Treatment Decision Making
Approach treatment decisions following stroke or transient ischemic attack in a collaborative, multidisciplinary fashion. The hospitalist should facilitate appropriate consultation and evaluation—not only by neurologists and the medical stroke team but also by physical and/or occupational therapists, speech pathologists, and nutritionists/dieticians as needed. Clarify the roles of the hospital physician, especially in managing the patient through the care continuum systematically, as well as in relation to a specific patient.
Patients with stroke are susceptible to a range of potential complications during hospitalization and beyond—many of which are exacerbated by neurological damage and motor impairment. (See Table 2, p. 34.) These complications are significant contributors to poststroke morbidity and mortality; pulmonary embolism alone accounts for 10% of deaths after stroke, and sepsis secondary to urinary tract infection develops in about 5% of patients with stroke.3
The general approach to secondary stroke prevention should be based on the type of primary stroke that has occurred and should be refined according to specific stroke features and the findings obtained through additional diagnostic workup. (See Table 3, p. 36.)
The nonpharmacologic approach of managing lifestyle-related factors, such as quitting smoking, curbing alcohol consumption, and increasing physical exercise, remains an important element of preventive therapy; patients and their support teams should be encouraged to take an active role in making recommended changes.
As can be seen in Table 3, prevention of secondary events following stroke resulting from a confirmed cardioembolic source is based on anticoagulant (warfarin) therapy. For strokes resulting from carotid atherosclerosis, surgical repair (carotid endarterectomy) is of demonstrated benefit in patients with at least 70% stenosis and should be considered in patients with stenosis greater than 50%. Surgical complication rates can, however, negate any advantage of endarterectomy.11,12
The cornerstone of medical therapy for preventing recurrence after any noncardioembolic ischemic stroke is treatment with antiplatelet (platelet antiaggregation) agents, including aspirin, the thienopyridine derivative clopidogrel, or a combination of aspirin and extended-release dipyridamole.
Studies of aspirin generally suggest that low daily doses provide efficacy comparable or equivalent to that of higher doses, along with a reduced risk for serious adverse events. An example is the Dutch Transient Ischemic Attack (TIA) Trial Study, which randomly assigned 3,131 patients who had experienced a recent stroke or transient ischemic attack to dosages of 30 mg/day or 283 mg/day of aspirin. After a mean follow-up period of 2.6 years, no significant between-group differences were noted with regard to the incidence of the composite outcome measure of vascular death, nonfatal stroke, or nonfatal acute myocardial infarction (14.7% and 15.2%, respectively). However, 24% fewer major bleeding complications and 41% fewer minor bleeding complications were reported with the low dose compared with the higher dose.13
Similarly, the United Kingdom TIA study randomly assigned 2,435 patients with recent transient ischemic attack or minor ischemic stroke to placebo or to aspirin at 1,200 mg/day or 300 mg/day. After a mean follow-up of four years, the aspirin groups were virtually identical with regard to the composite vascular death, nonfatal stroke, or nonfatal acute myocardial infarction endpoint; relative risk reduction for combined aspirin groups versus placebo was 15%. The 1,200 mg/day aspirin group, however, reported a higher rate of upper gastrointestinal symptoms and bleeding episodes.14
Additional support for the efficacy of low-dose aspirin was provided by the Swedish Aspirin Low-Dose Trial (SALT), which randomly assigned 1,360 patients to 75 mg/day of aspirin or a placebo. In aspirin-treated subjects, an 18% reduction versus placebo was observed in the primary endpoint of stroke or death (P=0.02). In addition, aspirin reduced the incidence of a composite secondary outcome (stroke, or two or more transient ischemic attacks within a week, necessitating a change in therapy) by 20% versus placebo (P=0.03).15