Guidelines

Canadian Stroke Best Practice Recommendations: secondary prevention of stroke

guidelines, update 2014
Shelagh B. Coutts1, Theodore H. Wein2, M. Patrice Lindsay3*, Brian Buck4, Robert Cote5,
Paul Ellis6, Norine Foley7, Michael D. Hill1, Sharon Jaspers8, Albert Y. Jin9,
Brenda Kwiatkowski10, Carolyn MacPhail11, Dana McNamara-Morse12, Michael S. McMurtry13,
Tania Mysak14, Andrew Pipe15, Karen Silver16, Eric E. Smith1, Gord Gubitz17, and on behalf of
the Heart, and Stroke Foundation Canada Canadian Stroke Best Practices Advisory Committee
Correspondence: Patrice Lindsay*, McGill University Stroke Prevention
Clinic, Montreal General Hospital, Heart and Stroke Foundation, C/o
11 Woodbank Road, Etobicoke, ON, Canada M9B 5C3.
E-mail: plindsay@hsf.ca; www.strokebestpractices.ca
1
Calgary Stroke Program, Department of Clinical Neurosciences and
Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB,
Canada
2
Stroke Prevention Clinic, Montreal General Hospital, McGill University,
Montreal, QC, Canada
3
Heart and Stroke Foundation, University of Toronto, Toronto, ON,
Canada
4
Division of Neurology, Department of Medicine, University of Alberta,
Edmonton, AB, Canada
5
Department of Neurology, McGill University, Montreal, QC, Canada
6
Emergency Department, University Health Network, Toronto, ON,
Canada
7
WorkHorse Consulting, Foods & Nutrition, Brescia University College,
London, ON, Canada
8
Stroke, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON,
Canada
9
Division of Neurology, Department of Medicine, Queens University,
Kingston, ON, Canada
10
Stroke Prevention, University Hospital, Saskatoon, SK, Canada
11
Primary Care, Health PEI, Charlottetown, PE, Canada
12
Stroke, Valley Regional Hospital, Halifax, NS, Canada
13
Cardiology, University of Alberta, Edmonton, AB, Canada
14
Faculty of Pharmacy and Pharmaceutical Services, University of Alberta,
Edmonton, AB, Canada
15
Prevention and Rehabilitation, University of Ottawa Heart Institute,
Ottawa, ON, Canada
16
Department of Family Medicine, Dalhousie University, Saint John, NB,
Canada
17
Department of Neurology, Faculty of Medicine, Dalhousie University,
Saint John, NB, Canada
Received: 14 November 2014; Accepted: 24 November 2014; Published
online 23 December 2014
Conflict of interest: Dr Shelagh Coutts (first author): Dr Coutts is the lead
Canadian investigator for the NIH funded POINT trial. Dr Theodore
Wein (second author): Bayer, funded researcher, speaker; Boehringer
Ingleheim, funded researcher, speaker; Allergan, speaker. Dr Patrice
Lindsay: none declared. Brian Buck: Bayer, speaker; Alberta Health Services, committee member, funded researcher. Robert Cote: Bayer, speaker;
Pfizer, speaker. Paul Ellis: none declared. Norine Foley: none declared. Dr
Michael Hill: Heart and Stroke Foundation of Alberta Board Chair, salary
award holder; Institute for Circulatory and Respiratory Health of CIHR
Advisory Board member; Vernalis Group Ltd and Merck Ltd Consultant;
Hoffmann-LaRoche Canada, provided drug for clinical trial, consultancy
and CME lecturer; Coviden, research grant holder; Servier Canada, CME
lecturer (funds donated to charity); BMS Canada, consultancy (funds
donated to charity); Alberta Innovates Health Solutions, salary award.
Sharon Jaspers: Pfizer, speaker; Bayer, speaker. Albert Jin: none declared.
Brenda Kwiatkowski: none declared. Carolyn MacPhail: none declared.

