Revised: October 8, 2013
Accepted: October 17, 2013
Published online: December 28, 2013
Processing time: 201 Days and 11.1 Hours
In spite of a documented reduction in incidence in high-income countries over the last decades, stroke is still a leading cause of death and disability worldwide. With the ageing of the population stroke-related economic burden is expected to increase, because of residual disability and its complications, such as cognitive impairment, high risk of falls and fractures, depression and epilepsy. Furthermore, because of the substantial rate of early and long-term vascular recurrences after the first event, secondary prevention after cerebral ischaemia is a crucial issue. This is even more important after minor stroke and transient ischaemic attack (TIA), in order to reduce the risk of potentially more severe and disabling events. To accomplish this aim, acute long-term medical and surgical treatments as well as lifestyle modifications are strongly recommended. However, apart from the well-established indications to thrombolysis, studies in acute phase after a first stroke or TIA are scarce and evidence is lacking. More trials are available for long-term secondary prevention with different classes of drugs, including antithrombotic medications for ischaemic events of arterial and cardiac origin, especially related to atrial fibrillation (antiplatelets and anticoagulants, respectively), lipid lowering agents (mainly statins), blood pressure lowering drugs, surgical and endovascular revascularization procedures.
Core tip: Aggressive and combination treatments in the acute phase after transient ischaemic attack or minor stroke have been shown to be beneficial in few studies, but results of ongoing randomized trials are required. On the other side, in long-term prevention the most important innovation is the advent of new anticoagulant agents for stroke prevention in atrial fibrillation. Recent trials showed efficacy and safety of thrombin and factor Xa inhibitors, compared to vitamin K antagonists, whose use is hampered by several limitations. These new drugs will potentially increase the number of patients treated according to guidelines, thus preventing a remarkable proportion of strokes.