vascular event should be treated with a statin to achieve an LDL-Cholesterol ≤2.0 mmol/l.
Unless contraindicated, low dose ASA therapy (80-325mg/day) is recommended in all patients with diabetes with evidence of cardiovascular disease and those with atherosclerotic risk factors.

31. System Implications
Coordinated diabetes awareness programs at the provincial and community levels that involve community groups, pharmacists, primary care and other relevant partners.
Coordinated education and support programs for persons with diabetes to increase compliance and reduce ongoing risks for cardiovascular complications.
In order for recommendations related to diabetes prevention strategies to be successfully implemented, several structural pieces and supports from management need to be in place.

32. Performance Measures
Proportion of the population with a confirmed diagnosis of diabetes (Type l and Type ll).
Proportion of persons with diabetes presenting to hospital with a new stroke event.
Monitoring the relationship between stroke and diabetes will help organizations be more aware of the population needs and therefore target strategies appropriate to those populations.
Highlighted performance measures are the initial measures that should be put in place. Additional measures should also be adopted for more in-depth monitoring where possible.

33. 2.5 Antiplatelet Therapy
All patients with ischemic stroke or transient ischemic attack should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for anticoagulation.
There is a 25% relative risk reduction in recurrent stroke for patients treated with ASA (Antithrombotic Trialists’ Collaboration. BMJ, 2002).
There is also some evidence to support the use of alternative antiplatelet agents including extended-release dipyridamole plus ASA or clopidogrel.
Long term use of combinations of aspirin and clopidogrel are not recommended. Studies revealed that the combination of aspirin and clopidogrel did not reduce the rate of myocardial infarction, stroke or death from cardiovascular causes and in one study there was an increase in the incidence of major bleeding in the group that received combination of aspirin and clopidogrel.

34. 2.5 Antiplatelet Therapy
Aspirin (ASA), combined ASA and extended release dypyridamole, or clopidogrel may be used depending in the clinical circumstances.
For adult patients on ASA, the usual maintenance dosage is mg/day.
For children with stroke, the usual maintenance dosage for ASA is 3-5 mg/kg per day.
Long term combinations of aspirin and clopidogrel are not recommended.

35. System Implications
Stroke Prevention Clinics in place to improve secondary stroke prevention care.
Optimization of strategies at local, regional and provincial levels to prevent recurrence of stroke.
Stroke prevention awareness and education of secondary prevention for primary care practitioners and specialists who manage stroke patients during the acute phase and post-discharge from acute care.
Stroke prevention clinics and protocols for rapid and comprehensive assessment of stroke patients to reduce the risk of recurrence are important to have in place in order to effectively implement these recommendations.

36. Performance Measures
Proportion of stroke/TIA patients prescribed antiplatelet therapy on discharge from acute care.
Proportion of stroke/TIA patients prescribed antiplatelet therapy on discharge from secondary prevention clinic
Monitoring the rates of antiplatelet prescribing will identify areas where opportunities for improvement may exist.
Performance measures, that are highlighted, are the initial measures that should be put in place. Additional measures should also be adopted for more in-depth monitoring where possible.

37. 2.6 Antithrombotic Therapy in Atrial Fibrillation
Patients with stroke and atrial fibrillation should be treated with warfarin at a target INR of 2.5, range 2.0 to 3.0 (target INR of 3.0 for mechanical cardiac valves, range 2.5 to 3.5).
These patients should be likely to be compliant with the required monitoring and are not at high-risk for bleeding complications.
There is general agreement that all patients with atrial fibrillation should be considered for treatment with warfarin or aspirin for primary prevention of stroke.
There is also strong recommendations for warfarin in patients at high risk of stroke.
The Cochrane Review suggests that there is a 68% relative risk reduction in recurrent stroke for patients anticoagulated with adjusted-dose warfarin (Cochrane, 2003).
For patients with atrial fibrillation and recent cerebral ischemia, warfarin is indicated over aspirin for secondary stroke prevention.
The timing for anticoagulation is variable but in most cases should take place prior to discharge.
The Cochrane Library identified 2 trials (Saxena et al, 2006), the European Atrial Fibrillation Trial involving 455 patients who received either anticoagulants (INR ) or aspirin (300mg/day). Patients joined the trial within 3 months of a TIA or minor stroke. Follow-up mean was 2.3 years. The second trial was the Studio Italiano Fibrillazione Atriale trial with 916 patients with NRAF and a TIA or minor stroke, within 15 days and were randomized to either open label anticoagulants or indobufen. Follow-up was one year. While there were incidents of intracranial bleeding, the absolute difference was small.
The evidence demonstrated that anticoagulant therapy was superior to antiplatelet therapy for stroke prevention in patients with NRAF and recent non-disabling stroke or TIA.
Potential patients need to be compliant with required monitoring and are not at high risk for bleeding complications.

