Blood Pressure Management in Stroke Gorelick, Philip B; Whelton, Paul K; Sorond, Farzaneh ...
Hypertension,
12/2020, Letnik:
76, Številka:
6
Journal Article
Recenzirano
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Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common ...cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia.
Stroke is the second-leading cause of death worldwide and is a disabling disease of both older and younger adults. Stroke is also among the most highly preventable disorders because there are ...well-defined risk factors and preventatives. The establishment of new risk markers or factors for stroke risk assessment provides a new avenue for stroke prevention. Lipoprotein-associated phospholipase A2 (Lp-PLA2 ) is an enzyme that hydrolyzes oxidized phospholipids, releasing lysophosphatidylcholine, which has proinflammatory properties thought to be involved in the development of atherosclerosis and plaque rupture. In 2005, the Lp-PLA2 blood test was approved by the US Food and Drug Administration (FDA) for assessing the risk of ischemic stroke and coronary artery disease. In epidemiologic studies, low-density lipoprotein cholesterol and other lipid factors have not been shown to be consistent predictors of stroke risk. Lp-PLA2 measures, on the other hand, have shown a consistent association with stroke risk, conferring about a 2-fold increase in stroke occurrence. This relation has been studied in both first and recurrent stroke and is reviewed in this article. Importantly, a recent study has now shown that Lp-PLA2 may increase the area under the curve beyond that of traditional cardiovascular risk factors and C-reactive protein. Therefore, Lp-PLA2 determination may provide a pivotal opportunity to appropriately classify previously misclassified persons who are actually at high risk of stroke and in need of aggressive stroke intervention.
Alpha-linolenic acid (ALA) is plant-based essential omega-3 polyunsaturated fatty acids that must be obtained through the diet. This could explain in part why the severe deficiency in omega-3 intake ...pointed by numerous epidemiologic studies may increase the brain’s vulnerability representing an important risk factor in the development and/or deterioration of certain cardio- and neuropathologies. The roles of ALA in neurological disorders remain unclear, especially in stroke that is a leading cause of death. We and others have identified ALA as a potential nutraceutical to protect the brain from stroke, characterized by its pleiotropic effects in neuroprotection, vasodilation of brain arteries, and neuroplasticity. This review highlights how chronic administration of ALA protects against rodent models of hypoxic-ischemic injury and exerts an anti-depressant-like activity, effects that likely involve multiple mechanisms in brain, and may be applied in stroke prevention. One major effect may be through an increase in mature brain-derived neurotrophic factor (BDNF), a widely expressed protein in brain that plays critical roles in neuronal maintenance, and learning and memory. Understanding the precise roles of ALA in neurological disorders will provide the underpinnings for the development of new therapies for patients and families who could be devastated by these disorders.
Cerebral hyperperfusion is a relatively rare syndrome with significant and potentially preventable clinical consequences. The pathophysiology of cerebral hyperperfusion syndrome (CHS) may involve ...dysregulation of the cerebral vascular system and hypertension, in the setting of increase in cerebral blood flow. The early recognition of CHS is important to prevent complications such as intracerebral hemorrhage. This review will focus on CHS following carotid endarterectomy and carotid artery stenting. We will discuss the typical clinical features of CHS, risk factors, pathophysiology, diagnostic modalities for detection, identification of patients at risk, and prevention and treatment. Although currently there are no specific guidelines for the management of CHS, identification of patients at risk for CHS and aggressive treatment of hypertension are recommended.
In the United States (US) stroke care has undergone a remarkable transformation in the past decades at several levels. At the clinical level, randomized trials have paved the way for many new stroke ...preventives, and recently, several new mechanical clot retrieval devices for acute stroke treatment have been cleared for use in practice by the US Federal Drug Administration. Furthermore, in the mid 1990s we witnessed regulatory approval of intravenous recombinant tissue plasminogen activator for administration in acute ischemic stroke. In the domain of organization of medical care and delivery of health services, stroke has transitioned from a disease dominated by neurologic consultation services only to one managed by vascular neurologists in geographical stroke units, stroke teams and care pathways, primary stroke center certification according to The Joint Commission, and most recently comprehensive stroke center designation under the aegis of The Joint Commission. Many organizations in the US have been involved to enhance stroke care. To name a few, the American Heart Association/American Stroke Association, Brain Attack Coalition, and National Stroke Association have been on the forefront of this movement. Additionally, governmental initiatives by the US Centers for Disease Control and Prevention and legislative initiatives such as the Paul Coverdell National Acute Stroke Registry program have paved the way to focus on stroke prevention, acute treatment and quality improvement. In this invited review, we discuss a brief history of organized stroke care in the United States, evidence to support the value of primary and comprehensive stroke centers, and the certification criteria and process to become a primary or comprehensive stroke center.
