Reducing the risk of stroke recurrence

Administration of intravenous recombinant tissue plasminogen activator (tPA) significantly reduces disability and death from acute ischemic stroke when treatment can be given within 3 hours of clearly defined symptom onset and patients meet other inclusion and exclusion criteria. However, there are a number of other measures that can be taken to reduce the risk of recurrence for those patients as well as in individuals who are not candidates for tPA, said Subramanian Hariharan, MD, clinical associate professor of neuroscience at Seton Hall University, Edison, NJ.

Antiplatelet therapy should be started after 24 hours in patients with acute ischemic stroke. Aspirin 325 mg/day is the best choice, but clopidogrel offers an alternative for aspirin allergic patients. In an effort to prevent a future stroke, the work-up of ischemic stroke patients should also seek and treat modifiable risk factors, including cardioembolic causes and carotid stenosis. Blood pressure control is important, but clinical trial evidence indicates that antihypertensive treatment is safe and effective for preventing recurrence even in patients who are normotensive. Elevated cholesterol should be controlled with lipid-lowering therapy. However, data are still being awaited regarding the efficacy of statin treatment for secondary stroke prevention and the jury is still out on whether all stroke patients should be placed on a statin.

Clinicians should also be aware of tests and treatments that are of no value. "Screening of antiphospholipid antibodies and CRP is unnecessary in the evaluation of ischemic stroke patients, there is no role for IV magnesium treatment in acute stroke, and there is no benefit for checking homocysteine levels or administering vitamins to lower homocysteine for reducing stroke risk," Hariharan said.