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.