Large artery intracranial occlusive disease (LAICOD) is a common and important stroke subtype. In this commentary, we review key epidemiological aspects of LAICOD.
LAICOD has emerged as the most ...common stroke subtype worldwide and is associated with a high risk of recurrent stroke. Hypotheses have been proposed to explain causation, which include such factors as traditional cardiovascular risk factors, high blood volume states, and genetic abnormalities. Approaches to treatment such as antithrombotic therapies, revascularization procedures, and counterpulsation devices hold promise.
LAICOD poses a major stroke problem worldwide and is likely the most common stroke subtype. The etiology and treatment of this disorder remain poorly defined. International collaborations are needed to pool collective knowledge and develop definitive studies to better understand causation and treatment of LAICOD.
Migraine headaches are among the most common and potentially debilitating disorders encountered by primary healthcare providers. In the treatment of acute migraine and the prevention of recurrent ...attacks, there are prescription drugs of proven benefit. However, for those without health insurance or high co-pays, these drugs may be neither available nor affordable and, for all patients, they may be either poorly tolerated or contraindicated.
The totality of evidence, which includes data from randomized trials, suggests that high-dose aspirin, in doses from 900 to 1300 mg, taken at the onset of symptoms, is an effective and safe treatment option for acute migraine headaches. In addition, the totality of evidence, including some, but not all, randomized trials, suggests the possibility that daily aspirin, in doses from 81 to 325 mg, may be an effective and safe treatment option for the prevention of recurrent migraine headaches.
The relatively favorable side effect profile of aspirin and extremely low costs compared with other prescription drug therapies may provide additional options for primary healthcare providers in the treatment of both acute and recurrent migraine headaches.
Atherosclerotic vertebrobasilar (VB) occlusive disease is a significant etiology of posterior circulation stroke, with regional hypoperfusion as an important potential contributor to stroke risk.
To ...test the hypothesis that, among patients with symptomatic VB stenosis or occlusion, those with distal blood flow compromise as measured by large-vessel quantitative magnetic resonance angiography (QMRA) are at higher risk of subsequent posterior circulation stroke.
A prospective, blinded, longitudinal cohort study was conducted at 5 academic hospital-based centers in the United States and Canada; 82 patients from inpatient and outpatient settings were enrolled. Participants with recent VB transient ischemic attack or stroke and 50% or more atherosclerotic stenosis or occlusion in vertebral and/or basilar arteries underwent large-vessel flow measurement in the VB territory using QMRA. Physicians performing follow-up assessments were blinded to QMRA flow status. Follow-up included monthly telephone calls for 12 months and biannual clinical visits (for a minimum of 12 months, and up to 24 months or the final visit). Enrollment took place from July 1, 2008, to July 31, 2013, with study completion on June 30, 2014; data analysis was performed from October 1, 2014, to April 10, 2015.
Standard medical management of stroke risk factors.
The primary outcome was VB-territory stroke.
Of the 82 enrolled patients, 72 remained eligible after central review of their angiograms. Sixty-nine of 72 patients completed the minimum 12-month follow-up; median follow-up was 23 (interquartile range, 14-25) months. Distal flow status was low in 18 of the 72 participants (25%) included in the analysis and was significantly associated with risk for a subsequent VB stroke (P = .04), with 12- and 24-month event-free survival rates of 78% and 70%, respectively, in the low-flow group vs 96% and 87%, respectively, in the normal-flow group. The hazard ratio, adjusted for age and stroke risk factors, in the low distal flow status group was 11.55 (95% CI, 1.88-71.00; P = .008). Medical risk factor management at 6-month intervals was similar between patients with low and normal distal flow. Distal flow status remained significantly associated with risk even when controlling for the degree of stenosis and location.
Distal flow status determined using a noninvasive and practical imaging tool is robustly associated with risk for subsequent stroke in patients with symptomatic atherosclerotic VB occlusive disease. Identification of high-risk patients has important implications for future investigation of more aggressive interventional or medical therapies.