PDF herunterladen
Aktuelle Neurologie 2014; 41(02): 83-89
DOI: 10.1055/s-0034-1367001
Neues in der Neurologie
© Georg Thieme Verlag KG Stuttgart · New York

Neues in der Primär- und Sekundärprävention des Schlaganfalls

New Findings in Primary and Secondary Stroke Prevention
C. Weimar
1   Neurologie, Universitätsklinikum Essen
,
R. Weber
2   Neurologie, Alfried Krupp Krankenhaus Essen
,
H. C. Diener
1   Neurologie, Universitätsklinikum Essen
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
14. Februar 2014 (online)

Auch verfügbar auf
    Lizenzen und Reprints

Zusammenfassung

Anhand von selektierten Publikationen aus dem Jahr 2013 werden aktuelle Entwicklungen und Neuheiten in der Primär- und Sekundärprävention des Schlaganfalls dargestellt. Eine mediterrane Ernährung senkt das Schlaganfallrisiko in der Primärprophylaxe um 30%. Dabigatran sollte bei Patienten mit künstlicher Herzklappe nicht zur Embolieprophylaxe eingesetzt werden. Die Indikation zu einem Vorhofohrverschluß bei Pa­tienten mit Vorhofflimmern und Kontraindikation für eine orale Antikoagulation sollte nach wie vor zurückhaltend gestellt werden. Eine Metaanalyse der großen Studien zur frühen Antikoagulation mit Heparin nach Schlaganfall konnte keinen Vorteil dieser Behandlung, auch nicht bei Untergruppen, identifizieren. Eine duale Thrombozytenfunktionshemmung mit ASS und Clopidogrel in den ersten 3 Wochen nach TIA oder leichtem Schlaganfall zeigte dagegen eine signifikante Reduktion von Re-Infarkten ohne wesentliche Erhöhung des Blutungsrisikos. Nach Stentanlage sollte eine ­duale Thrombozytenfunktionshemmung unter oraler Antikoagulation (z. B. wegen Vorhofflimmern oder künstlicher Herzklappe) möglichst bald auf eine einfache Thrombozytenfunktionshemmung reduziert werden. Die Indikation zu einem PFO-Verschluss bei jungen Patienten mit kryptogenem Schlaganfall bleibt nach 3 negativen Studien weiterhin umstritten und sollte streng gestellt werden.

Abstract

Based on selected publications from 2013, current developments and innovations in primary and secondary stroke prevention are reviewed. A mediterranean diet reduces the stroke risk in primary prevention by about 30%. Dabigatran should not be given for prevention of embolism in patients with mechanical heart valves. Patients with atrial fibrillation and con­traindications for vitamin K antagonists should be very cautiously selected for left atrial appendage closure due to reported procedural side effects and the availability of new oral anticoagulants. A metaanalysis of the large studies on early anticoagulation with heparins after ischemic stroke could not identify any benefit, neither in subgroup analysis. A dual antiplatelet therapy with aspirin and clopidogrel during the first 3 weeks after TIA or minor stroke showed a signifikant reduction in recurrent stroke rates without any relevant increase in bleeding rates. Following stenting, a dual antiplatelet therapy in combination with oral anticoagulation (e. g. in patients with atrial fibrillation and mechanical heart valve) should be reduced to only one antiplatelet agent as soon as possible. The indication for PFO-closure in young patients with cryptogenic stroke remains debated after 3 negative trials and should be given conservatively in selected patients only.