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Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals. The
2014 update of the Canadian Secondary Prevention of Stroke
guideline is a comprehensive summary of current evidencebased recommendations for clinicians in a range of settings,
who provide care to patients following stroke. Notable
changes in this 5th edition include an emphasis on treating the
highest risk patients who present within 48 h of symptom
onset with transient or persistent motor or speech symptoms,
who need to be transported to the closest emergency department with capacity for advanced stroke care; a recommendation for brain and vascular imaging (of the intra- and
extracranial vessels) to be completed urgently using computed
tomography/computed tomography angiography; prolonged
cardiac monitoring for patients with suspective cardioembolic
stroke but without evidence for atrial fibrillation on electrocardiogram or holter monitoring; and de-emphasizing the
need for routine echocardiogram. The Canadian Stroke Best
Practice Recommendations include a range of supporting
materials such as implementation resources to facilitate the
adoption of evidence to practice, and related performance
measures to enable monitoring of uptake and effectiveness of

Dana McNamara-Morse, none declared. M. Sean McMurtry: none

declared. Tania Mysak: none declared. Andrew Pipe: Pfizer, advisory
board, funded researcher, speakers bureau; Johnson & Johnson, research
support. Karen Silver: Eli Lily, education consultant; Merck, education
consultant. Eric E. Smith: none declared. Gord Gubitz (senior author):
Bayer, speaker; Boehringer Ingleheim, speaker; BMS Pfizer, speaker.
Funding: The development of the Canadian Stroke Best Practice Recommendations is funded in their entirety by the Heart and Stroke Foundation, Canada. No funds for the development of these guidelines come
from commercial interests, including pharmaceutical companies. All
members of the recommendation writing groups and external reviewers
are volunteers and do not receive any remuneration for participation in
guideline development, updates and reviews. All participants complete a
conflict of interest declaration prior to participation.
Contributions: Shelagh B. Coutts and Theodore H. Wein are chairs of the
Secondary Prevention of Stroke expert writing group and lead authors; M.
Patrice Lindsay is senior editor and writer of supplementary documentation; Brian Buck, Paul Ellis, Sharon Jaspers, Albert Y. Jin, Brenda Kwiatkowski, Carolyn MacPhail, Dana McNamara-Morse, Michael Sean
McMurtry, Tania Mysak, Andrew Pipe, and Karen Silver are all members
of the expert writing group; Gord Gubitz is senior advisor to the writing
group and contributed significantly to the content and provided review
and edits to the overall document; Eric E. Smith, Michael D. Hill, and
Robert Cote provided extensive review and feedback for the recommendations and this manuscript; Norine Foley conducted the evidence
searches and completed the evidence tables and evidence summaries.
DOI: 10.1111/ijs.12439
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the recommendations using a standardized approach. The
guidelines further emphasize the need for a systems approach
to stroke care, involving an interprofessional team, with access
to specialists regardless of patient location, and the need to
overcome geographical barriers to ensure equity in access
within a universal health-care system.
Key words: guidelines, ischemic stroke, prevention, transient ischemic
attack

Introduction
Every year, approximately 62 000 people with stroke and transient
ischemic attack (TIA) are treated in Canadian hospitals (1). The
annual cost of stroke is approximately $36 billion, taking into
account both health-care costs and lost economic output (2).
Moreover, it is estimated that for each symptomatic stroke, there
are nine silent strokes that result in subtle changes in cognitive
function and processes (3). The risk of recurrent stroke after a TIA
is 1020% within 90 days, and the risk is front-loaded, with half of
the strokes occurring in the first two-days following initial
symptom onset (47). The seven-day risk of stroke following a TIA
can be more than 30% in patients with multiple risk factors (8).
Timely initiation of secondary prevention medical therapy and
carotid endarterectomy has been shown to significantly reduce the
risk of major stroke after an initial TIA or nondisabling stroke.
The Canadian Stroke Best Practice Recommendations are
intended to provide up-to-date evidence-based guidelines for the
prevention and management of stroke, to promote optimal recovery and reintegration for people who have experienced stroke
(patients, families and informal caregivers). The target audience
for this guideline is all health-care professionals involved in the
care of people with stroke across the continuum. The goals of
disseminating and promoting implementation of these recommendations are to reduce practice variations in the care of stroke
patients across geographic regions; reduce the gap between
current knowledge and clinical practice; and improve patient outcomes. The Canadian Stroke Best Practice Recommendations are
updated and released in seven modules every two-years: Stroke
Prevention; Mood, Cognition and Fatigue; Hyperacute Stroke;
Acute Stroke; Rehabilitation; Transitions; and Telestroke (9).
Up-to-date and comprehensive Canadian Best Practice Recommendations for Stroke Care are freely available at www
.strokebestpractices.ca (9). This print publication summarizes the
recommendations for Secondary Prevention of Stroke, including
a summary of the methods for their development and the evidence grading scheme used. In addition, the Web site contains
detailed rationales for the recommendations with supporting evidence, health systems implications, suggested performance measures, implementation resources (such as decision tools and
templates for standing orders), summary of the evidence, and
detailed tables of evidence. The reader is encouraged to visit the
Web site for more details.

