"The Triptan's Hangover": A Multicentric Cross-sectional Observational Study of the Adverse Events of Triptans in Patients With Migraine.

ABSTRACT: The emergence of triptans represented a breakthrough in the treatment of migraine, but in clinical practice, patients describe symptoms that resemble those of a hangover after taking them. We propose the use of the Hangover Symptoms Scale (HSS) to evaluate this syndrome in patients that take triptans, which may help identify patients at higher risk of presenting these adverse effects that may interfere with therapeutic compliance.A cross-sectional observational pilot study with prospective data collection through a clinical-demographic questionnaire and the HSS was carried out on patients with migraine treated in headache units in 3 tertiary hospitals in Madrid.Sixty-six patients were included in the study. The median HSS was 4 and all symptoms were present in at least 15% of the patients, with difficulty to concentrate being the most frequent (57.6%). No significant differences were found between the presence of a higher HSS score and the sociodemographic characteristics of the patient or his migraine. The presence of aura was associated with a higher percentage of trembling (P = 0.029) and fatigue (nonvisual, polymodal auras; P = 0.017).According to our study, triptans are responsible for a set of symptoms overlapping with those that occur during a hangover. Therefore, we propose that the HSS could be a useful tool for the evaluation and quantification of these effects in patients receiving triptans. In addition, we found that clinical features could be more frequently associated with the appearance of these adverse effects that, however, are not related to any particular patient profile.

Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid / Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program

INTRODUCCIÓN: La pandemia por COVID-19 ha obligado a una reorganización de los sistemas sanitarios y una saturación excepcional de sus recursos. En este contexto es vital asegurar la atención al ictus agudo y optimizar los procesos asistenciales del código ictus para reducir el riesgo de contagios y racionalizar el uso de recursos hospitalarios. Para ello desde el Grupo multidisciplinar Ictus Madrid proponemos una serie de recomendaciones. MÉTODOS: Revisión bibliográfica no sistemática de las publicaciones disponibles con los términos "stroke" y "covid-19" o "coronavirus" o "SARS-COV-2", así como otras conocidas por los autores. En base a ésta se redacta un documento de recomendaciones que es sometido a consenso por el Grupo multidisciplinar Ictus Madrid y su Comité de Neurología. RESULTADOS: Las recomendaciones se estructuran en cinco líneas fundamentales: (1) Coordinar la actuación para garantizar el acceso la asistencia hospitalaria de los pacientes con ictus, (2) Reconocer a los pacientes con ictus potencialmente infectados por COVID-19, (3) Organización adecuada para garantizar la protección de los profesionales sanitarios frente al riesgo de contagio por COVID-19, (4) la realización de Neuroimagen y otros procedimientos que conlleven contactos de riesgo de infección COVID-19 hay que procurar reducirlos y asegurar la protección, y (5) alta y seguimiento seguros procurando optimizar la ocupación hospitalaria. Resumimos el procedimiento de forma esquemática con el acrónimo CORONA (COordinar, Reconocer, Organizar, Neuroimagen, Alta). CONCLUSIONES: Estas recomendaciones pueden servir de apoyo para la organización del sistema sanitario en la atención al ictus agudo y la optimización de sus recursos, garantizando la protección de sus profesionales

BACKGROUND: The COVID-19 pandemic has forced a reorganization of healthcare systems and an exceptional saturation of their resources. In this context, it is vital to ensure acute stroke care and optimize the care processes of the stroke code to reduce the risk of contagion and rationalize the use of hospital resources. To do this, the Ictus Madrid multidisciplinary group proposes a series of recommendations. METHODS: Non-systematic bibliographic review of the available publications with the terms "stroke" and "covid-19" or "coronavirus" or "SARS-COV-2", as well as other already known for the authors. We provide a document of recommendations as a result of the consensus of the Ictus Madrid multidisciplinary group and its Neurology Committee. RESULTS: Our recommendations are structured on five lines: (1) Coordinate to guarantee the access to hospital care for stroke patients, (2) Recognize potentially COVID-19 infected stroke patients, (3) Organize to ensure the protection of healthcare professionals from COVID-19 infections, (4) Neuroimaging and other procedures potentially associated to risks for COVID-19 infection should be reduced and secured to avoid contagion, and (5) At home as soon as posible and supported follow-up to optimize hospital occupancy. The procedure is shown summarized under the acronym CORONA (Coordinate, Recognize, Organize, Neuroimaging, At home). CONCLUSIONS: These recommendations can support the organization of healthcare services for acute stroke care and the optimization of their resources, guaranteeing the protection of healthcare professionals

Prehospital selection of thrombectomy candidates beyond large vessel occlusion: M-DIRECT scale.

