Ischemic Stroke: Management by the

Nurse Practitioner
Susan E. Wilson, DNP, ANP-BC, and Susan Ashcraft, DNP, ACNS-BC

ABSTRACT
Approximately 800,000 people living in the United States are diagnosed with a stroke
each year. Nurse practitioners are positioned to impact and improve stroke survivor’s
outcomes in the primary and acute care setting. This article provides an overview of
stroke management pre- and postdischarge in the primary care setting and addresses
acute stroke treatment during hospitalization.

Keywords: acute hospital management, nurse practitioner, prehospital management,

prevention, stroke
Ó 2018 Elsevier Inc. All rights reserved.

A
pproximately 800,000 people in the United
States experience a stroke each year. Stroke
ranks as the fifth leading cause of death and
the leading cause of disability, with over $40 billion
annual cost.1 The nurse practitioner (NP) may
significantly impact patient outcomes during the
prehospital, acute, and posthospital phase of care.
This article addresses preischemic stroke, acute, and
postischemic stroke care by the NP with a focus on
the American Heart Association 8 D’s of stroke chain
of survival. The 8 D’s include detection, dispatch,
delivery, door, data, decision, drug/device, and
disposition.2
COMMUNITY PRESTROKE MANAGEMENT
Case Study
A 63-year-old man with coronary artery disease,
hypertension, hyperlipidemia, and tobacco use,
currently taking aspirin, enalapril, and atorvastatin,
presents with a sudden onset (at 8:45 AM) of slurred
speech, aphasia, and right-sided weakness.
objective is to identify symptoms consistent with a
neurologic focal deficit and determine the
timing of symptom onset. Once a stroke is
suspected, emergency medical services (EMS) dispatch
is crucial.
History
A quick comprehensive history includes identifi-
cation of symptoms, time of symptom onset,
medical history, and medication use. The identifi-
cation of symptoms aids the clinician in deter-
mining focal neurologic deficits, assisting in ruling
out stroke mimics. The timing of symptom onset is
crucial because treatment initiation must occur
within 24 hours of symptom presentation.
Comorbidities that increase the risk of stroke
include atrial fibrillation, coronary artery disease,
diabetes, high cholesterol, and hypertension. It is
important to determine medication history
because the use of anticoagulants impacts
treatment decision.

