Challenges for the prevention of primary and secondary stroke: the importance of lowering blood pressure and total cardiovascular risk

It is well established that blood pressure lowering is effective for the primary prevention of stroke and other cardiovascular disorders in subjects with blood pressures as low as 140/90 mmHg, and up to 80 years of age. Despite this knowledge, blood pressure levels are controlled in less than 25% of the hypertensive population worldwide. It has taken longer to prove that blood pressure lowering is equally effective for the prevention of recurrent stroke. The results of PROGRESS (Perindopril Protection Against Recurrent Stroke Study) have confirmed that a perindopril-based regimen in subjects with cerebrovascular disease substantially reduces the incidence of secondary stroke and primary myocardial infarction. It is daunting to recall that it has taken almost two decades for beta-blockers to be widely used for the secondary prevention of myocardial infarction, since widespread use of the PROGRESS regimen would prevent more than half a million strokes worldwide each year. The real challenge now is to implement novel and effective strategies for the control of blood pressure and other cardiovascular risk factors worldwide. Strategies should include lifestyle measures, such as stopping smoking, exercise and reducing overweight. There is a real need to identify hypertensive subjects and treat them with blood pressure lowering drugs for primary prevention. In subjects with established cardiovascular disease, consideration should be given to a range of proven interventions for secondary prevention, such as blood pressure lowering, irrespective of current blood pressure, anti-platelet drugs, statins for lowering cholesterol and glycaemic control in diabetics. Among new strategies to lower overall cardiovascular risk, consideration should be given to the development of single-pill combinations of drugs of known efficacy, including various combinations of ACE inhibitors, diuretics, beta-blockers, aspirin and statins, among others.     

高龄老年人卒中一级预防中的血压管理

高龄老年人口增长迅速,其预期寿命也明显延长.年龄是卒中的独立危险因素,高龄老年人卒中风险极高.高血压是高龄老年人最常见的可干预卒中危险因素.近20年来,抗高血压在卒中一级预防中的作用的相关研究结果逐一公布,其中一些大型随机对照研究具有里程碑式的意义,为高龄老年人的血压管理提供了切实的证据.     

Antiplatelet treatment in primary and secondary stroke prevention in women

Stroke is a leading cause of death worldwide and the first cause of disability in the Western world. Over the last 20years, antiplatelet agents have reduced overall stroke rates in primary and secondary prevention in men. However, this has not been the case for women. In this narrative review, the most widely used antiplatelet therapies for primary and secondary prevention in stroke, excluding cardioembolic stroke, will be outlined. First, the largest randomised controlled trials will be analysed as well as the enrolment percentages of women. Second, analyses on sex-interaction effects in each study will be examined. Moreover, the Authors will discuss the need to develop targeted antiplatelet therapies specifically for women. Based on current results, the most randomised clinical trials and meta-analyses on antiplatelet agents in cerebrovascular disease have not performed sub-analyses on sex-related differences and this is mainly because women were underrepresented. Despite this, antiplatelet agents are considered to be equally effective for both sexes in primary and secondary stroke prevention. Finally, aspirin is the most widely studied antiplatelet in women and has been shown to provide greater benefit for women as primary prevention of ischemic stroke without a significant increased risk in haemorrhage.     

Strategies for primary and secondary stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is the most common type of cardiac rhythm abnormality in adults, affecting 1 to 1.5% of the general population in the Western world and is the major risk factor for stroke with a fivefold risk compared with the general population. Pharmacological and nonpharmacological strategies are available for controlling recurrent or permanent AF as well as for prevention of AF. Prevention of recurrent AF is one of the best protections against AF-related stroke and reduces the prevalence of stroke by almost 25%. Antiplatelet compounds are indicated for CHAD scores 0-1 and reduce the risk of stroke from AF by 20 to 25%. For CHAD scores >1 oral anticoagulation with vitamin K antagonists is indicated and reduces the risk of stroke by 62%. Since inhibitors of coagulation factors Xa, VII , or II a have either not been clinically tested for their efficacy for prevention of stroke from AF, did not show a comparable effect to well-established drugs, or had excess side effects (idraparinux, ximelagatran), and since mechanical devices are highly questionable concerning their long-term effect, there is currently no alternative to oral anticoagulation with vitamin K antagonists as primary or secondary stroke prevention in high-risk AF patients.     

Isolated systolic hypertension: lowering the risk of stroke in older patients. SHEP Cooperative Research Group.

The Systolic Hypertension in the Elderly Program (SHEP) was the first clinical trial to demonstrate the efficacy of low-dose antihypertensive medication in preventing stroke in older individuals with isolated systolic hypertension (ISH). The trial was multicentered, double-blind, randomized, placebo-controlled and involved 4,736 men and women, black and white, age 60 and over with ISH. Results showed a highly significant 36% reduction in nonfatal plus fatal stroke over 5 years in the group treated with active medication (low-dose chlorthalidone was step one), compared with the placebo group. Nonfatal plus fatal coronary disease and cardiovascular disease were also significantly reduced with antihypertensive medication, by 27% and 32% respectively, and total mortality was lower by 13%.     