OBJECTIVE: Current prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C. METHODS: In this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort). RESULTS: The M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts. CONCLUSIONS: The M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.

Is There a Characteristic Clinical Profile for Patients with Dementia and Sundown Syndrome?

BACKGROUND: Sundown syndrome (SS) is the onset or worsening of behavioral symptoms in the evening in patients with dementia. OBJECTIVE: To identify the differential clinical profile of patients with dementia who present SS. METHODS: A cross-sectional, case-control observational study was conducted by retrospectively reviewing the medical records of patients with dementia in a specialized Memory Unit. We compared the characteristics of patients with and without SS, including sociodemographic variables, etiology, and severity of the dementia, behavioral symptoms, sleep disorders (considering insomnia and hypersomnia), other diseases and treatments employed. We identified the factors related to SS and conducted a logistic regression analysis to establish a predictive nomogram. RESULTS: Of the 216 study patients with dementia, 41 (19%) had SS. There was a predominance of women (2.4:1), advanced age (p = 0.0001), dependence (p < 0.0001), institutionalization (p < 0.0001), caregiver burden (p < 0.0001), anxiety (p < 0.0001), delirium (p < 0.0001), hallucinations (p < 0.0001), wandering (p < 0.0001), Lewy body dementia (p = 0.05), higher Global Deterioration Scale score (GDS; p < 0.0001), and sleep disorders (p < 0.0001). The multivariate analysis revealed that age (p = 0.048), GDS score (p = 0.01), and the presence of insomnia or hypersomnia (p < 0.0001) independently defined the presence of SS. We established a predictive nomogram for developing SS in patients with dementia, with a predictive capacity of 80.1%. CONCLUSION: In our study, age, a higher score on the GDS, and the presence of insomnia or hypersomnia are differential clinical characteristics of patients with SS. We defined a nomogram that helps predicting the occurrence of SS in patients with dementia.

Infarto cerebral como complicación de una endocarditis infecciosa / Cerebral infarction complicting infectious endocarditis

No disponible

Cumplimiento de las medidas de prevención de factores de riesgo vascular en pacientes ingresados con ictus agudo. Análisis de un registro multicéntrico: registro EPICES (III) / Compliance with the measures for preventing vascular risk factors in hospitalised patients with acute stroke. Analysis of a national multi-centre registry: EPICES registry (III)

Introducción. Medidas farmacológicas, dietéticas y de estilos de vida para controlar los factores de riesgo son eficaces para prevenir la enfermedad cerebrovascular; sin embargo, su implementación en la clínica no parece óptima. Objetivo. Identificar el cumplimiento de medidas de prevención en una muestra hospitalaria de 6.197 pacientes hospitalizados con ictus atendidos por neurólogos.Pacientes y métodos. Análisis de un objetivo secundario del registro EPICES. Se consideró prevención primaria en los pacientes sin antecedentes previos de ataque isquémico transitorio, ictus, enfermedad coronaria o enfermedad arterial periférica (n = 3.977); prevención secundaria, en pacientes con antecedentes de enfermedad coronaria o arterial periférica, pero sin antecedentes de enfermedad cerebrovascular (n = 1.047); y prevención secundaria neurológica, en pacientes con antecedentes de ataque isquémico transitorio o ictus, independientemente de que hubiesen presentado enfermedad coronariao arterial periférica (n = 1.173).Resultados. La prevención secundaria y secundaria neurológica fue más eficaz que la prevención primaria (p = 0,028 yp < 0,0001, respectivamente). El control fue superior en los centros con algún tipo de estructura asistencial para la atención de los pacientes con ictus (p < 0,0001). La influencia de la edad en las decisiones terapéuticas siguió un patrón similar en los tres tipos de prevención, con una disminución significativa de la anticoagulación en los pacientes con más de 80 años.Conclusión. El registro EPICES confirma el mal control de los factores de riesgo cerebrovascular. Globalmente, se demuestra que los objetivos que implican la modificación de los estilos de vida se cumplimentan peor que las medidas preventivas farmacológicas (AU)

