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 their 10-year cardiovascular risk and consider an LDL-cholesterol target. Refer to the
2023 Lipids ACE Clinical Guidance 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 possibility 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:
Aspirin 100 mg/day
Clopidogrel 75 mg/day
Aspirin 100 mg/day + dipyridamole 150 mg TDS
Ticlopidine 250 mg BD*
*According to Lindsay 20124, ticlopidine is no longer recommended for stroke prevention and has largely been replaced by clopidogrel.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):
Warfarin Target International Normalised Ratio (INR) for AF is 2-3. Target INR for other cardioembolic causes to follow cardiology/neurology input.
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:
|
As recommended under the National Adult Immunisation Schedule |
COVID-19 Vaccination |
One initial COVID-19 dose for unvaccinated patients aged 5 years and above.#
An additional dose around one year (and not earlier than five months) after the last dose received for patients aged 6 months and above.
# Two initial doses (eight weeks apart) for unvaccinated persons aged 6 months – 4 years | As recommended in MOH Circular No. 80/2024 dated 25 October 2024, for all persons aged 60 years and older, medically vulnerable individuals (e.g. chronic neurologic conditions) and residents of aged care facilities.
|
* More frequently if clinically indicated, except for vaccination.
^ 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: |