ESOC 2018- Stroke Prevention and Epidemiology

The session on “Stroke Prevention and Epidemiology” provided a comprehensive review of important topics highly relevant in secondary prevention. We heard not only cutting-edge trial data, but also high quality data from prospective cohort studies. Linxin Li from Oxford reports:

Although it is reassuring to hear that stroke incidence in high-income countries are decreasing, it is alarming to see that the absolute numbers of incident strokes are rising with the aging population. In addition, given the decreasing case-fatality, we are also faced with increasing numbers of stroke survivals, adding to the overall burden of stroke. Areas to improve include better control of blood pressure and improving use of anticoagulants for atrial fibrillation at older ages.

Given the ageing population, it is also important to understand how we could treatment stroke patients more safely. Data from the Oxford Vascular Study showed that for patients taking long-term antiplatelet treatment at older ages, the risk of bleeding was much higher, more severe, more sustained with worse outcome, with substantial risk of disabling or fatal upper GI bleeding. They suggested that co-prescription of gastric protection could be an option. Screening or eradication of H. Pylori at older ages might also be an alternative.

Presentation on ESUS (embolic stroke of undetermined source) concept and consequences attracted a lot of interest. Although it was disappointing to hear the negative NAVIGATE-ESUS trial (Rivaroxban vs. Aspirin), we are waiting to hear from the RE-SPECT ESUS trial, which is due to report in October this year in the World Stroke Conference.

In addition to antithrombitic agents, the session also covered blood pressure lowering drugs and new cholesterol lowering agents including the PCSK9 inhibitors. Echoing with each other, the concept of “the lower the better” perhaps still holds true for both. Most encouragingly, data from the EBBINGHAUS study found no evidence that adding PCSK9 inhibitor evolocumab on top of statin treatment causes cognitive impairment, at least at 1 year follow-up.