Introduction. Pharmacological and dietary measurements, as well as life style, to control risk factors are efficient procedures to prevent cerebrovascular diseases, though their implementation in the clinics seems not optimal. Aim. To identify the fulfillment of preventive measurements on a sample of 6197 hospitalized stroke patients, attended byneurologists. Patients and methods. Analysis of a secondary objective of the EPICES registry. Primary prevention was considered in patients without previous record of transitory ischemic attack, stroke, coronary diseases and/or peripheral arterial disease(n = 3977); secondary prevention was considered in patients with record of coronary and/or peripheral arterial disease, but without record of cerebrovascular disease (n = 1047); neurological secondary prevention was considered in patients with a record of transitory ischemic attack and/or stroke, independently of the presence of coronary and/or peripheral arterial disease (n = 1173). Results. Secondary prevention and neurological secondary prevention were more efficient than primary prevention (p = 0.028 and p < 0.0001, respectively). Control was higher in centers with some type of structure to assist stroke patients(p < 0.0001). Influence of age in the taking of therapeutic decisions followed a similar pattern in all three types ofprevention, with a significant reduction on anticoagulation for patients older than 80 years. Conclusion. The EPICES registry confirms the poor control of risk factors for cerebrovascular diseases. Globally it demonstratedthat the objectives that imply the modification of lifestyle are fulfilled worse than pharmacological preventive measurements (AU)

[Compliance with the measures for preventing vascular risk factors in hospitalised patients with acute stroke. Analysis of a national multi-centre registry: EPICES registry (III)]. / Cumplimiento de las medidas de prevención de factores de riesgo vascular en pacientes ingresados con ictus agudo. Análisis de un registro multicéntrico: registro EPICES (III).

INTRODUCTION: Pharmacological and dietary measurements, as well as life style, to control risk factors are efficient procedures to prevent cerebrovascular diseases, though their implementation in the clinics seems not optimal. AIM: To identify the fulfillment of preventive measurements on a sample of 6197 hospitalized stroke patients, attended by neurologists. PATIENTS AND METHODS: Analysis of a secondary objective of the EPICES registry. Primary prevention was considered in patients without previous record of transitory ischemic attack, stroke, coronary diseases and/or peripheral arterial disease (n = 3977); secondary prevention was considered in patients with record of coronary and/or peripheral arterial disease, but without record of cerebrovascular disease (n = 1047); neurological secondary prevention was considered in patients with a record of transitory ischemic attack and/or stroke, independently of the presence of coronary and/or peripheral arterial disease (n = 1173). RESULTS: Secondary prevention and neurological secondary prevention were more efficient than primary prevention (p = 0.028 and p < 0.0001, respectively). Control was higher in centers with some type of structure to assist stroke patients (p < 0.0001). Influence of age in the taking of therapeutic decisions followed a similar pattern in all three types of prevention, with a significant reduction on anticoagulation for patients older than 80 years. CONCLUSION: The EPICES registry confirms the poor control of risk factors for cerebrovascular diseases. Globally it demonstrated that the objectives that imply the modification of lifestyle are fulfilled worse than pharmacological preventive measurements.

Tiempos de llegada al hospital y hasta la atención neurológica de pacientes con ictus agudo. Análisis de un registro multicéntrico nacional: registro EPICES (II) / Hospital arrival times and delay before acute stroke patients receive neurological care. Analysis of a national multi-centre registry: EPICES registry (II)

Introducción. Los tiempos en la llegada al hospital o el retraso hospitalario en la atención especializada a los pacientescon ictus siguen siendo la primera causa para no recibir el mejor de los tratamientos posibles.Objetivo. Analizar los tiempos de llegada al hospital y hasta la atención neurológica en una serie multicéntrica de pacientescon ictus. Pacientes y métodos. El registro EPICES es un estudio observacional y prospectivo realizado con metodología de registro de historias clínicas consecutivas en pacientes con ictus hospitalizados bajo atención neurológica. La muestra para analizar los tiempos inicio-puerta fue de 5.454 pacientes, para el tiempo puerta-neurólogo fue de 5.379 pacientes y para eltiempo de permanencia en urgencias fue de 5.825 pacientes.Resultados. El 90% de los pacientes presentó el ictus entre las 8 y las 24 horas. La estación del año no influyó en la frecuencia, ni en la distribución de los distintos tipos de ictus. El tiempo inicio-puerta fue de 264,1 ± 318,3 minutos; el 34,7%de los pacientes acudió al hospital en la primera hora después del inicio de los síntomas y el 63,7% en las tres primeras horas. El tiempo puerta-neurólogo fue de 378,1 ± 731,4 minutos; la edad del paciente (p < 0,0001) y el antecedente deun ictus previo (p < 0,0001) alargaron significativamente este tiempo. La existencia de guardias de neurología y de equiposde ictus se asoció a una disminución significativa de los tiempos intrahospitalarios. Conclusión. En relación con datos previos, el estudio actual muestra una reducción importante de los tiempos iniciopuerta y puerta-neurólogo en nuestro medio (AU)

