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Secondary prevention aims at preventing a stroke after a transient ischemic attack (TIA) or a recurrent stroke after a first stroke. About 80–85% of patients survive a first ischemic stroke [1, 2]. Of those between 8% and 15% suffer a recurrent stroke in the first year. Risk of stroke recurrence is highest in the first few weeks and declines over time [3–5]. The risk of recurrence depends on concomitant vascular diseases (CHD, PAD) and vascular risk factors and can be estimated by risk models [6, 7]. Stroke risk after a TIA is highest in the first 3 days . Therefore immediate evaluation of patients with stroke or TIA, identification of the pathophysiology and initiation of pathophysiology based treatment is of major importance . In the following sections, we will deal with the treatment of risk factors, antithrombotic therapy and surgery or stenting of significant stenosis of extra- or intracranial arteries. Each paragraph will be introduced by recommendations, followed by the scientific justification.
Treatment of risk factors
Antihypertensive therapy reduces the risk of stroke. The combination of an ACE inhibitor (perindopril) with a diuretic (indapamide) was significantly more effective than placebo, and an angiotensin-receptor blocker (ARB, eprosartan) was more effective than a calcium-channel blocker (nitrendipin). Ramipril reduces vascular events in patients with vascular risk factors.
Early initiation of antihypertensive therapy with telmisartan on top of the usual antihypertensive therapy is not more effective than placebo.
Most likely all antihypertensive drugs are effective in secondary stroke prevention. Beta-blockers (atenolol) show the lowest efficacy. More important than the choice of a class of antihypertensives is to achieve the systolic and diastolic blood pressure targets (<140/90 mmHg in non-diabetics and <130/80 in diabetics). In many cases this requires combination therapy. Concomitant diseases (kidney failure, congestive heart failure) have to be considered.
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