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Advances in Prevention and Health Services Delivery 2010–2011

2012; Lippincott Williams & Wilkins; Volume: 43; Issue: 2 Linguagem: Inglês

10.1161/strokeaha.111.642678

1524-4628

Larry B. Goldstein, Peter M. Rothwell,

Atrial Fibrillation Management and Outcomes

HomeStrokeVol. 43, No. 2Advances in Prevention and Health Services Delivery 2010–2011 Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBAdvances in Prevention and Health Services Delivery 2010–2011 Larry B. Goldstein, MD, FAAN, FAHA and Peter M. Rothwell, MD, PhD, FRCP, FMedSci Larry B. GoldsteinLarry B. Goldstein From the Department of Medicine (L.B.G.), Duke University and VA Medical Center, Durham, NC; Stroke Prevention Research Unit (P.M.R.), Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK. and Peter M. RothwellPeter M. Rothwell From the Department of Medicine (L.B.G.), Duke University and VA Medical Center, Durham, NC; Stroke Prevention Research Unit (P.M.R.), Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK. Originally published19 Jan 2012https://doi.org/10.1161/STROKEAHA.111.642678Stroke. 2012;43:298–299Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 SStroke mortality has decreased, in large part because of better prevention. There are several new treatment options for patients with atrial fibrillation. Reduction in cancer risk may be an additional benefit of aspirin. Aggressive lowering of blood pressure for secondary stroke prevention might be harmful. Changes in the organization of care enhance utilization of evidence-based therapies. Further reductions in stroke risk and mortality are anticipated.In December 2010, the Centers for Disease Control and Prevention released 2008 data indicating that stroke declined from the third to the fourth leading cause of death in the United States, in part reflecting a steady decline in stroke-related mortality.1 There were similar reductions in Western Europe.2 Arguably, more effective prevention is the greatest contributor to the declines.3 Declining stroke rates with medical therapy suggest that revascularization procedures for most persons with asymptomatic carotid artery stenosis may no longer be of value4 and contributed to negative trials of angioplasty/stenting for intracranial steno-occlusive disease5 and extracranial–intracranial bypass for carotid occlusion.6 New research supports both novel and established therapies, and improved strategies for care delivery promise to add to the success of modern stroke prevention.Studies consistently show a gap in the appropriate treatment of atrial fibrillation (AF). This partially may be related to the perceived bleeding risk associated with vitamin K antagonists, the required monitoring, and concern for drug and dietary interactions. Several stratification schemes identify patients with AF whose risk is low enough to obviate anticoagulation but can yield differing assessments. The CHADS2 score is commonly used, but a considerable number of patients have "intermediate risk." This prompted a refinement, the CHA2DS2-VASc, having fewer intermediate risk classifications (15.1% vs 34.9%).7Clinical trials support alternative therapies for AF patients. The RE-LY trial compared dabigatran, a direct thrombin inhibitor, with warfarin.8 Randomization to dabigatran (150 mg twice daily) led to lower rates of stroke (including hemorrhagic stroke), but similar major bleeding (net benefit relative risk, 0.912; 95% CI, 0.82–1.00; P=0.04). Although having no food interactions, p-glycoprotein inhibitors increase dabigatran levels. Aside from dialysis, its effects cannot be emergently reversed. Although the aPTT may be prolonged, there is no rapid assay to measure its activity.The AVERROES trial compared apixabam, a factor Xa inhibitor, to aspirin in patients with AF and 1 additional risk factor who were considered unsuitable for warfarin.9 Apixabam lowered the risk of ischemic stroke/systemic embolization (hazard ratio, 0.45; 95% CI, 0.32–0.62), with lower rates of hemorrhagic stroke but similar rates of major and intracranial hemorrhages. As with dabigatran, there is no way of assessing drug activity and no antidote.The ARISOTLE trial compared apixabam