Presentation Neurologic Examination

Rapid evaluation and detection of stroke symptoms is
critical in providing prompt intervention and
potentially reducing disability. Familiarity with the
most common signs/symptoms of stroke (Table 1)
enables the NP to detect patients requiring emergent
care. Because neuroimaging is not emergently
available in the primary care setting, the NP must rely
on history and clinical assessment. The critical
www.npjournal.org
A stroke may cause a focal neurologic deficit
depending on the location of tissue damage. A
neurologic examination may reveal the vascular ter-
ritory affected and assists in determining appropriate
stroke center transfer by EMS and acute treatment.
The NP should perform a neurologic examination,
including mental status/level of consciousness, cranial
nerves, muscle strength, coordination, and sensory
The Journal for Nurse Practitioners - JNP 47
Table 1. Signs and Symptoms of Stroke2
Numbness or weakness on 1 side of the body
Confusion, difficulty thinking
Difficulty speaking or understanding speech/
conversation
Difficulty seeing, blurred vision
Unexplained dizziness; difficulty with walking, balance,
or coordination
Severe headache
Loss of consciousness
Sudden nausea and/or vomiting in addition to symptoms
above
Stroke symptoms occur suddenly.
function, or use a stroke-specific scale to evaluate the
patient (Table 2, available online).
Several scales exist for rapid stroke evaluation by
EMS responders and the lay public such as Face,
Arm, Speech, Time, Cincinnati Prehospital Stroke
Scale, and Los Angeles Prehospital Stroke Screen.
The National Institutes of Health Stroke Scale used
by neurologists, neuroscience nurses, emergency
department (ED) physicians and nurses evaluates
stroke severity, determines treatment eligibility, and
predicts prognosis. The scale ranges from 0 to 42,
with higher scores signaling larger strokes. Use of the
National Institutes of Health Stroke Scale requires
training to improve reliability.4
Blood Pressure Management: Prehospital Setting
Elevated blood pressures (BPs) generally should not
be treated in the prehospital setting. During an
ischemic stroke, the brain experiences decreased
blood flow to the area of ischemia because of loss of
vasoregulatory capability. Thus, the brain relies on
cardiac output and mean arterial pressure, which is
often the cause of an elevated BP. Lowering the BP
may decrease cerebral perfusion and worsen the
ischemic damage. Optimal BP management is
determined during the acute hospital phase based
on treatment candidacy. For nontreatment eligible
(thrombolysis or endovascular mechanical
thrombectomy) candidates with severe high BP
(
220/120) and no comorbidities, it is unclear if
the BP should be lowered within the first
48 The Journal for Nurse Practitioners - JNP
72 hours.5 Therefore, it is reasonable for the
NP not to treat an elevated BP during the
prehospital phase.
Blood Glucose Management
Upon arrival, EMS rapidly obtains a glucose level to
rule out hypo- or hyperglycemia because both may
produce symptoms that mimic stroke. Although
hypoglycemia may cause symptoms of altered mental
status, focal neurologic symptoms of stroke typically
do not occur until the blood glucose is less than 45
mg/dL. Prompt treatment of a blood sugar below 45
mg/dL in the prehospital setting is beneficial.
Hyperglycemia may worsen cerebral edema and
outcomes. Currently, no data exist supporting
treatment in the prehospital setting.3
Cardiac Monitoring, Antiplatelet Use, and
Supplemental Oxygen
Cardiac abnormalities occur in 60% of acute stroke
patients.6 Cardiac monitoring should be initiated by
EMS and continued for 24 hours to evaluate for
ischemic changes and atrial fibrillation. It is
impossible to know if the patient is suffering an
ischemic or hemorrhagic stroke. Therefore, withhold
aspirin unless concern for myocardial infarction
necessitates the initiation of EMS cardiac protocols.
Current practice recommends maintaining oxygen
saturation above 94%. There is no functional
outcome benefit in supplemental oxygen in
nonhypoxic patients.5
Case Study Continued
The patient’s history and physical determine stroke
risk, and no medications that would interfere with
thrombolysis are discovered. A brief neurologic
examination reveals the following:
 Mental status: alert, follows commands, dys-
arthric speech, and aphasia
 Cranial nerves: right facial droop
 Motor: right-side flaccid
 Sensory: decreased right-sided sensation
 BP: 176/98, blood glucose: 102; positive Los
Angeles Prehospital Stroke Screen
EMS called stroke alert to the closest stroke cen-
