[Secondary prevention after ischemic stroke]

This paper reviews secondary prevention of stroke by the therapy of vascular risk factors, anticoagulation, surgical and endovascular procedures. Two recently published studies, the PROtection aGainst REcurrent Stroke Study (PROGRESS) and the Heart Protection Study (HPS) demonstrated for the first time the efficacy of antihypertensive and lipid lowering by statins in stroke secondary prevention. PROGRESS has shown that the combination of perindoprile and indapamide reduced the occurrence of ischemic and hemorrhagic strokes in hyper- and normotensive patients by 40%, whereas HPS demonstrated a 20% reduction of ischemic strokes in cases with normal or elevated serum cholesterol. Symptomatic carotid stenoses with a distal degree of > or = 70% should undergo endarterectomy; in the presence of a distal degree of stenosis of 50-69% an individual treatment decision is performed; carotid surgery is not indicated in < 50% stenoses. Patients with a cardiac source of embolism (except those with cardiac myxoma or bacterial endocarditis) should be anticoagulated with a target INR of 2.5 (range 2-3). Patients who have no indication for vascular surgery or anticoagulation will be treated with platelet inhibitors. Aspirin 100 mg/d or the combination aspirin-dipyridamole are the treatment of choice. If cerebral ischemia reoccurs with aspirin or in case of aspirin intolerance clopidogrel will be administered. Patients with cerebral ischemia occurring while they are treated with clopidogrel may receive an oral anticoagulation with a target INR of 2.0 (range 1.5-2.5).