Multimodality stroke prevention

Prevention harbors the greatest potential for reducing the societal burden from stroke. As evidence accumulates on the multifactorial pathogenesis of vascular disease and the impact of novel combination therapies targeted at reducing recurrent vascular events, a new paradigm is emerging, which is that of multimodality vascular prevention. Knowledge of the evidence behind this strategy and the effective means for implementing it could be useful to the practicing neurologist taking care of stroke patients.

Our review presents the evidence behind the broadening therapeutic options for recurrent vascular event prevention in ischemic stroke patients whose underlying stroke pathophysiologic mechanism is either presumed to be due to atherosclerosis or who have prior evidence of systemic atherosclerosis. We elaborate on conventional and novel vascular risk factors, as well as risk factor prediction models. Therapies discussed include antithrombotics, statins, antihypertensives, surgical/endovascular treatments, and lifestyle modification. Basis for evidence (or the lack thereof), national guideline recommendations, areas of controversy, and avenues of future focus for these treatments are also discussed in this paper. Furthermore, the knowledge-treatment gap as it pertains to optimal vascular risk-factor control and appropriate initiation and maintenance of evidence-based preventive therapies is explored, and an effective hospital-based intervention involving the in-hospital initiation of these treatments prior to discharge, that may help bridge this gap, is detailed.

Neurologists should be aware that a timely, systematic, evidence-based multimodal preventive approach to atherothrombotic disease in stroke patients that transcends the continuum of care across points of service will likely increase treatment rates and improve clinical outcomes.