PubMed · 15061051
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Gord Gubitz, Peter Sandercock, Elizabeth Warburton. 2004. [Stroke: management].. https://doi.org/10.1024/0301-1526.33.1.55
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There have been major advances in stroke treatment based on robust evidence from large clinical trials. This review covers both acute treatment and secondary prevention. Thrombolysis is now established as a therapy for ischaemic stroke presenting within 3 hours, and the possibility of extending the time window and refining the selection of suitable patients, is being addressed in further trials. Anticoagulants are of proven benefit in cardioembolic stroke, and particularly atrial fibrillation. For prevention of other stroke subtypes antiplatelet agents appear to have a better risk-benefit ratio. Evidence for the use of dual antiplatelet therapy, including the recent MATCH study, are discussed. Carotid endarterectomy is of proven benefit in patients with>70% symptomatic stenosis. Recent analysis has emphasised the importance of operating as soon after symptom onset as possible. Operating on asymptomatic carotid stenosis remains controversial; even after the recent Asymptomatic Carotid Surgery Trial which showed that by operating on 32 people one disabling stroke or death could be prevented over a 5 years period.
Aspirin is currently the most cost-effective drug for the secondary prevention of cardiovascular disease, but treatment failures are relatively common. Several factors have been linked to these recurrent vascular events in patients prescribed aspirin, including smoking, drug interactions, nonadherence, comorbid conditions, and aspirin resistance. The term aspirin resistance has been used to describe not only an absence of the expected pharmacologic effects of aspirin on platelets but also poor clinical outcomes, such as recurrent vascular events, in patients treated with aspirin. Aspirin resistance is perhaps more precisely understood as the phenomenon of measurable, persisting platelet activation that occurs in patients prescribed a therapeutic dose of aspirin and may underlie an unknown proportion of aspirin treatment failures. Key challenges for future research are to standardize a definition of aspirin resistance and to compare whether different measures of platelet activation, either alone or in combination, independently predict cardiovascular events. These challenges must be met before researchers conduct studies to assess the clinical utility of testing on patient outcomes and cost-effective prescribing.