The Secondary Prevention of Ischemic Stroke

The Secondary Prevention of Ischemic Stroke: 

The Secondary Prevention of Ischemic Stroke By NASSER ALNAZARI

Dangerous is it ……??: 

Dangerous is it ……?? 790,000 people in USA have stroke each year . One every 40 seconds . 150,000 people in the USA die from a stroke each year . One every 4 minute . Third leading cause of death .

High risk groubs: 

High risk groubs Risk of stroke VS general population PAD 2-3 times MI 3-4 times Stroke 9 times

TIA vs. Stroke : 

TIA vs. Stroke The distinction is becoming less impotant . They share common pathological mechanisms. Preventive approaches are similar.

TIA vs. Stroke : 

TIA vs. Stroke However , patients with TIA recive less aggressive treatment than stroke patients ,, despite a 5 years stroke risk over 30% 

Express TIA care study ,,, so what: 

Express TIA care study ,,, so what Final result of 90 day risk of recurrent stroke 80 % reduction in risk . Lancet 2007

Target Big risks: 

Target Big risks

Hypertension: 

Hypertension The most important risk factor for srtoke . Strok risk rise linearly from 115/75 mmhg . For every SBP elevation of 20 mmhg or DBP elevation of 10 mmhg , there is a doubling of sroke mortality .

HTN: 

HTN After the acute event has passed , tight blood pressure control is essential …….. Less than 130/80 mmhg if DM, CKD,CAD or CAD equivalent of 10 years risk more than 10% ( carotid disease , PAD , AAA ) And less than 120/80 if LVD .

HTN: 

HTN Antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in persons who have had an ischemic stroke or TIA and are beyond the hyperacute period (Class I, LOE A) .

HTN: 

HTN in PROGRES study ( Perindopril Protection Against Recurrent Stroke ) and in HOPE study (t he Heart Outcomes Prevention Evaluation ) ramipril . patients without hypertension benefited as much as those with hypertension !!!!

HTN: 

HTN The optimal drug regimen remains uncertain . Tight blood pressure control after the acute period is essentail . ( class I , LOE A ) Start blood pressure therapy regardless of presence of basline hypertension (class IIa , LOE B)

Hypercholesterolemia : 

Hypercholesterolemia Cholesterol studies mainly looked at patients from cardiac point of view . Relative risk reduction of ischemic stroke in these studies 20 – 30 % . Statins were the most studied agents . Niacin showed a reduction of CVA events in the Coronary Drug Project .

Hypercholesterolemia : 

Hypercholesterolemia SPARCL study ( Stroke Prevention by Aggressive Reduction in Chlosterol Levels ) . Atorvastatin 80 mg vs. placebo . Followed for 4.9 years . LDL levels at end of study Atorvastatin groub : 73mg/dl Placebo groub : 129mg/dl

Hypercholesterolemia : 

Hypercholesterolemia SPARCL cont Absolute risk reduction of stroke : 2.2 % . Absoulte risk reduction of major cardiaovascular event : 3.5 % .

Hypercholesterolemia : 

Hypercholesterolemia Statin theapy shuld be started during hospitalizations for patients with TIA/ stroke regardless of baseline LDL Class I , LOE A if known atherosclerotic disease or elevated cholesterol level . Class IIa , LOE B if no evidence of atherosclerosis and normal cholesetrol level .

Smoking: 

Smoking Major independent risk factor for ischemic stroke . Doubling of risk compared with nonsmokers . Risk of recurrent stroke decreases after quitting, and disappears after 5 years . Reduction in stroke-related hospitalizations .

Smoking : 

Smoking Healthcare providers should strongly advice every patient with CVA/TIA who has smoked in the past year to quit Class I , LOE C

Antiplatelet: 

Antiplatelet A lot of study …………….. Swedish Aspirin low Dose trial . Given 75 mg of aspirin or palcebo . Duration of 32 month /// endpoint of stroke . ARR=2.6 ; NNT=38 . NNT/year = 101 .

Clopidogrel vs. Aspirin in Patients at Risk of Ischemic Events ( CAPRIE ): 

C lopidogrel vs. A spirin in P atients at R isk of I schemic E vents ( CAPRIE ) Conclusion was …. No significante better than aspirin . No statistical significance .