ter, delivering the patient for rapid evaluation.
Volume 15, Issue 1, January 2019
 Rapid transport to the closest hospital is crucial to
receiving prompt treatment, recovery, and prognosis.
There are currently 4 levels of stroke care: acute
stroke-ready, primary stroke, thrombectomy
capable, and comprehensive stroke. All levels are
capable of providing initial acute stroke evaluation;
the ability to provide complex care increases with
each level. The stroke systems of care literature
emphasizes both professional and community
awareness of facilities with systems and teams in
place to expedite care.5
ACUTE HOSPITAL STROKE MANAGEMENT
The immediate objective of ischemic stroke treat-
ment is to improve perfusion and prevent further
tissue damage. To improve patient outcomes,
recanalization strategies include the administration of
intravenous (IV) recombinant tissueetype plasmin-
ogen activator (alteplase) and intra-arterial clot
retrieving techniques.
EMS provides prearrival medical information to
receiving EDs, enhancing rapid triage and prepa-
ration. Once the patient arrives at the door, the
rapid American Heart Associationerecommended
time targeted metrics, focused on data collection,
occurs to determine appropriate
treatment (Table 3).
Acute Evaluation (Data) and Treatment Decision
Initial acute evaluation of the stroke patient in the
ED requires rapid nursing and medical assessment and
intervention (Table 4, available online). Restoring
blood flow is time sensitive, with recent mechanical
intervention trials extending the treatment window
to 24 hours for specific patients.
Intravenous Thrombolysis: Drug
Alteplase is US Food and Drug Administration
approved for administration within 3 hours of
stroke symptom onset in patients who meet specific
criteria. In order to determine patient candidacy for
thrombolytic therapy, the NP must review the
extensive inclusion/exclusion criteria.5
The European Cooperative Acute Stroke Study
(ECASS-lll) extended the thrombolysis window to
4.5 hours in specific patients. Although the
extended window did not receive Food and Drug
www.npjournal.org
Table 3. American Heart Associationerecommended
Stroke Evaluation Benchmarks7
Evaluation Vital Components Time Target
Door to doctor/nurse 10 minutes
practitioner/physician assistant
Evaluation by neurology expert 15 minutes
Arrival to CT scan completion 20-25 minutes
Arrival to CT scan interpretation 30-45 minutes
Arrival to treatment with 45-60 minutes
intravenous thrombolysis
Arrival to groin puncture for 60-90 minutes
endovascular treatment
Arrival to admission to stroke unit 3 hours
or intensive care unit
CT ¼ computed tomographic.
Administration approval, it is recommended in the
guidelines and incorporated into stroke treatment
protocols across the US.5 There are additional
exclusion criteria for the extended window;5
however, based on recent research, these may not
be justified in clinical practice. A meta-analysis
found improved outcomes with the administration
of alteplase within the 4.5-hour window regardless
of age or stroke severity.8
The benefit of alteplase is well established in
multiple randomized clinical trials and is a first-line
treatment requiring that patients are brought to the
closest hospital capable of administering thrombol-
ysis.5 Patients should be treated rapidly because the
possibility of a favorable outcome decreases over
time. The probability of a favorable outcome when
treated in less than 3 hours of symptom onset is 75%,
within 3 to 4.5 hours it is 26%, and when treated in
greater than 4.5 hours of symptom onset it is a
nonsignificant 15%.8
It is safe to administer thrombolysis to patients on
antiplatelet therapy. A study evaluating 43,000 stroke
patients taking antiplatelet medication and treated
with thrombolysis found a greater risk of hemorrhage
but improved scoring on functional assessments.9
Yet, there are no guidelines on the safety of
thrombolysis in patients on thrombin inhibitors or
factor Xa inhibitors. Thrombolysis should not be
administered unless activated partial thromboplastin
time, international normalized ratio, platelet count,
The Journal for Nurse Practitioners - JNP 49
ecarin clotting time, thrombin time, or direct factor
Xa activity assays are normal or there is a reliable
history that the patient has not had a dose within
48 hours.5
Endovascular Mechanical Thrombectomy Device
Endovascular mechanical thrombectomy may be
used in addition to IV thrombolysis or as an
alternative in patients not eligible for thrombolysis
to restore blood flow. The use of neuroimaging
