Good cardiac care is good stroke prevention
Warfarin, aspirin, and HDL levels all in the mix
To reduce the costs of cardiac patient care, make sure you do what is necessary to prevent a first incident as well as rehospitalizations for stroke. Anticoagulant prophylaxis and a diet focused on elevating high-density lipoprotein (HDL) cholesterol are essential for effective stroke prevention.
Nonrheumatic atrial fibrillation (AF) is the most potent common risk factor for stroke. Six randomized controlled trials have demonstrated that long-term anticoagulant use can safely remove almost all risk of stroke attributable to AF. Despite that, an article authored by Massachusetts General Hospital and Harvard investigators, both in Boston, reported that though warfarin use increased between 1989 and 1993, its application has dropped off recently despite its proven efficacy.1
The investigators reported that only 32% of eligible patients with atrial fibrillation used the drug. Nineteen percent of patients over 80 used warfarin as compared to 36% of patients under 80, and the elderly are at highest risk for ischemic stroke if not treated.
The American Health Quality Association in Washington says, Not so. Through their efforts, they say, the use of warfarin is increasing significantly. Warfarin is prescribed more by internists and cardiologists than by family physicians. Intense anticoagulant monitoring is warranted in patients taking it.
An aspirin a day but how much?
A 50 mg/day regimen of aspirin has been shown to reduce the incidence of secondary vascular occlusive events in only 25% of patients. The regimen’s relative ineffectiveness may be due to low dosage. A Spanish investigator recently published a report that a single loading dose 500 mg at two-week intervals may amplify its therapeutic potential.2 An editorial accompanying the report, however, said that the observations don’t provide the basis for an alteration in therapy and that a clinical advantage of the added high-dose has yet to be demonstrated.3
Stroke risk has been shown to be lower when HDL levels are kept high. Now there’s yet another reason for keeping "good" cholesterol levels high. Three studies have demonstrated that elevated HDL cholesterol can protect against ischemic stroke. In addition to a latest report from Israeli scientists4, the Framingham (MA) Heart Study and the Copenhagen (Denmark) City Heart Study came to similar conclusions. Whereas the Framingham and Copenhagen studies looked at stroke rates within a six-year time span, the Israeli study followed patients for 21 years.
References
1. Stafford RS, Singer DE. National patterns of warfarin use in atrial fibrillation. Arch Intern Med 1996; 156:2,537-2,541.
2. Santos MT, Valles J, Aznar J, et al. Prothrombotic effects of erythrocytes on platelet reactivity reduction by aspirin. Circulation 1997; 95:63-68.
3. Rocca B, FitzGerald GA. Editorial. Circulation 1997; 95:11-13.
4. Tanne D, Yaari S, Goldbourt U. High-density lipoprotein cholesterol and risk of ischemic stroke mortality. Stroke 1997; 28:83-87.
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