Long-term prevention of ischaemic stroke and stroke recurrence

Stroke is the third most important cause of mortality, but the leading caus e of severe handicap, dependency, and loss of social competence, Because of the high recurrence rate, active secondary prevention is mandatory once a stroke has occurred. Secondary prevention of stroke implies the primary pre vention of cardiovascular disorders as well. Among the modifiable risk fact ors hypertension is worst and should be normalized according to recent WHO criteria, also in the elderly. Smoking is another major risk factor and har d to delete. Diabetes mellitus and hyperlipidaemia are also important risk factors and should be treated consequently by diet and medication. Moderate alcohol intake, normalization of body weight and regular physical activity also contribute considerably to prevention of stroke. Whether hyperhomocys teinaemia should be normalized has not yet been clarified. Cardiovascular d isorders are an important source of ischemic strokes, particularly atrial f ibrillation. Low dose anticoagulation can dramatically reduce stroke risk. Carotid endarterectomy in symptomatic stenoses is the most expensive means of stroke prevention. In less severe stenoses, or ICA occlusions, antiplate let agents are the treatment of choice. Composite drugs with ASS and other antiplatelet agents seem to be superior to either compound alone, Dissectio ns of the cervical arteries should not be operated on but may be treated by anticoagulation or antiplatelet agents in the acute and subacute phase. Th e potency of a consequent and comprehensive stroke prevention in preventing disability and death is much greater than any sophisticated acute stroke t reatment. (C) 2000 Elsevier Science Ltd. All rights reserved.