guides the selection of appropriate patients most
likely to benefit, based on identifying a large vessel
occlusion. The most effective devices approved are
stent retrievers, providing the highest recanaliza-
tion and outcome rates. Recent stroke trials
showed a benefit of extending the endovascular
treatment window to 24 hours after symptom
identification.5
Similar to IV thrombolysis, time is critical to
improved clinical outcomes from symptom onset to
reperfusion from endovascular treatment. Endovas-
cular treatment requires an experienced team
including neurointerventionalists and periprocedural
nurses and technicians to perform rapid assessment
and treatment to achieve reperfusion as soon
as possible.
BP Management: Acute Stroke Management
During early ischemic stroke, elevated BP is com-
mon, yet the appropriate level to improve outcomes
is unclear. Although there is no research on man-
agement of the hypotension in acute stroke, it is
recommended to correct hypovolemia and the low
BP to assist with systemic perfusion.5
For patients not eligible for thrombolysis or endo-
vascular treatment, current guidelines recommend
allowing permissive hypertension up to 220/120 in
patients without comorbid conditions, such as aortic
dissection, hypertension emergency, and cardiovascular
disease. In patients with comorbidities, the 2018
guidelines recommend lowering the BP by 15% during
the first 24 hours. The writing committee for the 2018
guidelines suggest in patients with BPs < 220/120,
there is no functional outcome or decreased mortality
benefit to starting or restarting antihypertensive medi-
cations within the first 48 to 72 hours.5
50 The Journal for Nurse Practitioners - JNP
Treatment of elevated BPs is indicated in patients
treated with thrombolysis and/or mechanical
thrombectomy. Before treatment, the NP must
ensure the BP is below 185/110. After IV throm-
bolysis is started, the BP must be maintained below
180/105 for the first 24 hours.5
Admission to a stroke unit or intensive care
unit, with nurses specialized in providing neuro-
logic care and providing standardized stroke pro-
tocols, improves management and outcomes.
These specialized units increase the likelihood of
survival and independence 1 year after the stroke.5
Coordination of rehabilitation services during the
acute hospital stay provides the stroke patient with
the greatest opportunity for physical and cognitive
functional recovery. In addition, the NP focuses on
the prevention of poststroke complications, such as
prevention of worsening cerebral edema, venous
thromboembolism, and aspiration pneumonia.
Patients receive an individualized evaluation to
determine the cause of stroke, thus guiding
prevention strategies. Secondary prevention
emphasizes modifiable risk factors identified during
the workup and are initiated during acute
hospitalization. The NP collaborates with case
management, social workers, or navigators to
ensure a smooth transition from acute to postacute
care settings.
Case Study Continued
The patient was taken directly to computed tomo-
graphic (CT) imaging, and the following occurred:
 Rapid evaluation occurred, confirming history
and last known well at 08:45 AM
 National Institutes of Health Stroke Scale ¼ 19
(facial droop, right-sided weakness, decreased
sensation, dysarthria, aphasia, and neglect), CT
scan negative for hemorrhage, and BP increased
to 197/108
 IV labetalol 10 mg and nicardipine 5 mg/h
brought BP down to 173/88
 Alteplase administered 105 minutes after last
known well; CT perfusion revealed left middle
cerebral artery occlusion
 Taken for thrombectomy procedure with suc-
cessful clot retrieval
Volume 15, Issue 1, January 2019
  Postprocedure National Institutes of Health
Stroke Scale ¼ 3 (right-sided drift with some
effort against gravity)
The patient was discharged on aspirin, atorvastatin
80 mg, nicotine patch, enalapril, and outpa-
tient therapy.
COMMUNITY POSTSTROKE MANAGEMENT:
DISPOSITION
Postacute discharge needs focus on poststroke
complications and secondary stroke prevention.
Unfortunately, compared with the organized
guideline-driven acute hospital care, the same level of
organized guideline-driven postdischarge community
care does not exist. Patients may have limited contact
with health care providers, making patients and
their families responsible for health maintenance,
monitoring, and management activities.10
Stroke survivors are encouraged to schedule an
appointment with their primary care provider within
2 weeks and a neurology specialist within 1 month.
During the follow-up visit, the NP has an opportu-
