Primary and secondary prevention of ischemic stroke

Primary prevention is aimed at reducing the risk of stroke in asymptomatic people. The most effective prevention is through control of modifiable risk factors. Adequate blood pressure reduction, cessation of cigarette smoking and use of antithrombotic therapy in atrial fibrillation are the most effective measures. Carotid endarterectomy may be useful in selected patients. Although very useful for health in general, tight control of diabetes and hypercholesterolemia, physical exercise and alimentary diet did not show a major influence for primary stroke prevention. Aspirin seems to be not very effective for primary stroke prevention, whereas some ACE inhibitors (e.g. ramipril), ARBs (e.g. losartan) or statins, may have a preventive role beyond their antihypertensive or hypocholesterolemic properties. Secondary stroke prevention is aimed at reducing the risk of recurrence after a first stroke or transient ischemic attack. Acting on risk factors is probably as effective as in primary prevention. Carotid endarterectomy for symptomatic stenoses > 70% and anticoagulation in patients with atrial fibrillation are by far the most effective measures. Antiplatelet therapy (aspirin, ticlopidine, clopidogrel and long acting dipyridamole-aspirine association) reduces significantly stroke recurrence. Most recent data suggest also that perindopril, eprosartan and some statins are beneficial against stroke recurrence even in normotensive and normocholesterolemic patients.