Prevention, management, and rehabilitation of stroke in low- and middle-income countries

Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.

Developments in antiplatelet therapy for acute coronary syndromes and considerations for long-term management

OBJECTIVE

This article reviews the currently available antiplatelet therapies and emerging investigational drugs in the treatment of acutecoronary syndrome (ACS), and considerations for primary and secondary prevention in the long-term management of ACS patients undergoing percutaneous coronary intervention (PCI).

RESEARCH DESIGN AND METHODS

Primary studies and reviews in the peer-reviewed, English-language literature were identified through searches of MEDLINE (1966-2008) using the terms 'acute coronary syndrome', 'antiplatelet', 'aspirin', 'long-term management', 'P2Y(12) receptor', and 'thienopyridine'. Additional references were obtained by searching the reference lists of the identified articles. Articles were included if they were recently published and pertinent, patient-focused, and authors were recognized as leaders in the field. Current review is limited by literature search on single database.

RESULTS

Platelets play a major role in atherogenesis and the formation of thrombi, the main events in the pathogenesis of ACS. Although aspirin is an effective antiplatelet agent, efficacy and safety data from a number of randomized clinical trials on atherothrombotic disease support the use of dual antiplatelet therapies such as aspirin and thienopyridines over single antiplatelet therapy for ACS and up to 1 year following ACS. Antiplatelet agents reduce, but do not eliminate, ischemic events after ACS due, in part, to variable individual response (or resistance) in antiplatelet agents, non-compliance, progression of atherosclerosis, modest inhibition of platelet aggregation (IPA) levels and other factors. Several antiplatelet agents, including novel P2Y(12)-receptor antagonists and thrombin-receptor antagonists, are currently under investigation for ACS and primary and secondary prevention in the long-term management of patients undergoing PCI.

CONCLUSIONS

Current antiplatelet therapies have clinical benefits such as reducing immediate and long-term cardiovascular risk, but substantial residual risk remains indicating a need for new therapeutic agents. Additional large randomized trials are necessary to determine the most appropriate treatment regimens for ACS patients.

Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization: results from the Clinical Pathways for Acute Coronary Syndromes in China (CPACS) study

BACKGROUND

Coronary heart disease has emerged as a leading cause of death in China. Although there is strong evidence for the use of antiplatelet, blood pressure-lowering, and lipid-lowering therapy in patients with acute coronary syndromes, the extent to which these medications are used in China remains uncertain.

METHODS

We conducted a multicenter prospective study using data from consecutive patients diagnosed with suspected acute myocardial infarction or unstable angina pectoris admitted to the inpatient wards during the recruitment period. Medication adherence and reasons for nonadherence were reported using standardized questionnaires. Logistic regression was used to identify important patient and hospital characteristics associated with use of medication at 6 and 12 months after hospital discharge.

RESULTS

The use of drug therapy was high (above 90% for aspirin, 70% for beta-blockers and angiotensin-converting enzyme inhibitors, 80% for statin) at the time of hospital discharge but decreased during follow-up. However, fewer than half (48%) of patients were discharged on 4-drug combination therapy (antiplatelet, beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statin), and the proportion remaining on this treatment 1 year after discharge was even lower (41%). In adjusted logistic regression analyses, medical insurance, dyslipidemia, hypertension, and administration of invasive therapy (percutaneous coronary intervention or coronary artery bypass graft) were important in determining use of treatment at discharge and during follow-up. In a substantial proportion of patients, medication was considered "not indicated" by the treating physician.

CONCLUSIONS

The findings highlight opportunities to improve the use and maintenance of appropriate combinations of evidence-based treatment among patients with acute coronary syndromes presenting to hospitals in China.

Platelet ADP-receptor antagonists for cardiovascular disease: past, present and future

Aspirin is the foundation antiplatelet therapy for patients at risk of cardiovascular events. The thienopyridine, clopidogrel, is modestly more effective than aspirin and in patients with stroke seems to be as effective as the combination of aspirin and dipyridamole. The addition of clopidogrel to aspirin further reduces the risk of cardiovascular events in patients with acute coronary syndromes and those who undergo percutaneous coronary intervention, but uncertainty remains about whether this combination has incremental efficacy over clopidogrel monotherapy in patients with stroke or peripheral arterial disease. Clopidogrel has pharmacological limitations that have prompted the search for more effective ADP-receptor antagonists. Promising results have been achieved with the thienopyridine, prasugrel, which has been compared with clopidogrel in patients treated with aspirin. The nonthienopyridine P2Y(12) inhibitors AZD6140 and cangrelor are presently being evaluated in phase III, randomized, controlled trials.