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July 1, 2021

Intensive Medical Management to Prevent Large and Small Artery Atherothrombotic Stroke: Time to Expand the Horizon

Author Affiliations
  • 1Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzi, Taiwan
  • 2Department of Neurology, University of California, San Francisco, San Francisco
  • 3Department of Neurology and Stroke Center, University of California, Los Angeles, Los Angeles
  • 4Associate Editor, JAMA
JAMA. 2021;326(3):217-218. doi:10.1001/jama.2021.9917

For the past 2 decades, pharmacologic medical management to prevent first and recurrent ischemic stroke due to large and small artery atherothrombosis has focused on a 3-agent class approach: antithrombotic therapies, blood pressure– lowering medications, and low-density lipoprotein (LDL) cholesterol lowering with statins.1 However, in recent years randomized trials have demonstrated that several additional medical-pharmacologic strategies can confer additional protection. Because these advances have occurred incrementally and often with ischemic stroke prevention as just 1 component of general cardiovascular event prevention, they are not yet widely appreciated or used by general neurologists and vascular neurology clinicians. Increased awareness of these new agent classes and the evidence supporting them could help facilitate their routine addition to neurologic practice to attain the maximal possible reduction in stroke risk for patients.

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    3 Comments for this article
    Folate Treatment For Stroke Prevention
    Charles Brill, MD | Thomas Jefferson University
    A probable mechanism for folate's effectiveness is through lowering homocysteine (HC). HC can be elevated in carriers of homocysteinuria and patients who have 2 mutations for MTHFR, either homozygous or compound heterozygotes. This also applies to patients with classical migraine.
    Michael Plunkett, MD MBA | Teaching
    All these purported “studies” are deeply flawed. And the NNT to stop death or any meaningful MACE is >100. Not exactly cost-effective. The appeal for reincarnating folic acid is absurd. It’s only useful in severely poor parts of the world like rural China or rural Iran.

    Stick with good cholesterol control and good blood pressure control. Those are really cheap, proven incredibly effective, and essentially side effect-free. If Statins are not effective enough, go straight to the PCSK 9 inhibitors. Not cheap (but 57s cheaper than the new Alzheimers drug) and really bring down cholesterol.
    H Silverstein, MD | Preventive Medicine Center
    This article is certainly in the right direction and much appreciated. It might also be helpful to point out that hypertension, diabetes, and elevated lipids can be managed without medications or supplements: not easy but so doing offers freedom from medication use, medication-induced side effects, clinician visits, time inconvenience, savings in general, and reduced risks for cancer and many other conditions.