Elsevier

Progress in Cardiovascular Diseases

Volume 50, Issue 4, January–February 2008, Pages 264-273
Progress in Cardiovascular Diseases

A Review of Therapeutic Strategies for Risk Reduction of Recurrent Stroke☆

https://doi.org/10.1016/j.pcad.2007.09.001Get rights and content

Although cardiovascular disease (CVD) is a major source of morbidity and mortality in the United States, a relatively small percentage of deaths related to CVD result from ischemic stroke. However, the impairment and costs associated with stroke are large—and largely preventable. Large-scale trials have demonstrated benefit with antihypertensive therapy for secondary prevention, showing significantly reduced rates of stroke and cardiovascular events. Statins have shown efficacy in primary stroke prevention, and one trial showed reduced incidence of stroke and cardiovascular events in patients with recent stroke or transient ischemic attack (TIA). The merits of antiplatelet therapy in primary and secondary stroke prevention have been demonstrated across numerous trials and meta-analyses. Trials assessing aspirin plus clopidogrel or aspirin plus extended-release dipyridamole for preventing secondary stroke have produced somewhat contradictory findings. This review discusses the relationship between CVD and risk of secondary stroke or TIA and summarizes secondary prevention strategies, focusing on antiplatelet agents, to provide guidance for the practicing cardiologist. Certain combination therapies appear to be more effective for secondary prevention of stroke or TIA than therapy with single antiplatelet agents. The choice of agents may be important, based on results of several trials. The ongoing, large-scale, comparative Prevention Regimen for Effectively Avoiding Second Strokes (PR. FESS®) trial should provide cardiologists with more definitive recommendations.

Section snippets

Hypertension

The risk of stroke increases continuously and steeply above blood pressure (BP) levels of approximately 115/75 mm Hg.27 Because much of the US population has BP levels higher than 115/75 mm Hg, hypertension is a substantial risk factor. However, hypertension is readily addressed through lifestyle modification and pharmacologic therapy. Based on meta-analyses of randomized, controlled trials, risk of stroke can be reduced by approximately 30% to 40% through BP control.27, 28

Diabetes

Although diabetes has

Lifestyle Modification

Prevention of stroke—particularly among patients with previous stroke or TIA—is a critical yet achievable goal for reducing disease burden.41 One of the easiest and yet highly effective approaches to reducing stroke and TIA risk is lifestyle modification. Smoking, alcohol consumption, and obesity should all be addressed to reduce stroke risk.15 The rationale for and recommended approaches to lifestyle modification are summarized in Table 1.15

In addition to lifestyle modifications, pharmacologic

Review of Antiplatelet Therapy Trials

Antiplatelet therapies reduce the risk of recurrent stroke in patients with TIA or ischemic stroke due to thrombosis. Numerous clinical trials have evaluated the safety and efficacy of antiplatelet therapy for the secondary prevention of stroke.17, 18, 19, 20, 21, 22, 23, 24, 25, 26

Implications for the Cardiologist

The latest AHA stroke guidelines recommend the use of antiplatelet agents to reduce recurrent stroke and other cardiovascular events in patients with ischemic stroke or TIA.15 Although clopidogrel plus aspirin is recommended over aspirin alone for patients with acute coronary syndromes, the results of MATCH did not demonstrate a similar risk-benefit ratio for patients with stroke and TIA; therefore, that combination is not recommended as a strategy for prevention of recurrent stroke.15 In

Summary and Conclusions

Stroke, both primary and recurrent, has major impact on mortality, morbidity, and health care costs. Risk factors for stroke are well established, as are pharmacologic and nonpharmacologic approaches for preventing stroke and TIA. Antihypertensive therapy has been proven to reduce CVD risk, including risk of recurrent stroke, in large-scale trials. The large-scale SPARCL trial results demonstrate decreased risk of stroke, major coronary events, and revascularization procedures with statin

Acknowledgment

This work was supported by Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT.

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    ☆

    Editorial assistance for the development of the manuscript was provided by Jeffrey Mucciolo, Boehringer Ingelheim Pharmaceuticals, Inc.

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