Guidelines For Prevention Of Stroke Research Articles

Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial Fibrillation

The rate of stroke among adults with atrial fibrillation (AF) varies widely, ranging between 1% and 20% annually (mean 4.5% per year) depending on comorbidities and a patient’s history of prior cerebrovascular events.1 Stratification of stroke risk is important, because the major risk of antithrombotic medications used to lower the incidence of AF-related stroke is bleeding. For warfarin, this involves balancing a bleeding risk of 1% to 12% per year against the risk of ischemic events, with its use generally reserved for individuals at greatest thromboembolic risk.1–3 The advent of several new antithrombotic agents offers alternatives to warfarin and may lower the threshold for thromboembolic risk for initiating therapy in patients with AF. In this update to the American Heart Association/American Stroke Association (AHA/ASA) “Guidelines for the Primary Prevention of Stroke”4 and the prevention of stroke in patients with stroke or transient ischemic attack (TIA),5 we review recent trials testing the safety and efficacy of a thrombin inhibitor (dabigatran) and 2 factor Xa inhibitors (rivaroxaban and apixaban) in preventing stroke in patients with AF, and we revise management recommendations.4,5 Recommendations follow the AHA’s and the American College of Cardiology’s methods of classifying the level of certainty of the treatment effect and the class of evidence (Table 1). View this table: Table 1. Applying Classification of Recommendations and Level of Evidence ### Risk Stratification The absolute risk of stroke varies 20-fold among AF patients according to age and associated vascular comorbidities. Several stroke risk stratification schemes have been developed and validated.6–8 These, however, can yield differing results.9 Current AHA guidelines use the CHADS2 stratification scheme7 (CHADS2 is an acronym for Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and prior Stroke or TIA). The CHADS2 score was derived from independent …

Implementación de las guías de práctica clínica sobre ictus isquémico agudo en atención especializada

IntroductionCerebrovascular disease is associated with high morbidity and mortality. In 2008, the Spanish Ministry of Health published its Clinical Practice Guidelines for stroke prevention, but implementation of that document has not yet been assessed. Our study aims to investigate compliance with the Guidelines by analysing control over vascular risk factors, antithrombotic treatment and lipid lowering treatment in patients who had suffered an acute ischaemic stroke and who were under the care of neurologists or internists. MethodsCross-sectional study based on data from clinical reports (vascular risk factors, diagnosis and treatment), blood pressure readings and laboratory tests pertaining to 203 patients diagnosed with acute ischaemic stroke and admitted to a medium-to-long stay hospital for rehabilitation and care. ResultsThe mean patient age was 75±10 years; 56% were women. The most common risk factors were hypertension (68%) and diabetes mellitus (40%). Intravenous fibrinolytic therapy had been administered to 8.9% of the patients. Of the patients with thrombotic cerebral infarction, 91.7% received antiplatelet agents; 59.4% of patients with embolic infarction received anticoagulants. Statins were prescribed to 65% of patients with thrombotic infarction. Laboratory tests upon admission showed that 23% of patients had total cholesterol levels above 175mg/dl and 26.6% had plasma glucose levels above 126mg/dl. Of the patient total, 70% received antihypertensive therapy, but 47.5% had blood pressure levels above 130/80mm Hg. ConclusionsIn our opinion, secondary prevention of acute cerebrovascular disease could be improved, mainly by increasing the percentage of patients treated with antiplatelet or anticoagulant drugs (depending on aetiology), increasing prescription of statins, and improving blood pressure control

Stroke and Renal Dysfunction

Cerebrovascular disease may represent an important clinical presentation of atherosclerosis in chronic kidney disease (CKD), and atherosclerosis is frequently encountered in CKD. In fact, kidney disease is now considered a risk factor for development of cardiovascular disease. Although guidelines for primary prevention of stroke have been recently published, CKD is hardly mentioned. Based on a series of available studies, we analyzed the relationship between reduced renal function, end-stage renal disease (ESRD), and stroke. Reduced renal function and risk of stroke appear to be related to the highest risk of patients on dialysis treatment. Primary and secondary prevention of stroke should be encouraged in participants with renal dysfunction.

