What are the recommended follow-up protocols for patients discharged after a stroke or TIA event?

Recommended follow-up protocols for patients discharged after stroke or transient ischemic attack (TIA):

• Arrange follow-up in primary care at discharge, at 6 months, and then at least annually to review health and social care needs, ongoing risk factors, and secondary prevention measures. This includes assessment of access to benefits, community participation, housing, and return to work.
• Review the health and social care needs of carers at 6 months and then annually.
• Provide verbal and written information to patients and their families/carers about stroke, TIA, vascular risk factors, medication for secondary prevention (including reasons, timing, and side effects), lifestyle advice, and driving and return to work guidance as appropriate.
• Encourage lifestyle modifications such as daily physical activity, smoking cessation, healthy diet (including at least five portions of fruit and vegetables daily and two portions of oily fish weekly), and limiting alcohol intake to 14 units per week spread over at least 3 days.
• Review and optimize secondary prevention medications including antiplatelet therapy, anticoagulation if indicated (e.g., atrial fibrillation), lipid-lowering therapy with high-intensity statins, and antihypertensive treatment with appropriate blood pressure targets.
• Screen for and manage comorbidities such as diabetes, hypertension, obstructive sleep apnea, heart failure, and obesity.
• Offer early supported discharge services where appropriate, ensuring continuity of rehabilitation and care coordination by a stroke key worker or equivalent.
• Discuss and agree a health and social care plan with the patient and carers before transfer from hospital, providing copies to all relevant providers.

These follow-up protocols aim to ensure comprehensive ongoing care, secondary prevention, rehabilitation, and support for patients and their carers after stroke or TIA.

References: ¹,²,³