Introduction. Delays on arrival time and specialized care at hospital are still the first cause that hampers the application of best possible treatments to the stroke patients.Aim. To analyze the arrival time to the hospital up to the neurological care of patients, in a multicentric series of stroke patients.Patients and methods. The EPICES registry is an observational and prospective study performed with a methodology of registering consecutive clinical records of stroke patients admitted to the hospital under neurological attention. The sample used to analyze starting-door times it was 5,454 patients, for the door-neurologist time it was 5,379 patients, and for the time of stay at ER room it was 5,825 patients.Results. 90% of the patients presented a stroke between 8 and 24 h. The season of the year had no influence on the frequency, neither on the distribution of stroke type. onset-door time was 264.1 ± 318.3 minutes; 34.7% of the patientsarrived to the hospital during the first hour after the onset of the symptoms, and 63.7% of them arrived during the first threehours. Door-neurologist time was 378.1 ± 731.4 minutes; patients’ age (p < 0.0001) and previous strokes (p < 0.0001) significantly prolonged such time. The availability of neurologist on call at the emergency service and of stroke units were associated to a significant reduction of hospital indoor times. Conclusion. In relation to previous data, current study shows an important reduction of onset-door and door-neurologisttimes (AU)

Epidemiología de los subtipos de ictus en pacientes hospitalizados atendidos por neurólogos: resultados del registro EPICES (I) / Epidemiology of the subtypes of stroke in hospitalised patients attended by neurologists: results of the EPICES registry (I)

Introducción. Los registros basados en las poblaciones hospitalizadas son una forma válida para estimar el número de ictus y sus características que presenta una determinada población. Los diferentes tipos de ictus difieren en su incidencia y pronóstico, por lo que el conocimiento de su historia natural es imprescindible. Objetivo. Determinar la incidencia de los subtipos de ictus y la prevalencia de sus factores de riesgo. Pacientes y métodos. El EPICES es un registro observacional, multicéntrico y prospectivo de la totalidad de los pacientes con ictus ingresados en los hospitales públicos participantes bajo una atención neurológica. Se incluyeron 6.197 pacientes entre abril de 2008 y enero de 2009. El 57,2% fueron hombres y la edad media fue de 71,4 ± 12,8 años.Resultados. El 12,4% presentó una hemorragia intracerebral y el 87,6% un ictus isquémico. 1.543 (28,4%) se diagnosticaron de ictus aterotrombótico, 1.424 (26,2%) cardioembólico, 1.202 (22,5%) lacunar y 1.125 (20,7%) de etiología indeterminada. Un 2,4% fueron ictus de etiología poco frecuente. La hipertensión fue el factor de riesgo más prevalente en el ictus isquémico (67%) y en la hemorragia intracerebral (69,1%). Los diferentes tipos de ictus isquémicos y hemorrágicos presentaron diferencias en la prevalencia de los factores de riesgo. Conclusiones. La distribución de los tipos de ictus fue similar a la de los países de nuestro entorno. Las prevalencias de los factores de riesgo difieren en los diversos tipos, aunque la hipertensión permanece como el factor de riesgo modificable ás importante (AU)