nity to review medications prescribed at discharge
and provide education on the importance of their use
in secondary prevention of stroke. Knowledge of
medications and understanding of their necessity have
been found to promote medication adherence in
stroke patients.11 Hence, the NP is in a position to
effectively oversee and meet the comprehensive
needs of the stroke survivor. Individualized care plans
should focus on modifiable risk factors, prevention of
poststroke complications, and continued
rehabilitation to assist in community reintegration.
At 1 year, recurrent stroke risk is reported at 1%,
at 5 years 16%, and at 10 years 25%.12
Comprehensive treatment involves risk assessment
and strategies targeting individual risk factors. To
decrease stroke risk, effective modification of risk
factors involves patient education and compliance to
meet guideline targets for modifiable risk factors
(Table 5, available online). The hospital discharge
summary should address the cause of stroke,
complications, and modifiable risk factors.
Antithrombotic Therapy for Noncardioembolic Stroke
Three antiplatelet medications are guideline recom-
mended for secondary stroke prevention. These
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include aspirin, clopidogrel, and dipyridamole/
aspirin, decreasing the risk of stroke by approxi-
mately 22%.13
Aspirin is accessible, inexpensive, and reduces
stroke risk between 13% and 23%. A dose of 81 mg
provides a similar benefit as 325 mg with less bleeding
risk associated with lower doses.14
Clopidogrel as a single agent is comparable with
aspirin in stroke prevention. A Cochrane review re-
ported a nonsignificant benefit of clopidogrel over
aspirin in secondary stroke prevention.15 Compared
with aspirin, clopidogrel has a lower risk of serious
hemorrhage but causes diarrhea and rash more
frequently.16
The Prevention Regimen for Effectively Avoid-
ing Second Strokes (PRoFESS) trial found similar
stroke rates between dipyridamole/aspirin (9%) and
clopidogrel (8.8%) with similar hemorrhage rates.
Yet, a high discontinuation rate because of headaches
occurred in the dipyridamole/aspirin group
compared with clopidogrel (5.9 vs 0.9%).15 If
dipyridamole/aspirin is prescribed, start at half dose (1
tablet daily) for the first 2 weeks before increasing to
the full dose (1 tablet twice daily).
Dual antiplatelet therapy may be beneficial for
early stroke prevention. The Clopidogrel in High-
Risk Patients with Acute Nondisabling Cerebrovas-
cular Events (CHANCE) trial evaluated clopidogrel/
aspirin combination and aspirin alone begun within
24 hours of symptom onset and treating patients with
dual antiplatelet (DAP) for 21 days. Stroke occurred
8.2% in the clopidogrel/aspirin group and 11.7% in
the aspirin group. The Clopidogrel and Aspirin in
Acute Ischemic Stroke and High-Risk TIA (POINT)
trial, which treated subjects with DAP for 90 days,
supports CHANCE’s findings, reporting lower
ischemic events occurring in the clopidogrel/aspirin
group (5.0%) compared with aspirin alone (6.5%).
However, POINT reported an increased hemorrhage
risk in the longer DAP treatment period (0.9%)
compared with CHANCE’s reported hemorrhage
risk of zero. For stroke prevention, it is reasonable to
treat patients with combination therapy for 21 days.5
Hypertension: Poststroke Management
The effective treatment of hypertension, the most
common risk factor for stroke, can radically decrease
The Journal for Nurse Practitioners - JNP 51
recurrent stroke. Prevalence among ischemic stroke
survivors is approximately 70%.13 Treatment should
be individualized with consideration of comorbidities
guiding treatment decision and instructing patients
on self-measurement and BP monitoring. Multiple
trials revealed that self-management reduces BP and
improves medication adherence in hypertension
when combined with education from providers or
pharmacists. A meta-analysis revealed that self-
measurement of BP was superior to usual care in
reducing systolic BP at 12 months.17
Hyperlipidemia
The 2018 stroke guidelines recommend treatment
with statins regardless of low-density lipoprotein.5
Measuring cholesterol levels in patients with
nonatherosclerotic reasons for stroke, such as arterial
dissection, may be of value to guide treatment
decision. The Stroke Prevention by Aggressive
Reduction in Cholesterol Levels (SPARCL) trial
showed decreased recurrent stroke risk with the use
of high-intensity atorvastatin (80 mg).18 Following a
Mediterranean diet provides the patient an
opportunity to positively affect BP, weight, blood
