Ischemic stroke secondary prevention: Difference between revisions

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(/* Secondary prevention for specific causes of ischemic stroke{{cite journal| author=Donnan GA, Fisher M, Macleod M, Davis SM| title=Stroke. | journal=Lancet | year= 2008 | volume= 371 | issue= 9624 | pages= 1612-23 | pmid=18468545 | doi=10.1016/S0140-...)
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===Secondary prevention for specific causes of ischemic stroke<ref name="pmid18468545">{{cite journal| author=Donnan GA, Fisher M, Macleod M, Davis SM| title=Stroke. | journal=Lancet | year= 2008 | volume= 371 | issue= 9624 | pages= 1612-23 | pmid=18468545 | doi=10.1016/S0140-6736(08)60694-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18468545  }} </ref>===
===Secondary prevention for specific causes of ischemic stroke<ref name="pmid18468545">{{cite journal| author=Donnan GA, Fisher M, Macleod M, Davis SM| title=Stroke. | journal=Lancet | year= 2008 | volume= 371 | issue= 9624 | pages= 1612-23 | pmid=18468545 | doi=10.1016/S0140-6736(08)60694-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18468545  }} </ref>===
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Cause of ischemic stroke}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Revascularisation}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Multifacrorial risk reduction}}


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! colspan="2" rowspan="2" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Cause of ischemic stroke}}
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=2  | {{fontcolor|#FFFFFF|Revascularization}}
! style="background: #4479BA; padding: 5px 5px;" colspan=4 | {{fontcolor|#FFFFFF|Multifactorial risk reduction}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Large vessel atherosclerosis'''
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Carotid endartectomy}}
*Carotid artery stenosis and occlusion
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Carotid stenting}}
*Intracranial artery atheroscerosis
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Antiplatelet therapy}}
*Vertebral artery stenosis
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Statins}}
*Extracranial artery dissection
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Antihypertensives}}
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Anticoagulants}}
| style="padding: 5px 5px; background: #F5F5F5;" |
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Small vessel disease'''
| rowspan="5" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | ''Large artery disease''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Carotid Artery Stenosis
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | g
| style="padding: 5px 5px; background: #F5F5F5;" | g
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Cardiac embolism '''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Carotid occlusion
*Atrial fibrillation
| style="padding: 5px 5px; background: #F5F5F5;" | g
*Recent Myocardial infarction
| style="padding: 5px 5px; background: #F5F5F5;" | g
*Cardiac failure
! style="padding: 5px 5px; background: #F5F5F5;" | ++
*Dilated cardiomyopathy
! style="padding: 5px 5px; background: #F5F5F5;" | +
*Valvular heart disease
! style="padding: 5px 5px; background: #F5F5F5;" | ++
:*Rheumatic heart disease
! style="padding: 5px 5px; background: #F5F5F5;" | +
:*Prosthetic heart disease
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Blood Dyscrasias'''
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Vertebral artery
*Inherited thrombophilias
| style="padding: 5px 5px; background: #F5F5F5;" | g
*Sickle cell disease
| style="padding: 5px 5px; background: #F5F5F5;" | g
*Antiphospholipid syndrome
! style="padding: 5px 5px; background: #F5F5F5;" | ++
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" |
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Large vessel atherosclerosis
| style="padding: 5px 5px; background: #F5F5F5;" | g
| style="padding: 5px 5px; background: #F5F5F5;" | g
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Arterial dissection
| style="padding: 5px 5px; background: #F5F5F5;" | g
| style="padding: 5px 5px; background: #F5F5F5;" | g
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| rowspan="5" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Cardiac embolism
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Atrial fibrillation
| style="padding: 5px 5px; background: #F5F5F5;" | g
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Valvular heart disease
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Recent MI
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Heart failure
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Dilated cardiomyopathy
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" rowspan="3" | Hypercoaguable states
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" rowspan="1" |Protein C/S deficiency
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" rowspan="1" |Sickle cell disease
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" rowspan="1" |Antithrombin III deficiency
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
! style="padding: 5px 5px; background: #F5F5F5;" | ++
! style="padding: 5px 5px; background: #F5F5F5;" | +
|
|}
|}
A) Revascularization [carotid artery occlusion, stenosis, vertebral artery stenosis, intracranial large artery atherosclerosis,
*Carotid endartectomy :prefferd
*Carotid stenting
B)Multifactorial risk reduction
*Antiplatelet agents
*Antilipid
*Antihypertensive med
Treatment of risk factors in patients who have already had strokes (secondary prevention) is also very important as they are at high risk of subsequent events compared with those who have never had a stroke. Medication or [[Pharmacology|drug therapy]] is the most common method of stroke prevention. Aspirin (usually at a low dose of 75 mg) is recommended for the primary and secondary prevention of stroke.  Also see [[Antiplatelet drug]] treatment.  Treating risk factors like [[hypertension]], [[diabetes mellitus]], [[smoking cessation]], control of  [[hypercholesterolemia]], [[physical exercise]], and avoidance of [[Illegal drug trade|illicit drugs]] and excessive alcohol consumption are all recommended ways of reducing the risk of stroke in a patient who already has a history of previous strokes.<ref name="americanheart risk">American Heart Association. (2007). [http://www.americanheart.org/presenter.jhtml?identifier=4716 Stroke Risk Factors] Americanheart.org. Retrieved on [[January 22]], [[2007]].</ref>
Treatment of risk factors in patients who have already had strokes (secondary prevention) is also very important as they are at high risk of subsequent events compared with those who have never had a stroke. Medication or [[Pharmacology|drug therapy]] is the most common method of stroke prevention. Aspirin (usually at a low dose of 75 mg) is recommended for the primary and secondary prevention of stroke.  Also see [[Antiplatelet drug]] treatment.  Treating risk factors like [[hypertension]], [[diabetes mellitus]], [[smoking cessation]], control of  [[hypercholesterolemia]], [[physical exercise]], and avoidance of [[Illegal drug trade|illicit drugs]] and excessive alcohol consumption are all recommended ways of reducing the risk of stroke in a patient who already has a history of previous strokes.<ref name="americanheart risk">American Heart Association. (2007). [http://www.americanheart.org/presenter.jhtml?identifier=4716 Stroke Risk Factors] Americanheart.org. Retrieved on [[January 22]], [[2007]].</ref>