甄别卒中危险因素,开展个体化卒中一级预防

美国心脏协会/美国卒中协会(American HeartAssociation/American Stroke Association,AHA/ASA)于2010年12月6日在线发布了卒中一级预防指南[1],并明确该指南作为神经科医生的继续教育工具.<国际脑血管病杂志>已刊出其中文版[2].这是10年来第2次更新该指南[3-4],虽然在结构上与2006版没有太大变化,但其覆盖范围大大增加.就标题而言,由原来的"缺血性卒中一级预防",改为"卒中一级预防",内容包含了原先未涉及的出血性卒中.过去的10年里,美国在卒中预防方面做了大量工作,取得了显著成绩.AHA制定了降低心血管和卒中死亡率的目标:10年内下降25%.1996-2006年期间,因卒中死亡的总人数下降了18.4%.卒中死亡率降低了33.5%.尽管减少卒中死亡已取得进步,但卒中发病率仍在上升.因此,指南继续强调卒中一级预防的重要意义.     

围手术期卒中:风险评估、预防和治疗

围手术期卒中是指在手术前、手术过程中以及术后30 d内出现的急性缺血性或出血性卒中.虽然近年来麻醉及外科治疗水平不断提高,但围手术期卒中发生率并无明显下降.传统血管危险因素,例如高龄、高血压、糖尿病等,亦是围手术期卒中发病的危险因素.此外,围手术期卒中与手术部位、手术方式、麻醉等围手术期事件密切相关.有关围手术期卒中的治疗和预防日益受到包括外科、麻醉科、神经内科等多个学科医生的关注.文章对围手术期卒中风险的评估、预防和治疗进行了综述.     

International Society of Hypertension (ISH): statement on blood pressure lowering and stroke prevention

The ISH Statement on blood pressure lowering and stroke prevention was finalized after presentation and discussion at the World Health Organization and International Society of Hypertension (WHO-ISH) Meeting on Stroke and Blood Pressure, held in Melbourne Australia, 5-7 December 2002. The meeting was conducted under the auspice of the Austin Hospital Medical Research Foundation, Melbourne.     

24-hour blood pressure in primary and secondary hypertension

The blood pressure is subject to physiological day-night fluctuations, which can be attenuated in secondary hypertension as well but not in essential hypertension. In this study, the blood pressure profile over 24 hours was determined in a large collective of patients with primary and secondary hypertension for comparison to assess the relevance of ambulatory blood pressure monitoring in secondary hypertension. There were 88 patients with essential hypertension (age 20 to 73 years) and 80 patients with secondary hypertension (age 19 to 70 years) with a mean blood pressure value from 8 a.m. to 8 p.m. greater than 135 mm Hg. Blood pressure and heart rate were monitored for 24 hours. In 58/80 patients with secondary hypertension renal parenchymal disease was present, 14 had renovascular disease, three had Cushing's syndrome, four had primary hyperaldosteronism and one had a pheochromocytoma. Of the 88 patients with essential hypertension 67, and of the 80 patients with secondary hypertension 69 were on antihypertensive treatment. The measurements were carried out with a portable automatic ambulatory monitor unit (SpaceLabs 90202) between 6 a.m. and midnight at intervals of 15 minutes and from midnight to 6 a.m. at intervals of 30 minutes. The duration of sleep was documented. In patients with secondary hypertension, as compared with patients with essential hypertension, there were higher blood pressure values during the night from 8 p.m. to 8 a.m., and during sleep (Table 1). The profile of the hourly mean values for systolic and diastolic blood pressure (Figure 1) shows that patients with secondary hypertension, as compared with patients with essential hypertension, have a clearly diminished blood pressure reduction during the night.(ABSTRACT TRUNCATED AT 250 WORDS)     

Blood pressure change and risk of hypertension associated with parental hypertension: the Johns Hopkins Precursors Study

BACKGROUND: Parental hypertension is used to classify hypertension risk in young adults, but the long-term association of parental hypertension with blood pressure (BP) change and risk of hypertension over the adult life span has not been well studied. METHODS: We examined the association of parental hypertension with BP change and hypertension risk from young adulthood through the ninth decade of life in a longitudinal cohort of 1160 male former medical students with 54 years of follow-up. RESULTS: In mixed-effects models using 29 867 BP measurements, mean systolic and diastolic BP readings were significantly higher at baseline among participants with parental hypertension. The rate of annual increase was slightly higher for systolic (0.03 mm Hg, P= .04), but not diastolic, BP in those with parental hypertension. After adjustment for baseline systolic and diastolic BP and time-dependent covariates--body mass index, alcohol consumption, coffee drinking, physical activity, and cigarette smoking--the hazard ratio (95% confidence interval [CI]) of hypertension development was 1.5 (1.2-2.0) for men with maternal hypertension only, 1.8 (1.4-2.4) for men with paternal hypertension only, and 2.4 (1.8-3.2) for men with hypertension in both parents compared with men whose parents never developed hypertension. Early-onset (at age 相似文献