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Recent Advances in Stroke Prevention

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中华脑血管病杂志（电子版） 2020年第1期14卷 1-12页

作者： j.david spence Neurology&Clinical Pharmacology Western University/Stroke Prevention&Atherosclerosis Research CentreRobarts Research Institute

Stroke is the most important cause of death and disability in China,and most strokes(~80-90%)are *** advances in a number of measures to reduce stroke are discussed in this narrative review,including smoking cessation,a Mediterranean pattern of eating,salt restriction,B vitamins to lower homocysteine,antiplatelet therapy,anticoagulants and the management of patent foramen ovale and carotid *** of homocysteine with B vitamins does prevent stroke,but patients with variants of MTHFR require higher doses of folic acid,and because of harm from cyanocobalamin among persons with renal impairment,we should use methylcobalamin or oxocobalamin *** resistance appears to be due to enteric coating,and>50% of Chinese have a reduced response to clopidogrel because of variants of CYP2C19,required to convert the prodrug to its active *** acting oral anticoagulants(DOACs)have revolutionized anticoagulation;important differences among the DOACs are *** closure of patent foramen ovale(PFO)does reduce the risk of stroke,but in most patients with stroke and PFO the PFO is incidental;it is important to identify the subgroup in whom paradoxical embolism was the probable cause of the *** patients with PFO would be better treated with anticoagulants because of the risk of pulmonary *** stenting carries a higher risk in older patients,and most patients with asymptomatic carotid stenosis would be better treated with intensive medical therapy than with either stenting or endarterectomy;the few who could benefit can be identified.

关键词： vitamin doses instead

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从高血压到伴有高同型半胱氨酸血症的高血压

科学通报:英文版 2023年第18期68卷 1975-1977页

作者：范芳芳 j.davidspence 霍勇 Department of Cardiology Peking University First HospitalBeijing 100034China Institute of Cardiovascular Disease Peking University First HospitalBeijing 100034China Hypertension Precision Diagnosis and Treatment Research Center Peking University First HospitalBeijing 100034China Divisions of Neurology and Clinical Pharmacology Western UniversityLondon ON N6G 2V4Canada

Over the last 30 years,the number of people with cardiovascular disease(CVD)has continued to increase globally,with hypertension being the leading risk factor for *** burden of hypertension is especially large in countries and regions undergoing economic development and lifestyle *** latest survey data from China show that from 2012 to 2015,the prevalence of hypertension among residents aged18 years was as high as 27.9%;that is,one in four adults suffer from hypertension[1].It follows that the current prevention and control of hypertension is ***,how best to improve hypertension management to reduce the CVD burden is a major global *** we depict the challenges that cardiologists and neurologist face in the present era of CVD.

关键词： hypertension prevention 高同型半胱氨酸血症

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致《中华脑血管病杂志(电子版)》贺信

中华脑血管病杂志（电子版） 2020年第1期14卷 I0011-I0011页

作者： j.david spence 黄骁(译) 加拿大西安大略大学加拿大西安大略大学脑卒中防治和动脉粥样硬化研究中心加拿大内科学和外科学皇家学院加拿大健康科学学会世界卒中组织董事会不详

《中华脑血管病杂志(电子版)》是中华医学会旗下重要、广受欢迎的成员。卒中是中国主要致死和致残的病因:虽然心血管疾病的风险近年不断增加(可能与肉蛋的摄入增加有关),卒中发病率仍然是心肌梗死的2倍左右。卒中的预防是必须要抓住的... 详细信息

《中华脑血管病杂志(电子版)》是中华医学会旗下重要、广受欢迎的成员。卒中是中国主要致死和致残的病因:虽然心血管疾病的风险近年不断增加(可能与肉蛋的摄入增加有关),卒中发病率仍然是心肌梗死的2倍左右。卒中的预防是必须要抓住的重要契机。

关键词：中华医学会脑血管病心血管疾病卒中发病率心肌梗死电子版致残杂志

Cardioembolic stroke:everything has changed

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Stroke & Vascular Neurology 2018年第2期3卷 76-83页

作者： j.david spence Stroke Prevention and Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondonOntarioCanada

Historically,because of the difficulty of using warfarin safely and effectively,many patients with cardioembolic stroke who should have been anticoagulated were instead given ineffective antiplatelet therapy(or no antithrombotic therapy).With the arrival of new oral anticoagulants that are not significantly more likely than aspirin to cause severe haemorrhage,everything has *** antiplatelet agents are much less effective in preventing cardioembolic stroke,it is now more prudent to anticoagulate patients in whom cardioembolic stroke is strongly *** advances include the recognition that intermittent atrial fibrillation is better detected with more prolonged monitoring of the cardiac rhythm,and that percutaneous closure of patent foramen ovale(PFO)may reduce the risk of ***,because in most patients with stroke and PFO the PFO is incidental,this should be reserved for patients in whom paradoxical embolism is likely.A high shunt grade on transcranial Doppler saline studies,and clinical clues to paradoxical embolism,can help in appropriate selection of patients for percutaneous *** patients with atrial fibrillation who cannot be anticoagulated,ablation of the left atrial appendage is an emerging *** is also increasingly recognised that high levels of homocysteine,often due to undiagnosed metabolic deficiency of vitamin B_(12),markedly increase the risk of stroke in atrial fibrillation,and that B vitamins(folic acid and B_(12))do prevent stroke by lowering ***,with regard to B_(12),methylcobalamin should probably be used instead of *** important considerations for judicious application of therapies to prevent cardioembolic stroke are discussed.

关键词： vitamin markedly likely

Controlling resistant hypertension

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Stroke & Vascular Neurology 2018年第2期3卷 69-75页

作者： j.david spence Stroke Prevention&Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondonOntarioCanada

Resistant hypertension(failure to achieve target blood pressures with three or more antihypertensive drugs including a diuretic)is an important and preventable cause of *** is highly prevalent in China(>60%of persons above age 65),and only~6%of hypertensives in China are controlled to target *** strokes occur among persons with resistant hypertension;approximately half of strokes could be prevented by blood pressure *** for uncontrolled hypertension include(1)non-compliance;(2)consumption of substances that aggravated hypertension,such as excess salt,alcohol,licorice,decongestants and oral contraceptives;(3)therapeutic inertia(failure to intensify therapy when target blood pressures are not achieved);and(4)diagnostic inertia(failure to investigate the cause of resistant hypertension).In China,an additional factor is lack of availability of appropriate antihypertensive therapy in many healthcare *** restriction in combination with a diet similar to the Cretan Mediterranean or the DASH(Dietary Approaches to Stop Hypertension)diet can lower blood pressure in proportion to the severity of *** individualised therapy for hypertension based on phenotyping by plasma renin activity and aldosterone can markedly improve blood pressure *** hypertension(high renin/high aldosterone)is best treated with angiotensin receptor antagonists;primary aldosteronism(low renin/high aldosterone)is best treated with aldosterone antagonists(spironolactone or eplerenone);and hypertension due to overactivity of the renal epithelial sodium channel(low renin/low aldosterone;Liddle phenotype)is best treated with *** latter is far more common than most physicians suppose.

关键词： hypertension hypertensive markedly

Diet for stroke prevention

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Stroke & Vascular Neurology 2018年第2期3卷 44-50页

作者： j.david spence Stroke Prevention&Atherosclerosis Research Centre Robarts Research InstituteLondonOntarioCanada Neurology and Clinical Pharmacology University of Western OntarioLondonOntarioCanada

Lifestyle is far more important than most physicians *** changes in China that have resulted from increased prosperity are probably responsible for a marked rise in coronary risk in the past several decades,accelerating in recent *** of meat and eggs has increased,while intake of fruits,vegetables and whole grains has *** 2003 and 2013,coronary mortality in China increased 213%,while stroke mortality increased by 26.6%.Besides a high content of cholesterol,meat(particularly red meat)contains carnitine,while egg yolks contain *** are converted by the intestinal microbiome to trimethylamine,in turn oxidised in the liver to trimethylamine n-oxide(TMAO).TMAO causes atherosclerosis in animal models,and in patients referred for coronary angiography high levels after a test dose of two hard-boiled eggs predicted increased cardiovascular *** strongest evidence for dietary prevention of stroke and myocardial infarction is with the Mediterranean diet from Crete,a nearly vegetarian diet that is high in beneficial oils,whole grains,fruits,vegetables and *** at risk of stroke should avoid egg yolk,limit intake of red meat and consume a diet similar to the Mediterranean diet.A crucial issue for stroke prevention in China is reduction of sodium *** changes,although difficult to implement,represent an important opportunity to prevent stroke and have the potential to reverse the trend of increased cardiovascular risk in China.

