Intended for healthcare professionals

Clinical Review Evidence based cardiology

Prevention of ischaemic stroke

BMJ 1999; 318 doi: (Published 05 June 1999) Cite this as: BMJ 1999;318:1539

This article has a correction. Please see:

  1. Henry J M Barnett, scientist (,
  2. Michael Eliasziw, scientist,
  3. Heather E Meldrum, research associate.
  1. John P Robarts Research Institute, 100 Perth Drive, PO Box 5015, London, ON, Canada N6A 5K8
  1. 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

    Anticoagulants in stroke prevention

    Seven randomised trials …

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