Aspirin Plus Clopidogrel Flops for Secondary Stroke Prevention

NEW ORLEANS – The combination of aspirin and clopidogrel proved no more effective than aspirin alone for secondary stroke prevention, and dual therapy significantly boosted the major hemorrhage rate and patient mortality in a randomized, multicenter trial with more than 3,000 patients. The poor performance of this dual antiplatelet combination in this large study, called the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, leaves the secondary stroke prevention guidelines, published last year by the American Heart Association and American Stroke Association, unchanged in its recommendation of three antiplatelet drug options for patients with a history of stroke or transient ischemic attack: aspirin, aspirin plus dipyridamole, or clopidogrel (Stroke doi:10.1161/STR.0b013e318lf7d043), Dr. Oscar R. Benavente said at the International Stroke Conference. The new trial results “do not support the use of combination therapy for secondary stroke prevention in patients with lacunar strokes,” said Dr. Benavente, the study's co-principal investigator and research director of the Stroke and Cerebrovascular Disease Program at the Vancouver Coastal Health Research Institute. The SPS3 study enrolled 3,020 patients within 180 days of a small, subcortical, lacunar stroke at 81 sites in eight countries during 2003–2011. The trial excluded patients with cortical stroke, cardioembolic disease, or carotid stenosis. More than half of the enrolled patients received care at U.S. centers. Their average age was 63 years, about two-thirds were men, and they entered the study an average of 76 days following their index stroke. The study randomized 1,503 patients to treatment with 325 mg of aspirin daily and 1,517 patients to the same aspirin dosage plus 75 mg of clopidogrel (Plavix) daily. The study's data and safety monitoring board stopped this portion of the trial early last July, after an average follow-up of 3.5 years, because of safety and futility. (The study continues with a concurrent randomization that is comparing the efficacy of usual and “intensive” blood pressure control.) The antiplatelet randomization stopped because the results showed a “surprising,” statistically significant increased rate of all-cause mortality and major hemorrhages in patients treated with dual antiplatelet therapy, Dr. Benavente said. All-cause mortality occurred at a rate of 1.4%/patient-year in the aspirin-only group and a rate of 2.1%/patient-year in the dual-therapy arm, a 50% relative risk difference. A breakdown of the causes of death showed a statistically significant difference for only one subgroup, “probable vascular” death, which was threefold higher in the aspirin plus clopidogrel patients than in those on aspirin only. The causes of death will require more analysis to better understand the danger posed by the dual-drug regimen, Dr. Benavente said at the meeting, which was sponsored by the American Heart Association. Major hemorrhages occurred in 1.1% of the aspirin-only patients and in 2.1% of those on the dual regimen. When separated by type of hemorrhage, the only significant difference between the two treatment groups was in the incidence of non-central nervous system hemorrhages, a category that mostly consisted of gastrointestinal bleeds, he said. The two regimens showed no significant difference for the study's primary efficacy outcome, the incidence of ischemic and hemorrhagic strokes, which occurred at 2.7%/patient-year among those on aspirin only and 2.5%/patient-year in those on both drugs. The rates of ischemic strokes only, hemorrhagic strokes only, major vascular events, and myocardial infarctions also showed no significant differences between the two treatment arms. SPS3 did not include a patient group treated only with clopidogrel because previous large studies had already compared clopidogrel alone with aspirin alone, and with aspirin plus dipyridamole. The results of those studies “have not clearly established that [clopidogrel] is superior to or even equivalent to” aspirin, aspirin plus dipyridamole, and ticlopidine (Ticlid), said last year's treatment recommendations from the American Heart Association and American Stroke Association. The SPS3 study was sponsored by the National Institute of Neurological Disorders and Stroke. Dr. Benavente said that he has received research support from Sanofi-Aventis and Bristol-Myers Squibb. You can see Dr. Benavente's slides from his conference presentation on SPS3 at http://myamericanheart.org (search for SPS3).

