stroke - recomendações para prevenir as recorrencias

Recommendations for Prevention of Recurrent Stroke Reviewed Laurie Barclay, MD January 27, 2009 — Recommendations for prevention of recurrent stroke are reviewed in the January issue of Mayo Clinic Proceedings. In addition to control of modifiable risk factors, virtually all patients who have had ischemic stroke should be prescribed antiplatelet agents. "Stroke is the leading cause of death and disability in the United States," writes Harold Adams Jr, MD, from the University of Iowa in Iowa City. "The economic consequences of stroke, including health care costs and lost economic productivity, are substantial. These are the reasons that stroke prevention, including treatment of underlying causes, are clearly of critical importance." The leading cause of ischemic stroke is atherosclerotic vascular disease, which gives rise to occlusion or severe stenosis of major intracranial or extracranial arteries, as well as narrowing of small penetrating arteries of the brain. Coronary artery disease, or atherosclerosis of the coronary arteries, may result in myocardial infarction, which in turn is an indirect cause of cardioembolic stroke. Atrial fibrillation and cardioembolic stroke may also complicate ischemic heart disease. "Some risk factors associated with increased likelihood of advanced atherosclerosis and ischemic disease are not modifiable," Dr. Adams writes. "These risk factors include age, sex, ethnicity, family history and premature vascular disease. However, several conditions that augment the course of atherosclerosis can be effectively addressed across the continuum of care." For patients with symptomatic ischemic cerebrovascular disease, a crucial aspect of treatment is prevention of recurrent stroke, myocardial infarction, and other ischemic events. This requires optimal control of modifiable risk factors that accelerate development of atherosclerosis, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking. Management of hypertension should aim to achieve a normal blood pressure for the patient, realizing that no single, specific antihypertensive regimen is ideal for all patients. When prescribing a blood pressure–lowering treatment plan, clinicians should consider a patient's history, while awaiting the results of ongoing and future studies. Some evidence suggests that aggressive lowering of cholesterol levels may modestly increase the risk for hemorrhagic stroke. However, the benefits of statins to decrease the risk for recurrent ischemic stroke and other ischemic vascular events are thought to outweigh the risk of bleeding. In patients with diabetes mellitus, management should include aggressive control of blood pressure and lipid levels as well as of blood glucose levels. More aggressive interventions may be required, such as carotid endarterectomy and endovascular treatment. In selected patients, carotid endarterectomy should be considered as complementary to use of antiplatelet agents and other medications. For other patients with atherosclerotic cerebrovascular disease, extracranial-intracranial bypass surgery and carotid artery stenting may be considered, pending the results of ongoing clinical trials. The keystone of management to prevent recurrent stroke and other cardiovascular events in patients at risk continues to be administration of antiplatelet agents, which should be prescribed for virtually all patients who have had ischemic stroke. Therapeutic options include aspirin, aspirin plus extended-release dipyridamole, or clopidogrel. Specific choice among these should be guided by the patient's previous treatment and history of ischemic events as well as allergies or other potential contraindications. Specific recommendations of the American Heart Association/American Stroke Association for antithrombotic therapy in patients with ischemic stroke of noncardioembolic origin (secondary prevention), and their accompanying levels of evidence, are as follows: Antiplatelet agents are recommended vs oral anticoagulants (level of evidence, I, A). Preferred options for initial treatment are aspirin (50 - 325 mg/day), a combination of aspirin and extended-release dipyridamole, or clopidogrel (level of evidence, I, A). The combination of aspirin and extended-release dipyridamole may be preferred vs aspirin alone (level of evidence, I, B). Instead of aspirin alone, clopidogrel may be considered (level of evidence, IIb, B). Clopidogrel is a reasonable option for patients who are hypersensitive to aspirin (level of evidence, IIa, B). Addition of aspirin to clopidogrel increases the risk for hemorrhage (level of evidence, III, A). "Use of an integrated treatment approach involving risk-factor management, antiplatelet therapy and surgical procedure when indicated presents the opportunity to lower the risk of recurrent stroke and other ischemic events in patients with recent ischemic stroke," Dr. Adams concludes. "Future research may provide support for using new medications, clarify the role of currently available medications, and better define the appropriate role of surgery, particularly endovascular treatments." In an accompanying editorial, James F. Meschia, MD, from the Mayo Clinic in Jacksonville, Florida, confirms that "after the immediate post-thrombolytic period, care needs to focus on secondary prevention." "Patients with acute ischemic stroke are at high risk of recurrent stroke," Dr. Meschia writes. "If successful reperfusion therapy is like dodging a bullet, successful secondary prevention is like being caught in the line of fire again. [Dr. Adams'] review will be welcomed by clinicians seeking guidance beyond evidence-based guidelines." The Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership funded editorial support for Dr. Adams' review. Dr. Adams has disclosed no relevant financial relationships. Dr. Meschia has received support from the Siblings with Ischemic Stroke Study and the Carotid Revascularization Endarterectomy vs Stenting Trial. Mayo Clin Proc. 2009;84:3-4, 43-51. Related Links Resource Centers Stroke/Cerebrovascular Disease