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Recurrent stroke, vascular event rate on decline during past 50 years
Hong K. Circulation. 2011;123:2111-2119.
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During a 50-year span, the annual event rate of strokes and major vascular events declined by roughly 1% per decade each, according to an analysis of nearly 60 secondary prevention trials.
The systematic review included only randomized controlled trials (n=59) published from 1960 to 2009 with a more than 6-month follow-up. Other inclusion factors were that most qualifying events were ischemic stroke or transient ischemic attack and intervention was a medical treatment. A total of 66,157 patients comprised the study population.
During the 50 years, annual event rates for recurrent stroke declined by 0.996% per decade (P=.001), with similar reductions also found for fatal stroke (0.282% decline per decade; P=.003). However, the greatest percent deduction was found with major vascular events, which declined by 1.331% per decade (P=.001).
The researchers then performed multiple regression analysis to determine the underlying causes of the decline in stroke and found that increasing use of antithrombotic agents and lowering systolic/diastolic BPs were the major contributors.
In the clinical perspective of the study, the researchers wrote on the influence of drug therapy, commenting that the introduction into practice of successive waves of therapies with proven efficacy in stroke prevention “has been notably successful, resulting in a substantial decline in the rate of recurrent vascular events in the control arms of secondary stroke prevention trials. Consequently, trials of new therapies are more arduous, requiring ever larger sample sizes to confirm treatment efficacy, and clinical investigators must cope with the paradox of progress.”
Other study data of interest showed that compared with the 3 decades before 1990, the past 20 years saw rises in hypertension, diabetes and hyperlipidemia, whereas smoking and transient ischemic attacks declined (P<.05 for all). – by Brian Ellis
For more information:
- Goldstein L. Stroke. 2011;42:517-584.
- Roger V. Circulation. 2011;123:e18-e209.
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The report by Hong et al supports the belief that improvements in medical therapy over the last decades is leading to reductions in the risk of recurrent stroke and other vascular events. Similar advances have undoubtedly led to a reduction in the risk of first strokes, with better prevention likely contributing to the 34.3% reduction in the annual stroke death rate in the United States between 1997 and 2007. Advances in medical therapy have also led to a reassessment of the benefits of revascularization in patients with asymptomatic carotid stenosis, with guidelines now noting that, “The advantage of revascularization over current medical therapy alone is not well established,” and that “the benefit of [carotid endarterectomy] may now be lower than anticipated based on randomized trial results [and that] the cited 3% threshold for complication rates may be high because of interim advances in medical therapy.” Advances in medical therapy have also been reflected in recent, negative, randomized trials of intracranial angioplasty and stenting and extracranial-intracranial bypass that each found much lower event rates with medical therapy than had been anticipated. The results further underscore that studies using historic controls are inappropriate.
– Larry B. Goldstein, MD, FAAN, FAHA
Cardiology Today Editorial Board member
Disclosures: Dr. Goldstein reports no relevant financial disclosures.
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