Prevention of stroke: Antihypertensives, cholesterol-lowering drugs, antithrombotics, anticoagulation, carotid surgery, and stenting

• Main Author: Michael Brainin
• Format: Article
• Language: English
• Published: Wolters Kluwer Medknow Publications 2018-01-01
• Series: Hamdan Medical Journal
• Subjects: anticoagulation; antihypertensive therapy; antithrombotics; aspirin; carotid stenting; carotid surgery; clopidogrel; stroke prevention
• Online Access: http://www.hamdanjournal.org/article.asp?issn=2227-2437;year=2018;volume=11;issue=1;spage=2;epage=12;aulast=Brainin

Antihypertensive drugs are very effective in secondary stroke prevention. More important than the choice of a class of antihypertensives is to achieve the systolic and diastolic blood pressure targets (<140/90 mmHg in nondiabetics and < 130/80 mmHg in diabetics). In many cases, this requires a combination therapy and lifestyle modification. Statin therapy reduces the rate of recurrent stroke and vascular events. The target range of low-density lipoprotein is 70–100 mg/dL. Patients with transient ischemic attack (TIA) or ischemic stroke should receive antiplatelet drugs. The choices are acetylsalicylic acid (ASA 50–150 mg) or clopidogrel (75 mg). Short-term use of dual antiplatelet therapy (ASA plus clopidogrel) may be considered in patients with acute minor stroke or TIA and high risk of recurrence. Patients with a cardiac source of embolism, in particular atrial fibrillation (AF), should be treated with oral anticoagulation. Options for patients with AF include dose-adjusted warfarin (international normalized ratio 2.0–3.0), apixaban, dabigatran, edoxaban, or rivaroxaban. Patients with contraindications to use oral anticoagulation should receive ASA 100–300 mg/day. Symptomatic patients with significant stenosis of the internal carotid artery (degree of stenosis between 70% and 95%) should undergo carotid endarterectomy. Carotid artery stenting is an alternative to endarterectomy in patients who are unsuitable or at high risk for endarterectomy. Patients should receive ASA before, during, and after endarterectomy or the combination of clopidogrel (75 mg) plus ASA (75–100 mg) and after carotid stenting for 1–3 months. Symptomatic patients with intracranial stenosis or occlusions should be treated with optimal medical management, which includes antiplatelet therapy and high-dose statins (if deemed appropriate). In patients with recurrent events, angioplasty can be considered.