with warfarin in patients with AF and 1 additional risk factor.10 Stroke or systemic embolization was reduced by 21% (hazard ratio, 0.79; 95% CI, 0.66–0.95; P<0.001 for noninferiority; P=0.01 for superiority). Both hemorrhagic and total strokes were lower, although there was no effect on ischemic or unknown-type strokes. Both intracranial and major hemorrhages were reduced (net benefit 3.2% vs 4.1%; P<0.001).The ROCKET trial compared rivaroxabam, another Xa inhibitor, with warfarin in patients with AF.11 Rivaroxabam was not inferior to warfarin in reducing stroke or systemic embolization (hazard ratio, 0.88; 95% CI, 0.74–1.03, P<0.001) but was not superior (P=0.12). Although major hemorrhage rates were similar, fatal and intracranial hemorrhages and hemorrhagic stroke rates were lower.Aspirin remains the standard for prevention of vascular events in patients without AF. The PERFORM trial compared the selective thromboxane-prostaglandin receptor antagonist terutroban with aspirin in patients with recent transient ischemic attack or ischemic stroke.12 PERFORM was stopped because of futility, with the primary end point occurring in 11% of subjects receiving either terutroban or aspirin (hazard ratio, 1.02; 95% CI, 0.94–1.12); there was no difference in major bleeding.Adding to evidence that aspirin reduces colorectal cancer,13 additional reports show it lowers the incidence and mortality of other cancers.14,15 The effect of aspirin on cancer risk provides an additional indication for its use in primary prevention. Work is necessary to determine how this additional effect influences the overall risk of aspirin vs benefit.Blood pressure-lowering remains the most important primary stroke prevention medical intervention, but whether there is a level of blood pressure below which further treatment is ineffective or harmful remains controversial.16 Exploratory analysis of PRoFESS trial data suggests increased stroke risk with systolic blood pressures <120 mm Hg in the secondary prevention setting.17 Evidence showing harm for primary prevention is lacking, although there are little data from randomized trials assessing outcomes in otherwise healthy elderly patients with systolic blood pressures <160 mm Hg.Effective implementation is necessary to optimize prevention. Quality-improvement programs lead to higher rates of compliance with evidence-based interventions.18 Although up to one-third of stroke patients stop ≥1 secondary prevention medications within 1 year of hospital discharge, most do so based on health care professional recommendations.19 Just as organized inpatient care is associated with improved ischemic and hemorrhagic stroke patient outcomes,20,21 organized outpatient care also may be advantageous.22 Continued advances in prevention and implementation should lead to further reductions in stroke incidence and mortality.Sources of FundingDr Goldstein was supported by an ASA-Bugher Foundation Stroke Prevention Research Center award. Dr Rothwell was supported by National Institute of Health Research and Wellcome Trust Senior Investigator Awards.DisclosuresNone.FootnotesCorrespondence to Larry B. Goldstein, MD, Box 3651, Duke University Medical Center, Durham, NC 27710. E-mail larry.[email protected]eduReferences1. 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Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA. 2011; 306:1983–1992.CrossrefMedlineGoogle Scholar7. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137:263–272.CrossrefMedlineGoogle Scholar8. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009; 361:1139–1151.CrossrefMedlineGoogle Scholar9. Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, et al. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011; 364:806–817.CrossrefMedlineGoogle Scholar10. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011; 365:981–992.CrossrefMedlineGoogle Scholar11. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011; 365:883–891.CrossrefMedlineGoogle Scholar12. Bousser MG, Amarenco P, Chamorro A, Fisher M, Ford I, Fox KM, et al. Terutroban versus aspirin in patients with cerebral ischaemic events (PERFORM): A randomised, double-blind, parallel-group trial. Lancet. 