glucose, and cholesterol levels.13 Diet modification
requires a change in current self-care behavior. The
NP must consider habitual behaviors, culture, and
social consequences during patient counseling.
Diabetes
After stroke, the plasma glucose level may tempo-
rarily be inflated; therefore, the use of hemoglobin
A1c to screen for diabetes is appropriate. The existing
2018 American Diabetes Association Standards of
Medical Care in Diabetes for glucose control
recommend hemoglobin A1c < 7%, and in
individuals at less risk of hypoglycemia they
recommend a target < 6.5%. It is also reasonable to
set the goal of < 8% in patients with a limited life
expectancy, multiple comorbid complications, or
long-term diabetic patients having difficulty meeting
the < 7% goal. Providing patients with support
through health coaches in the community or nurse
navigators, who provide education and structured
communication systems, improves outcomes.19
52 The Journal for Nurse Practitioners - JNP
Atrial Fibrillation
Atrial fibrillation occurs in approximately 6 million
Americans, causing over 15% of all strokes. Throm-
boembolic strokes caused by atrial fibrillation result in
higher mortality, morbidity, and extended hospital
admission.20 Warfarin is effective in preventing stroke
when the therapeutic international normalized ratio
of 2 to 3 is consistently maintained through close
monitoring. Direct-acting oral anticoagulants, such as
dabigatran, apixaban, edoxaban, and rivaroxaban, are
equally effective in preventing stroke, have a reduced
risk of hemorrhage, and do not require frequent
monitoring but are substantially more expensive.
Fewer thromboembolic events and lower mortality
rates are associated with self-monitoring because of
improved adherence to anticoagulant medication.
Appropriate patient selection and education are
necessary for the best outcome.10
CASE STUDY CONCLUDED
The NP reviewed and provided education regarding
secondary stroke prevention medications. The NP
also reviewed medication side effects, recommended
a Mediterranean diet, and continued therapy and
offered community resources, such as a stroke sup-
port group to assist with coping.
A plan to reduce the incidence or treat compli-
cations after stroke should be made before discharge.
During follow-up visits, the NP must evaluate
poststroke complications, such as increased
mobility-related falls, urinary tract infection, depres-
sion, and seizures. The NP should also ensure patient
participation in rehabilitation services as designed
before discharge.
The NP serves as a leader in the chain of survival
for stroke patients. The NP places a stroke patient in
a position for the best outcome by recognizing a
stroke and initiating emergent services for timely
treatment decisions. After a stroke, the NP assists the
patient with risk factor modification and promotes
self-management as the goal for effective secondary
prevention. The NP plays a pivotal role across the
continuum of stroke care by leading the multidisci-
plinary team and providing evidenced-based medical
and nursing care.
Volume 15, Issue 1, January 2019
SUPPLEMENTARY DATA 11. Crayton E. Psychological determinants of medication adherence in stroke
survivors: a systematic review of observational studies. Ann Behav Med.
Supplementary tables associated with this article can 2017;51:833-845. https://doi.org/10.1007/s12160-017-9906-0.
12. Pennlert J. Long-term risk and predictors of recurrent stroke beyond the acute
be found in the online version at https://doi.org/10 phase. Stroke. 2014;45(6):1839-1841. https://doi.org/10.1161/STROKEAHA.
114.005060.
.1016/j.nurpra.2018.07.019. 13. Kernan W, Ovbiagele B, Black HR, et al. Guidelines for the prevention of
stroke in patients with stroke and transient ischemic attack: a guideline for
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2013;3(4):97-114. https://doi.org/10.5316/wjn.v3i4.97.
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ischemic stroke: a guideline for healthcare professionals from the American
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Caplan LR, Biller J, Leary MC, Lo EH, Thomas AJ, Yenari M, Zhang JH, eds.
Primer on Cerebrovascular Diseases 2nd ed. 2017:749-753. https://doi.org/10
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7. American Heart Association/American Stroke Association. Target: Stroke
Phase II Manual. 2014. http://www.strokeassociation.org/idc/groups/heart-
the department of neurology at the University of North Carolina-
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www.npjournal.org The Journal for Nurse Practitioners - JNP 53

