Stroke prevention therapies and management of patient subgroups.

Stroke is the third leading cause of death in the United States. Efforts directed at reversing acute cerebral ischemia are promising but are hampered by multiple logistic and physiologic barriers. Prevention of stroke, therefore, remains of critical importance. Primary prevention is accomplished through reduction of risk factors and the appropriate use of warfarin or aspirin in patients with cardiac sources of emboli such as atrial fibrillation. Secondary prevention is designed to reduce the risk of stroke in patients with known stroke precursors, including transient ischemia, reversible ischemic deficits, and completed stroke. Aspirin and ticlopidine are two antiplatelet agents with an established role in secondary stroke prevention. In a major North American clinical trial, ticlopidine demonstrated superior efficacy to aspirin for the prevention of recurrent stroke, particularly in the first year following a stroke. Dipyridamole has not been shown to be useful for stroke prevention. The role of warfarin in the prevention of recurrent noncardiogenic stroke remains controversial and is currently under investigation. Stroke prevention remains an important challenge, and therapy should be individualized to achieve optimal results.