From the University Department of Neurology, Charité Medical
School, Berlin, Germany.
Correspondence to Prof Dr K.M. Einhäupl, Neurologische Klinik und Poliklinik der Charité, Medizinische Fakultät der Humboldt-Universität, Schumannstraße 20/21, 10117 Berlin, Germany. E-mail einhaeupl{at}neuro.charite.hu-berlin
Background and Purpose—Large
multicenter trials have evaluated the benefit of different medical and
surgical therapies to prevent stroke. However, the application of trial
results to clinical practice remains uncertain for some areas of stroke
prevention and has been discussed passionately among international
experts. As part of a worldwide survey, the purpose of this
analysis was to provide an informative and comparative view of
the current practice of leading experts in North America (NA) and
Western Europe (WE), where most of the large prevention trials have
been performed.
Methods—The survey was performed worldwide among 185 neurologists
who are currently leading the discussions of stroke prevention
practices. It contained questions on the use of antiplatelet
agents, oral anticoagulation, and surgery for the prevention of
ischemic stroke. The population of this present
analysis is the two groups of experts from WE (n=73) and NA
(n=48) exclusively.
Results—Of each group, >90% responded to the survey. Nearly all
respondents reported prescribing aspirin in patients at risk of
atherothrombotic stroke, but significant differences between NA and WE
are shown by the recommended doses (P<.0001): aspirin
doses of >500 mg daily are given exclusively by American participants
(36%), whereas doses <200 mg are recommended only in Europe (51%).
Eighty-six percent of American versus 59% of European respondents
reported using ticlopidine as their second choice
(P<.005), and 23% of respondents from WE used warfarin
compared with 5% from NA (P<.05). The reported use of
anticoagulants in patients with atrial fibrillation increased in
accordance with the patient's individual risk of stroke, but
respondents from WE were more reluctant to use anticoagulants in
patients older than 75 years. Relatively higher target international
normalized ratio values were reported by European respondents. Nearly
all participants recommend carotid endarterectomy
in patients with symptomatic carotid stenosis. The
use of carotid endarterectomy in
asymptomatic patients was significantly more common among
responding experts from NA (48% versus 28%; P<.05),
particularly in patients with >95% stenosis (89% versus
53%; P<.0005).
Conclusions—This analysis shows significant differences
in several areas of stroke prevention practices between leading experts
from NA and WE. These differences may be explained partly by divergent
results of trials from the two continents, but in some areas of
controversy currently available trial data are not sufficient to form
an international consensus to guide daily clinical practice.
© 1998 American Heart Association, Inc.
Original Contributions
Differences in Medical and Surgical Therapy for Stroke Prevention Between Leading Experts in North America and Western Europe
Key Words: aspirin • atrial fibrillation • carotid endarterectomy • North America • stroke prevention • ticlopidine • warfarin • Western Europe
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