APPENDIX

Table 2. Stroke Assessment Scales3-5

Scale Assessment Validity Strengths Weaknesses
CPSS Arm drift Excellent reproducibility, Easy to use, no Designed to identify
Facial droop sensitivity 44%-95%, certification required middle cerebral artery
Abnormal speech specificity 23%-96% strokes, does not
identify posterior
circulation strokes

FAST Facial droop Sensitivity 79%-85%, Easy to use Does not detect 38% of
Arm weakness specificity 68% for posterior strokes
Slurred speech or anterior cerebral strokes
difficulty speaking
Time is important, call 911
LAPSS Age ¼ over 45 Sensitivity 91% with Rapid identification of Takes longer to
Seizure ¼ no history trained EMS personnel stroke; excludes mimics complete
New-onset neurologic
symptoms
Walks at baseline
Glucose range: 60-400 mg/dL
Facial droop
Arm weakness
NIHSS Using the NIHSS4 Reliable when performed Reliable rapid Requires training and
by different professionals assessment certification
CPSS ¼ Cincinnati Prehospital Stroke Scale; EMS ¼ emergency medical services; FAST ¼ Face, Arm, Speech, Time; LAPSS ¼ Los Angeles Prehospital Stroke Screen;
NIHSS ¼ National Institutes of Health Stroke Scale.

Table 4. Initial Evaluation

1 Rapid assessment to ensure airway, breathing, and
circulation are stabilized
2 Verify blood pressure and blood glucose obtained
by emergency medical services
3 Verify time of stroke symptom onset

4 Verify medical and current medication history

5 Perform rapid neurologic examination (NIH Stroke
Scale) to establish stroke severity and determine
eligibility for thrombolysis and mechanical
thrombectomy treatment
6 Obtain initial noncontrast head CT scan to rule out
hemorrhagic stroke or tumors that may mimic
stroke; additional imaging necessary for treatment
decision may include CT angiography, CT perfusion,
or multimodal magnetic resonance imaging
7 Obtain laboratory studies including complete blood
count, basic chemistry panel, coagulation studies,
cardiac biomarkers, toxicology screening, and
pregnancy testing
8 Place 2 intravenous lines
CT ¼ computed tomographic.

53.e1 The Journal for Nurse Practitioners - JNP Volume 15, Issue 1, January 2019
Table 5. Modifiable Risk Factors and Interventions13
Modifiable Risk Risk Reduction Goal/Percent
Factor Stroke Risk Reduction Intervention
Hypertension < 130/80-140/90 Mediterranean diet, regular physical activity,
Risk reduction: limited alcohol intake, and use of
25%-32% antihypertension medications
Hyperlipidemia < 70-100 mg/dL Mediterranean diet, regular physical activity;
Risk reduction: high-intensity statin therapy (eg, atorvastatin
11.2% 80 mg) in patients  75 and in patients > 75,
moderate-intensity statin therapy (eg,
atorvastatin 40 mg) regardless of LDL
Diabetes < 6.5%-8% HbA1C Diet modification and blood glucose control with
Risk reduction: medication
Type 1: 57%
Type 2: no data
Atrial Risk reduction: Warfarin INR goal: 2.0-3.0
fibrillation Warfarin: 68% May use aspirin 325 mg if anticoagulant
Aspirin: 20% contraindicated
DOAC: similar to warfarin
Smoking Risk reduction: 50% at Smoking cessation counseling, nicotine
cessation 1 year, no risk by year 5 replacement, oral smoking cessation medication
DOAC ¼ directing-acting oral anticoagulant; INR ¼ international normalized ratio; LDL ¼ low-density lipoprotein.

www.npjournal.org The Journal for Nurse Practitioners - JNP 53.e2