Handbook of Stroke Prevention in Clinical Practice

314 Pages·2004·6.224 MB·English

by  Eric E. Smith, Walter J. Koroshetz (auth.), Karen L. Furie MD, MPH, Peter J. Kelly MD, MS, MRCPI (eds.)

Handbook of
Stroke Prevention in Clinical Practice
CURRENT CLINICAL NEUROLOGY
Daniel Tarsy,
MO, SERIES EDITOR
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Handbook of
Stroke Prevention
in Clinical Practice
Edited by
Karen L. Furie,
MD, MPH
Massachusetts General Hospital and Harvard Medical School, Boston, MA
and
J.
Peter Kelly,
MD, MS, MRCPI
Mater Misericordiae University Hospital and University College,
Dublin, Ireland and Massachusetts General Hospital, Boston, MA
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Library of Congress Cataloging-in-Publication Data
Handbook of stroke prevention in clinical practice I edited by Karen L.
Furie, Peter J. Kelly.
p. ; cm. -- (Current clinical neurology)
Includes bibliographical references and index.
ISBN 978-1-4684-9856-1 ISBN 978-1-59259-769-7 (eBook)
DOI 10.1007/978-1-59259-769-7
1. Cerebrovascular disease--Prevention--H andbooks, manuals, etc.
[DNLM: 1. Cerebrovascular Accident--prevention & control--Handbooks.
WL 39 H2368 2004] I. Furie, Karen L. II. Kelly, Peter J., MB. III.
Series.
RC388.5.H345 2004
616.8'1--dc22
2003020644
Series Editor's Introduction
Despite major advances in the understanding of stroke mechanisms that
have occurred over the past quarter century, stroke continues to rank among
the leading causes of death and disability worldwide. Although currently it
may be difficult to believe, early doubts were expressed as to whether inter
ventions in risk factors for either coronary disease or stroke would actually
lead to a reduction in the incidence of these disorders. However, large clini
cal trials in hypertension, carotid disease, atrial fibrillation, and
antithrombotic and antiplatelet therapies have effectively demonstrated the
efficacy of these targeted interventions in reducing stroke incidence. More
recently, after earlier uncertainty regarding the role of elevated lipids as a
risk factor for stroke, clinical trials of the statins have also demonstrated a
significant reduction in the incidence of ischemic stroke. However, as em
phasized in Handbook of Stroke Prevention in Clinical Practice, despite these
gains and the initial decline in stroke incidence that did occur in the 1960s
and 1970s, the incidence of stroke disappointingly has failed to show a fur
ther significant decline since that time.
The editors of Handbook of Stroke Prevention in Clinical Practice raise the
very important question of whether recognized strategies for stroke preven
tion have been widely or effectively implemented. They correctly empha
size the critical importance of identifying the mechanism of stroke in each
patient so as to properly direct prevention and treatment. As Dr. Louis
Caplan so eloquently stated, the essential question in management of
patients with cerebrovascular disease is to first ask and answer the ques
tion, "What is wrong with Mr. Jones?" (1). That is, exactly why has this
patient had transient ischemic attack? It then becomes clearer what should
be done about it. Early stroke prevention and treatment studies considered
ischemic stroke collectively without clearly identifying the mechanism of
stroke in enrolled patients. Undoubtedly, the same can often be said of
stroke management as it routinely takes place in the community. The chap
ters on vascular, cardiac, embolic, uncommon, and cryptogenic causes of
stroke in this volume usefully serve to emphasize the very wide variety of
circumstances that can result in ischemic stroke.
The editors have also further updated the list of risk factors for stroke
including tobacco and alcohol, obesity and physical activity, hormonal sta
tus, serum biomarkers, and genetic factors, all of which will require further
study to determine their importance as risk factors and the impact of inter
vention in these areas. Useful tables and definitive summary statements
concerning the current state of the art concerning risk factors and available
v
Series Editor's Introduction
VI
interventions will hopefully serve to improve the prospects for patients at
risk for stroke. The CD-ROM that is included can be downloaded into a
computer or PDA and should maximize the value of this information to the
practicing clinician.
REFERENCE
1. Caplan LR. TIAs: We need to return to the question, "What is wrong with Mr. Jones?"
Neurology 1988;38:791-793.
Daniel Tarsy, MD
Movement Disorders Center,
Beth Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA
Preface
Stroke is a major cause of death and disability worldwide. In the United
States, it is the third leading cause of death, after heart disease and cancer.
There are approximately 600,000 ischemic strokes each year and up to one
third of these individuals remain permanently disabled. Globally, stroke is
projected to be the fourth most common cause of premature death and dis
ability by the year 2020. Since the 1970s, several large international cohort
studies have provided a wealth of information about stroke risk factors,
many of which may be modified by lifestyle changes or medical therapies.
During the same epoch, large clinical trials have established targeted inter
ventions for preventing stroke associated with specific high-risk condi
tions, such as carotid disease and atrial fibrillation. Yet, even with the risks
defined and the prevention strategies proven, the incidence of stroke has
not decreased significantly in recent years. Although scientifically vali
dated and widely accepted, these strategies for stroke prevention are often
not effectively implemented.
The failure to identify and treat risk factors for stroke contributes to the
high rates of recurrent stroke and vascular death seen in patients with cere
brovascular disease. Although issues related to vascular protection are not
unique to the cerebrovascular circulation, the failure to modify such risk
factors as hypertension, hyperlipidemia, smoking, and obesity contributes