Introduction. Hospital-based population studies are a good way to determinate the number and features of strokes that occur in a given society. The major stroke subtypes have different patterns of incidence and outcome, for that reason information on the natural history of stroke subtypes is essential. Aim. To determine the incidence of the stroke subtypes and the prevalence of the major risk factors in the Spanish population. Patients and methods. EPICES is an observational, multicenter and prospective study. Methodology includes systematic review of consecutive medical records of hospitalized stroke patients in neurological care. 6,197 patients were included during the period April 2008 and January 2009. 3,544 (57.2%) were men. Mean age was 71.4 ± 12.8 years. Results. Intracerebral haemorrhage was diagnosed in 771 patients (12.4%) and ischemic stroke in 5,426 (87.6%). 1,543 (28.4%) were classified as large-artery atherosclerosis, cardioembolic 1,424 (26.2%), small-vessel occlusion 1,202 (22.5%), undetermined etiology 1,125 (20.7%). Stroke of other uncommon origin was founded in 132 (2.4%). Hypertension is the most common risk factor in both ischemic stroke (67%) and intracerebral haemorrhage (69.1%). The different types of ischemic and hemorrhagic stroke showed differences in risk factors prevalence. Conclusions. The overall distribution of stroke subtypes are not significantly different from those of most Western countries. The frequency of vascular risk factors differs between stroke subtypes. Hypertension remains the most important modifiable risk factor (AU)

Estudio coste-efectividad del uso de dosis altas de atorvastatina en la prevención secundaria del ictus en España / Cost-eff ectiveness analysis of using high doses of atorvastatin for the secondary stroke prevention in Spain

Aim. To estimate the cost-effectiveness of atorvastatin at high doses (80 mg/day) for the reduction of the risk of fatal and nonfatal stroke in patients with recent cerebrovascular accident or transient ischemic attack (TIA) and without coronary heart disease in Spain using data from the SPARCL study. Patients and methods. A discrete event simulation was developed to represent the natural evolution of a cohort of 1000 patients following a stroke or TIA. The risk for fatal and non fatal cardiovascular events was calculated from the clinical characteristic of patients in the SPARCL study for both treatment arms (atorvastatin 80 mg/day and placebo). Survival time, quality-adjusted-life-years (QALY), clinical events, and medical direct costs for a period of 5 years with a 3% per year discount were calculated for the two alternatives. A probabilistic sensitivity analysis was made running 1000 simulations. esults. Compared to placebo, atorvastatin 80 mg/day prevented 22 strokes (14 nonfatal and 8 fatal), 22 myocardial infarctions (19 nonfatal and 3 fatal), 33 TIAs, 8 unstable angina episodes and 37 re-vascularisations per 1000 patients over5 years. The incremental cost eff ectiveness ratio after 1000 simulations was 9914 € (95% CI = 5717 to 26 082) per QALY. The acceptability curve showed 99% of the simulations falling below an acceptability threshold of 30 000€/QALY.Conclusions. Compared with placebo, use of high dose atorvastatin (80 mg/day) for secondary stroke prevention is not only of signifi cant clinical benefi t but can also be considered cost eff ective in Spain. It produces important benefi ts in health with an incremental cost within reasonable limits (AU)

Objetivos. Estimar los costes y la relación coste-efectividad de dosis altas de atorvastatina (80 mg/día) en la reducción del riesgo de recurrencia del ictus en pacientes con ataque isquémico transitorio (AIT) o ictus reciente y sin antecedentes de cardiopatía isquémica conocida, a partir de los resultados del estudio Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL). Pacientes y métodos. Se utilizó un modelo de simulación de eventos discretos que representa la historia natural de una cohorte de pacientes con ictus/AIT después del evento agudo. El modelo predijo sus riesgos de ictus, otras enfermedades cardiovasculares y muerte para atorvastatina y placebo. Se calcularon la supervivencia, los años de vida ajustados por calidad (AVAC), eventos clínicos y los costes médicos directos con un horizonte de cinco años (descuento, 3%). Se realizó un análisis de sensibilidad probabilístico mediante 1.000 simulaciones. Resultados. Comparada con placebo, la atorvastatina previno 22 ictus (14 no fatales y 8 fatales), 22 infartos de miocardio (19 no fatales y 3 fatales), 33 AIT, 8 anginas inestables y 37 revascularizaciones por 1.000 pacientes en cinco años. La razón coste-efectividad incremental media de las 1.000 simulaciones fue de 9.914 €/AVAC (IC 95% = 5.717-26.082). En la curva de aceptabilidad, el 99% estuvo por debajo de 30.000 €/AVAC. Conclusiones. Comparado con placebo, el uso de dosis altas de atorvastatina en la prevención secundaria del ictus es coste-efectivo, ya que produce benefi cios en salud importantes a un coste incremental razonable, en el que el 99% de las simulaciones cae por debajo del umbral de efi ciencia de 30.000 €/AVAC (AU)

[Cost-effectiveness analysis of using high doses of atorvastatin for the secondary stroke prevention in Spain]. / Estudio coste-efectividad del uso de dosis altas de atorvastatina en la prevención secundaria del ictus en España.

