This patient should be referred for polysomnography. His chief symptom of fatigue is highly prevalent among patients in the poststroke period. Common reversible causes of fatigue after stroke include depression, sleep apnea of the central or obstructive type, and heart failure. This patient has had no recent depression and has normal findings on cardiac examination. He has an elevated BMI and hypertension, both of which are associated with sleep apnea. The diagnosis of sleep apnea is typically confirmed by polysomnography. Appropriate treatment of the sleep apnea can lead to lessening of fatigue symptoms and improved control of hypertension.

Cardiovascular stress testing is inappropriate in this patient who reports no exercise-induced fatigue and has normal findings on a recent electrocardiogram and echocardiogram. Myocardial ischemia is thus unlikely as an explanation of his symptoms. Patients with ischemic stroke are nonetheless at high risk for myocardial infarction, and a previous ischemic stroke is a coronary risk equivalent for the purposes of cardiovascular disease risk factor management strategies.

Depression is highly prevalent after stroke and is associated with poorer recovery and nonadherence to medical therapy. Use of antidepressant medications or cognitive behavioral psychotherapy (or both) is standard treatment of patients with stroke who experience depression. Although this patient has a remote history of depression, and fatigue can be a symptom of depression, he does not exhibit depressed mood or anhedonia, which are both elements of the two-question depression screening instrument. Treatment with citalopram or another antidepressant medication is therefore not necessary, although he should continue to be screened for this complication on routine visits.

Stimulants, including amphetamines, have shown no clinical benefits in stroke recovery and may exacerbate patients' hypertension. Dextroamphetamine is thus not appropriate in the management of this patient's poststroke fatigue.