The Periodical Second Issue, November 2002

 

 
Editors Note SAGAS Objectives SAGAS News Stroke Risk Factors: An Overview
A Need For A World Stroke Federation International Article Review The Periodical Quiz The Periodical Case

International Articles Review

1- Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke.

In this report, authors examined the published evidence relevant to the effects of anticoagulants and antiplatelet agents on acute ischemic stroke mortality, morbidity, and recurrence rates as well as associated ancillary benefits and risks of those treatments on the rates of deep vein thrombosis, pulmonary embolus, and cardiovascular complications. As part of these analyses, they also sought to determine whether there was evidence supporting differential efficacy of these drugs according to ischemic stroke subtypes. The result of this review analysis is summarized in the following recommendations:

Recommendations

  1. Patients with acute ischemic stroke presenting within 48 hours of symptom onset should be given aspirin (160 to 325 mg/day) to reduce stroke mortality and decrease morbidity, provided contraindications such as allergy and gastrointestinal bleeding are absent, and the patient has or will not be treated with recombinant tissue-type plasminogen activator (Grade A). The data are insufficient at this time to recommend the use of any other platelet antiaggregant in the setting of acute ischemic stroke. 

  2. Subcutaneous unfractionated heparin, LMW heparins, and heparinoids may be considered for DVT prophylaxis in at-risk patients with acute ischemic stroke, recognizing that nonpharmacologic treatments for DVT prevention also exist (Grade A). A benefit in reducing the incidence of PE has not been demonstrated. The relative benefits of these agents must be weighed against the risk of systemic and intracerebral hemorrhage. 

  3. Although there is some evidence that fixed-dose, subcutaneous, unfractionated heparin reduces early recurrent ischemic stroke, this benefit is negated by a concomitant increase in the occurrence of hemorrhage. Therefore, use of subcutaneous unfractionated heparin is not recommended for decreasing the risk of death or stroke-related morbidity or for preventing early stroke recurrence (Grade A).

  4. Dose-adjusted, unfractionated heparin is not recommended for reducing morbidity, mortality, or early recurrent stroke in patients with acute stroke (i.e., in the first 48 hours) because the evidence indicates it is not efficacious and may be associated with increased bleeding complications (Grade B).

  5. High-dose LMW heparin or heparinoids have not been associated with either benefit or harm in reducing morbidity, mortality, or early recurrent stroke in patients with acute stroke and are, therefore, not recommended for these goals (Grade A).

  6. IV, unfractionated heparin or high-dose LMW heparin/heparinoids are not recommended for any specific subgroup of patients with acute ischemic stroke that is based on any presumed stroke mechanism or location (e.g., cardioembolic, large vessel atherosclerotic, vertebrobasilar, or "progressing" stroke) because data are insufficient (Grade U). Although the LMW heparin, dalteparin, at high doses may be efficacious in patients with atrial fibrillation, it is not more efficacious than aspirin in this setting. Because aspirin is easier to administer, it, rather than dalteparin, is recommended for the various stroke subgroups (Grade A).

See the full article on Stroke Journal

2- AHA Guidelines for Primary Prevention of Stroke and Cardiovascular Disease

2002 Update

These Guidelines are intended to assist primary care providers in their assessment, management, and follow-up of patients who may be at risk for, but who have not yet manifested, cardiovascular disease. The continuing message is that adoption of healthy life habits remains the cornerstone of primary prevention, including the avoidance of tobacco (including secondhand smoke), healthy dietary patterns, weight control, and regular, appropriate exercise. An important role of healthcare providers is to support and reinforce these public health recommendations for all patients.

Risk Assessment

Recommendations

Risk factor screening

Goal: Adults should know the levels and significance of risk factors as routinely assessed by their primary care provider.

Risk factor assessment in adults should begin at age 20 y. Family history of CHD should be regularly updated. Smoking status, diet, alcohol intake, and physical activity should be assessed at every routine evaluation. Blood pressure, body mass index, waist circumference, and pulse (to screen for atrial fibrillation) should be recorded at each visit (at least every 2 y). Fasting serum lipoprotein profile (or total and HDL cholesterol if fasting is unavailable) and fasting blood glucose should be measured according to patient’s risk for hyperlipidemia and diabetes, respectively (at least every 5 y; if risk factors are present, every 2 y).

Global risk estimation

All adults  40 y of age should know their absolute risk of developing CHD. Goal: As low risk as possible.

Every 5 y (or more frequently if risk factors change), adults, especially those  40 y of age or those with  2 risk factors, should have their 10-y risk of CHD assessed with a multiple risk score. Risk factors used in global risk assessment include age, sex, smoking status, systolic (and sometimes diastolic) blood pressure, total (and sometimes LDL) cholesterol, HDL cholesterol, and in some risk scores, diabetes. Persons with diabetes or 10-y risk >20% can be considered at a level of risk similar to a patient with established cardiovascular disease (CHD risk equivalent). Equations for calculation of 10-y stroke risk are also available. (See circulation journal for scores)

AHA indicates American Heart Association.

CHD indicates coronary heart disease.

See full article on Circulation Journal