Prevention of ischaemic stroke

From trainee to consultant, BMJ Group offers doctors around the world tailored information, special events, learning resources and recruitment services at every step along their career path.

... by doctors, for doctors, for patients
We are open for entries!

Online learning

BMJ Learning

High-quality CME / CPD for doctors and other healthcare professionals. BMJ Learning features hundreds of accredited, peer-reviewed learning modules in text, video, and audio formats. Find out more

Courses and Qualifications

BMJ Masterclasses

BMJ Masterclasses, led by experts, help clinicians to use the latest evidence and recent guidelines in practice and meet their CPD/CME requirements. Find out more

Exam Preparation

The leading provider of online exam preparation, helping over 167,000 healthcare professionals to pass their exams. Find out more

onExamination

Search all BMJ education articles:

From

Limit by

The BMJ iPad app brings you the best of print and online, including live links to the latest news, blogs, video, and podcasts. Get the BMJ iPad app.
You can use bmj.com to help you with your continuing medical education. Find out about CME/CPD credits for BMJ articles
Keep up to date with cardiology: Access the latest cardiovascular medicine resources from across BMJ Group.
Countdown to London 2012: BMJ Group's Olympics portal highlights latest Olympics and sports medicine-themed research, comment and learning

This article has a correction

Please see: Evidence based cardiology: Prevention of ischaemic stroke

Access to the full text of this article requires a subscription or payment. Please log in or subscribe below.

Henry J M Barnett, scientist (barnett@rri.on.ca),
Michael Eliasziw, scientist,
Heather E Meldrum, research associate.

John P Robarts Research Institute, 100 Perth Drive, PO Box 5015, London, ON, Canada N6A 5K8

Correspondence to: Dr Barnett

Stroke is the second most common cause of death worldwide, exceeded only by heart disease.1 Coincident with the emergence of prevention strategies, incidence of stroke is declining dramatically in developed countries. The prevention of stroke is an obligation facing everyone involved with delivering health care.

Summary points

Managing the risk factors of hypertension, tobacco, and hyperglycaemia reduces the risk of stroke

Managing hyperglycaemia will diminish the severity of strokes

Warfarin prevents stroke in non-valvular atrial fibrillation

Aspirin is the first choice of platelet inhibitors for stroke prevention

Endarterectomy prevents stroke when symptoms are due to severe stenosis;with moderate stenosis the benefit is muted

Endarterectomy is of uncertain benefit for asymptomatic carotid stenosis

Manageable risk factors for stroke

Prospective population studies and retrospective case series have identified modifiable risk factors important for ischaemic and haemorrhagic stroke.

The Four Horsemen of the Apocalypse of stroke display the banners of hypertension, tobacco, diabetes mellitus, and hyperlipidaemia.2 All are responsible for cerebral arteriosclerosis. Transient ischaemic events are powerful predictors of stroke. Coronary artery disease and atrial fibrillation increase stroke risk. Compounds lowering cholesterol, the “statins,” reduce the risk of myocardial infarction and stroke.3

At no age and in neither sex is a systolic blood pressure above 160 mm Hg and a diastolic pressure above 90 mm Hg acceptable. Even elderly subjects and heavy smokers reduce the risk of stroke by abandoning cigarettes.4

Control of insulin dependent diabetes has not been shown to reduce stroke.5 A stroke in the presence of hyperglycemia is more disabling.

Family history of stroke requires the Four Horsemen be sought and managed in the early decades of life. Fatalistic attitudes are wrong. Genetics deals the cards. The play can be determined by environmental influences.

Coagulation abnormalities and homocysteinaemia add to the likelihood of early stroke but are manageable.6