Canadian Stroke Best Practice

Recommendations: Secondary Prevention

of Stroke Update 2020

David J. Gladstone, M. Patrice Lindsay, James Douketis, Eric E. Smith ,

Dar Dowlatshahi, Theodore Wein , Aline Bourgoin, Jafna Cox, John B. Falconer,

Brett R. Graham, Marilyn Labrie, Lena McDonald, Jennifer Mandzia, Daniel Ngui,

Paul Pageau, Amanda Rodgerson, William Semchuk, Tammy Tebbutt,

Carmen Tuchak, Stephen van Gaal , Karina Villaluna, Norine Foley,

Shelagh Coutts, Anita Mountain, Gord Gubitz, Jacob A Udell, Rebecca McGuff,

risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes,

atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of

the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment

of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are

revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor

stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermin ed source ; low-density lipoprotein lowering;

hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical

guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer- associated ischemic stroke is

addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care

delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been

University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences, Calgary, Canada (EES, SC); University of Ottawa, Department of Neurology, Ottawa,

Canada (DD); Stroke Prevention Clinic, McGill University Health Centre, Montreal, Canada (TW); Stroke Prevention Clinic, Champlain Regional Stroke Network, Ottawa, Canada (AB);

Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Canada (JC); Division of Neurology, Faculty of Medicine, University of British

Columbia, Kelowna, Canada (JBF); Faculty of Medicine, Department of Neurology, University of Saskatchewan, Saskatoon, Canada (BRG); Faculty of Medicine (Neurology), Laval

University, Quebec City, Canada (ML); Heart Health Clinic, St. Martha’s Regional Hospital, Antigonish, Canada (LMD); Department of Clinical Neurological Sciences, Western

University, London, Canada (JM); Dept of Family Medicine, University of British Columbia, Vancouver, Canada (DN); The Ottawa Hosp ital, Department of Emergency Medicine,

Ottawa, Canada (PP); Provincial Rehabilitation Unit, Queen Elizabeth Hospital, Charlottetown, Canada (AR); College of Pharmacy, University of Saskatchewan, Regina, Canada (WS);

District Stroke Centre, Waterloo Wellington, Kitchener, Canada (TT); Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Canada (CT); Division of

Neurology, Faculty of Medicine, University of British Columbia, Vancouver, Canada (SvG); Vancouver Stroke Program, Vancouver, Canada (KV); WorkHORSE Consulting Inc.,

London, Canada (NF); Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada (AM); Queen Elizabeth II Health Sciences Centre, Stroke

Foundation, Toronto, Canada. Email: patrice.lindsay@heartandstroke.ca

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THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES 315

Optimizing stroke prevention is a major public health priority.

Stroke remains a leading cause of adult neurological disability

(both physical and cognitive), dementia, and death globally. The

seventh update of the Canadian Stroke Best Practice Recom-

mendations (CSBPR) Secondary Prevention of Stroke guidelines

includes a summary of current evidence-based recommendations

for healthcare professionals. They focus on reducing the risk of

recurrent stroke following an index ischemic stroke or transient

ischemic attack (TIA) and are applicable to patients managed

across a variety of care settings. They emphasize a coordinated

shared decision-making, and encourage patient adherence and

persistence with treatment recommendations.

These recommendations have been developed in collaboration

with the Canadian Stroke Consortium. We collaborate with the

Canadian Cardiovascular Society, Thrombosis Canada, Diabetes

Canada, and Hypertension Canada to ensure alignment of recom-

mendations wherever possible. Those guidelines should be con-

sulted for additional detail and information beyond the scope of

the CSBPR. The Canadian Stroke Best Practice Recommenda-

rigorous framework

the AGREE trust model.

updates to the CSBPR has previously published

methodology can be found on our Canadian Stroke Best Practices

Evidence levels were assigned based on the quality of

available evidence and expert opinion. These guidelines have

undergone extensive internal and objective external review and

consensus was achieved for all content. For additional methodol-

ogy and information on these recommendations, including ratio-

nale, system implications, performance measures, knowledge

translation and implementation tools, and an extended summary

of the evidence, please visit https://www.strokebestpractices.ca/

recommendations/secondary-prevention-of-stroke.

