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Published on: June 23, 2015
Drugs and surgery in the prevention of ischemic stroke
H J Barnett1, M Eliasziw, H E Meldrum
1Department of Clinical Neurological Sciences, University of Western Ontario, London, Canada.
Insights
Warfarin therapy effectively reduces stroke risk in specific patient groups. Aspirin and carotid endarterectomy offer benefits, but optimal use and effectiveness for certain conditions require further investigation.
Area of Science:
- Neurology
- Cardiology
- Vascular Surgery
Background:
- Randomized trials confirm warfarin's efficacy in reducing stroke risk for nonvalvular atrial fibrillation and post-myocardial infarction patients.
- Aspirin provides a smaller risk reduction than warfarin for patients unsuitable for long-term anticoagulation.
- Aspirin and ticlopidine offer modest benefits in preventing stroke for those with noncardiac cerebral ischemic symptoms.
Purpose of the Study:
- To review the established and emerging evidence for stroke prevention strategies.
- To identify areas of uncertainty regarding antiplatelet therapy and surgical interventions.
- To guide clinical decision-making in stroke risk management.
Main Methods:
- Systematic review of randomized clinical trials and current research.
- Analysis of evidence for anticoagulant therapy (warfarin).
- Evaluation of antiplatelet agents (aspirin, ticlopidine, dipyridamole, sulfinpyrazone) and surgical intervention (carotid endarterectomy).
Main Results:
- Warfarin is superior to aspirin for stroke risk reduction in indicated populations.
- Aspirin and ticlopidine show modest benefits for specific ischemic stroke types.
- Carotid endarterectomy is beneficial for symptomatic patients with severe stenosis (≥70%).
Conclusions:
- Warfarin remains a primary therapy for high-risk patients.
- The role of aspirin in combination with other agents and its optimal dosage for stroke prevention are still under investigation.
- The efficacy of carotid endarterectomy for moderate stenosis and asymptomatic lesions requires further research.
Abstract:
Randomized clinical trials have proved that warfarin therapy decreases the risk of stroke in patients with nonvalvular atrial fibrillation and in those who have had a myocardial infarction. In patients who are not candidates for long-term anticoagulant therapy, aspirin is beneficial, but the reduction in risk is smaller with aspirin than with warfarin. In patients with cerebral ischemic symptoms of noncardiac origin, aspirin and ticlopidine reduce the risk of stroke, but the benefit is modest. Given alone, neither dipyridamole nor sulfinpyrazone prevents stroke. The question remains whether either of these drugs plus aspirin is better than aspirin alone. The optimal dose of aspirin for stroke prevention has not been established. Carotid endarterectomy reduces the risk of stroke in symptomatic patients with at least 70 percent stenosis, as determined by arteriography. Current trials are addressing the question of whether endarterectomy is beneficial for patients with moderate degrees of carotid stenosis. The benefit of endarterectomy for patients with asymptomatic carotid lesions remains unclear.
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