Stroke: secondary prevention

Overview

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Substantive changes at this update

One systematic review added, which found that antiplatelet therapy for acute ischaemic stroke reduced the incidence of recurrent ischaemic stroke from 21 days' to 6 months' follow-up.[11] Categorisation unchanged (Beneficial).

Blood pressure reduction One new RCT added, comparing telmisartan versus placebo in people with a history of ischaemic stroke, which found no significant difference between telmisartan and placebo in recurrent stroke, all-cause mortality, or the composite outcome of cardiovascular events. [16] Categorisation unchanged (Beneficial).

Cholesterol reduction One systematic review added, which found that statins significantly reduced mortality, all-cause stroke, and ischaemic stroke compared with placebo.[27] One new RCT added, which found that atorvastatin reduced the risk of stroke and other major cardiovascular events in people with carotid atherosclerosis.[28] Categorisation unchanged (Beneficial).

Alternative antiplatelet regimens to aspirin One systematic review added, which found that aspirin plus dipyridamole significantly reduced incidence of stroke and serious vascular events compared with aspirin alone in people with previous stroke or TIA.[42] One RCT comparing aspirin plus dipyridamole versus clopidogrel added, which found no significant difference between the two groups in recurrent stroke and the composite outcome of stroke, MI, and vascular death.[43] Categorisation unchanged (Beneficial).

Anticoagulation in people in sinus rhythm One already included systematic review updated;[64] one RCT added, which found no significant difference between medium-intensity oral anticoagulants and aspirin on stroke, vascular death, and a composite outcome of vascular death, non-fatal stroke, non-fatal MI, and non-fatal bleeding complications.[65] It found that anticoagulants were associated with a significantly increased risk of major bleeding complications compared with aspirin. Categorisation unchanged (Likely to be ineffective or harmful).

Vitamin B supplements (including folate) Two systematic reviews and one RCT comparing folate versus placebo added, which all found no significant difference in rates of stroke between folate and placebo. Categorisation changed from Unknown effectiveness to Unlikely to be beneficial.

Eversion versus conventional carotid endarterectomy One RCT comparing eversion carotid endarterectomy versus conventional techniques added, which found that conventional techniques were associated with a significant increase in central neurological complications in the 7 days after surgery compared with eversion carotid endarterectomy, but reported no significant difference in long-term survival between the two techniques.[93] Categorisation unchanged (Unknown effectiveness).

Carotid percutaneous transluminal angioplasty (PTA) plus stenting Two systematic reviews and one RCT added, which showed no significant difference between carotid PTA plus stenting versus endarterectomy. [98][99][100] Categorisation unchanged (Unknown effectiveness).

Abstract

INTRODUCTION: People with a history of stroke or transient ischaemic attack (TIA) are at high risk of all vascular events, such as myocardial infarction (MI), but are at particular risk of subsequent stroke (about 10% in the first year and about 5% each year thereafter). METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive non-surgical interventions in people with previous stroke or transient ischaemic attack? What are the effects of preventive surgical interventions in people with previous stroke or transient ischaemic attack? What are the effects of preventive anticoagulant and antiplatelet treatments in people with atrial fibrillation and previous stroke or transient ischaemic attack? What are the effects of preventive anticoagulant and antiplatelet treatments in people with atrial fibrillation and without previous stroke or transient ischaemic attack? What are the effects of preventive anticoagulant and antiplatelet treatments in people with atrial fibrillation and without previous stroke or transient ischaemic attack and with low to moderate risk of stroke or transient ischaemic attack? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 130 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: alternative antiplatelet regimens to aspirin, anticoagulation (oral dosing, or in those with sinus rhythm), aspirin (high or low dose), blood pressure reduction, carotid and vertebral percutaneous transluminal angioplasty (PTA), carotid endarterectomy (in people with: asymptomatic but severe carotid artery stenosis, less than 0% symptomatic carotid artery stenosis, moderate [30%–49%] symptomatic carotid artery stenosis, moderately severe [50%–69%] symptomatic carotid artery stenosis, severe [greater than 70%] symptomatic carotid artery stenosis, or symptomatic near occlusion of the carotid artery), cholesterol reduction, vitamin B supplements (including folate), and different regimens to lower blood pressure.

Cite as

Lip GY, Kalra L. Stroke: secondary prevention . Systematic review 207. BMJ Clinical Evidence. . 2010 March. Accessed [date].

Latest citations

Effect of Intensive Versus Usual Blood Pressure Control on Kidney Function Among Individuals With Prior Lacunar Stroke: A Post Hoc Analysis of the Secondary Prevention of Small Subcortical Strokes (SPS3) Randomized Trial. ( 24 March 2016 )

Rates, Predictors, and Outcomes of Early and Late Recurrence After Stroke: The North Dublin Population Stroke Study. ( 17 February 2016 )