Secondary Prevention of

1

• Secondary Prevention of
• Ischemic Stroke or
• Transient Ischemic Attack
• Milan C. Mathew
• Resident in Internal Medicine
• Memorial Hospital of Rhode Island

2
The Challenge

• Survivors of Stroke/TIA Increased risk of
  recurrence
• Recurrence estimates 200,000 of 700,000 / year
• Estimates of TIA much higher
• 90 day risk 10.5 greatest in first week
• Guidelines for AHA/ASA supported by AAN and CCRI
  reviewed
• Reference
• Sacco RL, Adams R, Albers G, et al., Guidelines
  for prevention of stroke in patients.Stroke.
  2006 Feb37(2)577-617.

3
Definition

• By Convention
• Stroke Neurological symptoms gt 24 hrs
• TIA Neurological symptoms lt 24 hrs
• Proposed
• TIA Brief episode of neurological dysfunction
  caused by focal disturbance of brain or retinal
  ischemia with clinical symptoms lasting lt 1hr and
  without evidence of infarction.

4
Risk Factor Reduction

• Hypertension
• Continuous association SBP/DBP and stroke
• 30-40 risk reduction with BP control
• Recommendations
• Treat all after hyper-acute period
• Target BP Uncertain, Individualize
• Average reduction for benefit 10/5 mm Hg
• Optimal drug Uncertain
• Diuretics/ Diuretics ACE
• Choice guided by co-morbidities
• Life style modifications

5
Risk Factor Reduction

• Diabetes
• Normal FBS lt 100 mg/dl (5.6 mmol/l)
• Impaired FBS 100-126 mg/dl (5.6-6.9 mmol/l)
• Diabetic FBS gt 126 mg/dl (7 mmol/l) or CBS gt 200
  mg/dl (11.1 mmol/l)
• HbA1c gt 7 inadequate control
• Recommendations
• Rigorous control to near normoglycemic levels
• For HTN ACE / ARB reduce renal disease
  progression
• Target HbA1c lt 7

6
Risk Factor Reduction

• Lipids
• Relationship not well established in absence of
  CHD
• Recommendations
• Treat per NCEP ATP III
• CHD or CHD equivalent LDL-C lt 100
• Very high risk LDL-C lt 70
• Multiple or poorly controlled risk factors
• ACS, Metabolic syndrome
• Reasonable Treat low HDL with Gemfibrozil/Niacin
• Reasonable Treat even if no indication for
  statins

7
Risk Factor Reduction

• Smoking and ETS
• Well established relationship, Rec Quit
• Alcohol consumption
• Controversial, Suggestion of J shaped
  relationship
• Rec Heavy Eliminate/reduce, Consider lt 2
  drinks per day for men, 1 drink per day for non
  pregnant women
• Obesity
• Independent risk factor in PHS
• BMI (kg/m2) 18.5-24.9 Healthy, 25-29.9 Overweight
  gt 30 Obese
• Rec Lower to ideal levels
• Physical activity
• Capable of PA At least 30 mts of mod intensity
  PA
• Not capable/Disability Supervised regimen

8
Interventional Approaches

• Extracranial Carotid Artery Disease
• Recent TIA/Stroke (lt 6months) and
• Ispilateral severe stenosis (70-99) CEA by
  Surgeon with lt 6 MNM Difficult access, great
  surgical risk, restenosis, consider angioplasty
  and stenting
• Ispilateral moderate stenosis (50-69)
  Recommended for specific cases
• Ispilateral stenosis lt 50 Not indicated
• Surgery within 2 weeks
• Extracranial Vertebrobasilar Disease
• Recurrent TIA/Strokes despite optimal medical
  therapy
• Consider CAS Data limited (II b C)
• Intracranial atherosclerosis
• Limited data CAS investigational (II b C)

9
Medical TreatmentCardiogenic Embolism

• Cardiogenic Emboli 20 of ischemic strokes
• 50 Non valvular AF, 25 VHD,33 LV thrombus
• Atrial fibrillation
• Warfarin Goal 2.5 (2-3)
• Timing within 2 weeks unless large/uncontrolled
  HTN
• ASA if unable to take warfarin
• Acute MI and Left Ventricular Thrombus (imaging)
• Warfarin Goal 2.5 (2-3) for at least 3 months to
  a year
• ASA
• Dilated Cardiomyopathy
• Warfarin Goal 2.5 (2-3) or Antiplatelet therapy
  (II b C)

10
Medical TreatmentCardiogenic Embolism

• Rheumatic MV disease
• Warfarin Goal 2.5 (2-3), Irrespective of AF
• Suggest aspirin use only with treatment failure
• MVP
• Antiplatelet therapy
• Mitral Annular Calcification IIb C
• Consider antiplatelet therapy
• WIth MR consider antiplatelet therapy or
  anticoagulation
• Aortic valve disease
• Consider antiplatelet therapy
• Prosthetic heart valves
• Mechanical Warfarin Goal 3.0 (2.5-3.5)Add
  aspirin if treatment failure
• Bioprosthetic/Low risk Mechanical valves
  Warfarin Goal 2.5 (2-3)

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Medical TreatmentNoncardioembolic Stroke

• Aspirin
• Low dose similar efficacy as high dose
• Ticlopidine
• GI symptoms, Rash, TTP, Neutropenia Limits use
• Clopidogrel
• CAPRIE trial Suggestion of greater efficacy for
  composite endpoints
• Suggestion of greater efficacy in diabetics
• Dipyridamole ASA
• ESPS 2 ASA 50 mg Dipyridamole 400 mg ER
  Greater efficacy
• Headaches, concern for ACS
• Clopidogrel ASA
• MATCH trial, No benefit with addition of ASA
• Increase risk of Major hemorrhage Rec for ACS

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Medical TreatmentNoncardioembolic Stroke

• Summary
• Antiplatelets over anticoagulants Individualize
• ASA (50-325) or ASA ER Dipyridamole or
  Clopidogrel
• Suggested ASA ER Dipyridamole
• ASA Clopidogrel Not recommended
• Clopidogrel can be used instead of ASA
• No evidence to suggest increase dose of ASA with
  failure
• No alternate agents studied in case of ASA
  failure
• ESPIRIT trial Warfarin vs. ASA vs. ASA ER
  Dipyridamole
• MATCH trial in journal club

13
My Patient

• 65 yrs M
• HTN Uncontrolled Needs Better Control
• DM FBS 92 - Monitor
• Lipids TC 166, HDL 25, TG 133 LDL 114 FHS 10
  year Risk of CHD gt 30 - Add statin TLC
  Monitor, Treat low HDL
• Smoking Quit
• Alcohol Reduced to 1-2 beers occasionally
• Metabolic Syndrome Present - TLC
• Physical activity ? Enrolment in a formal
  program
• Medications ASA - ?lower dose, Simplify anti HTN
  regimen
• Adherence Ideas to improve adherence
• Health Maintenance Screening Colon Ca, AAA and
  Depression
• ? Missed

14

• Thank you