Stroke often imposes an enormous burden, both physically and emotionally, on the individual who experiences it, as well as on his or her loved ones. In addition, cerebrovascular disease, currently the third leading cause of death and the leading cause of disability in the United States, poses an enormous public health problem. Preventing stroke is, therefore, of crucial importance. While the initiation of risk reduction strategies to decrease the likelihood of an initial stroke generally falls to the primary care provider, we, as neurologists, frequently become involved with the patient at the time of the first stroke. At that point, we can make a critical difference by actively ensuring that every possible measure is taken to reduce the likelihood of a recurrent cerebrovascular event.
This issue of CONTINUUM, under the guest editorship of Dr Bruce Ovbiagele, focuses on secondary prevention of stroke. However, considerable overlap exists between primary and secondary stroke prevention measures, so the issue also provides much information about the former subject. In addition, valuable pointers about our current understanding of both ischemic and hemorrhagic stroke will be gleaned by reading this important issue.
Dr Mitchell Elkind sets the stage for the other contributors by reviewing the epidemiology of stroke and delineating the risk factors that contribute to it. In his article, he also reviews recent changes in the concept and definition of TIA.
Hypertension is probably the most important modifiable risk factor for stroke, and an aggressive approach to lowering blood pressure pays great dividends in reducing cerebrovascular events. Drs Adnan Qureshi and Biggya Sapkota discuss this subject, carefully reviewing the plethora of trials that have considered the effects of antihypertensive management. Indeed, lowering of blood pressure, even when it is in the so-called normal range, may be beneficial.
Just as with the management of blood pressure, experts have recently argued for a more aggressive approach to the lowering of total cholesterol and low-density lipoprotein cholesterol levels and to the raising of high-density lipoprotein cholesterol levels. Drs Pratik Bhattacharya and Seemant Chaturvedi review the evidence regarding dyslipidemia. In a later article, Dr Amytis Towfighi discusses other metabolic conditions that impact the risk of stroke, such as insulin resistance, obesity, and the metabolic syndrome. Neurologists often neglect to emphasize the importance of lifestyle changes to their patients, but these interventions may be just as important as the prescription of medication.
The prevention of ischemic stroke often involves strategies to decrease the development and progression of thrombotic disease or to prevent the occurrence of cerebral embolization. In his article, Dr Mark Alberts reviews the use of antiplatelet agents and anticoagulants for these purposes. He provides a thoughtful discussion of the pros and cons of the available agents, including discussion of alternatives to the traditional anticoagulant, warfarin, such as dabigatran (a new oral direct thrombin inhibitor). In select patients, particularly those with high-grade extracranial stenotic arterial lesions, risk-benefit analyses suggest that revascularization procedures may be the best approach. Recent years have seen the development of novel procedures and the increasing use of stents, which has prompted controversy over the best approach to revascularization. Drs Dileep Yavagal and Diogo Haussen will bring you up-to-date on this hot topic.
Most of this issue on secondary stroke prevention justifiably focuses on ischemic cerebrovascular disease since this represents approximately 85% of all strokes. Nonetheless, hemorrhagic stroke is critically important as it is a devastating and often fatal disorder. In their article on intracerebral hemorrhage, Drs Carlos Kase and Tobias Kurth note the lack of studies specifically addressing secondary prevention of intracerebral hemorrhage and appropriately extrapolate from information available about primary prevention of such events.
In the final review article, Drs Cheryl Bushnell and Patrick Reynolds tackle a systems approach to the reduction of secondary stroke risk and address strategies to enhance medication adherence and reduce medication errors. These are important subjects that we too often neglect. It is vitally important that as neurologists we understand that our job does not end with the writing of a prescription.
Most of us have faced the dilemma of caring for critically ill patients requiring urgent decision making in the absence of an available surrogate. Dr Fred Rincon addresses this subject in his discussion of an incapacitated stroke patient in this issue's Ethical Perspectives section.
Neurologists and other physicians frequently confront the dilemma of management of patent foramen ovale in a patient with stroke. While definitive answers have been elusive, Dr Cheryl Jaigobin provides a thorough discussion of the options in the Practice Issues section. Dr Laura Powers presents useful information on coding for stroke prevention services to ensure the valuable time you spend counseling your patients is appropriately reimbursed.
Each issue of CONTINUUM provides additional educational opportunities in the form of multiple-choice questions, herein crafted by Drs Joseph Safdieh and Douglas Gelb, and in the Patient Management Problem. In the latter exercise, guest editor Dr Ovbiagele and Dr Amy Guzik lead you through a series of decision points regarding an elderly woman who is brought to the hospital after experiencing a 30-minute episode of left hemiparesis. By working through this problem, you will have the opportunity to incorporate much of the information you have learned by reading the rest of the issue.
We are indebted to Dr Ovbiagele and the other experts who have contributed to this Secondary Stroke Prevention issue. They have enabled us to see a more complete picture and to be better physicians to our stroke patients. What more can I say!
-Aaron E. Miller, MD