Whats new in 2014

The updated Canadian Secondary Prevention of Stroke guidelines
have a few notable changes from the previous edition. These
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guidelines focus on management of people who have already had
an initial stroke or TIA. While we recognize the critical role of
primary prevention strategies, these are considered out of scope
for this particular module, and this update has been refined to
focus on prevention of recurrent stroke and TIA. Triage of patients
with TIA and minor stroke for evaluation for secondary prevention remains an important focus of these guidelines. In a previous
revision we removed a recommendation to use the ABCD2 score
for triage evaluation of TIA patients, as the score has not validated
well in real-world practice. In this 5th edition of the guidelines we
emphasize that patients who present within 48 h of symptom
onset with transient or persistent motor or speech symptoms need
to be transported to the closest emergency department with
capacity for advanced stroke care (section 1.1). We recommend
brain and vascular imaging (of the intra- and extracranial vessels)
to be completed urgently using computed tomography (CT)/CT
angiography (CTA; section 1.3). Another addition to this version
of the prevention guidelines is the recommendation that in
patients with suspected cardioembolic stroke, should the initial
electrocardiogram (ECG), Holter monitor or cardiac monitoring
not identify atrial fibrillation, then prolonged cardiac monitoring
should be included as part of the diagnostic process (sections 1.3
and 7.1). The importance of obtaining a routine echocardiogram
has been de-emphasized (section 1.3).
Recommendations for secondary prevention of stroke should
be implemented throughout the recovery phase, including during
emergency department and acute inpatient care, inpatient and
outpatient rehabilitation, reintegration into the community and
ongoing follow-up by primary care practitioners. Secondary prevention should be addressed at all appropriate health-care
encounters on an ongoing basis following a stroke or TIA. The
health-care and stroke system should be set up to ensure secondary prevention is offered and maintained in all stages of stroke
care. To help support ongoing stroke prevention monitoring and
management, the global poststroke checklist has been adapted
and modified and included as a helpful knowledge translation
tool (9,10). The adapted Canadian version of the poststroke
checklist is available online at www.strokebestpractices.ca (8).

Guideline development methodology

The Canadian Stroke Best Practice Recommendations development
and update process follows a rigorous framework adapted from
the Practice Guideline Evaluation and Adaptation Cycle (11). An
interprofessional group of stroke prevention experts were
convened to participate in reviewing, drafting, and revising all
recommendation statements. Members who have extensive experience in the topic area, are considered leaders and experts in their
field, have been involved in clinical trials or publications on the
topics addressed in this module, and those who have experience
appraising the quality of research evidence were selected. People
who have experienced a stroke or their family members are also
included as group members and/or external reviewers. The
interprofessional writing group included stroke neurologists,
family physicians, internists, nurses, emergency physicians,
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cation experts. This interprofessional approach ensures that the
perspectives and nuances of all relevant health disciplines are
considered in the development of the recommendations, and
mitigates the risk of potential or real conflicts of interest from
individual members. Other experts outside the writing group
were consulted for very specific issues such as sleep apnea.
A systematic literature search was conducted to identify
research evidence for each topic area addressed in the prevention
of stroke module. All literature searches are conducted by individuals with expertise performing systematic literature reviews
that are not directly involved in active research or the writing
group to ensure objective selection of evidence. Literature
searches include set time frames, which overlap the previous
search time frame by six-months to ensure high catchment of key
articles within that time frame.
The writing group was provided with comprehensive evidence
tables that include summaries of all high-quality evidence identified through the literature searches. The writing group discusses
and debates the value of the evidence and through consensus
develops a final set of proposed recommendations. Through their
discussions, additional research may be identified and added to the
evidence tables if consensus on the value of the research is
achieved. All recommendations are assigned a level of evidence
ranging from A to C, according to the criteria defined in Table 1.
When developing and including C-Level recommendations, consensus is obtained among the writing group and validated through
the internal and external review process. This level of evidence is
used cautiously, and only when there is a lack of stronger evidence
for topics considered important system drivers for stroke care (e.g.
transport using ambulance services or some screening practices).
Recommendations with this level of evidence may also be made in
response to requests from a range of health-care professionals who
seek guidance and direction from the experts in the absence of
strong evidence on certain topics that are faced on a regular basis.
After completion of the draft update to the recommendations,
the prevention module underwent an internal review by the
Table 1 Summary of criteria for levels of evidence reported in the
Canadian Best Practice Recommendations for Stroke Care (update
2014)
Level of
evidence Criteria*
A

