Stable Stroke
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Last updated on 2 September 2024

Stable Stroke Care Protocol will be implemented from January 2025 – HSG GPs may refer to updates from AIC for details on the implementation of these protocols.​


The incidence of stroke  in Singapore was 283.9 per 100,000 population in 20211,2 up from 188.9 per 100,000 in 2010. It was the fourth most common cause of death in 2021, accounting for close to 6.1% of all deaths in Singapore.3 Hyperlipidaemia and hypertension were consistently the two most common risk factors among stroke patients across the years, being found in 83.2% and 80.6% of stroke patients in 2021 respectively. Diabetes mellitus (DM), smoking and atrial fibrillation/flutter were also prevalent among stroke patients, with 43.1%, 34.0% and 19.5% of them having these risk factors respectively in 20212.​

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Stroke is a heterogeneous disease. There are clear pathological sub-types – transient ischaemic attack (TIA) , cerebral infarction, primary intracerebral haemorrhage and subarachnoid haemorrhage.

The focus of this Care Protocol (CP) is the medical management of patients with stable stroke, defined as patients who experienced stroke more than 6 months prior.​

While post-stroke rehabilitation is not the primary focus of this CP, general practitioners (GPs) with patients who may benefit from rehabilitation can consider referring to the section on “A Resource Guide for Stroke Survivors and their Caregivers “in the management section below. This includes referrals through Agency for Integrated Care (AIC) Integrated Referral Management System (IRMS) . ​​

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Lifestyle

1. Smoking – smoking cessation/counselling clinic

2. Obesity –​ weight management advice/programme 

3. Diet 

4. Sedentary lifestyle – exercise advice/prescription 

5. Excessive alcohol – to take alcohol in moderationi

iDefined as not exceeding 2 standard drinks per day for men and 1 standard drink per day for women, if one chooses to or is allowed to drink.


Risk factor control

1.      Hypertension – In the follow-up phase, blood pressure (BP) should be maintained below 130/80 mmHg. Less stringent targets may be appropriate for certain patients e.g. frail elderly.

2.      Hyperlipidaemia – maintain low density lipoprotein (LDL)-cholesterol < 1.8 mmol/L or 70mg/dL in patients with ischaemic stroke. For patients with haemorrhagic stroke, in the absence of other significant comorbidities, clinicians may use the Cardiovascular Risk Assessment calculator to determine the LDL-cholesterol target. Refer to the Lipid Disorders Care Protocol for more details.

3.      Diabetes mellitus – maintain HbA1c ≤ 7.0%. May be more or less stringent depending on patient characteristics. Refer to the Diabetes Care Protocol​ for more details.

 

Anti-Thrombotics (For Ischaemic Stroke)

1.   Anti-Platelets

Anti-platelets should only be started after excluding the p​ossibility of brain haemorrhage. Stable stroke patients who are not on antiplatelet therapy for secondary stroke prevention should be engaged in discussion to explore the reasons for this. The following medications are options that can be used for non-cardioembolic stroke:

  1. Aspirin 100 mg/day

  2. Clopidogrel 75 mg/day

  3. Aspirin 100 mg/day + dipyridamole 150 mg TDS

  4. Ticlopidine 250 mg BD*

 

*According to Lindsay 2012​4, ticlopidine is no longer recommended for stroke prevention and has largely been replaced by clopidogrel.  However, some older patients may have been on ticlopidine for a long-time post-stroke and are stable on it. Hence, GPs are not expected to need to change the drug and may retain its use.

 

2.   Anti-coagulants (e.g., for Atrial Fibrillation (AF), Certain Valvular Disorders):

  1. Warfarin Target International Normalised Ratio (INR) for AF is 2-3. Target INR for other cardioembolic causes to follow cardiology/neurology input.

  2. Newer oral anticoagulants such as rivaroxaban, dabigatran and apixaban.

Please refer to the Healthier SG whitelist for the full list of subsidised drugs.​

Post-stroke Management - Provide and use “A Resource Guide for Stroke Survivors and their Caregivers" 

1.      Stroke survivors can experience a host of post-stroke complications, including physical problems (e.g. limb spasticity, limitations in mobility, incontinence, and chronic pain), mood changes, cognitive issues, financial difficulty and caregiver stress. The  post-stroke checklist is a helpful framework for identifying the needs of stroke survivors. 

 

2.      “A Resource Guide for Stroke Survivors and their Caregivers" provides in detail, information about stroke and a variety of resources available to GPs and patients for addressing post-stroke needs, including referrals to government supported and social enterprise agencies. For full list of available resources, please refer to the details here​.​

Recommended Care Components5

Table 1: Recommended Care Components

Recommended Care Components

Minimum Frequency*

​

Remarks

Thromboembolism Risk Assessment

As clinically indicated

Evaluate for atrial fibrillation, cardiac murmurs, fasting glucose and need for anti-thrombotic therapy

Rehabilitation Need Assessment At baseline ​​
Blood Pressure Measurement Twice a year ​
Lipid Profile
 Annually

All patients with ischaemic stroke are at high risk of cardiovascular events and do not require further risk stratification.