Antithrombotics for secondary prevention of noncardioembolic ischaemic stroke

Antiplatelet therapy is more effective than anticoagulation for the prevention of noncardioembolic ischaemic stroke. The choice of antiplatelet regimen, however, remains contentious. Recent controversies regarding aspirin resistance and the optimal dosing of aspirin, as well as recognition of the variable bioactivation of clopidogrel, have added further confusion to the debate. The American Heart Association (AHA) and American Stroke Association (ASA) recently released their third joint guideline in the past 5 years on secondary stroke prevention. The European Stroke Organisation has published three guidelines on this issue since 2000. These frequent updates have been necessary because of rapidly accumulating data from clinical trials. Careful consideration of the sometimes confusing trial results reveals that the 2011 AHA-ASA guidelines are correct in no longer specifying a 'preferred' antiplatelet regimen from among the choices recently studied. This recommendation does not, however, mean that all antiplatelet regimens should be considered equal. This Review discusses the various antiplatelet regimens, and the trials that led to the rapid evolution of the guidelines for secondary prevention of ischaemic stroke.

Use of Cilostazol for Secondary Stroke Prevention: An Old Dog with New Tricks?

To evaluate the safety and efficacy of cilostazol for secondary prevention of non-cardioembolic ischemic stroke. PubMed and MEDLINE searches were performed (January 1970-September 2011) using the key words cilostazol, antiplatelet, aspirin, acetylsalicylic acid, secondary stroke prevention, ischemic stroke, intracerebral hemorrhage, intracranial, cerebrovascular accident, and transient ischemic attack. Additionally, reference citations from publications identified were reviewed. Articles published in English and relevant primary literature evaluating the efficacy and safety of cilostazol in the secondary prevention of atherosclerotic ischemic stroke were included. Antiplatelet therapy plays a vital role in the multifaceted approach to secondary stroke prevention. Current American Heart Association/American Stroke Association clinical guidelines for secondary stroke prevention support the use of aspirin, clopidogrel, and combination aspirin/extended-release dipyridamole. The antiplatelet, antithrombotic, and vasodilatory effects of cilostazol make it a potential alternative agent for atherosclerotic stroke prevention. Recent literature has demonstrated superior efficacy of cilostazol 100 mg twice daily for secondary stroke prevention compared to placebo and aspirin. Three clinical trials were reviewed (1 placebo-controlled, 2 aspirin-controlled), all of which were conducted in Japan or China. Cilostazol reduced the primary outcome of recurrence of stroke, with significantly fewer major bleeding events when compared to aspirin. Available literature suggests that cilostazol may be safer and more effective than aspirin in the secondary prevention of stroke in Asian patients. Further large-scale studies in more heterogeneous study populations are warranted to determine whether cilostazol is a viable therapeutic option for patients with a history of non-cardioembolic ischemic stroke.

Traditional risk factor management for stroke

Recently, many guidelines have given new evidence on the risk factors for stroke. In this review, I refer to the most important guidelines for primary prevention of stroke and hypertension, especially focused on diet and physical activity. The health behavior recommendations in recent guidelines for the primary prevention of stroke are virtually identical, and the same recommendations appear in the recent guidelines for the management of hypertension, especially with respect to diet and physical activity. The recommended health behaviors consist of weight reduction, reduction of salt intake, increase in fruit and vegetable intake, decrease in saturated and total fat intake (increase in fish intake), physical activity, and moderation of alcohol consumption. Fruits and vegetables have high levels of potassium, antioxidants, phytochemicals, and dietary fiber, and thus are also considered preventive of cardiovascular disease and its risk factors. It was found that individuals with many of these health behaviors have been shown to have a lowered risk of stroke. The health behaviors, especially those related to diet and physical activity, appearing in recent guidelines for the management of hypertension are also important for the primary prevention of stroke, and appear in recent stroke guidelines.

