Stroke Prevention: Little-Known and Neglected Aspects

Abstract

Combining available therapies has the potential to reduce the risk of stroke by 80% or more. A comprehensive review of all aspects of stroke prevention would be very lengthy; in this narrative review, we focus on some aspects of stroke prevention that are little-known and/or neglected. These include the following: (1) implementation of a Mediterranean diet; (2) B vitamins to lower homocysteine; (3) coordinated approaches to smoking cessation; (4) intensive lipid-lowering therapy; (5) lipid lowering in the elderly; (6) physiologically individualized therapy for hypertension based on renin/aldosterone phenotyping; (7) avoiding excessive blood pressure reduction in patients with stiff arteries; (8) treatment of insulin resistance with pioglitazone in stroke patients with prediabetes and diabetes; (9) impaired activation of clopidogrel in patients with variants of CYP2C19; (10) aspirin pseudoresistance due to enteric coating; (11) rationale for anticoagulation in patients with embolic stroke of unknown source; (12) pharmacologic properties of direct-acting oral anticoagulants that should be considered when choosing among them; (13) the identification of which patients with asymptomatic carotid stenosis are at a high enough risk to benefit from carotid endarterectomy or stenting; and (14) the importance of age in choosing between endarterectomy and stenting. Stroke prevention could be improved by better recognition of these issues and by implementation of the principles derived from them.

Primary stroke prevention worldwide: translating evidence into action

“…To develop an economic case for the pragmatic solutions for the primary prevention of stroke, we measured the global economic burden of stroke. The estimated economic burden accounted for the global financial costs of providing acute care to patients with stroke in hospital, including rehabilitation, and in the post-acute phase, including medical care, social services, and informal caregiving (appendix pp [7][8][9][10][11][12][13][14][15][16][17][18][19][20]. We also estimated the income losses associated with people who have had a stroke and their households due to premature death and disability, and we estimated production losses as a result of stroke (appendix pp 7-20).…”

“…8 The growing burden of stroke across the globe strongly suggests that current primary stroke and cardiovascular disease prevention strategies are either not used widely enough or are insufficiently effective. Comprehensive reviews of primary and secondary prevention of stroke 9,10 have mostly focused on individual risk factors and measurements of the effectiveness of preventive interventions. This Health Policy paper is based on a multifaceted approach, including a critical review of existing primary prevention strategies and current guidelines, economic analysis, and identification of gaps in primary stroke prevention.…”

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

“…89 For example, based on renin/aldosterone phenotyping, an aldosterone antagonist, such as spironolactone, is most appropriate for those with low renin/high aldosterone (primary hyperaldosteronism, much more likely in patients of African origin), an ARB for those with high renin/high aldosterone (secondary hyperaldosteronism), and amiloride for those with low renin/low aldosterone (Liddle syndrome). 90…”

Optimal periprocedural antithrombotic treatment in carotid interventions: An international, multispecialty, expert review and position statement

“…Up to 30% of Europeans and 50% of Chinese carry non-functional alleles of the CYP2C19 gene and cannot activate clopidogrel via the CYP2C19 pathway. [39][40][41] High on Treatment Platelet Reactivity (HTPR) to aspirin and clopidogrel (previously called "antiplatelet resistance") is associated with inadequate secondary prevention of TIA/ischemic strokes. Patients on clopidogrel/aspirin with HTPR have an approximately 80% higher risk for recurrent TIA/ischemic stroke episodes than individuals without HTPR (RR, 1.81; 95% CI, 1.30-2.52; P < 0.001).…”