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Aim:The principal aim of the REACT study (REassessment of Antihypertensive Chronic Therapy) was to Abstract achieve a comprehensive assessment of hypertension management in Italy from both the physician and patient points of view. Blood pressure control, global risk factors, target organ damage stratification, use of diagnostic examinations, prescribing practices and physician/patient satisfaction with the planned therapeutic regimen, as well as an assessment of patient quality of life were evaluated. A total of 1482 hypertensive patients and their physicians participated in this study. Experimental Design: REACT was a multicentre, non-intervention, cross-sectional, observational study of the management of hypertension in Italy. Hypertensive patients were selected from specialised clinics from the following sub-specialties: cardiology, internal medicine, geriatrics, diabetology and nephrology. Patient Population: Between 10 and 20 patients were enrolled in each of the 131 participating centres. Eligible patients had to have been diagnosed with primary hypertension for at least 1 year and been on stable antihypertensive therapy for at least 1 year. Enrolment began in March 2003 and concluded in March 2004. Conclusions: Hypertension management in Italy remains inadequate. This conclusion is based on poor control of blood pressure and cardiovascular risk factors, persistence of target organ damage, inadequate use of diagnostic tests and examinations, and a deficient therapeutic approach. Since this study was performed in patients with antihypertensive treatment established for at least 1 year and followed by expert specialist physicians, these findings are worrisome and indicate the need for more stringent and effective recommendations for the clinical management of hypertensive patients.

The incidence of stroke in patients with atrial fibrillation (AF) is five times greater than that in age-matched controls. Warfarin reduces this incidence by two thirds and is the most effective agent for this indication. However, despite its efficacy, warfarin management is tedious and is useful only in a subsegment of the population who needs anticoagulation and has no contraindications. Many agents are poised to replace warfarin as an effective anticoagulant for stroke prevention in AF. The direct thrombin inhibitor dabigatran is furthest along in clinical development, followed by the factor Xa inhibitors rivaroxaban and apixaban. All these agents seem effective, and none appears mechanistically superior over another. Dabigatran's advantage is that it was tested in two dosages in a phase 3 evaluation based on earlier phase 2 studies in patients with AF, whereas dosage data for the other agents were extrapolated from phase 2 programs for venous thromboembolism prevention. The vitamin K antagonist ATI-5923 offers clinical benefits similar to warfarin's, but with no or fewer drug-drug interactions, potentially greater time in therapeutic range, and probably less need for dose adjustment and laboratory monitoring. It challenges the newer mechanistic agents in efficacy and raises the bar for comparison in future head-to-head trials. Further analysis and clinical trial testing are still needed to determine whether one or all of these agents are effective anticoagulants for stroke prevention in patients with AF.

Conclusion:Aspirin and clopidogrel combined are associated with more bleeding than aspirin or clopidogrel alone.Summary: Aspirin is effective as an antithrombotic agent for secondary stroke prevention. It reduces the risk of secondary stroke 15% to 20% compared with placebo (BMJ 1994;308:81-106) but fails to prevent many events; therefore, other antithrombotic agents have been investigated for secondary stroke prevention. All antithrombotic agents, however, carry a bleeding risk, and some bleeding episodes are fatal; for example, bleeding associated with antithrombotic agents for secondary prevention leads to higher mortality in patients with acute coronary syndromes (Circulation 2006;114:774-82). In this report the authors sought to compare bleeding risk associated with secondary stroke prevention regimens for noncardioembolic strokes. They focused on analyzing recent studies of combinations of antiplatelet agents.The authors assessed annualized rates of total and major bleeding events in secondary stroke prevention trials of antithrombotic agents. They searched Medline for major randomized clinical studies with a follow-up duration of Ͼ1 year and identified 13 studies. They used pooled data sets to compare mean bleeding rates for aspirin (Յ325 mg/d), clopidogrel, anticoagulants (warfarin and other vitamin K antagonists), aspirin plus clopidogrel, and aspirin plus extended-release dipyridamole (ER-DP). Total bleeding occurred at mean rates of 4.8% with aspirin (Յ325 mg/d) alone, 2.9% with clopidogrel alone, 3.6% with aspirin plus ER-DP, 10.1% with aspirin plus clopidogrel, and 16.8% with anticoagulation. Mean bleeding occurred at mean rates of 1% with aspirin (Յ325 mg/d) alone, 0.85% with clopidogrel, 0.93% with aspirin plus ER-DP, 1.7% with aspirin plus clopidogrel, and 2.5% with anticoagulation.Comment: The 13 studies analyzed in this article included 87,205 patients. The estimated bleeding risks associated with various forms of pharmacologic secondary stroke prophylaxis are therefore probably accurate. However, reporting of bleeding rates is hampered by lack of a common classification scheme for bleeding episodes. The main point of this article is to point out that bleeding rates with combinations of antiplatelet therapies or anticoagulation, in patients with previous stroke, are really quite significant. In all but 1 of the 13 studies analyzed, the mean patient age was Ͻ70 years. If one wishes to extrapolate these data to vascular surgical patients, who are in many cases older than those analyzed here, the likely risk of dual antiplatelet therapy might be even higher.

Patients with coronary artery disease (CAD) commonly have varying degrees of coexisting cerebrovascular disease (CVD) and chronic kidney disease (CKD), and proper management is complicated partly because of a lack of unifying guidelines. The aim of this article is to review the current literature and propose the optimal treatment regimen in patients with all three disease states. Angiotensin‐converting enzyme inhibitors (ACE‐I) should be universally administered. High‐dose statin therapy to reach a target low‐density lipoprotein (LDL) of 70–100 mg/dL is advocated, although patients with a history of cerebral bleeding must be carefully monitored for possible recurrence. Beta‐blockers are appropriate after a recent coronary event, and amlodipine or thiazide diuretics should be used after a recent stroke (within 6 months). Patients with a history of stroke (with or without coexisting CAD and CKD) should receive aspirin (75–150 mg/day) indefinitely. Clopidogrel or aspirin plus extended‐release dipyridamole (ER‐DP) may be prescribed in patients allergic or resistant to aspirin. If stroke is attributable to cardiogenic embolism, anticoagulation is indicated. In patients with acute coronary syndromes (ACS) (excluding ST‐elevated myocardial infarct) who undergo percutaneous coronary intervention (PCI), aspirin plus clopidogrel is indicated for secondary prevention for up to 12 months. There are no data supporting the use of aspirin plus clopidogrel in patients with CKD who develop ACS. Aspirin plus clopidogrel is contraindicated for stroke prevention.