Traditional Stroke Risk Factor Treatment

Secondary prevention of stroke focuses on identifying and mitigating the often heterogeneous contributing causes to an index stroke. Fortunately, most of the major conditions leading to secondary stroke are also known as “traditional risk factors” and have been established for several years, with compelling clinical trial or observational study data indicating that modification of these entities will lead to a lower risk of recurrent cerebrovascular events. However, there remains a scientific evidence-clinical practice gap, and questions linger about how promptly to initiate these risk factor modification treatments after a stroke, which therapies apply to which stroke subtypes, degree of treatment intensity, therapeutic agent vs. class effects, possible pleiotropic actions of certain drugs, and differential approaches based on demographics (e.g., age). Leading contributors to recurrent stroke risk include dyslipidemias, hypertension, diabetes, and adverse daily health choices including smoking, dietary insufficiency or excess, and a sedentary lifestyle. Given these key multiple contributors to stroke, and differences in the presence/severity across stroke survivors, mechanisms for minimizing future stroke risk should be tailored to the needs of the individual patient based upon their corresponding risk factors. In this chapter, we focus mainly on the conventional medical and lifestyle management of atherosclerotic stroke. We discuss the aforementioned traditional risk factors including up-to-date information on various evidence-based therapies and strategies for ameliorating them (thereby lowering secondary stroke risk). We begin this chapter with two case vignettes that exemplify key management issues in traditional stroke risk factor treatment. We recommend that readers first go through these vignettes and decide how they would address the management questions posed. We will discuss our approach to both vignettes following the relevant sections. Case Vignettes #1: A 64-year-old man with hypertension that is well controlled develops left hemiparesis, hemisensory loss, hemineglect, and a left visual field defect while working in his garage one morning. Examination and imaging studies are consistent with a stroke in the territory of the right middle cerebral artery. His past history is notable for insulin-dependent diabetes and a myocardial infarction. In addition to insulin, he takes nadolol and clopidogrel. He has a high-density lipoprotein cholesterol level of 35 mg/dL and a low-density lipoprotein cholesterol (LDL-C) level of 115 mg/dL. How would you approach the serum lipid management of this patient to reduce recurrent vascular risk consistent with the prevailing expert consensus guideline recommendations? #2: A 71-year-old woman presents to her ophthalmologist for an urgent visit. She reports that 2 days prior she became aware of reduced vision and found herself bumping into objects on her left side because she could not see them. She is an active smoker. She takes aspirin 81 mg daily. On examination, her blood pressure is 146/88 mmHg. She has a dense left homonymous hemianopsia. The remainder of her neurologic examination is normal. An MRI demonstrates diffusion-weighted imaging hyperintensity in the right posterior cerebral artery territory with normal magnetic resonance angiography of the head and neck. Her glycosylated hemoglobin level is 5.9 %, other laboratory tests are unremarkable. What therapeutic plan would you implement to reduce this patient’s risk of a second stroke?