Chinese guidelines for the secondary prevention of ischemic stroke and transient ischemic attack 2010.

Correspondence Yong-Jun Wang, Neurology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. Tel.: 0086-010-67098351; Fax: 0086-010-67038316; E-mail: yongjunwang111@yahoo.com.cn and Su-Ming Zhang, Neurology Department, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China. Tel.: 0086-027-83612633; Fax: 0086-027-83612633; E-mail: suming_zhang@163.com and Liqun Zhang, Neurology Department, St George’s Hospital, London, UK. Tel.: 44-7837827866; Fax: 44-2087254505; E-mail: lqnzhang@yahoo.com Received 19 October 2011; revision 22 November 2011; accepted 26 November 2011

Prevention of Embolic Strokes: The Role of the American College of Chest Physicians

Patients with atrial fibrillation (AF) face an annual stroke risk of about 5%. Evidence that anticoagulants reduce the risk of stroke has evolved over the 20th century. The American College of Chest Physicians (ACCP) has played a critical role in presenting guidelines for stroke prevention in AF. This commentary highlights the role that the ACCP guidelines have played, from their inception to the ninth edition. The first ACCP Conference on Antithrombotic and Thrombolytic Therapy in 1986 developed evidence-based guidelines for the indications, dosage, and monitoring of antithrombotic therapy. The conference recommended that anticoagulants be monitored by the international normalized ratio, and the appropriate dosage was to increase the international normalized ratio to two to three times control. This recommendation was widely accepted. Anticoagulants were recommended for AF with mitral valve disease and for nonvalvular AF with a history of embolism. No recommendations were made for nonvalvular AF without a history of embolism. These recommendations stimulated numerous randomized controlled trials (RCTs). By the third ACCP conference in 1992, RCTs had demonstrated a dramatic 69% stroke reduction in patients with nonvalvular AF. The third ACCP conference was the first to strongly recommend anticoagulation for primary and secondary stroke prevention in nonvalvular AF. ACCP conferences since 1992 have refined recommendations for nonvalvular AF on the basis of associated risk factors. The most recent conference, in 2011, recommended a direct thrombin inhibitor, dabigatran, rather than warfarin as the anticoagulant of choice. These ACCP guidelines have played a critical role in changing physicians' practice patterns. In 1980 only 7% of patients with AF in the United States received OA; by 2007, this had increased to 57%.

Clinical Implications from Recent Trials and New Guidelines for Stroke Prevention in Atrial Fibrillation

After the release of the 2010 guidelines of the European Society of Cardiology (ESC) and the 2011 update of the guidelines of the American Heart Association/American College of Cardiology (AHA/ACC), new evidence has emerged that requires adaption of current clinical practice in the treatment of atrial fibrillation (AF). In 2011, results were published from two central AF trials concerning prevention of stroke in patients with AF: the Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonist for prevention of stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) and the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study. Other important aspects that have emerged since 2010 include findings of stroke risk in paroxysmal AF patients, prediction for AF-associated stroke and haemorrhage, risk–benefit considerations concerning oral anticoagulation in patients with chronic kidney disease and risk–benefit considerations with use of antiplatelet agents, alone, combined, or in combination with oral anticoagulants in AF patients. Canadian AF guidelines were updated earlier this year, incorporating the new evidence. Also, in 2012, the American College of Chest Physicians released guidelines for the antithrombotic therapy of AF. Similar updates of the ESC and the AHA/ACC guidelines are expected, which will include new findings from the cardiovascular congresses over the upcoming months. Additionally, also in 2012, the Heart Rhythm Society, the European Heart Rhythm Association and the European Cardiac Arrhythmia Society (HRS/EHRA/ECAS) released a consensus statement on the interventional treatment of AF. The following short review summarises these new data and furthermore highlights our current clinical practice.

