recurrent stroke

Management

• prevention
  • in patients with presumed cardioembolic stroke, rhythm monitoring has a limited role given the necessity of long-term anticoagulation
    • consider rhythm monitoring only for
      • consideration of stopping anticoagulation
      • other treatment decisions depend on arrhythmia detection
• monitor patients with ischemic stroke from presumed small-vessel or large-vessel disease for 2-4 weeks
  • anticoagulate if atrial fibrillation of >=5 minutes is identified

Clinical trials

• Warfarin Aspirin Recurrent Stroke Study (WARSS)
  • Design:
    • Double-blind, randomized trial
    • 2206 ischemic stroke patients at 47 centers
    • aspirin 325 mg QD vs warfarin (target INR 1.4-2.8)
  • primary endpoint: recurrent ischemic stroke or death
  • Results:
  • Hazard ratios (HR) favor aspirin:
    • stroke or death: HR = 1.13
  • hemorrhage: HR = 1.15
• Perindopril pROtection aGainst REcurrent Stroke Study
  • Study characteristics:
    • randomized, placebo-controlled trial
    • 6,105 individuals with previous stroke or TIA
    • 172 centres in Asia, Australasia, and Europe
    • 30% of participants were women
    • 4 years follow-up
  • Groups:
    • perinodopril 4 mg QD plus placebo
    • perinodopril 4 mg QD plus diuretic (indapamide)
    • placebo
  • Results:
    • 10% of treated groups suffered stroke vs 14% of placebo group
    • stroke risk reduction occurred regardless of whether subject was hypertensive
    • subjects treated with perinodopril plus indapamide had significantly fewer recurrent strokes than subjects treated with placebo (8% vs 14%)
    • perinodopril alone afforded no benefit for stroke reduction
    • the antihypertensive effect of perinodopril plus indapamide was greater than that of perinodopril alone 12/4 mm Hg vs 5/3 mm Hg

More general terms

• stroke; cerebrovascular accident (CVA)