Secondary prevention of ischaemic stroke

Recent trials within the past few years have influenced not only how we treat patients immediately after acute ischaemic stroke, but also how we investigate for aetiology. With the advent of improved medications, procedures and monitoring devices, modern stroke prevention strategies are more individualised, but the decision‐making process is more complex. We provide an approach to navigating these management options.     

Arterial hypertension and stroke prevention: an update

High blood pressure (BP) is the most important modifiable risk factor for stroke and other vascular diseases. Evidence from randomized controlled trials supports the use of antihypertensive drugs to lower blood pressure for stroke prevention. There is some evidence that specific classes of antihypertensive drugs have different effects and/or their pharmacological actions differ in patient subgroups. This review evaluates the development of antihypertensive therapies and the latest studies of arterial hypertension and stroke prevention: HOPE trial (ramipril versus placebo), ALLHAT trial (CCB or/ and Angiotensin-Conventing enzyme Inhibitors (ACE-Is) versus diuretic), LIFE trial (losartan versus atenolol), and PROGRESS trial (perindopril or/and indapamide versus placebo). Despite the results of these relevant clinical trails, some aspects still remain unresolved. Future clinical trials on hypertension and stroke prevention should answer the following questions: Does lowering BP reduce stroke risk due to specific drug effect or class effect? Are angiotensin II receptor blockers (ARBs) better than ACE-Is? Should ACE-Is and ARBs be considered routinely for either high-risk stroke patients or patients with history of stroke or transient ischemic attack, irrespective of blood pressure? What is the role of lifestyle in BP control?     

高血压和高脂血症对老年人纯音听阈影响

目的研究老年性耳聋与高血压及高脂血症的相关性。方法采用ＭａｄｓｅｎＭ－５　型听力计测定了老年男性高血压与高脂血症患者及健康老年人各５０例的纯音听阈，各组分为６０岁组及７０岁组，进行组间比较。结果（１）高血压组、高脂血症组与健康组的平均听阈均随增龄而增高，但两个疾病组中的６０岁及７０岁组在０．２５～８ｋＨｚ各频率的平均听阈均显著高于同龄健康组（Ｐ值＜０．０５或０．０１）；（２）听力损伤发生率在高血压两年龄组分别为４８％及７２％，高脂血症组分别为４４％及６４％，健康组分别为８％及１６％，疾病组中的两个年龄组也均明显高于同龄健康组（Ｐ值＜０．０１）。结论高血压及高脂血症对老年人听阈有明显影响，是加重老年聋的因素。     

Diabetes mellitus and hypertension in the elderly: concomitant hyperlipidemia and coronary heart disease risk

Age is an important factor in predicting risk of myocardial infarction (MI). Age is currently treated as an independent variable in assessing risk, but it is also related to other major risk factors including hyperlipidemia, hypertension and diabetes, all of which increase in prevalence with age. Current evidence indicates that a combination of 2 or more of the major risk factors predisposes a person to a high risk of MI. In the experience of the Prospective Cardiovascular Munster study, patients with diabetes alone have twice the risk of MI, but those with diabetes and hyperlipidemia have about a 15-fold increased risk. Similarly, patients with hypertension alone have twice the risk of MI, but those with hypertension combined with hyperlipidemia have approximately a 15-fold increased risk.     

Secondary prevention of cardioembolic stroke: oldest and newest promises

Atrial fibrillation (AF) is the most common cause of cardioembolism. An update on secondary prevention strategies used to protect from the risk of stroke AF patients is presented. The main line of actions of stroke prevention in AF are antithrombotics (anticoagulant or antiplatelet), antiarrhythmics (for rate control and sinus rhythm restore), mechanical means (for occlusion of the left atrial appendage or protection of the internal carotid artery from emboli). Classic pharmacological prevention with K vitamin Kantagonists such as warfarin may be overcome by direct thrombin inhibitors like ximelagatran and melagatran. New ablation technologies promise to cure, at least a part of Nonvalvolae AF in the community, restoring sinus rhythm. Recent achievements on endovascular procedures deploying carotid artery implants provide an opportunity to divert emboli to nonhazardous locations, whereas cardiac devices can seal left atrial appendages and avoid risk of clot migration in the blood stream. In the next decade, the challenge will be to understand competitiveness between old and new drugs with endovascular implants.     

缺血性卒中的二级预防及其依从性

研究显示,缺血性卒中的二级预防依从性并不理想。在影响二级预防依从性的因素中,性别、年龄或病情严重程度与依从性的相关性尚无明确结论,但已婚、医疗报销比例较高、对疾病认识较好、早期干预、医生的重视程度和医患关系良好可改善缺血性卒中二级预防的依从性。     

New evidence in hypertension and hyperlipidaemia

The benefits of blood pressure lowering on the risk of cardiovascular disease are seen with all commonly used classes of antihypertensive drugs. Although different drug classes may have different effects on cause specific outcomes (such as myocardial infarction or stroke), no differences are observed between their overall effects on combined major cardiovascular end points. The choice of first line antihypertensive drug is therefore likely to be of less importance than the use of any effective drug, particularly since the majority of patients will need two or more agents to achieve blood pressure goals. Recent trials have provided good evidence that lowering cholesterol with statins reduces the risk of cardiovascular events in "high risk" patients, irrespective of initial cholesterol concentrations. The benefits of both blood pressure lowering and lipid lowering treatment appear to be proportional to the extent of the reduction of blood pressure and lipids achieved.     

Treatment of hypertension and prevention of ischemic stroke

Data clearly indicate that treatment with antihypertensive drugs reduces the incidence of all strokes in men (by 34%), women (by 38%), elderly persons (by 36%), including those older than 80 years (by 34%), younger persons, those with systolic and diastolic hypertension, persons with isolated systolic hypertension, and in those with a history of stroke or transient ischemic attack (by 28%). Blood pressure should be reduced to less than 140/90 mm Hg. The overall data also suggest that reduction of stroke in persons with hypertension is related more to a reduction in blood pressure than to the type of antihypertensive drugs used.