Clinical guidelines for the treatment of patients who have had a stroke have been produced by the Royal College of Physicians. Covering the management of patients from onset of stroke symptoms through to longer-term rehabilitation, the guidelines are intended to be used by all health care professionals and aim to "help clinicians make the best decisions for each patient".
The chairman of the Intercollegiate Working Party for Stroke, which developed the guidelines, Dr Anthony Rudd (consultant physician for stroke, St Thomas's hospital, London) said in a press release: "The effective care of someone who has had a stroke requires the collaboration, skills and perseverance of many professionals, the patient and their carer." Optimal rehabilitation after stroke should be available for all patients. "This document sets out how such care should be provided," Dr Rudd said.
The guidelines say that it has been proven that patients managed by a specialist co-ordinated stroke team in a stroke unit have lower mortality and morbidity.
The guideline topics include the organisation of stroke care, diagnosis, acute treatment, secondary prevention, rehabilitation and issues for carers and families.
Under acute treatment, the guidelines say that 300mg aspirin should be given as soon as possible after the onset of stroke symptoms, providing a diagnosis of haemorrhage is unlikely. No other drug aimed at the treatment of stroke should be given unless as part of a randomised control trial. "For most drugs, the evidence is simply too weak to recommend use at this point," say the guidelines.
Local policies should be agreed for the early management of hypertension, hyperglycaemia, hydration and pyrexia. Centrally acting drugs should be avoided. Thrombolytic treatment with alteplase (tissue plasminogen activator, tPA) should only be given within three hours of the onset of symptoms, providing haemorrhage has been excluded, and in specialist centres. (This is currently an unlicensed use of the drug.)
Both aspirin (75-300mg daily) and compression stockings (for patients with weak or paralysed legs) should be given to patients to prevent venous thromboembolism, the guidelines say. Prophylactic anticoagulation should not be used routinely. An injection of botulinum toxin should be considered for patients with disabling or distressing spasticity.
In terms of long-term management, the guidelines say that secondary prevention of stroke or other cardiovascular event includes treatment for hypertension and antiplatelet treatment. Aspirin (50-300mg daily) (or aspirin and dipyridamole or, if aspirin is not tolerated, clopidogrel) should be given to all patients not on anticoagulation. Treatment with statins should be considered. Anticoagulation therapy should be given to all patients with atrial fibrillation (unless contraindicated) and considered for other patients.
"National Clinical Guidelines for Stroke", available from the RCP Publications Unit (tel 020 7935 1174 ext 254) price £22. Also available on the College's website (www.rcplondon.ac.uk/college/ceeu_stroke_home.htm).
A leaflet has also been produced for patients, and is available from RCP Publications (20 leaflets £10; one leaflet is supplied with the full report).