S

quickly as possible. Patients with acute TIA or minor stroke are at

risk of recurrent stroke both in the short-term (particularly within

the first week)

7

and long-term.

8

Our triage recommendations

have been simplified to focus on patients presenting within the

first 48 h of a suspected new acute TIA or stroke as they are at

highest risk of early recurrent stroke. For such patients, immedi-

ate assessment is recommended, with imaging of both brain (head

computerized tomography [CT] or magnetic resonance imaging

available that have rapid access to diagnostic services,

and they may be considered as appropriate referral

options for TIA and minor stroke patients where avail-

able and accessible.

1.2 Brain and Vascular Imaging

i. Brain imaging (CT or MRI) and non-invasive vascular

imaging (CTA or MR Angiogram [MRA] from aortic

arch to vertex) should be completed as soon as possible

following acute stroke or TIA [Evidence Level B].

a. CTA of head and neck (from aortic arch to vertex),

b. Neurovascular imaging is recommended to identify

patients with significant symptomatic extracranial

carotid artery stenosis (i.e., 50%–99% stenosis),

which should trigger an urgent referral for potential

carotid revascularization [Evidence Level A].

c. CTA is the first-line vascular imaging test for stroke/

TIA patients. MRA and carotid ultrasound (for extra-

cranial vascular imaging) are reasonable alternatives

to CTA as first-line tests for assessment of carotid

1.3 Blood Work

i. The following laboratory investigations should be rou-

tinely considered for patients with a TIA or minor ische-

mic stroke as part of the init ial evaluation:

hematology or thrombosis expertise [Evidence

Level C].

1.4 Cardiac Studies

1.4A Detection of Atrial Fibrillation

i. Patients with suspected ischemic stroke or TIA should

have a 12-lead ECG to assess for atrial fibrillation,

concurrent myocardial infarction, or structural heart dis-

would be potential candidates for anticoagulant therapy

[Evidence Level A].

stroke or TIA of undetermined source whose initial short-

term ECG monitoring does not reveal atrial fibrillation

but a cardioembolic mechanism is suspected, continuous

ECG monitoring for at least 2 weeks is recommended to

improve detection of paroxysmal atrial fibrillation in se-

ing anticoagulant therapy but who would be potential

i. Echocardiography should be considered for patients with

an embolic ischemic stroke or TIA of undetermined

source or when a cardioembolic etiology or paradoxical

embolism is suspected [Evidence Level C]. Routine

echocardiography is not required for all stroke patients.

[Evidence Level C].

ii. (New for 2020): For patients aged 60 years or younger

who are being investigated for an embolic ischemic

stroke or TIA of undetermined source, echocardiography

with saline bubble study is recommended for detection of

sensitivity than transthoracic echocardiography for

detection of right-to-left cardiac and extra-cardiac

shunts [Evidence Level B].

1.5 Functional Assessment:

i. Patients with stroke should be assessed for neurological

impairments and functional limitations (e.g., cognitive

evaluation, screening for depression, screening for dys-

phagia, screening of fitness to drive, need for potential

ii. Patients found to have neurological impairments and

i. Secondary stroke prevention services should establish

processes and technology to increase and ensure access

to services through virtual care delivery mechanisms for

patients who do not require in-person visits, and espe-

cially patients living in rural and remote settings without

local access to healthcare professionals with stroke ex-

Section 1.6 Clinical Considerations:

3. A contingency plan should be established to have

education or reliable resources on proper use. Mechan-

isms should be in place for follow-up and management of

care provide rs or Stroke Prevention Services (SPS).

