Prevention and health services delivery.

The most recent data from the American Heart Association estimate that 700 000 Americans have a stroke each year.1 Stroke also continues to be a major health problem in Europe and in other areas of the world. The development of more effective stroke prevention strategies continues to be an important goal. The US public’s awareness of stroke risk and warning signs remains poor. One factor that is generally thought to provoke behavioral change is the occurrence of a stroke or myocardial infarction in a close family member. The Coronary Artery Risk Development in Young Adults (CARDIA) study measured changes in cardiovascular and stroke risk factors among 3950 young adults (aged 18 to 30 years) who either did or did not have an immediate family member with a new stroke or myocardial infarction.2 There was no effect of these events on the rates of smoking cessation, weight reduction, physical activity levels, lipid profiles, or blood pressure. Family history alone is apparently not sufficient to motivate changes in these health-related behaviors. Black Americans are at higher risk of stroke-related mortality as compared with other Americans. The AfricanAmerican Antiplatelet Stroke Prevention Study (AAASPS) investigators evaluated the baseline levels of control of cardiovascular and stroke risk factors among participants in this clinical trial.3 Of participants known to be diabetic, 33% had serum glucoses 200 mg/dL, 48% of those without a history of hypertension had elevated blood pressures, and 24% without known hyperlipidemia had a cholesterol level 240 mg/dL. Considerable improvements can be made in the use of proven stroke preventive therapies in this epidemiologically high-risk population. Several important stroke prevention trials have been published over the last year. A multifactorial intensive intervention study in patients with type 2 diabetes targeted hyperglycemia, hypertension, dyslipidemia, and micro-albuminuria with interventions including behavioral risk factor modification, and the use of a statin, angiotensin-converting enzyme inhibitor (ACEI), angiotensin-receptor blocker (ARB), and antiplatelet drug as appropriate.4 After 7.8 years, the risk of cardiovascular events was reduced by 50% with intensive treatment. There were 3 nonfatal strokes and 3 cardiovascular deaths in the 80 patients in the intensive arm versus 11 nonfatal strokes and 1 cardiovascular death in the 80 patients in the control arm (a 54% risk reduction). This result is in accord with findings from the Heart Protection Study that reported a 22% reduction in major vascular events and a 25% reduction in strokes in 5963 diabetic patients treated with a statin (simvastatin) in addition to best medical care.5 Intensive blood pressure control has major beneficial effects in diabetic patients,6,7 in addition to other persons at risk of stroke.6 The Second Australian National Blood Pressure (ANBP-2) study compared an ACEI to diuretics in 6083 hypertensive patients.8 After 4.1 years, both groups achieved the same level of blood pressure control with no difference over the course of the trial. Those treated with an ACEI had fewer cardiovascular events or deaths (hazard ratio [HR] 0.89; 95% CI: 0.79, 1.00, P 0.05). However, a similar number of strokes occurred in each group (HR 1.02; 95% CI: 0.78, 1.33, P 0.91) with fatal strokes occurring more frequently in the ACEI group (HR 1.91; 95% CI: 1.04, 3.50, P 0.04). In the ALLHAT trial, performed in 33 357 patients, there was no difference in the primary end point between those treated with a diuretic, a calcium channel blocker (CCB), or an ACEI.9 An analysis of 7 sets of prospectively designed overviews with data from 29 randomized trials including 162 341 subjects found that, compared with placebo, strokes were reduced with treatment with an ACEI (relative risk reduction [RRR] 28%; 95% CI: 19, 36), a CCB (RRR 38%; 95% CI: 18, 53), or an ARB (RRR 21%; 95% CI: 10, 31). Differences between regimens were of borderline statistical significance. There were trends toward lesser risk reductions with ACEIs versus diuretics or beta-blockers (RRR 1.09; 95% CI: 1.00, 1.18), greater reductions with CCBs versus diuretics or beta-blockers (RRR 0.93; 95% CI: 0.86, 1.00), and lesser reductions with ACEIs versus CCBs (RRR 1.12; 95% CI: 1.01, 1.25), but no differences in major cardiovascular events or deaths.6 Therefore, although there may be some differences among regimens, there remain few data showing that the risk of stroke is greatly reduced with a particular class of antihypertensive. Regardless of the regimen, greater reductions in blood pressure are associated with greater reductions in stroke risk.10 Both European and North American guidelines target a blood pressure of 130/80 mm Hg in diabetic patients.11,12 The target blood pressure for secondary prevention of stroke remains 140/90 mm Hg, although one trial showed that reductions by at least 10/5 mm Hg is beneficial regardless of whether or not the patient is hypertensive.13 The optimal time to begin an antihypertensive following a stroke remains uncertain. In the ACCESS trial, candesartan started within 48 hours after stroke and continued for one year The opinions expressed in this editorial are not necessarily those of the editors or of the American Stroke Association. Received December 1, 2003; accepted December 3, 2003. From the Department of Medicine (Neurology) (L.B.G.), Duke Center for Cerebrovascular Disease, Stroke Policy Program, Center for Clinical Health Policy Research, Duke University and Veterans Affairs Medical Center, Durham, NC; and Department of Neurology and Stroke Center (P.A.), Bichat University Hospital and Medical School, Denis Diderot University–Paris VII, Paris, France. Correspondence to Larry B. Goldstein, MD, Box 3651, Duke Medical Center, Durham, NC 27710. E-mail [email protected] (Stroke. 2004;35:401-403.) © 2004 American Heart Association, Inc.