Level of Systolic Blood Pressure Within the Normal Range and Risk of Recurrent Stroke

Recurrent stroke prevention guidelines suggest that larger reductions in systolic blood pressure (SBP) are positively associated with a greater reduction in the risk of recurrent stroke and define an SBP level of less than 120 mm Hg as normal. However, the association of SBP maintained at such levels with risk of vascular events after a recent ischemic stroke is unclear. To assess the association of maintaining low-normal vs high-normal SBP levels with risk of recurrent stroke. Post hoc observational analysis of a multicenter trial involving 20,330 patients (age ≥50 years) with recent non-cardioembolic ischemic stroke; patients were recruited from 695 centers in 35 countries from September 2003 through July 2006 and followed up for 2.5 years (follow-up ended on February 8, 2008). Patients were categorized based on their mean SBP level: very low-normal (<120 mm Hg), low-normal (120-<130 mm Hg), high-normal (130-<140 mm Hg), high (140-<150 mm Hg), and very high (≥150 mm Hg). The primary outcome was first recurrence of stroke of any type and the secondary outcome was a composite of stroke, myocardial infarction, or death from vascular causes. The recurrent stroke rates were 8.0% (95% CI, 6.8%-9.2%) for the very low-normal SBP level group, 7.2% (95% CI, 6.4%-8.0%) for the low-normal SBP group, 6.8% (95% CI, 6.1%-7.4%) for the high-normal SBP group, 8.7% (95% CI, 7.9%-9.5%) for the high SBP group, and 14.1% (95% CI, 13.0%-15.2%) for the very high SBP group. Compared with patients in the high-normal SBP group, the risk of the primary outcome was higher for patients in the very low-normal SBP group (adjusted hazard ratio [AHR], 1.29; 95% CI, 1.07-1.56), in the high SBP group (AHR, 1.23; 95% CI, 1.07-1.41), and in the very high SBP group (AHR, 2.08; 95% CI, 1.83-2.37). Compared with patients in the high-normal SBP group, the risk of secondary outcome was higher for patients in the very low-normal SBP group (AHR, 1.31; 95% CI, 1.13-1.52), in the low-normal SBP group (AHR, 1.16; 95% CI, 1.03-1.31), in the high SBP group (AHR, 1.24; 95% CI, 1.11-1.39), and in the very high SBP group (AHR, 1.94; 95% CI, 1.74-2.16). Among patients with recent non-cardioembolic ischemic stroke, SBP levels during follow-up in the very low-normal (<120 mm Hg), high (140-<150 mm Hg), or very high (≥150 mm Hg) range were associated with increased risk of recurrent stroke. clinicaltrials.gov Identifier: NCT00153062.

Abstract P33: The Impact of Stroke Risk on Warfarin and Aspirin Use in Patients With Non-Valvular Atrial Fibrillation Followed in Community-Based Primary Care Practices

Background: The application of treatment guidelines for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in primary care practice is not well understood. This study examined the risk of stroke at diagnosis of NVAF and the decision to initiate oral anticoagulant (OAC) therapy or aspirin (ASA) in a community-based primary care population. Methods: A retrospective cohort of patients with NVAF followed from 1998-2008 in a health system with a shared electronic medical record was evaluated. The presence of NVAF, OAC use, ASA use, and CHADS2 stroke risk score were collected through a review of the problem list, office and hospital records, laboratory values, and medication use. Stroke events following diagnosis were identified using office and hospital records. CHADS2 risk scores were categorized as 0, 1, and ≥ 2. We used t-test and the Chi-square to assess the association between continuous and categorical variables. Results: A total of 840 NVAF patients were followed for a mean of 3.1 years. Those at high stroke risk (CHADS2 ≥ 2) were older (77 vs. 67 years, p &lt; .001), more likely to be female (56% vs. 43%, p &lt; .001), and followed for a shorter period of time (2.4 years vs. 3.6, p &lt;.001). A total of 400 patients (47.6%) were classified as high risk, 289 (34.4%) with CHADS2 score of 1, and 151 (18%) with CHADS2 score of 0. Overall, there were no significant differences (p = 0.2) in the choice of treatment strategy by level of stroke risk (see Table ). Conclusion: In this community setting, CHADS2 stroke risk in NVAF patients at the time of presentation appears to have little impact on the choice of treatment strategy. 35.8% of NVAF patients fail to receive warfarin anticoagulation despite CHADS2 treatment recommendations for stroke prevention. Additional research is needed to determine the reasons for failing to initiate stroke prevention therapy in real practice. Table: Treatment Strategy by CHADS2 Stroke Risk in NVAF Patients Treatment Strategy CHADS2 Score, n (%) No Treatment ASA Only Warfarin 0 19 (12.6) 51 (33.8) 81 (53.6) 1 37 (12.8) 81 (28.0) 171 (59.2) ≥ 2 43 (10.8) 100 (27.6) 257 (64.3)

