fix jd jr aku
TRANSCRIPT
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T h e NE W ENGL A ND JOUR NA Lo f MEDICINE
CLINICAL PRACTICE
Secondary Prevention after Isce!ic Stro"e
or Transient Isce!ic Attac"Stephen M. Davis, M.D., and Geoffrey A. Donnan, M.D.
This Jo#rna$feature begins with a case vignette highlighting a common clinical problem.
Evidence supporting various strategies is then presented, followed by a review of formal
guidelines, when they exist. The article ends with the authors clinical recommendations.
From the Melbourne Brain Centre, Royal
Melbourne Hospital S.M.D.!" the Depart#
ments of Medi$ine S.M.D.! and %eurol#o&y
S.M.D., G.A.D.!, 'niversity of Mel#bourne"
and the Florey %euros$ien$e (nstitutes
G.A.D.! ) all in Melbourne, *(C, Australia.
Address reprint re+uests to Dr. Davis at theMelbourne Brain Centre, Royal Melbourne
Hospital, ar-ville, *(C, Australia /0/, or
at stephen.davis1mh
.or&.au.
% 2n&l 3 Med 4/54"6675859#44.
Copyright 2012 Massachusetts Medical Society.
An audio
version of this
article is
available at
NEJM.org
A 62-year-
old woman
is seen 1
week after
an ischemic
stroke. She
hadpresented to
another
hospital
with
dysphasia
and right-
sided
weakness;
magnetic
resonance
imag-ing
(MR!
showed a
recent
infarction in
the left
parietal
corte"# and
comp$ted
tomo-
graphic
angiography
(%&A!showed a
high-grade
stenosis in
the left
pro"imal
internal
carotid
artery with
normal
intracranial
'essels (ig.
1!. She wastreated with
intra'e-no$s
recom)inan
t tiss$e plasminogen acti'ator and
discharged home# taking aspirin
and a statin. She stopped smoking
12 years ago. *n e"amination# the
)lood press$re is 1+,/ mm 0g.
She reports some mild resid$al
cl$msiness of her right hand.hat wo$ld yo$ ad'ise to red$ce
the risk of stroke rec$rrence
T%E
CLINICALPRO&LEM
Wor$d'ide( stro"e is te second!ost co!!on ca#se of deat
after !yocardia$ in)farction andis a $eadin* ca#se of ac+#ireddisa,i$ity- In so!e re*ions( teco!),ined incidence of stro"eand transient isce!ic attac"s.TIAs/ e0ceeds te incidence of
coronary vasc#$ar events-1More
tan 234 of fata$ stro"es occ#rin $o') and !id)d$e)inco!e
co#ntries-5(6
Patients 'it stro"e are at i*
ris" for s#,se+#ent vasc#$ar
events( inc$#din* rec#r)rent stro"e
.i*est ris"/( !yocardia$
infarction( and deat fro!vasc#$ar ca#ses- &eca#se te ris"
of stro"e is i*est in te ear$y
7eriod after te ac#te event(
7ro!7t initiation of tai$ored
7revention strate*ies is essentia$-8
A !eta)ana$ysis so'ed tat te
ris" of stro"e 'as as i* as
15-24 d#rin* te first 'ee" after
a TIA( ,#t te ris" 'as $o'est
'en e!er*ency treat!ent ad
,een *iven ,y s7ecia$i9ed stro"e
ser)vices-
8
It is esti!ated tat at$east 2:4 of rec#rrent events
!i*t ,e 7revented 'it te #se
of a co!7reensive a77roac tat
inc$#des dietary !odification(
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e0ercise( ,$ood)7ress#re
$o'erin*( anti7$ate$et tera7y(
and statin tera7y-8(3
STRATEGIESAND
E;IDENCE
EVALUATION
Stro"e iscate*ori9ed asisce!ic stro"e.2:4 of cases/(intracere,ra$e!orra*e
.134/( or s#,aracnoide!orra*e
.34/-
'eretraditiona$$ydefined as ,riefne#ro$o*ice7isodes of vasc#$ar ori*in$astin* $ess tan58 o#rs- Morerecent$y( TIAsave ,een
c$assified as
transient ne#ro$o*ic events'ito#t si*ns of ac#te
infarction on i!a*in*-
#7dated definition is ,asedon te evidence tat !anystro"es de)tected on
i!a*in*( 7artic#$ar$y MRI($ast $ess tan 58 o#rs or arec$inica$$y si$ent- Tis revie'foc#ses on secondary
7revention after a TIA orisce!ic stro"e-
1
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CLINICAL PRACTICE
I
n
7$a
nni
n*
sec
on
dary
7re
ve
nti
on(
it
is
i!
7or
)
tan
t toatt
e!