Schlüsselwörter

Schlaganfall - Prävention - TIA - Hirninfarkt

Key words

stroke - prevention - TIA - cerebral infarction
 

  • Literatur

  • 1 Hippisley-Cox J, Coupland C, Brindle P. Derivation and validation of QStroke score for predicting risk of ischaemic stroke in primary care and comparison with other risk scores: a prospective open cohort study. Bmj 2013; 346: f2573
    CrossrefPubMedGoogle Scholar
  • 2 Estruch R, Ros E, Salas-Salvado J et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368: 1279-1290
    CrossrefPubMedGoogle Scholar
  • 3 Eikelboom JW, Connolly SJ, Brueckmann M et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med 2013; 369: 1206-1214
    CrossrefPubMedGoogle Scholar
  • 4 Kakkar AK, Mueller I, Bassand JP et al. Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: perspectives from the international, observational, prospective GARFIELD registry. PLoS One 2013; 8: e63479
    CrossrefPubMedGoogle Scholar
  • 5 Albertsen IE, Rasmussen LH, Overvad TF et al. Risk of stroke or systemic embolism in atrial fibrillation patients treated with warfarin: a systematic review and meta-analysis. Stroke 2013; 44: 1329-1336
    CrossrefPubMedGoogle Scholar
  • 6 Hori M, Connolly SJ, Zhu J et al. Dabigatran versus warfarin: effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation. Stroke 2013; 44: 1891-1896
    CrossrefPubMedGoogle Scholar
  • 7 Urena M, Rodes-Cabau J, Freixa X et al. Percutaneous left atrial appendage closure with the AMPLATZER cardiac plug device in patients with nonvalvular atrial fibrillation and contraindications to anticoagulation therapy. J Am Coll Cardiol 2013; 62: 96-102
    CrossrefPubMedGoogle Scholar
  • 8 Reddy VY, Mobius-Winkler S, Miller MA et al. Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol 2013; 61: 2551-2556
    CrossrefPubMedGoogle Scholar
  • 9 Connolly S, Pogue J, Hart R et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006; 367: 1903-1912
    CrossrefPubMedGoogle Scholar
  • 10 Connolly SJ, Pogue J, Hart RG et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009; 360: 2066-2078
    CrossrefPubMedGoogle Scholar
  • 11 Biondi-Zoccai GG, Lotrionte M, Agostoni P et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 2006; 27: 2667-2674
    CrossrefPubMedGoogle Scholar
  • 12 Weimar C, Cotton D, Sha N et al. Discontinuation of antiplatelet study medication and risk of recurrent stroke and cardiovascular events: results from the PRoFESS study. Cerebrovasc Dis 2013; 35: 538-543
    CrossrefPubMedGoogle Scholar
  • 13 Geeganage CM, Diener HC, Algra A et al. Dual or mono antiplatelet therapy for patients with acute ischemic stroke or transient ischemic attack: systematic review and meta-analysis of randomized controlled trials. Stroke 2012; 43: 1058-1066
    CrossrefPubMedGoogle Scholar
  • 14 Wang Y, Wang Y, Zhao X et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013; 369: 11-19
    CrossrefPubMedGoogle Scholar
  • 15 Wong KS, Wang Y, Leng X et al. Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis. Circulation 2013; 128: 1656-1666
    CrossrefPubMedGoogle Scholar
  • 16 Lamberts M, Olesen JB, Ruwald MH et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation 2012; 126: 1185-1193
    CrossrefPubMedGoogle Scholar
  • 17 Dewilde WJ, Oirbans T, Verheugt FW et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115
    CrossrefPubMedGoogle Scholar
  • 18 Tsu LV, Dager WE.. Safety of new oral anticoagulants with dual antiplatelet therapy in patients with acute coronary syndromes. Ann Pharmacother 2013; 47: 573-577
    CrossrefPubMedGoogle Scholar
  • 19 Dans AL, Connolly SJ, Wallentin L et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation 2013; 127: 634-640
    CrossrefPubMedGoogle Scholar
  • 20 Collet JP, Cuisset T, Range G et al. Bedside monitoring to adjust antiplatelet therapy for coronary stenting. N Engl J Med 2012; 367: 2100-2109
    CrossrefPubMedGoogle Scholar
  • 21 Depta JP, Fowler J, Novak E et al. Clinical outcomes using a platelet function-guided approach for secondary prevention in patients with ischemic stroke or transient ischemic attack. Stroke 2012; 43: 2376-2381
    CrossrefPubMedGoogle Scholar
  • 22 Paciaroni M, Agnelli G, Micheli S et al. Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke 2007; 38: 423-430
    CrossrefPubMedGoogle Scholar
  • 23 Whiteley WN, Adams Jr. HP, Bath PM et al. Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: an individual patient data meta-analysis of randomised controlled trials. Lancet Neurol 2013; 12: 539-545
    CrossrefPubMedGoogle Scholar
  • 24 Southworth MR, Reichman ME, Unger EF. Dabigatran and postmarketing reports of bleeding. N Engl J Med 2013; 368: 1272-1274
    CrossrefPubMedGoogle Scholar
  • 25 Larsen TB, Rasmussen LH, Skjoth F et al. Efficacy and safety of dabigatran etexilate and warfarin in “real-world” patients with atrial fibrillation: a prospective nationwide cohort study. J Am Coll Cardiol 2013; 61: 2264-2273
    CrossrefPubMedGoogle Scholar
  • 26 Shibazaki K, Kimura K, Aoki J et al. Early initiation of new oral anticoagulants in acute stroke and TIA patients with nonvalvular atrial fibrillation. J Neurol Sci 2013; 331: 90-93
    CrossrefPubMedGoogle Scholar
  • 27 Benavente OR, Coffey CS, Conwit R et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet 2013; 382: 507-515
    CrossrefPubMedGoogle Scholar
  • 28 Furlan AJ, Reisman M, Massaro J et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991-999
    CrossrefPubMedGoogle Scholar
  • 29 Meier B, Kalesan B, Mattle HP et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083-1091
    CrossrefPubMedGoogle Scholar
  • 30 Carroll JD, Saver JL, Thaler DE et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368: 1092-1100
    CrossrefPubMedGoogle Scholar
  • 31 Wolfrum M, Froehlich GM, Knapp G et al. Stroke prevention by percutaneous closure of patent foramen ovale: a systematic review and meta-analysis. Heart. 2013 Jun 21 [Epub ahead of print]
    PubMedGoogle Scholar
  • 32 Kitsios GD, Thaler DE, Kent DM. Potentially large yet uncertain benefits: a meta-analysis of patent foramen ovale closure trials. Stroke 2013; 44: 2640-2643
    CrossrefPubMedGoogle Scholar
  • 33 Kent DM, Ruthazer R, Weimar C et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology 2013; 81: 619-625
    CrossrefPubMedGoogle Scholar
  • 34 Derdeyn CP, Chimowitz MI, Lynn MJ et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet. 2013 Oct 25 [Epub ahead of print]
    PubMedGoogle Scholar