38. System Implications
Stroke Prevention Clinics to improve secondary stroke prevention including management of atrial fibrillation in patients with stroke and TIA.
A process for appropriate outpatient monitoring of patient INR levels and follow-up communication with patients taking anticoagulants.
Optimization of strategies at local, regional and provincial levels to prevent recurrence of stroke.
Stroke prevention awareness and education of secondary prevention for primary care practitioners and specialists who manage stroke patients during the acute phase and post-discharge from acute care.

39. Performance Measures
Proportion of eligible stroke/TIA patients with atrial fibrillation prescribed anticoagulant therapy on discharge from acute care.
Proportion of stroke/TIA patients with atrial fibrillation prescribed anticoagulant therapy after a visit to a secondary stroke prevention clinic.
Proportion of patients with stroke and atrial fibrillation on aspirin and not prescribed anticoagulant agents.
Proportion of patients on warfarin with INR in therapeutic range at 3 months and 1 year following index of stroke event.
Recent studies show that the rates of anticoagulant prescribing are low and many opportunities for improvement in implementation of these recommendations exist.
Highlighted performance measures are the initial measures that should be put in place. Additional measures should also be adopted for more in-depth monitoring where possible.

40. 2.7 Carotid Intervention 2.7a. Symptomatic Carotid Stenosis
Patients with transient ischemic attack or nondisabling stroke and ipsilateral 70-99% internal carotid artery stenosis should be offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke unless contraindicated.
Carotid endarterectomy recommended for selected patients with moderate (50 to 69% symptomatic stenosis , should be evaluated by a physician with expertise in stroke management).
Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity and mortality of <6%.
Surgery to treat symptomatic carotid artery stenosis may be beneficial in specific patient types, significantly reducing the risk of recurrent stroke.
Carotid intervention is recommended in selected patients with moderate (50-69%) symptomatic stenosis. These patients should be assessed by a physician with expertise in stroke management.
The benefit of endarterectomy depends not only on the degree of stenosis but also on the timing of the surgery after the event.
The results of a recent pooled analysis of NASCET and ECST (Rothwell et al, 2004) demonstrated that the timing of surgery made a significant difference to patients.
Patients with severe stenosis (70-99%) benefited most from surgery performed within 2 weeks of the event.
Carotid endarterectomy for asymptomatic patients is controversial and not recommended in this document.
The standard of care procedure is a carotid endarterectomy which should be performed by a surgeon with a known perioperative morbidity and mortality rate of <6%.
Studies have shown that unfortunately, referral of appropriate patients for assessment for endarterectomy is inconsistent. The role of the stroke prevention clinic is large in ensuring appropriate adherence to guidelines for patient selection.
Carotid stenting may be offered open-label to those patients who are not operative candidates for technical, anatomical or medical reasons.
Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis.

41. 2.7 Carotid Intervention 2.7a. Symptomatic Carotid Stenosis
Carotid stenting may be considered for patients who are not operative candidates for technical, anatomical or medical reasons.
Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis.

42. 2.7 Carotid Intervention 2.7b. Asymptomatic Carotid Stenosis
Carotid endarterectomy may be considered for selected patients with asymptomatic 60-99% carotid stenosis.
Patients should be less than 75 years old with a surgical risk <3%, a life expectancy >5 years, and be evaluated by a physician with expertise in stroke management.
This is a new recommendation added in 2008.

