1. 12th October 2004GP lecture Series1 Primary and Secondary Prevention of Ischaemic Stroke David Hargroves, SpR in Stroke Medicine, SW Thames.

2. 12th October 2004GP lecture Series2 Incidence & Mortality Third commonest cause of death 3% of world’s disability Each year in England & Wales 110,000 suffer their first stroke.

3. 12th October 2004GP lecture Series3 Incidence

4. 12th October 2004GP lecture Series4 Primary Prevention Modifying Vascular risks * – Hypertension – Hyperlipidaemia – Hyperglycaemia – Smoking – Alcohol *Warlow, C., C. Sudlow, et al. (2003). "Stroke." Lancet 362(9391): 1211-24. Exercise Weight reduction Lower salt intake

5. 12th October 2004GP lecture Series5 Primary Prevention Identify those most at risk and treat aggressively*. – Diabetic patients. – Previous vascular disease. – Continued smokers. *Weih, M., J. Muller-Nordhorn, et al. (2004). "[Risk factors in ischemic stroke. Review of evidence in primary prevention]." Nervenarzt 75(4): 324.

6. 12th October 2004GP lecture Series6 Deciding exactly what an individuals risk is The estimated 10 yr. risk of CAD in a hypothetical 55yr old man and women according to levels of various risk factors. Lipids in units of mg/dl. Wilson,P.W. (1994) Am. J. Hypertension; 7:75.

7. 12th October 2004GP lecture Series7 Hypertension Arterovascular benefit from treating mild to moderate hypertension from 17 controlled studies. CAD reduced by 16% and Stroke by 40%. Absolute benefit slightly less ( numbers above graphs). Treatment for approximately 4-5 yrs prevented a CAD event or stroke in 2% of patients; preventing death in 0.8% patients. Herbert, P.R. et al (1993), Arch Intern Med; 153:576.

8. 12th October 2004GP lecture Series8 Cumulative incidence of cardiovascular events over time in 6859 men and women who were initially free of hypertension and cardiovascular disease. High/ normal BP compared to optimal BP was associated with an adjusted hazard ratio for cardiovascular disease of 1.6 in men and 2.5 in women.Vasan, R.S. et al (2001), N Engl J Med; 345:1291. Framingham Heart Study results: High/normal <139/89 Normal <129/84 Optimal < 120/80

9. 12th October 2004GP lecture Series9 Primary Prevention Persistently elevated BP> 160/100 if no other risks. Persistently elevated BP>140/90 if raised cardiovascular risk. NICE guidelines 18, Newcastle group (2004) Hypertension

10. 12th October 2004GP lecture Series10 Primary Prevention NICE guidelines on Hyperlipidaemia and cardiovascular risk 2004 still pending Hyperlipidaemia A practice decision based upon a cost/ risk local analysis.

11. 12th October 2004GP lecture Series11 Primary Prevention HbA1c < 7.5% if at risk of microvascular disease and < 6.5% if at risk of vascular disease * *NICE guidelines ( Excellence, N. I. f. C. (2004). Diabetes.) Hyperglycaemia

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13. 12th October 2004GP lecture Series13 Secondary Prevention Antiplatelet agents Anticoagulation Carotid Surgery Modification of vascular risk factors

14. 12th October 2004GP lecture Series14 Antiplatelet therapy Start 300 mg aspirin daily for 7-10 days Ideally after brain imaging Reduce 75mg thereafter Avoids death or disabling stroke in 1 in 100 pts RCP guidelines (I. S. W. Party (2004). national clinical guidelines for Stroke - 2nd edition, Royal College of Physicians.)

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18. 12th October 2004GP lecture Series18 Clopidogrel vs. Aspirin ? ‘Match’ study compared Aspirin with Aspirin and Clopidogrel in patients who had had a TIA or minor Stroke and were already taking Clopidogrel. No significant benefit achieved and increase in bleeding in Clop. + ASA grp. Diener, H. C., J. Bogousslavsky, et al. (2004). "Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial." Lancet 364(9431): 331-7.

19. 12th October 2004GP lecture Series19 Choice of Antiplatelet Aspirin first line post TIA / CVA Aspirin plus Dipyridamole second line. Clopidogrel third line or in those intolerant to Aspirin. RCP guidelines (I. S. W. Party (2004). national clinical guidelines for Stroke - 2nd edition, Royal College of Physicians.)

20. 12th October 2004GP lecture Series20 Anticoagulation for AF Anticoagulation should be started in every patient in atrial fibrillation unless contraindicated Should be considered for patients with ischaemic stroke associated with mitral valve disease, prosthetic heart disease or within 3 months of myocardial infarction Anticoagulation should be not be started until brain imaging has excluded haemorrhage and until 14 days have passed from onset of ischaemic stroke

21. 12th October 2004GP lecture Series21 NNT to prevent one stroke =22

22. 12th October 2004GP lecture Series22 Access to Neurovascular (NV)Clinics Study of delay from initial event to clinic assessment in three different localities; offering daily, weekly and fortnightly NV clinics. 377 enrolled. No. of patients seen within 14 day recommended window was 91%, 49%, 20% respectively. Giles, M. F., Flossman, E., Rotherwell, P.M. (2004). How frequent must TIA and Stroke clinics be to satisfy guidelines on urgency of assessment ? British Geriatric Society, Harrogate.

23. 12th October 2004GP lecture Series23 Percutaneous Transluminal Angioplasty Useful: - Contraindications to CEA - Stenosis at inaccessible sites - Restenosis after CEA

24. 12th October 2004GP lecture Series24 National Clinical Guidelines Any patient with carotid territory area stroke and with minor or absent residual disability should be considered for CEA Carotid ultrasound should be performed on all patients being considered for CEA CEA should only be undertaken by a specialist surgeon with a proven low complication rate, and only if the stenosis is measured at greater than 70%

25. 12th October 2004GP lecture Series25 Modifying vascular profile as secondary prevention. Hypertension Hyperlipidaemia

26. 12th October 2004GP lecture Series26 Hypertension Common –80% Multifactorial Hypertension associated poor outcome

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31. 12th October 2004GP lecture Series31 Secondary Prevention Targets are systolic BP < 140 and diastolic < 85 mmHg – < 130/ 80 for patients with diabetes. Reduction should be considered using a combination of long acting ACE inhibitor (eg Perindopril or Ramipril) and a thiazide diuretic (eg Indapamide) Hypertension Targets RCP guidelines (I. S. W. Party (2004). national clinical guidelines for Stroke - 2nd edition, Royal College of Physicians.)

32. 12th October 2004GP lecture Series32 Secondary Prevention If total cholesterol is > 3.5 then a high dose statin is required. e.g. Simvastatin 40mg or Atorvastatin 20mg. Hyperlipidaemia RCP guidelines (I. S. W. Party (2004). national clinical guidelines for Stroke - 2nd edition, Royal College of Physicians.)

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37. 12th October 2004GP lecture Series37 Conclusions Clear evidence from good quality research Challenge now is to implement change Therapeutic nihilism no longer justified

38. 12th October 2004GP lecture Series38 Thank You David Hargroves, SpR Stroke Medicine.