Should I start all my ischaemic stroke and TIA patients on a statin, an ACE inhibitor, a diuretic, and aspirin today?
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK
- Correspondence to: Professor Sandercock;
- Received 7 May 2003
- Accepted 1 July 2003
- ASCOT, Anglo-Scandinavian cardiac outcomes trial
- AVASIS, aspirin versus anticoagulants in symptomatic intracranial stenosis
- ESPRIT, European/Australian stroke prevention in reversible ischaemia trial
- GALA, general anaesthetic versus local anaesthetic for carotid endarterectomy
- PROGRESS, perindopril protection against recurrent stroke study
- PROSPER, pravastatin in elderly individuals at risk of vascular disease
- SPORTIF, stroke prevention by oral thrombin inhibition IV
- TIA, transient ischaemic attack
- WARCEF, warfarin-aspirin reduced cardiac ejection fraction study
- WASID, warfarin-aspirin symptomatic intracranial disease study
Stroke is eminently preventable.1,2 A combination of individual and population based interventions could lower the global incidence of vascular events by as much as 50%.2 However, the public health and legislative changes required to achieve substantial primary prevention of vascular disease (for example, by reducing the salt content of processed food) is really the territory of public health systems and governments2 and is beyond the scope of this article. In this short review I shall therefore deal with stroke prevention from the perspective of the hospital clinician and hence focus on secondary prevention. In the 1980s, the only treatment offered to many patients with transient ischaemic attack (TIA) or minor ischaemic strokes was aspirin. There is now a much wider range of evidence based interventions available for reducing the risk of recurrent stroke and other serious vascular events.1 In brief, I will identify who is at high enough risk to justify intervention; which interventions are effective; and how best to arrange neurovascular services to deliver the interventions efficiently.
WHO IS AT HIGHEST RISK?
Individuals at high absolute risk of vascular events
In neurological and neurosurgical practice, the people who have most to gain from secondary prevention are those with minimal or no disability who are at highest absolute risk of disabling stroke—that is, those who have had a recent TIA or minor stroke. Some individuals with atrial fibrillation but no history of a cerebrovascular event may have a comparably high absolute risk. If one follows up such individuals, they are likely to suffer not just strokes but also myocardial infarcts, or to require vascular surgical procedures (on the cerebral, coronary or peripheral arteries), or to die from vascular causes. For an intervention such as carotid endarterectomy for symptomatic carotid stenosis (with an average 3–5% risk of fatal or disabling stroke complicating the procedure), it is important to offer …