Preventing ischemic stroke: Current approaches to primary and secondary prevention

Preventing stroke is the most important strategy for reducing the cost of this disease. Management of modifiable risk factors, especially hypertension and cigarette smoking, has the greatest impact on prevention of first stroke. Other primary prevention strategies include: Oral anticoagulation with warfarin for selected high-risk patients with nonvalvular atrial fibrillation; Carotid endarterectomy for selected patients with carotid artery stenosis greater than 60%; Regular physical exercise; Treatment with statin medications for patients who have coronary artery disease with or without hyperlipidemia; Routine use of antiplatelet medication has no proven role in primary stroke prevention, although aspirin is often prescribed for patients with vascular risk factors who have not yet had symptoms of either stroke or ischemic heart disease. The major strategies for secondary stroke prevention are: Appropriate evaluation to identify the mechanism of the initial stroke; Carotid endarterectomy for patients with symptomatic carotid artery stenosis of 50% or more; Oral anticoagulation with warfarin for patients with nonvalvular atrial fibrillation; Use of various antiplatelet agents, including aspirin, ticlopidine, clopidogrel, and the combination of aspirin and slow-release dipyridamole; Whether treatment of risk factors reduces the risk of secondary stroke is currently being evaluated in clinical trials.