Sekundärprävention des Schlaganfalls - Breit gefächertes Spektrum an Risikofaktoren konsequent kontrollieren

Neue Studienergebnisse haben interessante Aspekte hinsichtlich der Sekundärprävention nach Schlaganfall ergeben: ACE-Hemmer zum Beispiel verhindern in Kombination mit einem Diuretikum nicht nur kardiovaskuläre Ereignisse und Schlaganfälle, sondern auch das Risiko einer vaskulären Demenz. Ob Sartane, die ebenfalls in das Renin-Angiotensin-Aldosteron-System eingreifen, gegenüber ACE-Hemmern zusätzliche pleiotrope Eigenschaften hinsichtlich der Reduktion kardiovaskulärer Ereignise besitzen, kann derzeit nicht belegt werden. Die ONTARGET-Studie jedenfalls hat für den Angiotensinrezeptorblocker Telmisartan keinen Vorteil gegenüber dem ACE-Hemmer Ramipril dokumentiert. Statine wiederum senken nicht nur das kardiovaskuläre Risiko aller vaskulären Risikogruppen, sondern auch das Rezidivinfarktrisiko eines Schlaganfalls. Die Kombination des Thrombozytenfunktionshemmers Azetylsalizylsäure (ASS) mit retardiertem Dipyridamol ist der alleinigen ASS-Sekundärprophylaxe überlegen. Besteht zusätzlich eine periphere arterielle Verschlusskrankheit, sollten die Patienten auch mit Clopidogrel behandelt werden. Patienten mit absoluter Arrhythmie bei nichtvalvulärem Vorhofflimmern sollten nach einem Schlaganfall oral antikoaguliert werden. Dies reduziert das Risiko emboligener Ereignisse signifikant - auch bei Patienten im Alter über 75 Jahren. Einen Eingriff erfordern symptomatische hochgradige Karotisstenosen. Dabei ist die Karotisangioplastie mit Stenting der Endarteriektomie hinsichtlich des Auftretens ipsilateraler Schlaganfälle und der Mortalität leicht unterlegen und sollte nur an Zentren mit großer Erfahrung durchgeführt werden.

New secondary prevention studies shed some light on various aspects of stroke prevention. Hypertensive treatment with a combination of ACE-inhibitor and diuretic is highly effective in the reduction of all vascular events and stroke. Additionally, the rate of vascular dementia is reduced. The ONTARGET-Study could not show a benefit of the angiotensin-receptor-blocker (ARB) Telmisartan over the ACE-inhibitor Ramipril in the reduction of death from cardiovascular causes, myocardial infarction, stroke, or hospitalization for heart failure. Whether pleiotropic effects of ARBs play a major role in the reduction of cardiovascular risk is therefore questionable. Statines are highly effective in the reduction of vascular risks in all vascular risk groups. The SPARCL-study showed, that statines additionally reduce the risk of recurrent infarction and TIA. Oral anticoagulation is effective in old patients (>75 years) without increased bleeding risk. Symptomatic, high grade carotid stenosis should be operated. Carotid angioplasty with stenting is slightly inferior to carotid endarterectomy in the reduction of stroke and death and should therefore only be performed in highly specialized centers.

Key words

stroke - transient ischemic attack - secondary prevention - hypertension - stroke therapy

Literatur

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1 Perindopril Protection Against Recurrent Stroke Study

2 MOrbidity and mortality after Stroke - Eprosartan vs nitrendipine for Secondary prevention

3 ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial

4 Stroke Prevention by Aggressive Reduction in Cholesterol Levels

5 European/Australian Stroke Prevention in Reversible Ischaemia Trial

6 Europäische Schlaganfall-PräventionStudie

7 Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events

8 Cardiac failure, Hypertension, Age, Diabetes, Stroke (Doubled)

9 Birmingham Atrial Fibrillation Treatment of the Aged Study

10 Aterial fibrillation Clopidogrel Trail with Irbesartan for prevention of Vascular Events

11 Stent protected Percutaneous and Angioplasty of the Carotid artery versus Endarteriectomy

12 PROspective PioglitAzone Clinical Trial In macroVascular Events

13 PROject on Stroke services in ITaly

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