Evidence from a meta-analysis of randomized controlled

trials or consistent findings from two or more
randomized controlled trials. Desirable effects clearly
outweigh undesirable effects or vice versa.
Evidence from a single randomized controlled trial or
consistent findings from two or more well-designed
nonrandomized and/or noncontrolled trials, and large
observational studies. Desirable effects outweigh or are
closely balanced with undesirable effects or vice versa.
Writing group consensus and/or supported by limited
research evidence. Desirable effects outweigh or are
closely balanced with undesirable effects or vice versa,
as determined by writing group consensus.

*Adapted from Guyatt et al. (2008) (12).

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Canadian Stroke Best Practices Advisory Committee, and an
external review by 10 experts in stroke prevention who were not
involved in any aspects of the guideline development, including
two international reviewers. All feedback was reviewed and
addressed by the writing group members and the advisory committee to ensure a balanced approach to addressing suggested
edits. All recommendations are accompanied by additional supporting information, including a rationale for inclusion of the
topics, system implications to ensure the structural elements and
resources are available to achieve the recommended levels of care,
performance measures to monitor care delivery and patient outcomes, as well as implementation resources and a summary of the
evidence to which the recommendations were based. The evidence tables are available as well. This additional supporting
information for the recommendations included in this
publication can be found at http://www.strokebestpractices.ca/
index.php/prevention-of-stroke/.
For a more detailed description of the methodology on the
development and dissemination of the Canadian Stroke Best Practice Recommendations please refer to the Canadian Stroke Best
Practice Recommendations Overview and Methodology documentation available on the Canadian stroke best practices Web site at
http://www.strokebestpractices.ca/wp-content/uploads/2014/08/
CSBPR2014_Overview_Methodology_ENG.pdf (13).

Secondary prevention of stroke Canadian Stroke

Best Practice Recommendations
This section provides recommendations, with accompanying evidence grades, for secondary prevention of stroke. For more details
on the rationale for the recommendations, health system implications, suggested performance measures, implementation
resources, and detailed evidence summaries and tables of evidence, please visit http://www.strokebestpractices.ca. All recommendations included in this section have been translated into
French, and the French version can be found in Appendix S1.
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
i. 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).
a. 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).
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S. B. Coutts et al.
b. 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.
c. An ECG should also be completed without delay
(Evidence Level B).
ii. 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).
a. 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
i. 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).
a. These patients should receive a comprehensive
clinical evaluation and investigations by a healthcare 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).
ii. 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).
a. These patients should receive a comprehensive
clinical evaluation and investigations by a healthcare 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
i. 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).
ii. 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
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neurologist or stroke specialist for evaluation (Evidence Level C).
1.2 Clinical investigations
i. 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).
a. 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).
b. 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).
c. When performing CTA or MRA, we recommend
including intracranial and extracranial vasculature (Evidence Level C).
ii. 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).
iii. 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).
iv. 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).
v. Echocardiogram may be considered in cases where the
stroke mechanism has not been identified (Evidence Level C).
vi. 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).
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i. They should receive information and counseling about
possible strategies to modify their lifestyle and risk factors
(Evidence Level B).
ii. 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 Canadas Food Guide (Evidence Level B).
i. 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).
i. 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).
ii. 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 185 to 249 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 Canadas 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