to the burden of stroke. Neurologists evaluating an individual at high risk
of recurrent stroke following transient ischemic attack or minor stroke are
sometimes ill-prepared to assume responsibility for managing such risk fac
tors as hypertension. In contrast, non-neurologists may feel uncomfortable
localizing neurological symptoms and determining the pathophysiology for
the event, which may lead to a failure to implement a mechanism-based
prevention strategy tailored to that individual.
Our purpose in writing the Handbook of Stroke Prevention in Clinical Prac
tice was to focus on the practical aspects of managing patients at high risk of
stroke and to provide the resources that a practicing clinician might find
valuable in assessing and treating these individuals. The summary state
ments, tables, and graphs were intended to leave sharp impressions that
could be woven into the clinical discourse and shared with patients and
their families. We sought to include the tools and references we use on a
regular basis in our practice and to consolidate them in one text. Our inten
tion was to provide a practical guide, rather than an exhaustive compen
dium of stroke epidemiology and clinical trial results. We made a
determined effort to include the most up-to-date targets and interventions,
recognizing that these will likely evolve over time.
vii
viii Preface
Our approach is based on the pathophysiology of cerebral ischemia and
infarction. The primary goal of the initial assessment of a symptomatic pa
tient should be to determine the mechanism of ischemia. The classification
schemes currently employed are useful, but not optimal, given that an indi
vidual might have multiple risk factors and potentially more than one
mechanism of disease. Identifying a single cause of symptoms, be it atrial
fibrillation or surgically remediable carotid stenosis, should not absolve the
physician from identifying and modifying other risk factors. There is in
creasing evidence that conventional and novel risk factors contribute to
stroke through effects on inflammation, endothelial injury, and activation
of the hemostatic system. For these reasons, although we address specific
mechanisms throughout the text, we chose to structure the book based pri
marily on states conferring increased stroke risk.
We wish to express our sincere appreciation for the valuable assistance
of the clinicians and researchers who contributed their time and expertise
to this work. We are grateful to Brenda Thornell and Susan Santilli who
provided invaluable assistance in preparing the text. Additionally, we wish
to acknowledge Dr. J. Philip Kistler and Dr. C. Miller Fisher of the Massa
chusetts General Hospital Stroke Service, whose pathophysiologic approach
to stroke diagnosis and management has profoundly influenced generations
of neurologists.
Karen L. Furie, MD, MPH
Peter J. Kelly, MD, MS, MRCPI
Contents
Series Editor's Introduction ................................................................................ v
Preface ................................................................................................................... vii
Contributors .......................................................................................................... xi
Value-Added eBook/PDA ............................................................................... xiii
1 Epidemiology of Stroke ............................................................................... 1
Eric E. Smith and Walter J. Koroshetz
2 Subtypes of Ischemic Stroke .................................................................... 19
John Sims and Walter J. Koroshetz
3 Hypertension As a Risk Factor for Stroke: Epidemiology
of Blood Pressure Risks and Evidence for Treatment Benefit ............... 35
Donald M. Lloyd-Jones and Christopher J. O'Donnell
4 Evaluation and Management of Hyperlipidemia
for Stroke Prevention ........................................................................... 51
Mehmet Akif Topcuoglu, Ferdinando S. Buonanno,
and Peter J. Kelly
5 Diabetes ....................................................................................................... 79
Maria Wormack and Ferdinando S. Buonanno
6 Tobacco and Alcohol ................................................................................ 87
Mehmet Akif Topcuoglu and Karen L. Furie
7 Diet, Obesity, and Physical Activity .................................................... 105
Karen L. Furie
8 Stroke Prevention With Antiplatelet Therapy ................................... 117
Dominick J. H. McCabe, Peter J. Kelly, and J. Philip Kistler
9 Hormonal Therapy .................................................................................. 139
MingMing Ning, Karen L. Furie, Jan L. Shifren,
and J. Philip Kistler
10 Stroke Due to Large Artery Atherosclerosis ...................................... 151
Karen L. Furie, Stelios M. Smirnakis, Walter J. Koroshetz,
and J. Philip Kistler
11 Craniocervical Endovascular Stenting and Angioplasty ................. 167
Cenk Ayata and Guy Rordorf
ix
12 Cardiac Embolism ................................................................................... 187
Karen L. Furie, Aneesh B. Singhal, and J. Philip Kistler
13 Cryptogenic Emboli and Other Elusive Causes of Stroke ............... 199
Stelios M. Smirnakis and Walter J. Koroshetz
14 Less Common Causes of Ischemic Stroke .......................................... 227
Raul G. Nogueira and Aneesh B. Singhal
15 Perioperative Stroke Risk Assessment and Management ............... 243
David M. Greer and Ferdinando S. Buonanno
16 Serum Biomarkers in Prediction of Stroke Risk and Outcome ...... 257
Rachel Farrell and Peter J. Kelly
17 Genetic Susceptibility and Early Stratification
of Stroke Risk ...................................................................................... 279
Peter J. Kelly and Karen L. Furie
Index .................................................................................................................... 303