Abstract P29: Positive Attitudes Towards Risk Factor Reduction in an Urban Underserved Population Newly Diagnosed With Stroke or TIA

Introduction: The transtheoretical model describes how people modify a problem behavior or acquire positive behaviors. The central construct is the stages of change, where behavior change is a continuum describing readiness to change: precontemplation, contemplation, preparation, action, and maintenance. People progress through these stages at varying rates, often moving back and forth along the continuum before attaining maintenance. We investigated whether urban underserved persons newly hospitalized for stroke or TIA intend to change their stroke prevention behaviors, and their belief about their premorbid behaviors. Methods: Participants in the PROTECT DC Phase II trial of health navigation to improve adherence with secondary stroke prevention behaviors were evaluated. They met the following criteria: atherogenic ischemic stroke or TIA diagnosed within 30 days, resident of the District of Columbia, community dwelling, and able to provide informed consent. Participants were recruited at 4 hospitals, and were interviewed regarding their risk factor management intentions. Results: In 87 participants aged 60.7 ± 12 yrs, the median NIH Stroke Scale score was 2(0-16), 45% were male, 90% were African-American. Long-term (&gt;6 mos) medication adherence was reported by 52%, 7% reported adherence &lt;6mos, and 32% intended to adhere during the next 6 mos. Dietary adherence &gt;6 mos was reported by 26%, and 62% intended to start adherence. Eighty percent intended to learn more about stroke, and 94% of active smokers (30 individuals) intended to quit smoking within 6 months. Discussion: In a sample of urban underserved hospitalized for acute stroke, a large proportion reported the intent to adhere to risk management behaviors or already believed themselves adherent. Our data suggest that this population is quite motivated to engage in the recommended behaviors. Many report adherence to medication, diet and exercise recommendations prior to stroke onset; it is unclear how these perceptions relate to current stroke prevention guidelines. Urban underserved populations are receptive to behavioral changes associated with risk reduction, acute hospitalization may provide an important opportunity to initiate and refine effective stroke prevention behaviors.

A Program to Improve Secondary Stroke Prevention

The key to secondary stroke prevention often lies in improved control of traditional stroke risk factors. Studies have shown that there is an evidence-practice gap, for both physicians and patients, when it comes to adhering to national stroke prevention guidelines. We developed a program to reinforce stroke prevention messages for 1 year after a patient's ischemic stroke or transient ischemic attack. Our results show encouraging improvement in our patients' adherence to treatment guidelines for 1 year after the event, as well as a reduction in recurrent strokes as compared with the number expected.