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risks and benefits of these treatments discussed with them
(Evidence Level C).
i. 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 assessment
All 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).
i. 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.
ii. 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).
a. 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).
b. 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).
iii. Patients with refractory hypertension should have comprehensive investigations for secondary causes of hypertension (Evidence Level B).
iv. 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 management
Blood pressure should be managed in all patients to reach optimal
control as follows:
i. 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).
ii. In patients with diabetes, blood pressurelowering
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
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diastolic blood pressure targets consistently lower than
80 mmHg (Evidence Level B).
iii. 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).
iv. 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).
v. Randomized controlled trials have not defined the
optimal time to initiate blood pressurelowering therapy
after stroke or TIA. Blood pressurelowering treatment
should be initiated or modified before discharge from hospital (Evidence Level B).
vi. 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).
vii. 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
i. 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
i. 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).
ii. 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 20 mmol/l,
or a 50% reduction in LDL cholesterol from baseline (Evidence Level B) (15).
iii. 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
i. 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).
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ii. 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
i. 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 70% to reduce the risk of microvascular
complications (Evidence Level A) and, in individuals with
type 1 diabetes, macrovascular complications (Evidence Level
C).
ii. To achieve an A1C 70%, patients with type 1 or type 2
diabetes should aim for a fasting plasma glucose or preprandial plasma glucose target of 40 to 70 mmol/l (Evidence
Level B).
iii. The two-hour postprandial plasma glucose target is 50 to
100 mmol/l (Evidence Level B). If A1C targets cannot be
achieved with a postprandial target of 50 to 100 mmol/l,
further postprandial blood glucose lowering, to 50 to
80 mmol/l, can be considered (Evidence Level C).
iv. 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
20 mmol/l (Evidence Level A).
v. 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).
i. 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).
ii. 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).
iii. 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
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unclear. These findings will be further investigated in the
POINT trial.
iv. 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.
v. 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.
vi. 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 0205 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
i. 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).
ii. 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
i. Patients with TIA or ischemic stroke and atrial fibrillation
should receive oral anticoagulation (Evidence Level A).
a. 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).
b. 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.
ii. 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).
iii. For patients with acute ischemic stroke and atrial fibrillation, routine use of bridging with heparin is not recom-

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mended (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
i. 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 20 (Evidence Level A).
ii. 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.
iii. 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 stenosis
Patients 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).
i. 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].
ii. 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).
a. Carotid endarterectomy should be performed by a
surgeon with a known perioperative morbidity and mortality of less than 6% (Evidence Level A).
iii. Carotid stenting may be considered for patients who are
not operative candidates for technical, anatomic or medical
reasons (Evidence Level A).
a. Interventionalists should have expertise in carotid
procedures and an expected risk of peri-procedural morbidity and mortality rate of less than 5%.
iv. 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).
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8.2 Asymptomatic and remotely symptomatic carotid stenosis
Carotid 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).
i. 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).
ii. Patients with asymptomatic carotid disease should be
evaluated by a physician with expertise in stroke management
(Evidence Level C).
iii. 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).
iv. 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).
v. 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
i. Intracranial stenting is not recommended for the treatment of recently symptomatic intracranial 70% to 99%
stenosis (Evidence Level B).
ii. 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).
iii. 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 healthcare encounter for active smokers.
i. 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).
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ii. Provide unambiguous, nonjudgmental, and patientspecific advice regarding the importance of cessation to all
smokers (Evidence Level B) and others who reside with the
patient.
iii. Offer assistance with the initiation of a smoking cessation attempt either directly or through referral to appropriate resources (Evidence Level A).
iv. People who are not ready to quit should be offered a
motivational intervention to help enhance their readiness to
quit (Evidence Level B).
v. A combination of pharmacological therapy and behavioral therapy should be considered in all smoking cessation
programs and interventions (Evidence Level A).
vi. 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).
a. The choice of appropriate pharmacotherapy should
take into account the patients medical stability, clinical
needs, other medical factors, and patient preferences
(Evidence Level C).
vii. For admitted stroke patients who are current smokers,
protocols should be in place to manage nicotine withdrawal
during hospitalization (Evidence Level B).
viii. 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).
ix. 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
i. Patients who have experienced a stroke or TIA should be
screened for the presence of sleep apnea symptoms (Evidence level B).
a. Screening for the presence of sleep apnea should
occur during follow-up visits (Evidence level C), using a
validated sleep apnea screening tool.
ii. 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 stroke
Stroke 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).
i. The management of all treatable vascular disease risk
factors should be optimized in patients with confirmed
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sleep apnea post stroke (Evidence Level B). Refer to other
sections in this Secondary Prevention of Stroke Module for
additional recommendations.
ii. First line therapies for the treatment of sleep apnea
include:
a. Avoidance of hypnotic and sedative medications and
alcohol (Evidence Level B);
b. Positional therapy (Evidence Level B);
c. Weight loss (Evidence Level B);
d. Continuous positive airway pressure (C-PAP) (Evidence Level B);
e. Dental appliances (Evidence level B) in consultation
with dental specialists.
iii. Long-term management plans should be developed in
consultation with a sleep specialist (Evidence Level C).
iv. 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).
i. 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
i. The current research evidence does not support closure of
patent foramen ovale in individuals with stroke (Evidence Level
A).
ii. 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).
iii. Aortic arch atheroma should be managed following the stroke
prevention recommendations included in this HSF Secondary
Prevention of Stroke Module (Evidence Level C).

