[Secondary stroke prevention - an update]

Organised secondary prevention is a prerequisite for successful stroke therapy. One of the most relevant factors is elevated blood pressure. It has been shown that long-term blood pressure treatment leads to a significant reduction in mortality of almost 10 % over a 5-year period. Additionally, a large meta-analysis in almost 1 million patients confirmed that blood pressure reduction leads to a constant reduction in secondary cerebrovascular events by 40 %, both in primary and secondary prevention. The preventive effect was stronger as the blood pressure reduction increased. Interactions between proton-pump inhibitors and the antiplatelet agent clopidogrel did not receive scientific confirmation. There is no reason to avoid this combination. Patients suffering from atrial fibrillation and stroke should, whenever possible, be treated by oral anticoagulation. In cases in which this treatment is abandoned, the combination of aspirin and clopidogrel offers some marginal benefits over aspirin alone (higher stroke risk reduction, but increase in brain haemorrhages). Dabigatran is a new direct oral thrombin antagonist. It has the advantage compared to the oral vitamin K antagonists that it acts immediately after intake and does not need further regular coagulation test controls. The huge RELY study revealed that dabigatran is safer with the same efficacy in the lower dose, but more effective with the same safety in the higher dose, compared to oral vitamin K antagonists. It will be licensed in 2010. Statins seem to be beneficial for as long as 10 years after a cerebrovascular accident. Carotid stenosis treatment seems to be better done by operation as revealed by the International Carotid Stenosis Stenting study. A patent foramen ovale is a slight risk factor with an OR of 1.1. Therefore, any aggressive treatment options in patients with stroke and pfo seem to be unjustified.