Stroke Prevention and Treatment

Cerebrovascular disease is the third leading cause of death inthe U.S. and the number 1 cause of long-term majordisability. It is estimated that there are 795,000 incidentstrokes in the U.S. each year, resulting in 1 of every 17deaths in the U.S. due to stroke.

There are more than 4.8million stroke survivors alive today (1). Although there wasa 60% decline in stroke mortality over the 29-year periodbetween 1968 and 1996, the rate of decline began to slow inthe 1990s and has plateaued in several regions of thecountry.

There are major regional differences in strokeincidence across the U.S. (Fig. 1) (1), with the persistenceover many decades of a high-incidence “stroke belt” cen-tered on southeastern and south central states

The decline in stroke incidence and mortality in the U.S. over the past 20 years is reaching a plateau, and the number of strokes may actually start to increase as the population ages. However, recent clinical trials have demonstrated that there are numerous opportunities to improve stroke prevention strategies and also opportunities to effectively intervene in and treat acute strokes. For patients with diabetes and for those with prior strokes or transient ischemic attacks, it has become evident that aggressive low-density lipoprotein lowering with statin medications will decrease the risk for total and fatal strokes.

Optimal anticoagulation and antiplatelet therapy for primary and secondary stroke prevention in atrial fibrillation is being carefully defined. With numerous novel factor Xa and direct thrombin inhibitor drugs completing phase III clinical trials, it is likely that additional oral anticoagulant drugs will be clinically available for stroke prevention soon. Additionally, a major clinical trial is nearing completion that may resolve the role of carotid stenting and carotid endarterectomy in primary and secondary stroke prevention.

There are recent notable advances in the acute treatment of stroke. It is likely that the time window for thrombolysis for appropriate patients with strokes will be increased from 3 to 4.5 h, permitting the inclusion of more patients in this treatment approach. There is ongoing investigation of intra-arterial thrombolysis and of acute intra-arterial thrombus extraction for treatment of selected patients with strokes. Unlike the progress in treatment of ischemic strokes, treatment of hemorrhagic stroke is progressing more slowly.

Reference

• Journal of the American College of Cardiology. Volume 56, Number 9

Authors

• ames D. Marsh, MD
• Salah G. Keyrouz, MD