Stroke Prevention

To be published December 2017
Prof. J. David Spence
Robarts Research Institute, CA
Summary

There have been important advances in stroke prevention in recent years, so it is timely to present a new series of talks from leading experts around the world.... read more

With regard to hypertension, the SPRINT trial confirmed that lower blood pressure is better, and significantly reduced stroke compared to more conventional blood pressure targets, with no indication of a J Curve. This highlights the importance of not assuming that white coat hypertension is benign, the importance of understanding the role of cuff artefact in the J Curve, and the importance of identifying the underlying cause of resistant hypertension in order to achieve control.

In the field of nutrition, there have been important advances in the role of the Mediterranean diet, the role of the intestinal microbiome, and the importance of dietary cholesterol and egg yolk. There has also been a resurrection of B vitamin therapy with the publication of the Chinese Stroke Primary Prevention Trial, and improved understanding of the role of renal impairment and cyanide from cyanocobalamin in accounting for the failure of some earlier studies that used cyanocobalamin. We now understand that we should be using B vitamins to reduce homocysteine in the prevention of stroke, but we should be using methylcobalamin instead of cyanocobalamin.

With regard to antiplatelet agents, there have been important developments including evidence that pseudoresistance due to enteric coating accounts for what used to be thought of as aspirin resistance, the development of new antiplatelet agents, and better evidence that dual antiplatelet therapy is more efficacious than aspirin or clopidogrel alone.

New oral anticoagulants that are no more likely to cause serious bleeding than aspirin have changed everything with regard to anticoagulation of patients with known or suspected cardioembolic stroke. These developments take on major importance in the light of evidence that atrial fibrillation can be better diagnosed by longer monitoring, and that with improved therapy of other stroke risk factors, cardioembolic strokes have markedly increased as a proportion of stroke subtypes.

Advances have also been made in revascularization of symptomatic carotid stenosis, and in the recognition that most patients with asymptomatic stenosis should be treated medically, and stronger evidence about how to identify the small proportion (~ 10%) of asymptomatic carotid stenosis who could benefit from revascularization.

These are exciting times in stroke prevention. I hope that viewers will be edified, entertained and excited by the presentations in this series.