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Prevenção Secundária , Acidente Vascular Cerebral , Humanos , Pioglitazona , TiazolidinedionasRESUMO
High blood pressure (BP) is the strongest risk factor for stroke. It is estimated that almost 50% of strokes may be attributable to hypertension. Both diastolic and isolated systolic hypertension are important predictors of primary or recurrent strokes, and even minor decreases in BP can reduce the risk of stroke. While the primary prevention of stroke through the treatment of hypertension is well established, the issue of lowering BP after a stroke has been uncertain, particularly since this might worsen cerebral perfusion if autoregulation remains chronically damaged or severe carotid artery stenosis is present. Furthermore, there is substantial evidence to support BP lowering for prevention of a first stroke; however, few trials have focused on antihypertensive therapy for recurrent stroke prevention. In fact, currently, BP management in patients with strokes remains problematic, and questions such as the choice of antihypertensive drug and by how much to reduce BP are yet to be resolved. Recently, the American Heart Association and American Stroke Association published updated guidelines for recurrent stroke prevention, and new recommendations on BP management have been included. Our review presents the most recent evidence on the management of hypertension in patients who have had a stroke.
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Anti-Hipertensivos/uso terapêutico , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Ensaios Clínicos como Assunto , Humanos , Guias de Prática Clínica como Assunto , Acidente Vascular Cerebral/etiologiaRESUMO
BACKGROUND: Hypertensive left ventricular hypertrophy (HLVH) is a major risk factor for cardiovascular morbidity, mortality, and stroke. However, little is known about the importance of transthoracic echocardiography (TTE) in the assessment of HLVH in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS: We studied 203 consecutive patients admitted to our hospital with AIS or TIA and who were referred for TTE over the last 4 years. We included 102 (50.2%) lacunar strokes, 76 (37.1%) nonlacunar strokes, and 25 (12.3%) TIAs. The mean age was 68.9 years (standard deviation ± 11) and 128 patients were male (63.1%). RESULTS: Hypertension was the most common risk factor (131 patients; 64.5%). HLVH was seen in 86 cases (42.3%), in 51.9% of patients with previous hypertension, and in 25% of patients without known hypertension. We found that neither stroke subtype nor any previous risk factor, with the exception of hypertension (P = .0001), were associated with HLVH. Patients with HLVH were younger (67 v 71 yrs; P = .013) and more frequently women (50.6% v 37.5%; P = .078). At discharge, patients with HLVH were more likely to receive antihypertensive treatment (97% v 80%; P = .009) and a higher average number of antihypertensive drugs (2.2 v 1.4; P = .0001). CONCLUSIONS: HLVH was common in patients with AIS or TIA. These individuals had an increased risk of stroke and needed a more intensive therapy. TTE should be carried out in all AIS and TIA patients in order to optimize the management of these patients.
Assuntos
Isquemia Encefálica/epidemiologia , Hipertensão/epidemiologia , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Ataque Isquêmico Transitório/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Distribuição de Qui-Quadrado , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertrofia Ventricular Esquerda/epidemiologia , Hipertrofia Ventricular Esquerda/terapia , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Fatores de Tempo , UltrassonografiaRESUMO
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.
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Antidepressivos/uso terapêutico , Transtorno Depressivo/tratamento farmacológico , Acidente Vascular Cerebral/complicações , Transtorno Depressivo/etiologia , HumanosRESUMO
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.
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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.
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Hemorragia/induzido quimicamente , Ataque Isquêmico Transitório/prevenção & controle , Inibidores da Agregação Plaquetária/efeitos adversos , Acidente Vascular Cerebral/prevenção & controle , Fatores Etários , Anticoagulantes/efeitos adversos , Aspirina/efeitos adversos , Índice de Massa Corporal , Hemorragia Cerebral/induzido quimicamente , Etnicidade , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Recidiva , Medição de Risco/métodos , Prevenção Secundária , Fatores SexuaisRESUMO
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.
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Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Glicemia/efeitos dos fármacos , Peptídeos Semelhantes ao Glucagon/uso terapêutico , Humanos , Metformina/uso terapêutico , Pioglitazona , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Tiazolidinedionas/uso terapêuticoRESUMO
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.
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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.
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Atorvastatina/uso terapêutico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Humanos , Ataque Isquêmico Transitório/prevenção & controle , Lipídeos/sangue , Ensaios Clínicos Controlados Aleatórios como AssuntoAssuntos
Isquemia Encefálica , Acidente Vascular Cerebral , LDL-Colesterol , Humanos , Fatores de RiscoRESUMO
No disponible
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Humanos , Acidente Vascular Cerebral/prevenção & controle , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Acidente Vascular Cerebral/etiologia , Diabetes Mellitus Tipo 2/complicaçõesRESUMO
Arterial hypertension (AHT) and cognitive problems, especially dementia, are very prevalent among the elderly. AHT is a direct risk factor for vascular dementia and recent studies have shown that it also has repercussions on the prevalence of Alzheimer's disease. Thus, given the fact that there is currently no effective treatment, the prevention of dementia with the aim of delaying or even preventing its appearance is a priority. Moreover, it leads us to pose the question as to whether treating AHT can help prevent dementia. To answer this question, we present a review of the main studies involving interventions with antihypertensive drugs in the prevention of dementia that have been published to date. These trials and meta-analyses suggest that antihypertensive treatment could reduce the risk of dementia by 3-20%, although with no clear statistical significance. However, there are a number of methodological limitations that largely account for the lack of conclusive results in the different intervention studies and which make it possible to deduce that the treatment of AHT does clearly reduce the appearance of dementia. Therefore, clearly further studies on hypertension need to be conducted with the primary aim of appraising the appearance of cognitive impairment or dementia.