¿Ha cambiado el paradigma de la prevención del ictus en los pacientes con diabetes? / Has the paradigm of stroke prevention changed in patients with diabetes?

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Pharmacological management of post-stroke depression.

Introduction: Post-stroke depression (PSD) is a common clinical problem affecting approximately one-third of stroke survivors. PSD is associated with poor functional outcome and higher morbidity and mortality rates. Currently, uncertainty remains regarding optimal pharmacological strategies for its prevention and treatment.Areas covered: This article reviews the state of the current literature on pharmacologic intervention strategies for PSD, providing a summary of the most recent evidence to support pharmacological treatment in PSD.Expert opinion: Experimental and clinical research have increased our knowledge on PSD, although unanswered questions still remain regarding the best time to begin treatment, the effect of the antidepressants in areas other than emotion, or their capability to reduce mortality in stroke patients, among others.Currently, though numerous trials and meta-analyses suggest that antidepressants are effective in treating PSD and guidelines recommend their use for PSD, in the daily clinical practice, only a minority of patients are properly assessed and treated. Therefore, though further evidence is needed to clarify the real role of antidepressants in patients with stroke, physicians and other healthcare professionals must be familiar with the pharmacological treatment of PSD, in order to improve the outcome and increase the quality of life of this vulnerable group of patients.

Evaluación del riesgo hemorrágico de la terapia antitrombótica en pacientes con ictus / Bleeding risk assessment for stroke patients on antithrombotic therapy

Introducción: Tras un evento cerebrovascular isquémico el riesgo de recurrencias es elevado, por lo que se hace necesario el uso de terapia antitrombótica para disminuir nuevos eventos. Desarrollo: A pesar de su beneficio, estas terapias aumentan el riesgo de sangrado. Por tanto, determinar qué pacientes presentan mayor riesgo de hemorragia es fundamental. Existen diferentes modelos predictores de hemorragia y, en particular, de hemorragia intracraneal, asociados al uso de antiagregantes en pacientes con ictus isquémico o AIT, como las escalas CCSC, Intracranial-B2LEED3S score o la S2TOP-BLEED. No obstante, mientras que las principales guías internacionales recomiendan el uso de escalas, como HAS-BLED, para evaluar el riesgo de sangrado en pacientes anticoagulados, no existe una recomendación específica en el caso del uso de antiagregantes. Conclusiones: En esta revisión se presentan los principales modelos disponibles en la actualidad para la predicción de sangrado de la terapia antitrombótica en pacientes con ictus o AIT

Introduction: After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. Discussion: Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. Conclusions: In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA

Statins in Ischemic Stroke Prevention: What Have We Learned in the Post-SPARCL (The Stroke Prevention by Aggressive Reduction in Cholesterol Levels) Decade?

PURPOSE OF REVIEW: We describe the current status of lipid-lowering therapies for ischemic stroke prevention. The SPARCL trial published in 2006 has been a landmark study in vascular neurology. The trial demonstrated that high-dose atorvastatin prevents recurrent stroke, and led the AHA/ASA to recommend statin therapy for patients with stroke or TIA of atherosclerotic origin. RECENT FINDINGS: Recently, the J-STARS study demonstrated that therapy with low-dose pravastatin reduced atherothrombotic infarction incidence among patients with prior ischemic stroke. Besides, several trials have shown improved stroke outcomes with non-statin lipid-lowering medications: IMPROVE-IT with ezetimibe on top of simvastatin and PCSK9 inhibitors-FOURIER with evocolumab and ODYSSEY-OUTCOMES with alirocumab-on top of statin therapy. LDL-cholesterol remains the primary lipid treatment target for reduction of stroke risk. Randomized trials have shown that each reduction of 40 mg/dL in the level of LDL-cholesterol reduces the stroke risk by approximately one quarter, and further, reductions in LDL-cholesterol levels have shown to produce additional reductions in stroke risk. Currently, we have evidence of benefit for adding non-statin lipid-modifying therapies to statins to reduce stroke risk. Surely, these novel strategies to reduce residual lipidic risk will provide future benefits on stroke prevention.

Bleeding risk assessment for stroke patients on antithrombotic therapy. / Evaluación del riesgo hemorrágico de la terapia antitrombótica en pacientes con ictus.

INTRODUCTION: After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION: Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS: In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.

Antidiabetic drugs and stroke risk. Current evidence.

Cardiovascular disease (CVD) is the major cause of morbidity and mortality for individuals with type 2 diabetes (T2D). In particular, the risk for stroke is twice that of patients without diabetes, and diabetes may be responsible for >8% of first ischemic strokes. Therefore, the way to prevent stroke in these patients has become an important issue. Traditionally, glucose-lowering drugs had not been shown to protect against stroke. Moreover, several antidiabetic drugs (i.e., sulfonylureas, rosiglitazone) have been reported to be associated with increased risks of CVD and stroke. On the contrary, data on the CV risks and benefits associated with new antidiabetic treatment in patients with T2D are emerging - and look promising. Therefore, it could be of great value to find out if any type of these new antidiabetic agents has protective effect against stroke. We review the available evidence regarding the risk of stroke in individuals taking non-insulin antidiabetic agents. To date, several antidiabetic agents have shown to have a positive effect on stroke prevention. The accumulated evidence suggests that metformin, pioglitazone and semaglutide reduce stroke risk. These agents do not represent only a way of controlling blood glucose and but also offer the opportunity to reduce stroke risk. Surely, new data from ongoing and future studies will provide additional information to select the best treatment for decreasing stroke risk in T2D patients.