7t
to
ide
ntif
y
te
7at
o
*e
nesis
of
te
TI
A
or
isc
e
!i
c
str
o"e(
7ar
tic
#$a
r$y
to
det
ect
c$i
nic
a$$
y
si*
nifi
can
t
cardiac
or
$ar*e)
artery
ca#ses
tat
'arrant
te #se
of
strate*ies
tai$ored
to te
individ
#a$
7atient-
In
c$inica$
7ractic
e( te
Tria$ of
Or*1:1=5
in
Ac#te
Stro"e
Treat!
ent
.TOAS
T/
c$assifi
cation
for
isce!ic
stro"e
is
#sef#$
in de)
$ineatin
*
!a>or
7ato*
eneses
on te
,asisof
c$inica$
findin*
s and
investi
*ations
-=
Tese
in)
c$#de
cardioe
!,o$is!
.!ost
co!!o
n$y
fro!
atri)a$
fi,ri$$at
ion/(
$ar*e)
artery
disease
( s!a$$)
vesse$occ$#si
on
.$ac#na
r
stro"e/(
stro"e
of
oter
deter)
!ined
ca#se
.e-*-(arteria$
dissecti
on(
dr#*)
re$ated
stro"e(
or a
y7erc
oa*#$a
,$e
disorde
r/( andstro"e
of
#ndeter
!ined
ca#se
.t'o or
!ore
identifi
ed
ca#ses
or
ne*ative or
inco!7
$ete
eva$#at
ion/-
Even
'en
f#$$y
investi
*ated(
#7 to
6:4 ofcases
of ce)
re,ra$
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isc
e
!i
a
re
!a
in
#n
e0
7$a
ine
d
.?c
ry7
to*
en)
ic
str
o"
e@/
-
U
r*e
nt
eva
$#a
tio
n
is
'a
rra
nte
d
aft
er
a
str
o"
e
or
TI
A(
,ec
a#s
e
!any
rec
#rr
ent
eve
nts
occ
#r
ear
$y-
&r
aini!
a*i
n*
is
!andat
ory for
dia*no
sis(
c$assi)
fication
( and
!ana*
e!ent-MRI is
!#c
!ore
sensitiv
e tan
co!7#t
ed
to!o*r
a7y
.CT/ in
te
dia*nosis of
ac#te
isce!
ia(
a$to#*
CT is
!ore
'ide$y
avai$a,
$e-
Arteria
$i!a*in
* 'it
te #se
of
carotid
Do77$e
r
#$traso
no*ra7
y(
CTA(
or
!a*)
netic
resona
nce
an*io*r
a7y
.MRA/
is
#s#a$$y
necessa
ry- In
!any
centers
( CT is
no'
co!,in
ed 'it
CTA-
E$ectro
cardio*
ra7y
is
ro#tine
$y 7er)
for!ed- To
detect
7aro0y
s!a$
atria$
fi,ri$$at
ion(
a!,#$a
tory
!onito
rin* is
#sef#$-Transt
oracic
or
transes
o7a*e
a$
ecoca
rdio*ra
7y is
often
#sed to
detectcardiac
so#rces
of
e!,o$i
s!
oter
tan
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atri
a$
fi,
ri$$
ati
on-
Ro
#ti
ne
,$o
od
tes
ts
!a
y
rev
ea$
7re
dis
7o
sin*
ca
#se
s(
s#c
as
7o$
yc
yt
e!
ia(ren
a$
i!
7ai
r!
ent
(
e$e
ctr
o$y
te
dis
t#r
,a
nc
es(
an
d
y
7er
)
*$y
ce!i
a-
M
ANAGEMENT
A**res
sive
ris")
factor
!ana*
e!ent
and
$ifesty$e
advice
are
essenti
a$ for
a$$
7atient
s-
O,serv
ation)a$
st#dies
of
7atients 'it
a
istory
of
stro"e
in)
dicate
tat
ea$ty
$ifesty$
e
,eavi
ors(
inc$#di
n*
re*#$ar
e0ercis
e and
a,stine
nce
fro!
s!o"in
*( are
associa
ted'it
red#ce
d
!orta$i
ty-2(#sted 'arfarin as ,een $et tera7y and intensive ris")factor !ana*e!ent
te !ainstay of tera7y- A !eta)ana$ysis of tria$s are reco!!ended for s#c 7atients- A rando!i9edco!7arin* 'arfarin 'it 7$ace,o or as7irin so'ed tria$ co!7arin* 'arfarin 'it as7irin in 7atients
red#ctions in te ris" of stro"e of :4 and 8:4( 'it stro"e or TIA ca#sed ,y intracrania$ stenosis
res7ective$y( a$to#* tese 'ere cief$y 7ri!ary) 'as ter!inated ear$y o'in* to i*er ris"s of ad)
7revention tria$s-82
Warfarin as a$so ,een so'n verse o#tco!es 'it 'arfarin(36
and a tria$ co!)
to ,e !ore effective tan as7irin12
or te co!,i) 7arin* an*io7$asty and stentin* 'it a**ressive
nation of as7irin 7$#s c$o7ido*re$8or ,$eedin* ,#t a si*nificant$y $o'er te 7revention of stro"e in 7atients 'it an ini)
ris" of intracrania$ e!orra*e-1