This Article Full Text Full Text (PDF) CME: Take the course for this article: Stroke: June 2007, Volume 38, Number 6 All Versions of this Article: 38/6/1881    most recent STROKEAHA.106.475525v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hackam, D. G. Articles by Spence, J. D. Search for Related Content PubMed PubMed Citation Articles by Hackam, D. G. Articles by Spence, J. D. Related Collections Health policy and outcome research Secondary prevention Cerebrovascular disease/stroke Related Article

(Stroke. 2007;38:1881.)
© 2007 American Heart Association, Inc.

Original Contributions

Combining Multiple Approaches for the Secondary Prevention of Vascular Events After Stroke

A Quantitative Modeling Study

Daniel G. Hackam, BSc, MD, PhD, FRCPC J. David Spence, MD, FRCPC, FAHA

From the Division of Clinical Pharmacology & Toxicology (D.G.H.), Department of Medicine, University of Toronto, Canada; the Cardiac Rehabilitation & Secondary Prevention Program (D.G.H.), Toronto Rehabilitation Institute, and Institute for Clinical Evaluative Sciences, Canada; the Stroke Prevention and Atherosclerosis Research Center (J.D.S.), Robarts Research Institute, London, Canada; and the Division of Clinical Pharmacology and Department of Clinical Neurological Sciences (J.D.S.), University of Western Ontario, London, Canada.

Correspondence to Daniel G. Hackam, Room G-157, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5. E-mail Daniel.Hackam{at}ICES.ON.CA

Background and Purpose— Numerous effective strategies for the secondary prevention of cardiovascular events in high-risk patients have now been established. We sought to calculate the cumulative benefit of combining multiple strategies for preventing recurrent events in patients with a history of ischemic stroke or transient ischemic attack.

Methods— A comprehensive literature search was undertaken to identify meta-analyses of randomized controlled trials reporting on the efficacy of secondary prevention strategies. The baseline incidence of vascular events was modeled from the Life Long After Cerebral Ischemia study. Strategies were combined on a multiplicative scale and cumulative risk reductions were computed over a 5-year interval.

Results— The combination of 5 proven strategies applied to survivors of an initial stroke or transient ischemic attack—dietary modification, exercise, aspirin, a statin, and an antihypertensive agent—could result in a cumulative relative risk reduction of 80%. Given a 5-year major cardiovascular event rate of 24%, this translates to a number needed to treat of about 5. Further gains would result from applying multimodality therapy over longer intervals and enriching the base strategy with dual antiplatelet therapy, high-dose statins, and more intensive blood pressure–lowering. Even more benefit would be present in high-risk subgroups with the addition, where appropriate, of carotid endarterectomy, moderate intensity oral anticoagulants, glycemic control, and smoking cessation.

Conclusions— At least four-fifths of recurrent vascular events in patients with cerebrovascular disease might be prevented by application of a comprehensive, multifactorial approach.

Key Words: cerebrovascular disease • medical Rx • prevention • risk factor modification • secondary prevention • statistical models • stroke • systematic review

Related Article:

Making the Most of Secondary Prevention

Peter M. Rothwell
Stroke 2007 38: 1726. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

				R. Raine, W. Wong, G. Ambler, S. Hardoon, I. Petersen, R. Morris, M. Bartley, and D. Blane Sociodemographic variations in the contribution of secondary drug prevention to stroke survival at middle and older ages: cohort study BMJ, April 16, 2009; 338(apr16_2): b1279 - b1279. [Abstract] [Full Text] [PDF]

				G. Saposnik, S. G. Goodman, L. A. Leiter, R. T. Yan, D. H. Fitchett, N. H. Bayer, A. Casanova, A. Langer, A. T. Yan, for the Vascular Protection (VP), et al. Applying the Evidence: Do Patients With Stroke, Coronary Artery Disease, or Both Achieve Similar Treatment Goals? Stroke, April 1, 2009; 40(4): 1417 - 1424. [Abstract] [Full Text] [PDF]

				M. Bayley MD, P. Lindsay BScN PhD, C. Hellings BScH, E. Woodbury BCom MHA, S. Phillips MBBS, and on behalf of the Canadian Stroke Strategy (a joint Balancing evidence and opinion in stroke care: the 2008 best practice recommendations Can. Med. Assoc. J., December 2, 2008; 179(12): 1247 - 1249. [Full Text] [PDF]

				P. Talelli and R. J. Greenwood Review: Recurrent stroke: where do we stand with the secondary prevention of noncardioembolic ischaemic strokes? Therapeutic Advances in Cardiovascular Disease, October 1, 2008; 2(5): 387 - 405. [Abstract] [PDF]

				S. B. Coutts, M. D. Hill, C. R. Campos, Y. B. Choi, S. Subramaniam, J. C. Kosior, A. M. Demchuk, and for the VISION study group Recurrent Events in Transient Ischemic Attack and Minor Stroke: What Events Are Happening and to Which Patients? Stroke, September 1, 2008; 39(9): 2461 - 2466. [Abstract] [Full Text] [PDF]

				R. F. Lyons, A. G. Rudd, and C. Alvaro Advances in Health Policy 2007 Stroke, February 1, 2008; 39(2): 264 - 267. [Full Text] [PDF]

				R. Lehman Evidently... Evid. Based Med., October 1, 2007; 12(5): 135 - 135. [Full Text] [PDF]

				Other articles noted Evid. Based Med., October 1, 2007; 12(5): 159 - 160. [Full Text] [PDF]