关键词： prevention intake mortality

China Stroke Statistics 2019: a wealth of opportunities for stroke prevention

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Stroke & Vascular Neurology 2020年第3期5卷 240-241页

作者： j.david spence Stroke Prevention & Atherosclerosis Research Centre Western University Robarts Research Institute

The China Stroke Statistics published in this issue of the journal1 represent an enormous *** included data on 3010204 patients who had a stroke admitted in 2018 to 1853 tertiary care hospitals and compiled data from multiple sources on stroke and stroke risk factors in *** authors and the huge team of workers who must have compiled the statistics are to be commended on this enormous *** the report is a wealth of data on what is wrong in China to cause such a high risk of stroke but also a wealth of opportunity to make a *** reason this is so important is that~80%of strokes are preventable.

关键词： prevention admitted journal

Appropriate management of asymptomatic carotid stenosis

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Stroke & Vascular Neurology 2016年第2期1卷 64-71页

作者： j.david spence Hongsong Song Guanliang Cheng Robarts Research Institute Western UniversityLondonOntarioCanada Peking University Third Hospital BeijingThe People’s Republic of China Huai’an First People’s Hospital Nanjing Medical UniversityHuai’anThe People’s Republic of China

With modern intensive medical therapy,the annual risk of ipsilateral stroke in patients with asymptomatic carotid stenosis(ACS)is now down to∼0.5%.Despite this,there is a widespread practice of routine intervention in ACS with carotid endarterectomy(CEA)and stenting(CAS).This is being justified on the basis of much higher risks with medical therapy in trials conducted decades ago,compared with lower risks of intervention in recent trials with no medical *** extrapolations are *** recent trials have shown that after subtracting periprocedural risks the outcomes with CEA and CAS are now comparable to medical therapy,the periprocedural risks still far outweigh the risks with medical *** the asymptomatic carotid trial(ACT)1 trial,the 30-day risk of stroke or death was 2.9%with CAS and 1.7%with *** the CREST trial,the 30-day risk of stroke or death among asymptomatic patients was 2.5%for stenting and 1.4%for ***,intensive medical therapy is much safer than either CAS or *** only patients with ACS who should receive intervention are those who can be identified as being at high *** best validated method is transcranial Doppler embolus *** approaches in development for identifying vulnerable plaques include intraplaque haemorrhage on MRI,ulceration and plaque lucency on ultrasound,and plaque inflammation on positron emission tomography/*** medical therapy for ACS includes smoking cessation,a Mediterranean diet,effective blood pressure control,antiplatelet therapy,intensive lipid-lowering therapy and treatment with B vitamins(with methylcobalamin instead of cyanocobalamin),particularly in patients with metabolic B12 deficiency.A new strategy called‘treating arteries instead of risk factors’,based on measurement of carotid plaque volume,is promising but requires validation in randomised trials.

关键词： carotid asymptomatic stenosis

How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting

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Stroke & Vascular Neurology 2018年第2期3卷 92-100页

作者： Kosmas I Paraskevas Frank j Veith j.david spence Department of Vascular and Endovascular Surgery Royal Free HospitalLondonUK Department of Vascular Surgery New York University Langone Medical CenterNew YorkUSA Department of Vascular Surgery Cleveland ClinicClevelandOhioUSA Stroke Prevention&Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondonCanada

Offering routine carotid endarterectomy(CEA)or carotid artery stenting(CAS)to patients with asymptomatic carotid artery stenosis(ACS)is no longer considered as the optimal management of these *** suboptimal,however,is the policy of offering only best medical treatment(BMT)to all patients with ACS and not considering any of them for prophylactic *** the last few years,there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming *** patients with ACS should receive *** present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals,namely:(1)microemboli detection on transcranial Doppler,(2)plaque echolucency on Duplex ultrasound,(3)progression in the severity of ACS,(4)silent embolic infarcts on brain CT/MRI,(5)reduced cerebrovascular reserve,(6)increased size of juxtaluminal hypoechoic area,(7)identification of intraplaque haemorrhage using MRI and(8)carotid *** evidence suggests that approximately 10%-15%of patents with asymptomatic stenosis might benefit from intervention;this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical *** the meantime,no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke,from modalities such as those discussed here.

关键词： patients carotid stenosis