High lipoprotein(a) serum levels in three CADASIL families

We read with interest the paper by Gong et al. [1] on the clinical and genetic features of a cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) family with high values of lipoprotein(a) [Lp(a)]. They concluded that elevated Lp(a) levels might have contributed to the cerebrovascular phenotype in their family. We would like to report our three CADASIL families with elevated Lp(a) levels (Table 1). The mutations, all different from that reported by Gong and colleagues [1], are reported in Table 1. Lp(a) levels were measured for various reasons in eight members of these CADASIL families by the same laboratory, and found elevated in seven (Table 1) (one patient already reported) [2]. Patients had various association of other vascular risk factors. Symptomatic patients showed the typical clinical manifestations of the disease. Cerebral MRI picture was that typical of the disease, with different severity degrees of white matter lesions, also in accordance with the subjects’ ages. In only one of the patients with a history of stroke or in those who underwent vessel evaluation (ultrasound, MR angiography, or digital subtraction angiography) was evidence of large vessel pathology found. One 70-year-old man with dyslipidemia had mild carotid atherosclerosis. All the strokes were of the lacunar type, and no nonlacunar infarct was detected on cerebral MRI. In one patient, MRI revealed a cerebellar arteriovenous malformation, which was later found associated on digital subtraction angiography with a vertebral artery aneurysm. This case has already been reported [3]. All the members of these families have now been followed up for more than 10 years. In conclusion, we did not find clinical or radiological features suggestive of significant large vessel disease in any of our patients affected by CADASIL and with elevated Lp(a) levels. In our opinion, the finding of elevated Lp(a) levels in NOTCH3 mutations carriers seems to be incidental, of doubtful clinical significance, and does not appear to contribute to the cerebrovascular phenotype. However, our data are too limited to get definitive conclusions. While an elevated Lp(a) level is known as a risk factor for ischemic heart disease, its role is less clearly defined in cerebrovascular diseases [4]. In the recent Guidelines for the Primary Prevention of Stroke, elevation of Lp(a) level was included among the less well documented cerebrovascular risk factors (recommendation for treatment in primary prevention of ischemic stroke: class IIb; level of evidence B) [4]. Considering our small series and also Gong et al.’s report in which only one family member presented with large vessel pathology, we believe that systematic screening for elevated Lp(a) levels in CADASIL patients is not recommended. A few cases of large vessel pathology have been reported in this small vessel disease [5]. The value of Lp(a) levels evaluation in these patients remains to be elucidated. R. Valenti and S. Nannucci contributed equally to this work.

What’s new in stroke? The top 10 studies of 2009–2011. Part I

Five important studies from 2009-2011 that influence the clinical management of stroke and threatened stroke are summarized. Pooled analysis of individual patient data from 8 randomized trials testing intravenous tissue plasminogen activator confirmed important benefits for patients treated 3 to 4.5 hours after stroke onset, but treatment after 4.5 hours was associated with a higher mortality. Blood pressure lowering with candesartan in the first few days after stroke was of no benefit and was possibly harmful (SCAST trial). Thigh-length graduated compression stockings did not reduce venous thromboembolism after acute stroke and were associated with skin complications (CLOTS Trial 1). Long-term follow-up showed that endovascular coiling was as good as neurosurgical clipping for patients with small, ruptured intracranial aneurysms (ISAT trial). Percutaneous closure of a patent foramen ovale offered no apparent benefit to young patients with cryptogenic ischemic stroke based on the first randomized trial testing this intervention, but the number of stroke events was insufficient to draw definitive conclusions (CLOSURE I trial).

Evidence-based review of primary and secondary ischemic stroke prevention in adults: a neurosurgical perspective

In this paper, the authors' aim is to provide an evidence-based review of primary and secondary ischemic stroke prevention guidelines covering most of the common risk factors and stroke etiologies for the practicing neurosurgeon. The key to stroke prevention is in the identification and treatment of the major risk factors for stroke. These include hypertension, heart disease, diabetes mellitus, dyslipidemia, and tobacco smoking. An updated approach to secondary prevention of stroke in the setting of intracranial and extracranial large vessel atherosclerosis and cardioembolism is provided along with a brief overview of pertinent clinical trials. Novel pharmacological options for prevention of cardioembolic strokes, such as new alternatives to warfarin, are addressed with recommendations for interruption of therapy for elective surgical procedures. In addition, the authors have reviewed the anticoagulation guidelines and the risk of thromboembolic complications of such therapies in the perioperative period, which is an invaluable piece of information for neurosurgeons. Less common etiologies such as arterial dissections and patent foramen ovale are also briefly discussed. Finally, the authors have outlined the quality measures in the Medicare Physician Quality Reporting System and essential guidelines for Primary Stroke Center certification, which have implications for day-to-day neurosurgical practice.