Revision as of 19:56, 16 November 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

Secondary Prevention

Life style modification for secondary prevention

Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:

  • Increased physical activity
  • Eating healthy balanced diet
  • Treatment and maintainence of hypertension, diabetes mellitus and hyperlipidemias
  • Treatment of underlying coronary artery disease
  • Treatment of atrial fibrillation and maintaining anticoagulant prophylaxis in high risk patients
  • Proper management and follow up of genetic hypercoaguable conditions

Secondary prevention for specific causes of ischemic stroke[1]

Cause of ischemic stroke Revascularization Multifactorial risk reduction
Carotid endartectomy Carotid stenting Antiplatelet therapy Statins Antihypertensives Anticoagulants
Large artery disease Carotid Artery Stenosis g g ++ + + +
Carotid occlusion g g ++ + ++ +
Vertebral artery g g ++ + ++ +
Large vessel atherosclerosis g g ++ + ++ +
Arterial dissection g g ++ + ++ +
Cardiac embolism Atrial fibrillation g ++ + ++ + +
Valvular heart disease ++ + ++ + ++ +
Recent MI ++ + ++ + ++ +
Heart failure ++ + ++ + ++ +
Dilated cardiomyopathy ++ + ++ + ++ +
Hypercoaguable states Protein C/S deficiency ++ + ++ + ++ +
Sickle cell disease ++ + ++ + ++ +
Antithrombin III deficiency ++ + ++ + ++ +

Treatment of risk factors in patients who have already had strokes (secondary prevention) is also very important as they are at high risk of subsequent events compared with those who have never had a stroke. Medication or drug therapy is the most common method of stroke prevention. Aspirin (usually at a low dose of 75 mg) is recommended for the primary and secondary prevention of stroke. Also see Antiplatelet drug treatment. Treating risk factors like hypertension, diabetes mellitus, smoking cessation, control of hypercholesterolemia, physical exercise, and avoidance of illicit drugs and excessive alcohol consumption are all recommended ways of reducing the risk of stroke in a patient who already has a history of previous strokes.[2]

In patients who have strokes due to abnormalities of the heart, such as atrial fibrillation, anticoagulation with medications such as warfarin is often necessary for stroke prevention.[3]

Procedures such as carotid endarterectomy or carotid angioplasty can be used to remove significant atherosclerotic narrowing (stenosis) of the carotid artery, which supplies blood to the brain. These procedures have been shown to prevent stroke in certain patients, especially where carotid stenosis leads to ischemic events such as transient ischemic attack. (The value and role of carotid artery ultrasound scanning in screening has yet to be established.)

References

  1. ↑ Donnan GA, Fisher M, Macleod M, Davis SM (2008). "Stroke". Lancet. 371 (9624): 1612–23. doi:10.1016/S0140-6736(08)60694-7. PMID 18468545.
  2. ↑ American Heart Association. (2007). Stroke Risk Factors Americanheart.org. Retrieved on January 22, 2007.
  3. ↑ American Heart Association. (2007). Atrial Fibrillation Americanheart.org. Retrieved on January 22, 2007.

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