Current and future concepts in stroke prevention

STROKE IS A MAJOR CAUSE OF MORBIDITY and mortality in an aging population. The current understanding of the pathophysiology of atherosclerotic diseases, the most common cause of stroke, and the evidence for existing therapeutic interventions for the prevention of stroke are presented. Specifically, we review the evidence for antiplatelet agents, anticoagulants, antihypertensive medications, lipid-lowering agents and carotid endarterectomy for stroke prevention. Each year in Canada stroke occurs in 50 000 people and accounts for 7% of all deaths. Canada''s population of stroke survivors numbers almost 300 000, of whom 30% remain permanently disabled.^1,2,3 Care for stroke patients accounts for 2.1% of Canadian health care expenditures.⁴ Primary prevention of a first stroke and secondary prevention of recurrent events require rapid identification of risk factors and implementation of appropriate preventive measures.The risk of stroke following an initial cerebrovascular event is high. Of patients presenting to an emergency department with a transient ischemic attack (TIA), 10.5% will have a stroke (half of these occurring in the first 2 days) and 2.6% will die within 90 days.⁵ Overall, 8.8% of stroke survivors will have a recurrent stroke within the first 6 months, and 15% within 5 years.⁶ In most cases (about 50%) the stroke is atherothrombotic in origin, with a further 25% attributable to small-vessel lacunar disease and 20% to cardioembolism. Data from a stroke registry reveal that patients who have an atherothrombotic stroke have the highest rates of recurrence within 30 days (18.5%), as compared with those who have a lacunar (1.4%) or cardioembolic (5.3%) stroke.⁷In this review we present the current understanding of the pathophysiology of atherosclerotic disease, the most common cause of stroke. We also provide an overview of the available evidence for common therapeutic interventions used for stroke prevention: antiplatelet agents, anticoagulants, antihypertensive medications, lipid-lowering agents and carotid endarterectomy.