Antithrombotic Management for Transient Ischemic Attack and Ischemic Stroke (Other than Atrial Fibrillation)

The new definition and risk stratification for transient ischemic attack (TIA) have clear implications for the urgency of evaluation and treatment. The optimal antithrombotic treatment for TIA is being intensively studied. New guidelines for prevention of non-cardioembolic stroke in patients with stroke or TIA recommend the use of antiplatelet agents rather than oral anticoagulation. New antiplatelet drugs are being used in cardiovascular patients, and their role in cerebrovascular patients is being studied. The impact of genetic CYP2C19 polymorphisms is becoming clarified in cardiovascular patients and it is likely these polymorphisms will affect the management of cerebrovascular patients. The results of trials of clopidogrel plus aspirin in patients with lacunar strokes and acute TIAs are forthcoming. The results of CLOSURE I, a study of a patent foramen ovale device closure trial for cryptogenic stroke or TIA, showed no differences in stroke or TIA at 2 years.

PCV94 ANTICOAGULANT USE, THE PREVALENCE OF BRIDGING AND RELATION TO LENGTH OF STAY AMONG HOSPITALIZED PATIENTS WITH NON-VALVULAR ATRIAL FIBRILLATION

ASA/AHA guidelines for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) recommend anticoagulant (AC) therapy with a vitamin K antagonist (e.g., warfarin) for patients without hemorrhagic contraindication. Bridging with low molecular weight heparin (LMWH) was recently added to these guidelines (Class IIa), but with little supportive evidence (Level of Evidence C). Little is known about the use of AC therapy in the inpatient setting and how it relates to hospital length of stay (LOS). Patients with an NVAF discharge diagnosis between 7/1/04-9/30/09 were identified from administrative claims data representing over a hundred US hospitals. Inpatient AC use by drug type was reported to identify patients receiving warfarin alone and in combination with LMWH/pentasaccharide (PS) or unfractionated heparin (UFH), indicative of bridging. LOS was measured and reported by AC combinations. Non-parametric statistical tests were used to compare LOS among patients receiving warfarin only to those with bridge therapy. Of 6340 NVAF patients, 76% received inpatient AC therapy, with 3037 (48%) receiving warfarin. Of patients receiving warfarin, 64% were bridged with another AC. LMWH/PS was the most common bridge agent (45% of all bridged patients), followed by UFH (36%), and by LMWH/PS and UFH combined (18%). The mean LOS for patients receiving bridge therapies was 6.3 days (SD=6.1) compared to 4.2 days (SD= 3.1) for warfarin alone, p<.0001. By bridging drug type, mean LOS was 5.6 days (SD=5.3) for LMWH/PS; 6.0 days (SD=4.9) for UFH, and 8.4 days (SD=8.4) for LMWH/PS and UFH. Less than half of all NVAF patients received warfarin while hospitalized. Among those taking warfarin, bridging with other anticoagulants was common and was associated with longer LOS than patients receiving warfarin alone.

The missing ethnicity in primary cardiovascular trials

ARTICLE Success is going from failure to failure without a loss of enthusiasm Winston Churchill (1874–1965) British politician and statesman Cardiovascular disease (CVD) is the most common and one of the most preventable causes of death worldwide. The incident risk of stroke, myocardial infarction and peripheral vascular disease vary among ethnic groups. For example, individuals with African or Caribbean background have a high incidence of stroke and end-stage renal failure compared with Caucasians. On the other hand, South Asians have higher incidence of CVD.1,2 The recently published guidelines for the primary stroke prevention highlighted the increased age-adjusted prevalence of stroke in Asian (1.8%/100 000), Blacks (4.6%/100 000) and Hispanics (1.9%/100 000) compared with whites.3 The underlying causes of these disparities are not well understood. Differences in dietary and genetic factors, prevalence of hypertension, diabetes, or …