ISCHEMIC STROKE
Prevention of ischemic stroke
David Goldemund M.D.
Updated on 25/04/2024, published on 02/02/2024
- primary stroke prevention – interventions and measures taken to reduce the risk of stroke in asymptomatic individuals
- secondary stroke prevention – interventions taken to reduce the risk of recurrent ischemic stroke in individuals who have already suffered a stroke or TIA; the treatment is based on the cause of the previous ischemic stroke and takes into account individual vascular risk factors
Stroke prevention involves:
- initial vascular risk stratification (to assess an individual’s likelihood of experiencing a cardiovascular event) – analyze risk factors + personal medical history (including prior stroke or another cardiovascular event)
- SCORE2 (Systematic COronary Risk Evaluation) – a risk stratification tool used primarily in Europe to estimate the 10-year risk of fatal atherosclerotic cardiovascular disease (CVD), including stroke
- Framingham Risk Score (focuses on the risk of coronary disease)
- ASCVD (Atherosclerotic Cardiovascular Disease) Risk Calculator – used for primary prevention
- CHA2DS2-VASc Score (risk of stroke in patients with atrial fibrillation)
- management of vascular risk factors
- antithrombotic therapy
- antiplatelet agents – aspirin, clopidogrel, ticagrelor, or their combinations (DAPT) are commonly prescribed
- SAPT or short-term DAPT followed by SAPT
- SAPT + low-dose anticoagulants in selected patients
- anticoagulants – for those with cardioembolic risk factors (most commonly atrial fibrillation) or significant thrombophilia
- antiplatelet agents – aspirin, clopidogrel, ticagrelor, or their combinations (DAPT) are commonly prescribed
- surgical and endovascular procedures
- carotid endarterectomy or angioplasty with stenting on extracerebral and cerebral arteries
- PFO closure, LAA closure, pulmonary AV shunt occlusion, RF ablation, cardiac surgery, etc.
- regular monitoring and strict adherence to treatment are crucial
Cardiovascular disease risk predictors
Dyslipidemia
Arterial hypertension (HTN)
- arterial hypertension
- overview of oral antihypertensive agents
Cardioembolic strokes
Other risk factors
- smoking
- diabetes mellitus
- sleep apnea syndrome
- hyperhomocysteinemia
- oral contraceptives
- elevated hs-CRP
Carotid endarterectomy (CEA)
Angioplasty and stenting
Preventive cardiologic procedures
Anti-XI inhibitors
Anti-XI inhibitors, also known as factor XI inhibitors, are a novel class of anticoagulants that target factor XI, a component of the intrinsic coagulation pathway. While they have primarily been investigated for their potential to prevent venous thromboembolism (VTE) and reduce the risk of thrombosis without increasing the risk of bleeding, there is emerging interest in their role in cardiovascular prevention, including stroke prevention
- milvexian is a peroral factor XIa inhibitor
- AXIOMATIC-SSP – milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischemic stroke and did not meaningfully increase the risk of major bleeding
- ongoing stroke trial LIBREXIA
- osocimab
- ibisomab
Anti-inflammatory drugs
Inflammation plays a significant role in the development and progression of atherosclerosis
- colchicine
- by targeting inflammation, colchicine may help reduce the inflammatory burden on blood vessels, potentially slowing the progression of atherosclerosis and reducing the risk of stroke
- the CLEAR trial investigated the effect of colchicine on markers of inflammation and lipid profile in patients with a history of ischemic stroke/TIA. While the primary endpoints were changes in inflammatory markers and lipid profile, the study also reported a reduction in recurrent vascular events, including stroke, in patients treated with colchicine compared to placebo
- beyond colchicine, other anti-inflammatory agents and interventions targeting specific inflammatory pathways are being studied for their potential to reduce inflammation-related stroke risk
- interleukin-1 (IL-1) inhibitors (canakinumab and anakinra)
- tumor necrosis factor-alpha (TNF-α) inhibitors (such as infliximab and etanercept)
- P-selectin inhibitors (inclacumab and crizanlizumab)
- P-selectin is a cell adhesion molecule involved in the recruitment of leukocytes to sites of inflammation
- CCR2 inhibitors
- chemokine receptor 2 (CCR2) is involved in the recruitment of monocytes to sites of inflammation
- low-dose methotrexate (CIRT trial)