Summary
The Canadian Stroke Best Practice Recommendations provide a
common set of guiding principles for stroke care delivery and
describe the infrastructure necessary at a system level, and the
clinical protocols and processes that are needed to achieve and
enhance integrated, high-quality, and efficient stroke services.
Through the innovations embodied within the stroke best practices, these guidelines contribute to health system reform in
Canada and internationally.
The Canadian Stroke Best Practice Recommendations are developed and presented within a continuous improvement model and
are written for health system planners, funders, administrators,
and health-care professionals, all of whom have important roles

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in the optimization of stroke prevention and care and who are
accountable for results. A strong stroke research literature base is
drawn upon to guide the optimization of stroke prevention and
care delivery. Several implementation tools are provided to facilitate uptake into practice (available at www.strokebestpractices.ca)
and are used in combination with active professional development programs. By monitoring performance, the impact of
adherence to best practices is assessed and results then used to
direct ongoing improvement. Recent stroke quality monitoring
activities have compelling results, which continue to support the
value of adopting evidence-based best practices in organizing and
delivering stroke care in Canada.
The Canadian Stroke Best Practice Recommendations prevention guidelines continue to be a work in progress and are regularly
updated every two- to three-years in order to integrate newly
released data to help maximize patient outcomes from this disabling disease.

Acknowledgements
The authors wish to acknowledge and thank the many people who
provided internal and external review and feedback on earlier
drafts of the Secondary Prevention of Stroke recommendations
update 2014. The stroke team and communications team at the
Heart and Stroke Foundation, including Ian Joiner, Stephanie
Lawrence, Ev Glasser, Mary Elizabeth Harriman. Members of the
Canadian Stroke Best Practices Advisory Committee: Dr. Eric
Smith, Dr Mark Bayley, Dr Dariush Dowlatshahi, Dr Alexandre
Poppe, Dr Sam Yip, Dr Sean Dukelow, Dr Eddy Lang, Katie Lafferty, Dr Ian Graham Dr Maureen Markle-Reid, Dr Theresa
Green, Dr Michael Kelly, Barbara Ansley, Dr Stephen Phillips, Dr
Moira Kapral and Dr Janusz Kaczorowski. External reviewers:
Armi Armesto, Dr Simerpreet Bal, Dr Niall Davidson, Dr John
Falconer, Dr David Gladstone, Dr Jeff Habert, Dr Adam Kelly, Dr
David Marsters, Dr Yael Perez, Heather Perkins, Dr Natalia Rost,
and Dr Andrew Penn.

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Supporting information
Additional Supporting Information may be found in the online
version of this article at the publishers web-site:
Appendix S1. Recommandations sur les pratiques optimales de
soins de lAVC au Canada: Mise jour 2014 des lignes directrices
sur la prvention secondaire de lAVC [version Franaise].

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