Elsevier

The Lancet

Volume 354, Issue 9188, 23 October 1999, Pages 1457-1463
The Lancet

Review
Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations*

https://doi.org/10.1016/S0140-6736(99)04407-4Get rights and content

Summary

This review of the effectiveness of treatment for acute stroke and methods of secondary prevention shows that the highest priority for providers of a stroke service must be to establish a stroke unit and multidisciplinary team that delivers organised stroke care. Acute ischaemic stroke patients should be immediately started on aspirin 300 mg daily, and, if possible, many of them should be entered into further trials of thrombolysis and other promising treatments. After the acute phase, aspirin should be continued in a lower dose, 75 mg daily; smoking should be discouraged; high blood pressure treated initially with a diuretic; and fibrillating ischaemic stroke/transient ischaemic attack survivors anticoagulated long-term with warfarin or given aspirin if anticoagulation is not sensible. Statins are probably indicated in patients who already have symptomatic coronary heart disease. Adding dipyridamole to aspirin, substituting clopidogrel for aspirin, and carotid endarterectomy are all expensive interventions to prevent stroke, but if ways could be found to focus them on those patients at especially high risk, they would become more affordable.

Section snippets

Identification and selection of studies

We searched the Cochrane Library and the US National Library of Medicine's Medline for up-to-date systematic reviews and RCTs of acute stroke treatment and secondary stroke prevention. The latest reviews from the Cochrane Library were selected but if they did not include recently published RCTs we added data from those RCTs to data in the review. In the absence of a systematic review, we pooled data from RCTs. If no RCTs had been done we relied on observational cohort and case-control studies.

Acute stroke interventions

Interventions for which there is reasonable evidence are stroke units, aspirin, thrombolysis, and heparin; the evidence for all other medical therapies, and surgery for primary intracerebral haemorrhage (PICH) is inadequate. We shall give full details of RRR, ARR, deaths/dependents avoided per 1000 treated, and NNT for stroke units but table 1 summarises these calculations for all three effective acute stroke interventions.

Secondary prevention

The secondary prevention strategies for which there is reasonable evidence of effectiveness are control of vascular risk factors, antiplatelet drugs, anticoagulants, and carotid endarterectomy. The effectiveness indices are summarised in table 2.

Discussion

We have attempted to find and then apply the best available evidence of acute stroke treatments and secondary prevention strategies to a hypothetical population of 1 million people to determine the relative cost of each strategy, and the impact on the burden of stroke in the population.

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    Based on a talk given by G J H at The Lancet's conference The Challenge of Stroke, held in Montreal, Canada, In October, 1998.

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