FIX JD JR AKU

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T h e NE W ENGL A ND JOUR NA Lo f MEDICINE

CLINICAL PRACTICE

Secondary Prevention after Isce!ic Stro"e

or Transient Isce!ic Attac"Stephen M. Davis, M.D., and Geoffrey A. Donnan, M.D.

This Jo#rna$feature begins with a case vignette highlighting a common clinical problem.

Evidence supporting various strategies is then presented, followed by a review of formal

guidelines, when they exist. The article ends with the authors clinical recommendations.

From the Melbourne Brain Centre, Royal

Melbourne Hospital S.M.D.!" the Depart#

ments of Medi$ine S.M.D.! and %eurol#o&y

S.M.D., G.A.D.!, 'niversity of Mel#bourne"

and the Florey %euros$ien$e (nstitutes

G.A.D.! ) all in Melbourne, *(C, Australia.

Address reprint re+uests to Dr. Davis at theMelbourne Brain Centre, Royal Melbourne

Hospital, ar-ville, *(C, Australia /0/, or

at stephen.davis1mh

.or&.au.

% 2n&l 3 Med 4/54"6675859#44.

Copyright 2012 Massachusetts Medical Society.

An audio

version of this

article is

available at

NEJM.org

A 62-year-

old woman

is seen 1

week after

an ischemic

stroke. She

hadpresented to

another

hospital

with

dysphasia

and right-

sided

weakness;

magnetic

resonance

imag-ing

(MR!

showed a

recent

infarction in

the left

parietal

corte"# and

comp$ted

tomo-

graphic

angiography

(%&A!showed a

high-grade

stenosis in

the left

pro"imal

internal

carotid

artery with

normal

intracranial

'essels (ig.

1!. She wastreated with

intra'e-no$s

recom)inan

t tiss$e plasminogen acti'ator and

discharged home# taking aspirin

and a statin. She stopped smoking

12 years ago. *n e"amination# the

)lood press$re is 1+,/ mm 0g.

She reports some mild resid$al

cl$msiness of her right hand.hat wo$ld yo$ ad'ise to red$ce

the risk of stroke rec$rrence

T%E

CLINICALPRO&LEM

Wor$d'ide( stro"e is te second!ost co!!on ca#se of deat

after !yocardia$ in)farction andis a $eadin* ca#se of ac+#ireddisa,i$ity- In so!e re*ions( teco!),ined incidence of stro"eand transient isce!ic attac"s.TIAs/ e0ceeds te incidence of

coronary vasc#$ar events-1More

tan 234 of fata$ stro"es occ#rin $o') and !id)d$e)inco!e

co#ntries-5(6

Patients 'it stro"e are at i*

ris" for s#,se+#ent vasc#$ar

events( inc$#din* rec#r)rent stro"e

.i*est ris"/( !yocardia$

infarction( and deat fro!vasc#$ar ca#ses- &eca#se te ris"

of stro"e is i*est in te ear$y

7eriod after te ac#te event(

7ro!7t initiation of tai$ored

7revention strate*ies is essentia$-8

A !eta)ana$ysis so'ed tat te

ris" of stro"e 'as as i* as

15-24 d#rin* te first 'ee" after

a TIA( ,#t te ris" 'as $o'est

'en e!er*ency treat!ent ad

,een *iven ,y s7ecia$i9ed stro"e

ser)vices-

8

It is esti!ated tat at$east 2:4 of rec#rrent events

!i*t ,e 7revented 'it te #se

of a co!7reensive a77roac tat

inc$#des dietary !odification(


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e0ercise( ,$ood)7ress#re

$o'erin*( anti7$ate$et tera7y(

and statin tera7y-8(3

STRATEGIESAND

E;IDENCE

EVALUATION

Stro"e iscate*ori9ed asisce!ic stro"e.2:4 of cases/(intracere,ra$e!orra*e

.134/( or s#,aracnoide!orra*e

.34/-

'eretraditiona$$ydefined as ,riefne#ro$o*ice7isodes of vasc#$ar ori*in$astin* $ess tan58 o#rs- Morerecent$y( TIAsave ,een

c$assified as

transient ne#ro$o*ic events'ito#t si*ns of ac#te

infarction on i!a*in*-

#7dated definition is ,asedon te evidence tat !anystro"es de)tected on

i!a*in*( 7artic#$ar$y MRI($ast $ess tan 58 o#rs or arec$inica$$y si$ent- Tis revie'foc#ses on secondary

7revention after a TIA orisce!ic stro"e-

1


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CLINICAL PRACTICE

I

n

7$a

nni

n*

sec

on

dary

7re

ve

nti

on(

it

is

i!

7or

)

tan

t toatt

e!