Clopidogrel + Aspirin : 

Clopidogrel + Aspirin MATCH study M angment of A thero T hrombosis with C lopidogrel in H igh risk patients with TIA or CVA . No differnce in vascular events . Increase life-threatening bleeding in the Clopidogrel + Asprin groub No difference in mortality .

Warfrin vs. Antiplatelet for non-cardioembolic TIA/CVA: 

Warfrin vs. Antiplatelet for non- cardioembolic TIA/CVA No evidence of warfrin superioraty over antiplatelets for non- cardiembolic strok . By E uropean/ A ustralasian S troke P revention in R eversible I schemia T rial ( ESPRIT ) .

Antiplatelets : 

Antiplatelets *In patients with non- cardioembolic ischemic TIA/CVA , antiplatelets agents are recommended to reduce recurrent events . Class I , LOE A . *Aspirin + Aggrenox ( ER dipyridamole ) is more effective than aspirin alone . Class I, LOE B . * Clopidogrel is not superior to aspirin . Class IIa,LOE B .

Cardiogenic TIA/Stroke: 

Cardiogenic TIA/Stroke Warfarin should be given for those with TIA or stroke if: *Persistent or paroxysmal atrial fibrillation Risk of stroke is 5X higher Class I, LOE A (Reduces stroke by ~ 60%) *If unable to take warfarin , give aspirin 325 mg/day . Class I, LOE A (Reduces stroke by ~ 20%) *Acute MI with left ventricular thrombus Class IIa , LOE B .

Cardiogenic TIA/Stroke: 

Cardiogenic TIA/Stroke Warfarin should be given for those with TIA or stroke if: Rheumatic mitral valve disease Add aspirin 81 mg daily if recurrent embolism . Class IIa , LOE C Mechanical heart valves . Class I, LOE B Add aspirin 81 mg daily if recurrent embolism . Class IIa , LOE B

Carotid Stenosis: 

Carotid Stenosis NASCET . N orth A merican S ymptomatic C arotid E ndarterectomy T rial . Absolute risk reduction greater with increasing levels of stenosis : 90-99% = 26%ARR NNT = 4 80-89% = 18%ARR NNT = 6 70-79% = 12%ARR NNT = 8

Carotid Stenosis: 

Carotid Stenosis Better outcomes for CEA are seen with : Higher (>70%) vs. lower (50-69%) degrees of stenosis . Men vs. Women . Stroke vs. TIA . CEA within 2 weeks of event vs. waiting . Surgeons with low rates of complications .

Carotid Stenosis: 

Carotid Stenosis When the ipsilateral stenosis is severe (>70%), CEA is recommended (Class I, LOE A)

Diabetes mellitus: 

Diabetes mellitus PROactive Effects of Pioglitazone in Patients With Type 2 Diabetes With or Without Previous Stroke. In those with prior stroke, pioglitazone reduced fatal or nonfatal stroke . ARR = 4.6% NNT = 22

Diabetes mellitus: 

Diabetes mellitus *Use of existing guidelines for glycemic control and BP targets in patients with diabetes is recommended for patients who have had a CVA / TIA Class I , LOE B

Other rare risks : 

Other rare risks

Take Home Points: 

Take Home Points TIA/stroke is common, deadly, costly, and devastating . The early risk of a significant stroke after a TIA or minor stroke is very high .

Take Home Points: 

Take Home Points Start thiazide plus ACE-I after stroke regardless of baseline hypertension . Start a statin right away for patients with TIA/stroke, regardless of baseline LDL . Strongly emphasize smoking cessation .

Take Home Points: 

Take Home Points Start an antiplatelet agent after TIA/stroke . Don’t combine clopidogrel + aspirin solely for stroke prevention .

Take Home Points: 

Take Home Points Give warfarin to prevent another stroke if: Atrial fibrillation . Acute MI with LV thrombus . Rheumatic mitral valve disease . Mechanical heart valve .

Take Home Points: 

Take Home Points Order an early carotid ultrasound . Order a CTA or MRA if stenosis is greater than 50% on ultrasound . Great benefit for CEA for stenoses >70% and in select patients with stenoses 50-69% . Best done within 2 weeks of eve nt

Refference: 

Refference *American stroke association adivision of american heart association ( stroke oct21 ,2010) . *Lancet 2004 . * www.strokeassociation.org