Patients with haemorrhagic stroke should be risk stratified in the absence of significant medical conditions (please refer to the Cardiovascular Risk Assessment Care Protocol and Lipid Disorders Care Protocol for details)

Smoking Assessment

Annually for smokers; Once-off for non-smokers, unless there is a change in smoking habit  

 

Assessment on smoking habits (estimated sticks/day; zero for non- or ex-smoker) and provide smoking cessation counselling​ 

Influenza Vaccination^

​ Annually or per season for:

  • patients aged 18 to 64 years who have had stroke; and

  • ​all persons aged 65 years and older.​

As recommended under the National Adult Immunisation Schedule​

COVID-19 Vaccination

​Two initial COVID-19 vaccine doses at an interval of eight weeks apart ​

An additional dose of COVID-19 vaccine should be administered in 2024, around one year (and not earlier than five months) after the last dose received, is recommended for all persons aged 60 years and older, medically​ vulnerable individuals (e.g. chronic neurological conditions) and residents of aged care facilities.

As recommended in MOH Circular No. 12/2024 dated 29 February 2024​

* More frequently if clinically indicated.

^ Note on Pneumococcal Vaccines: While stroke alone is not an indication for pneumococcal vaccination under NAIS in an 18–64-year-old patient, such patients with stroke often have comorbidities such as diabetes or cardiovascular disease for which NAIS does recommend pneumococcal vaccination. 

For further details, please refer to:


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The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice. Submission of data fields marked with asterisks* is required for subsidy claims and Healthier SG payments.

 

Diagnosis

  1. Diagnosis*

  2. CDMP Condition(s)*

  3. Diagnosis Year


 Blood Glucose

  1. HbA1c (%) OR Fasting Plasma Glucose (FPG) (mmol/L or mg/dL)

    [If the patient with stable stroke concurrently has DM OR Pre-DM OR is being screened for DM, please refer to the respective DM, Pre-DM and CVRA​ screening protocols for more information on whether HbA1c or FPG is tied to payments]

  2. Date

 

​Blood Pressure

  1. Systolic BP (mmHg)*

  2. Diastolic BP (mmHg)*

  3. Date*


 
​Lipid profile

  1. LDL-Cholesterol (mmol/L or mg/dL)*

  2. HDL-Cholesterol (mmol/L or mg/dL)*

  3. Triglycerides (mmol/L or mg/dL)*

  4. Total Cholesterol (mmol/L or mg/dL)* 

  5. Date*


Weight 

  1. BMI (kg/m2), calculated from height*, weight* 

  2. Waist circumference (in cm; mandatory to fill* if weight is not feasible. Otherwise, optional field to fill)

  3. Weight not feasible (if applicable)* 

  4. Date*​

Smoking History

  1. Smoking Status (Never smoker, Ex-smoker, Current smoker)*

  2. Year Started Smoking (if smoker)

  3. No. of sticks smoked/day (For never smoker or ex-smoker, input 0)*

  4. Stage of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation (iv) Action, or (v) Maintenance

  5. Fagerstrom Test Score – For patients who are prepared to quit and are actively participating in a structured smoking cessation counselling programme, GPs can consider administering the Fagerstrom test to determine degree of nicotine dependence

  6. Date of Smoking Assessment
     

Vaccination

  1. SDD code* 

  2. Date of Vaccination* 

  3. Due Date of Next Dose 

  4. I acknowledge that I have reviewed the results and care delivery provided, that the vaccinations done are clinically indicated as per MOH's prevailing guidelines 

  5. Vaccination Exception Condition(s) (if applicable)*

  6. COVID-19 Vaccination Dose Type*

  7. COVID-19 Vaccination Condition(s)*

[COVID-19 Vaccination fields will be implemented in HSG-Compatible CMSes in Nov 2024]

 

Medical Therapy

  1. I have reviewed that the patient is on anti-platelet or anticoagulation therapy, as clinically appropriate.

  2. Date

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CHAS/PG/MG cardholders who are Healthier SG enrollees can opt to use the Healthier SG Chronic Tier at their enrolled clinics, which provides percentage-based subsidies for selected chronic medications sold within the stipulated price caps. When making claims for these medications, GPs will need to submit the quantities and selling prices for the drug product prescribed.

Details on the GP Annual Service Fee for enrollees with Stable Stroke can be found in the Healthier SG Enrollment Programme Agreement.​​

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  1. National Registry of Diseases Office. Singapore Stroke Registry Annual Report 2020. Singapore: Health Promotion Board; 2022.

  2. National Registry of Diseases Office. Singapore Stroke Registry Annual Report 2021. Singapore: Health Promotion Board. Forthcoming 2023.

  3. Principal Causes of Death. Ministry of Health, Singapore. Accessed on 19 Jul 2024.

  4. Lindsay MP, Gubitz G, Bayley M, Phillips S. Canadian Stroke Best Practices and Standards Working Group. Canadian best practice recommendations for stroke care. Stroke Prevention. 4th ed. 2;2012.

  5. Chronic Disease Management Programme – Handbook for healthcare professionals. Ministry of Health. 2022.​