AIM: To estimate the cost-effectiveness of atorvastatin at high doses (80 mg/day) for the reduction of the risk of fatal and nonfatal stroke in patients with recent cerebrovascular accident or transient ischemic attack (TIA) and without coronary heart disease in Spain using data from the SPARCL study. PATIENTS AND METHODS: A discrete event simulation was developed to represent the natural evolution of a cohort of 1000 patients following a stroke or TIA. The risk for fatal and non fatal cardiovascular events was calculated from the clinical characteristic of patients in the SPARCL study for both treatment arms (atorvastatin 80 mg/day and placebo). Survival time, quality-adjusted-life-years (QALY), clinical events, and medical direct costs for a period of 5 years with a 3% per year discount were calculated for the two alternatives. A probabilistic sensitivity analysis was made running 1000 simulations. RESULTS: Compared to placebo, atorvastatin 80 mg/day prevented 22 strokes (14 nonfatal and 8 fatal), 22 myocardial infarctions (19 nonfatal and 3 fatal), 33 TIAs, 8 unstable angina episodes and 37 re-vascularisations per 1000 patients over 5 years. The incremental cost effectiveness ratio after 1000 simulations was 9914 euros (95% CI = 5717 to 26,082) per QALY. The acceptability curve showed 99% of the simulations falling below an acceptability threshold of 30,000 euros/QALY. CONCLUSIONS: Compared with placebo, use of high dose atorvastatin (80 mg/day) for secondary stroke prevention is not only of significant clinical benefit but can also be considered cost effective in Spain. It produces important benefits in health with an incremental cost within reasonable limits.

Blood pressure as a risk factor for stroke and the impact of antihypertensive treatment.

We review hypertension and blood pressure levels as risk factors for stroke and the impact of antihypertensive treatment on the prevention of first stroke event and of recurrent stroke, not only with respect to the prevention of vascular events but also the prevention of cognitive deterioration, dementia, and physical disability. We review whether pharmacological blockage of the renin-angiotensin system has additional long-term effects over that of control of blood pressure levels alone, and the benefit of treatment with antihypertensive drugs in normotensive patients. Therapeutic objectives for blood pressure levels after stroke are defined together with recommendations of drugs and doses which have been demonstrated to have the greatest benefit in the prevention of stroke.

Lipids and stroke: the opportunity of lipid-lowering treatment.

Dyslipemia is a clear risk factor (RF) for ischemic heart disease and peripheral artery disease, but its relation with ischemic stroke (IS) is not so clear. HMG-CoA reductase inhibitor drugs or statins (simvastatin, atorvastatin, pravastatin) reduce the relative risk of IS by between 18 and 51% in patients with IHD, in patients with high vascular disease risk and in hypertensive patients with other RFs, acute coronary syndrome, and type 2 diabetes mellitus. According to the guidelines for use, statins are indicated in the majority of patients with IS since the risk is equivalent to that of IHD or high vascular disease risk. In view of the existing clinical evidence of benefit, it would not seem unreasonable to proceed with treatment of patients using statins while awaiting specific studies justifying their use. The non-lipid-lowering mechanisms of the statins and results of studies, such as the Heart Protection Study, provide evidence for widening the indications of statins beyond the prevention of dyslipemia, as a new therapeutic approach in the prevention of IS in patients with plasma levels of total cholesterol or low density lipoproteins currently considered within the normal distribution. The neuroprotective role, which these drugs may play in the acute phase of cerebral ischemia, remains to be clarified, but very recent evidence suggests that such patients may also benefit.

Organization of medical care in acute stroke: importance of a good network.

Stroke is a medical emergency which requires hospital care. Therapeutic and effective organizative measures, such as thrombolysis and stroke units, are available, but early attention is required, as the benefits are time dependent (therapeutic window). To achieve this objective, a high level of organization and coordination is required between the various steps of care. The chain of attention in acute stroke (from symptom onset till stroke unit admission) is a complex process. The main points are reviewed: delay in attention, knowledge and attitude towards stroke, emergency transportation, neurological attention, educational campaigns, clinical protocols and pathways, stroke codes, and existing resources for care. The organization must be modified to have the resources for care necessary for attending acute stroke available, if we want to achieve the real objective of maximum benefit for our patients as set out in the Declaration of Helsingborg.