10. For timely investigations, consider use of prolonged

patients with hypertension, counsel and educate indivi-

duals with TIA or stroke to reduce sodium intake to a goal

of no more than 2000 mg (5 g table salt or 87 mmol

sodium, equal to less than one teaspoon) per day [Evi-

dence Level A].

iii. Counsel and educate individuals with TIA or stroke to

participate in aerobic exercise 4 to 7 d per week, to

accumulate at least 150 min per week in episodes of

10 min or more, in addition to routine activities of daily

living [Evide nce Level B].

iv. Initiation of aerobic training should be considered after a

stroke or TIA once the patient is medically stable. To

1. Aerobic exercise intensity should be individualized.

Factors to consider include functional limitation, co-

existing medical problems such as cardiac disease, need

for an exercise stress test with electrocardiogram, and

planned exercise intensity (i.e., light, moderat e, or

vigorous).

for women and <102 c m for men*, or a body mass

index (BM I) of 18.5– 24.9 kg/m2 [Evidence Level B].

(*Note: these numbers a re reflective of current research

groups.)

ii. Couns el and educate individuals with TIA or stroke who

are overweight to set healthy weight loss goals and

develop individualized plans to achieve goals [Evidenc e

Level B].

prehensive history that explores root causes of weight

gain and avoids stigma and judgment.

i. Counsel and educate individuals with TIA or stroke to

avoid heavy alcohol use as excessive alcohol intake

increases the risk of hypertension, ischemic stroke and

ii. Counsel and educate individuals with TIA or stroke to

follow Canada’s Low-Risk Alcohol Drinking Guidelines

(2018): 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 B].

2.7 Recreational Drug Use

i. Individuals with stroke and known recreational drug use

that may increase the risk of stroke (such as cocaine,

amphetamines) should be counseled to discontinu e use

garding the use of these agents [Evidence Level B].

Section 2.7 Clinical Consideration

1. At present, there has been some association of smoking

2.8 Smoking Cessation

iii. Offer assistance with the initiation of a smoking cessa-

iv. A stepwise approach that starts with reduction in smok-

v. A combination of pharmacotherapy and behavioral ther-

apy should be considered in all smoking cessation pro-

take into account the patient’s medical stability, clini-

cal needs, other medical factors, patient preferences,

and patient’s ability to afford the therapy in those

cases in which it is not covered under a provincial

drug formulary [Evidence Level C].

b. The initiation of pharmacotherapy for smoking cessa-

tion should begin as soon as possible and supported

while in hospital for index stroke-related event

[Evidence Level C]. Earlier initiation of smoking cessa-

tion discussions may be beneficial [Evidence Level C].

hand) smoke [Evidence Level B].

ix. A referral to virtual smoking cessation services, smoking

cessation programs, supportive resources, and clinics

should be considered depending on regional availability

to optimize the success of smoking cessation [Evidenc e

Level B]

x. People who are not ready to quit should be offered a

motivational intervention to help enhance their readiness

to quit [Evidence Level B].

Section 2.8 Clinical Considerations

to vape even after cessation of cigarette use, in contrast to

use of nicotine replacement therapy which has not been

found to be continued in an ongoing basis.

16

3. Emerging evidence indicates an association between

vaping and elevated blood pressure; the strength of the

association is not clear at this time.

i. Discussions of pregnancy and implications for stroke

recurrence should be included as a routine part of post-

reproductive age [Evidence Level C].

ii. Contraception should be addressed base d upon the

patients’ fertility and pregnancy plans as well as the

stroke mechanism and type [Evidence Level C].

vi. (New for 2020) Contraceptive management alternatives

to estrogen containing hormonal contraceptives should

be considered for women with a history of migraine with

aura [Evidence Leve l C], especially if they are also

current tobacco smokers [Evidence Level B].

17

on the use and dose of acetylsalicylic acid (ASA) to

reduce the risk of a hypertensive disorder of pregnan-

cy (HDP) should be individualized based upon a

woman’s risk of HDP (i.e., women with a prior

i. Strong consideration should be given to the initiation of

antihypertensive therapy after the acute phase of a stroke

or TIA [Evidence Level A].

ii. For patients who have had an ischemic stroke or TIA,

blood pressure lowering treatment is recommended to

achieve a target of consistently lower than 140/90 mm Hg

[Evidence Level B]; this includes individuals with chron-

ic kidney disease.