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19 - Secondary prevention

from Section IV - Therapeutic strategies and neurorehabilitation

Published online by Cambridge University Press:  05 May 2010

By
Hans-Christoph Diener  and
Greg W. Albers
Edited by
Michael Brainin  and
Wolf-Dieter Heiss
Michael Brainin
Affiliation:
Zentrum für Klinische Neurowissenschaften, Donnau-Universität, Krems, Austria
Wolf-Dieter Heiss
Affiliation:
Universität zu Köln
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Summary

Introduction

Secondary prevention aims at preventing a stroke after a transient ischemic attack (TIA) or a recurrent stroke after a first stroke. About 80–85% of patients survive a first ischemic stroke [1, 2]. Of those between 8% and 15% suffer a recurrent stroke in the first year. Risk of stroke recurrence is highest in the first few weeks and declines over time [3–5]. The risk of recurrence depends on concomitant vascular diseases (CHD, PAD) and vascular risk factors and can be estimated by risk models [6, 7]. Stroke risk after a TIA is highest in the first 3 days [8]. Therefore immediate evaluation of patients with stroke or TIA, identification of the pathophysiology and initiation of pathophysiology based treatment is of major importance [9]. In the following sections, we will deal with the treatment of risk factors, antithrombotic therapy and surgery or stenting of significant stenosis of extra- or intracranial arteries. Each paragraph will be introduced by recommendations, followed by the scientific justification.

Treatment of risk factors

Hypertension

  • Antihypertensive therapy reduces the risk of stroke. The combination of an ACE inhibitor (perindopril) with a diuretic (indapamide) was significantly more effective than placebo, and an angiotensin-receptor blocker (ARB, eprosartan) was more effective than a calcium-channel blocker (nitrendipin). Ramipril reduces vascular events in patients with vascular risk factors.

  • Early initiation of antihypertensive therapy with telmisartan on top of the usual antihypertensive therapy is not more effective than placebo.

  • Most likely all antihypertensive drugs are effective in secondary stroke prevention. Beta-blockers (atenolol) show the lowest efficacy. More important than the choice of a class of antihypertensives is to achieve the systolic and diastolic blood pressure targets (<140/90 mmHg in non-diabetics and <130/80 in diabetics). In many cases this requires combination therapy. Concomitant diseases (kidney failure, congestive heart failure) have to be considered.

  • […]

Type
Chapter
Information
Textbook of Stroke Medicine , pp. 272 - 282
Publisher: Cambridge University Press
Print publication year: 2009

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