7t

to

ide

ntif

y

te

7at

o

*e

nesis

of

te

TI

A

or

isc

e

!i

c

str

o"e(

7ar

tic

#$a

r$y

to

det

ect

c$i

nic

a$$

y

si*

nifi

can

t

cardiac

or

$ar*e)

artery

ca#ses

tat

'arrant

te #se

of

strate*ies

tai$ored

to te

individ

#a$

7atient-

In

c$inica$

7ractic

e( te

Tria$ of

Or*1:1=5

in

Ac#te

Stro"e

Treat!

ent

.TOAS

T/

c$assifi

cation

for

isce!ic

stro"e

is

#sef#$

in de)

$ineatin

*

!a>or

7ato*

eneses

on te

,asisof

c$inica$

findin*

s and

investi

*ations

-=

Tese

in)

c$#de

cardioe

!,o$is!

.!ost

co!!o

n$y

fro!

atri)a$

fi,ri$$at

ion/(

$ar*e)

artery

disease

( s!a$$)

vesse$occ$#si

on

.$ac#na

r

stro"e/(

stro"e

of

oter

deter)

!ined

ca#se

.e-*-(arteria$

dissecti

on(

dr#*)

re$ated

stro"e(

or a

y7erc

oa*#$a

,$e

disorde

r/( andstro"e

of

#ndeter

!ined

ca#se

.t'o or

!ore

identifi

ed

ca#ses

or

ne*ative or

inco!7

$ete

eva$#at

ion/-

Even

'en

f#$$y

investi

*ated(

#7 to

6:4 ofcases

of ce)

re,ra$


4/28

isc

e

!i

a

re

!a

in

#n

e0

7$a

ine

d

.?c

ry7

to*

en)

ic

str

o"

e@/

-

U

r*e

nt

eva

$#a

tio

n

is

'a

rra

nte

d

aft

er

a

str

o"

e

or

TI

A(

,ec

a#s

e

!any

rec

#rr

ent

eve

nts

occ

#r

ear

$y-

&r

aini!

a*i

n*

is

!andat

ory for

dia*no

sis(

c$assi)

fication

( and

!ana*

e!ent-MRI is

!#c

!ore

sensitiv

e tan

co!7#t

ed

to!o*r

a7y

.CT/ in

te

dia*nosis of

ac#te

isce!

ia(

a$to#*

CT is

!ore

'ide$y

avai$a,

$e-

Arteria

$i!a*in

* 'it

te #se

of

carotid

Do77$e

r

#$traso

no*ra7

y(

CTA(

or

!a*)

netic

resona

nce

an*io*r

a7y

.MRA/

is

#s#a$$y

necessa

ry- In

!any

centers

( CT is

no'

co!,in

ed 'it

CTA-

E$ectro

cardio*

ra7y

is

ro#tine

$y 7er)

for!ed- To

detect

7aro0y

s!a$

atria$

fi,ri$$at

ion(

a!,#$a

tory

!onito

rin* is

#sef#$-Transt

oracic

or

transes

o7a*e

a$

ecoca

rdio*ra

7y is

often

#sed to

detectcardiac

so#rces

of

e!,o$i

s!

oter

tan


5/28

atri

a$

fi,

ri$$

ati

on-

Ro

#ti

ne

,$o

od

tes

ts

!a

y

rev

ea$

7re

dis

7o

sin*

ca

#se

s(

s#c

as

7o$

yc

yt

e!

ia(ren

a$

i!

7ai

r!

ent

(

e$e

ctr

o$y

te

dis

t#r

,a

nc

es(

an

d

y

7er

)

*$y

ce!i

a-

M

ANAGEMENT

A**res

sive

ris")

factor

!ana*

e!ent

and

$ifesty$e

advice

are

essenti

a$ for

a$$

7atient

s-

O,serv

ation)a$

st#dies

of

7atients 'it

a

istory

of

stro"e

in)

dicate

tat

ea$ty

$ifesty$

e

,eavi

ors(

inc$#di

n*

re*#$ar

e0ercis

e and

a,stine

nce

fro!

s!o"in

*( are

associa

ted'it

red#ce

d

!orta$i

ty-2(#sted 'arfarin as ,een $et tera7y and intensive ris")factor !ana*e!ent

te !ainstay of tera7y- A !eta)ana$ysis of tria$s are reco!!ended for s#c 7atients- A rando!i9edco!7arin* 'arfarin 'it 7$ace,o or as7irin so'ed tria$ co!7arin* 'arfarin 'it as7irin in 7atients

red#ctions in te ris" of stro"e of :4 and 8:4( 'it stro"e or TIA ca#sed ,y intracrania$ stenosis

res7ective$y( a$to#* tese 'ere cief$y 7ri!ary) 'as ter!inated ear$y o'in* to i*er ris"s of ad)

7revention tria$s-82

Warfarin as a$so ,een so'n verse o#tco!es 'it 'arfarin(36

and a tria$ co!)

to ,e !ore effective tan as7irin12

or te co!,i) 7arin* an*io7$asty and stentin* 'it a**ressive

nation of as7irin 7$#s c$o7ido*re$8or ,$eedin* ,#t a si*nificant$y $o'er te 7revention of stro"e in 7atients 'it an ini)

ris" of intracrania$ e!orra*e-1

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