In the midst of evidence-based medicine where randomized controlled trials (RCT) are the gold standard, supplement knowledge from population-based real world studies or long-term follow-up on trial patients are still strikingly important.
From a patient perspective, combined knowledge from RCTs and real world practice may guide us to advise individual patients taking into account both benefit and risk and long term effects of preventive medicine recommendations.
The “Prevention – no trial” session shows exciting and high quality research results relevant for clinical practice, and adds important data to guidelines.
The session covered a wide range of clinical-related topics in stroke prevention, ranging from carotid intervention (stenting and endarterectomy), blood pressure control, long-term antiplatelet treatment, to intensive statin therapy. The authors and the audience were also able to share experience in real-world clinical practice across different continents.
We learnt from the long-term follow-up of the ACST-1 trial that severe contralateral carotid stenosis or occlusion is associated with higher risk of stroke after carotid endarterectomy and also heard about the hyperperfusion syndrome post carotid angioplasty and stenting.
It was reassuring to know that intensive lowering of blood pressure after TIA and minor ischaemic stroke was associated with better cerebral perfusion and even in patients with significant burden of CMBs, the risks or recurrent ischaemic events outweighed the risks of intracranial bleeds at least in the first year. Whilst it might be possible and cost saving to prevent major upper GI bleeding in patients on long-term antiplatelet treatment at older ages with proton pump inhibitors (PPIs), stopping antiplatelet treatment after an acute bleed could be hazardous.
Finally, two comprehensive meta-analyses of current trial and observation data confirmed that intensive statin treatment reduces risk of recurrent ischaemic events in secondary prevention and there appeared to be no increase in the risk of recurrent intracranial bleeding even in those presenting with intracranial haemorrhage. In addition, using high resolution MRI, we were able to see that intensive statin therapy helped also to stabilize plaques in patients with ICAS.
To conclude, the “prevention, non-trial” session provided very encouraging results from our daily practice and we looked to hear more from the “prevention, trials” session later in the conference.