Stroke Program

Pharmacologic Prevention of StrokeJonathan Raser-Schramm, MD, PhDMedical Director, Stroke ProgramChristiana Care Health System

March 21, 2014DisclosuresNo financial relationshipsWill discuss off-label use of a number of antithrombotic agentsWhat is a stroke?sudden onset neurological deficit attributable to a vascular causeWhat is a stroke?

ICHSAHinfarctionWhat is a stroke?

ICHSAHinfarction80%15%5%Modifiable stroke risk factors

ICHSAHinfarctionhypertensiontobacco abuseModifiable stroke risk factors

infarctionAtherothrombosisVASCULAR NEUROLOGYLammie et al. Stroke (1999)

thrombusatheromatous plaqueThromboembolism

Lammie et al. Stroke (1999)thrombusatheromatous plaqueModifiable stroke risk factors

infarctiondiabetes mellitusdyslipidemiaOutlineantihypertensivesantilipid agentsantithromboticsother pharmacologic approachesTwo phases of stroke treatment

acute strokesecondary prevention

Two phases of stroke treatment

acute strokesecondary prevention

weeks to monthsHypertension and stroke

Who should be treated?All patients after stroke?All hypertensive patients after stroke?What about patients with non-atherosclerotic causes of stroke?Could some patients be harmed by lowering blood pressure?

Causes of cerebral infarctionsmall vesseldiseaseatrial fibrillation cryptogeniclarge vesseldiseaseotherWho should be treated?All patients after stroke?

Across numerous randomized studies, there has not been any subset of patients that does not clearly benefit from blood pressure reduction in stroke prevention.

YesWho should be treated?All hypertensive patients after stroke?

Stroke prevention occurs with treatment in patients regardless of baseline blood pressure.Who should be treated?What about non-atherosclerotic causes of stroke?

There is an argument that patients who are normotensive (120/70) and have specific causes of stroke such as atrial fibrillation, DVT with PFO, endocarditis, or hypercoagulable states may not benefit from treatment.

This question is not well-studied.Who should be treated?Who might be harmed?

large vesseldiseaseconcern for cerebral hypoperfusionWho should be treated?Who might be harmed?

For patients with large vessel stenosis >50% (especially >70%), there is a risk of recurrent stroke with aggressive treatment. However, some studies suggest benefit with long-term, stepwise aggressive lowering of blood pressure.

How much to lower?