¿Qué fármaco antihipertensivo deberíamos utilizar en pacientes con enfermedad cerebrovascular para prevenir un nuevo ictus? / Which antihypertensive drug should be used in patients with cerebrovascular disease to prevent a new stroke?

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Estatinas en la prevención secundaria del ictus: nuevas evidencias del estudio SPARCL / Statins in the secondary prevention of stroke: New evidence from the SPARCL Study

Hasta fechas recientes había poca evidencia de que el tratamiento con estatinas fuera capaz de reducir el riesgo de recurrencia de ictus. El estudio SPARCL, publicado en 2006, fue el primer ensayo específicamente diseñado con esa finalidad. El SPARCL demostró que el tratamiento con atorvastatina 80mg/día reducía el riesgo de ictus recurrente en pacientes con ictus o AIT recientes. Posteriormente se han realizado varios análisis post hoc de diferentes subgrupos que no han revelado diferencias según la edad, sexo o tipo de ictus. Además, el estudio SPARCL ha ayudado a identificar a los pacientes que pueden tener un mayor beneficio: pacientes con estenosis carotídea, con reducción más intensa de lípidos, y aquellos que alcanzan niveles óptimos de cLDL, de cHDL, de triglicéridos y de presión arterial. También ha ayudado a identificar a aquellos pacientes que presentan un riesgo más alto de nuevos episodios vasculares. Es evidente que hay un antes y un después en la prevención del ictus desde la publicación del estudio SPARCL

Until recently there was little evidence that statin therapy reduced the risk of stroke recurrence. The SPARCL trial, published in 2006, was the first trial to show the benefits of statin therapy in preventing recurrent stroke. The SPARCL trial showed that treatment with atorvastatin 80mg/day reduced recurrent stroke in patients with a recent stroke or transient ischemic attack (TIA). Several post hoc analyses of different subgroups followed the SPARCL trial. They have not revealed any significant differences when patients were grouped by age, sex or type of stroke. The SPARCL trial has also helped to identify patients who may have a greater benefit from statins: Patients with carotid stenosis, with more intense lipid lowering, and those who achieve optimal levels of LDL-C, HDL-C, triglycerides, and blood pressure. The trial has also helped to identify individuals at high risk of new vascular events. Clearly there is a before and after in stroke prevention since the SPARCL trial was published

Chronic Management of Hypertension after Stroke: The Role of Ambulatory Blood Pressure Monitoring.

Hypertension is the most important potentially reversible risk factor for stroke in all age groups; high blood pressure (BP) is also associated with increased risk of recurrent stroke in patients who have already had an ischemic or hemorrhagic event. Twenty-four hour ambulatory BP monitoring (ABPM) has become an important tool for improving the diagnosis and management of hypertension, and is increasingly used to assess patients with hypertension. Nevertheless, although ABPM devices are increasingly used for assessment of hypertension, their value in the chronic management of hypertension in patients with stroke has not been systematically studied. In fact, among large-scale randomized trials for secondary stroke prevention, only the Morbidity and Mortality After Stroke, Eprosartan Compared With Nitrendipine for Secondary Prevention trial included 24-hour ABPM. ABPM has demonstrated chronic disruption of the circadian rhythm of BP after acute phase of stroke and has shown higher sensitivity compared to office BP in evaluating the effectiveness of antihypertensive treatment among stroke survivors. High 24-hour BP is an independent predictor for cerebrovascular events, brain microbleeds, and subsequent development of dementia. Nevertheless, although stroke care guidelines endorse the importance of hypertension management, the specific role of ABPM among stroke survivors after the acute phase of disease has not been established. Further studies are needed to clarify whether routine application of ABPM among these patients should be recommended.

[Statins in the secondary prevention of stroke: New evidence from the SPARCL Study]. / Estatinas en la prevención secundaria del ictus: nuevas evidencias del estudio SPARCL.

Until recently there was little evidence that statin therapy reduced the risk of stroke recurrence. The SPARCL trial, published in 2006, was the first trial to show the benefits of statin therapy in preventing recurrent stroke. The SPARCL trial showed that treatment with atorvastatin 80mg/day reduced recurrent stroke in patients with a recent stroke or transient ischemic attack (TIA). Several post hoc analyses of different subgroups followed the SPARCL trial. They have not revealed any significant differences when patients were grouped by age, sex or type of stroke. The SPARCL trial has also helped to identify patients who may have a greater benefit from statins: Patients with carotid stenosis, with more intense lipid lowering, and those who achieve optimal levels of LDL-C, HDL-C, triglycerides, and blood pressure. The trial has also helped to identify individuals at high risk of new vascular events. Clearly there is a before and after in stroke prevention since the SPARCL trial was published.