CASE REPORT
RECURRENT STROKE: WHAT HAVE WE LEARNT?
Table 2. ACEI AND ARB TRIALs
| Clinical trial | Risk reduction |
| Perindopril Protection Against Recurrent Stroke Study (PROGRESS)6 | A randomized, double-blind, placebo-controlled trial that enrolled 6105 men and women,, with prior history of stroke or TIA. Active treatment of perindopril 4 mg daily was given for all participants, with the diuretic indapamide 2.5 mg daily in 58% of patients. There was 28% relative risk reduction in stroke. |
| Losartan intervention for endpoint reduction in hypertension study (LIFE)7 | A double blind randomized parallel group study of 1326 patients aged 55-80 years with high blood pressures and they were followed for a mean of 4.7 years. There was 40% relative risk reduction in any stroke, 70% fatal strokes, and 45% atherothrombotic stroke. |
| Heart Outcomes Prevention Evaluation Trial (HOPE)8 | A randomised placebo controlled study of 9297 patients aged >55 years at high risk for cardiovascular events because of evidence of coronary heart disease, stroke, peripheral vascular disease or diabetes plus one other coronary risk factor. They were randomly assigned to receive ramipril (10 mg per day) or placebo for a mean of 5 years. There was 31% and 20% relative risk reduction in stroke and MI respectively. |
Aspirin or other antiplatelet agents are highly efficacious for secondary prevention of stroke or TIA, but their effectiveness for primary prevention of stroke is controversial.11 Aspirin reduces the incidence of stroke by about 25%.3 The results of International Stroke Trial (IST) and the Chinese Acute Stroke Trial (CAST) showed that early treatment with aspirin reduces the rate of death or recurrent ischaemic stroke.12 Ticlopidine is significantly more effective than aspirin for prevention of stroke in patients with TIA or minor ischaemic stroke,13 and it reduces the relative risk reduction of stroke by about 25-40 %14 although it was not used in this patient. Clopidogrel, a congener of ticlopidine reduces the relative risk reduction of stroke by about 30%.14 This drug was used in this patient after several episodes of recurrent stroke because it is much costly than aspirin and ticlopidine and this patient was unable to afford it due to his financial constraint. A recent meta-analysis shows that thienopyridine derivatives (ticlopidine, clopidogrel) are modestly but significantly more effective than aspirin in patients at high risk of stroke.15
A recent large RCT, European Stroke Prevention Study (ESPS-2) found high dose dipyridamole 200 mg twice daily plus aspirin 25 mg twice daily to be superior to aspirin alone; with a 21% risk reduction relative to aspirin.16 However it was not used in this patient. Another meta-analysis showed that among patients presented with arterial vascular disease, dipyridamole in the presence or absence of another antiplatelet agent might reduce the risk of further vascular events. However further trials comparing the effects of the combination of dipyridamole with aspirin versus alone are needed.17
Patients with intracranial atherosclerosis, especially coexisting extracranial carotid disease are at higher risk of suffering death or further vascular events.1 Perth Community Stroke Study have shown that approximately 15% of survivors of a first ever stroke experienced a recurrent stroke over the next 5 years of which 25% are fatal within 28 days. The predictors of first recurrent stroke in this study were advanced age, haemorrhagic stroke, and diabetes mellitus. Because the risk of recurrent stroke is highest, 8.8% in the first six months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.18
Carotid endarterectomy reduces the risk of stroke for selected patients with cervical carotid atherosclerosis stenosis. Carotid endarterectomy offers important benefits for patients with high grade (70% or more) cervical carotid stenosis who also have ipsilateral focal ischaemic events i.e. symptomatic carotid artery stenosis.3 A recent meta analysis based on North American Symptomatic Carotid Artery Endarterectomy trial (NASCET) and European Carotid Surgery Trial (ECST) showed that carotid endarterectomy had reduced the risk of disabling stroke or death by 48% in patients with severe stenosis exceeding 70-80%.19
The efficacy, safety and durability of angioplasty with or without stenting for management of cervical and intracranial carotid artery stenosis are unclear at present.3 Based on recent meta analysis there is insufficient evidence to recommend angioplasty with or without stent placement in routine practice for the prevention of stroke in patients with intracranial artery stenosis.20 No randomised controlled trials were done and evidence from descriptive studies show that the procedure is feasible although it carries a significant morbidity and mortality risk.20