2011; 377:2013–2022.CrossrefMedlineGoogle Scholar13. Rothwell PM, Wilson M, Elwin CE, Norrving B, Algra A, Warlow CP, et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet. 2010; 376:1741–1750.CrossrefMedlineGoogle Scholar14. Rothwell PM, Fowkes FG, Belch JF, Ogawa H, Warlow CP, Meade TW. Effect of daily aspirin on long-term risk of death due to cancer: Analysis of individual patient data from randomised trials. Lancet. 2011; 377:31–41.CrossrefMedlineGoogle Scholar15. Burn J, Gerdes AM, Macrae F, Mecklin JP, Moeslein G, Olschwang S, et al. Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: An analysis from the capp2 randomised controlled trial. Lancet. 2011Nov1[Epub ahead of print].CrossrefMedlineGoogle Scholar16. Cooper-DeHoff RM, Gong Y, Handberg EM, Bavry AA, Denardo SJ, Bakris GL, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA. 2010; 304:61–68.CrossrefMedlineGoogle Scholar17. Ovbiagele B, Diener HC, Yusuf S, Martin RH, Cotton D, Vinisko R, et al. Level of systolic blood pressure within the normal range and risk of recurrent stroke. JAMA. 2011; 306:2137–2144.CrossrefMedlineGoogle Scholar18. Fonarow GC, Reeves MJ, Smith EE, Saver JL, Zhao X, Olson DW, et al. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes. 2010; 3:291–302.LinkGoogle Scholar19. Bushnell CD, Olson DM, Zhao X, Pan W, Zimmer LO, Goldstein LB, et al. Secondary preventive medication persistence and adherence 1 year after stroke. Neurology. 2011; 77:1182–1190.CrossrefMedlineGoogle Scholar20. Xian Y, Holloway RG, Chan PS, Noyes K, Shah MN, Ting HH, et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA. 2011; 305:373–380.CrossrefMedlineGoogle Scholar21. Lichtman JH, Jones SB, Leifheit-Limson EC, Wang Y, Goldstein LB. 30-day mortality and readmission after hemorrhagic stroke among medicare beneficiaries in joint commission primary stroke center-certified and noncertified hospitals. Stroke. 2011; 42:3387–3391.LinkGoogle Scholar22. Webster F, Saposnik G, Kapral MK, Fang J, O'Callaghan C, Hachinski V. Organized outpatient care: Stroke prevention clinic referrals are associated with reduced mortality after transient ischemic attack and ischemic stroke. Stroke. 2011; 42:3176–3182.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Zhang J, Zhu P, Liu B, Yao Q, Yan K, Zheng Q, Li Y, Zhang L, Li M, Wang J, Zhu C and Zhou M (2019) Time to recurrence after first-ever ischaemic stroke within 3 years and its risk factors in Chinese population: a prospective cohort study, BMJ Open, 10.1136/bmjopen-2019-032087, 9:12, (e032087), Online publication date: 1-Dec-2019. Kanikarla-Marie P, Kopetz S, Hawk E, Millward S, Sood A, Gresele P, Overman M, Honn K and Menter D (2018) Bioactive lipid metabolism in platelet "first responder" and cancer biology, Cancer and Metastasis Reviews, 10.1007/s10555-018-9755-8, 37:2-3, (439-454), Online publication date: 1-Sep-2018. Menter D, Davis J, Tucker S, Hawk E, Crissman J, Sood A, Kopetz S and Honn K (2017) Platelets: "First Responders" in Cancer Progression and Metastasis Platelets in Thrombotic and Non-Thrombotic Disorders, 10.1007/978-3-319-47462-5_74, (1111-1132), . Umar A, Steele V, Menter D and Hawk E (2016) Mechanisms of nonsteroidal anti-inflammatory drugs in cancer prevention, Seminars in Oncology, 10.1053/j.seminoncol.2015.09.010, 43:1, (65-77), Online publication date: 1-Feb-2016. Shih C, Liao C, Sun M, Su Y, Wen C, Morisky D, Sung F, Hsu C and Lin J (2015) A Retrospective Cohort Study Comparing Stroke Recurrence Rate in Ischemic Stroke Patients With and Without Acupuncture Treatment, Medicine, 10.1097/MD.0000000000001572, 94:39, (e1572), Online publication date: 1-Sep-2015. Tsai J, Rochon P, Raptis S, Bronskill S, Bell C and Saposnik G (2014) A Prescription at Discharge Improves Long-term Adherence for Secondary Stroke Prevention, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2014.04.026, 23:9, (2308-2315), Online publication date: 1-Oct-2014. February 2012Vol 43, Issue 2 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.642678PMID: 22267832 Manuscript receivedNovember 28, 2011Manuscript acceptedDecember 15, 2011Originally publishedJanuary 19, 2012 Keywordsblood pressurepreventionatrial fibrillationstrokeaspirinPDF download Advertisement SubjectsPrimary Prevention