43. System Implications
Initial assessment performed by clinicians experienced in stroke that are able to determine carotid territory involvement.
Timely access to diagnostic services for evaluating carotid arteries.
Timely access to surgical consults, including a mechanism in place for expedited referrals as required.
It is important that protocols and agreements be in place to ensure timely access to surgical services for patients requiring carotid endartarectomy.

44. Selected Performance Measures
Proportion of stroke patients with moderate to severe (70-99%) carotid artery stenosis who undergo a carotid intervention procedure following the index stroke.
Median time from stroke symptom onset to carotid endarterectomy surgery.
Proportion of stroke patients requiring carotid intervention, who undergo the procedure within two weeks of the index stroke event.
Proportion of moderate (50-69%) carotid stenosis who undergo carotid intervention procedure following the index stroke event.
These are the key performance measures for monitoring CEA in populations requiring this intervention. The target is for surgery to be completed within two weeks of stroke onset.
Highlighted performance measures are the initial measures that should be put in place. Additional measures should also be adopted for more in-depth monitoring where possible.

45. Stroke Prevention: Example
A Best Practice Example
Include a Stroke Prevention Best Practice example that profiles the region if it is available. If a local example is not available, consider an example from another region.

46. Implementation Tips
Form a working group, consider both local and regional representation.
Complete a gap analysis to compare current practices using the Canadian Best Practice Recommendations for Stroke Care Update: 2008 Gap Analysis Tool.
Identify strengths, challenges, opportunities
Identify 2-3 priorities for action
Identify local and regional champions
The implementation of recommendations can be a challenge and overwhelming for clinicians. This slide lists suggestions that may help to guide teams in their planning. These tips can be used both locally within an institution or regionally.
Form a working group that is willing to participate in looking at this issue. It is advisable to have the group comprised of both clinicians, managers, decision makers such as executives and stroke survivors and their caregivers. The working group should also reflect the care continuum, be able to create linkages with other health care providers and/or institutions as needed, include community organizations and services and stroke expertise.
Review the CSS Best Practice Recommendations and compare with current practices.
Analyze practices that are considered strengths, challenges and possible opportunities for change (See Gap Analysis Tool).
If available, utilize data that may help inform where needs exist.
Identify 2-3 priorities that the workgroup agrees on and develop an action plan. Include possible resources needed, data to be collected for evaluation of the plan, a communication plan, timelines, and key stakeholders.
Local and regional champions are important to the success of implementation. Gifford et al, 2006, looked at leadership strategies that influenced the use of clinical practice guidelines. They found that there were key behaviours and activities that contributed to successful implementation and sustainability. Although the target group was nursing, the behaviours and activities could be applicable to the role of the local and regional champions.
Key themes were:
Facilitate staff to use the guidelines/recommendation
Provide support (addressing clinician concerns, encouraging staff and creating opportunities for education).
Accessible and visible (bringing the guidelines/recommendations to staff).
Communicate well (utilizing multifaceted forms of communication, acknowledging staff efforts).
Create a positive milieu of best practice
Reinforce goals and philosophy (ensuring the change and use of the recommendations is embedded in the organization’s goals and philosophy).
Influence change (champions have a reputation for trying new things and being innovative, working well with teams and other departments to influence change).
Role Model Commitment
Ensure education and policies (ongoing staff education, development of documentation forms, policies to support practice change)
Monitor clinical outcomes (use of data can inform progress and quality assurance)
Support development of clinical champions (development of ongoing champions to model and influence practice behaviour).

47. Implementation Tips
Identify professional education needs and develop a professional education learning plan.
Consider local or regional workshops to focus on stroke prevention.
Access resources such as Heart and Stroke Foundation, provincial contacts
Consult with other strategies for lessons learned, resources.

48. www.canadianstrokestrategy.ca www.cmaj.ca
It is always important to keep perspective as we work to implement integrated stroke care.
Stroke patients, their family and caregivers should always be at the core of the work we do.
We will now take comments and questions. The Canadian Best Practice Recommendations for Stroke Care 2008 can be obtained from the following websites: 48

49. Thank the audience.
Take questions, facilitate discussion.