Pierre Amarenco, author of this review, is one of the leading experts in stroke prevention. Trained at the prestigious school of Marie Germaine Bousser in Paris, during his scientific career Dr. Amarenco has made several important achievements; worth remembering are his reports on the role of aortic atheroma as a cause of stroke and his work on stroke-related predisposing genetic factors. Furthermore, over the last few years Dr. Amarenco has been focusing his interest on the effects of lipid-lowering therapy in the prevention of stroke.
The present review proves to be both complete and exhaustive, and is simultaneously well-balanced with its evaluation of currently available scientific evidence. Statins are now recognized as one of the key tools for preventing cardiovascular diseases, in particular, stroke-related data prove to be ever more convincing.
The SPARCL trial analyzed in detail both overall outcomes and results related to specific sub-groups with various etiopathogenetic mechanisms (atherothrombotic, small vessel disease, etc.), and was the first study to target primarily patients with cerebrovascular events.
Collective data show that the effectiveness of statins also applies to individual etiopathogenetic sub-groups without relevant statistical heterogeneity between them.
Some issues need to be explored further, such as the possibility of employing aggressive treatments or varying doses consistently with heterogeneous clinical symptoms and varied degrees of exposure to risk, although data from the literature indicates that a dose-response effect is likely to take place.
Collected data suggests that statins may potentially achieve a favourable effect even on patients suffering from small vessel disease (lacunar stroke), where hypertension represents the first (if not the only) risk factor. Nonetheless, it would seem appropriate to further analyze the risk/benefit ratio on patients suffering from extensive subcortical microvascular abnormalities (leukoaraiosis), which in turn leads to increased risk of cerebral haemorrhage.
Amarenco’s assessments and related directions about strategies for surveillance and monitoring of preventive treatment of patients at risk should be given the utmost consideration, particularly in general internal medicine. It is widely accepted that therapeutic inconsistancy, treatment inadequacy (with respect to the achievement of target pressure and LDL cholesterol values), and patient negligence in following physician directions are among the main causes for unsuccessful stroke prevention.
The present study therefore suggests a scenario where medical outpatient facilities specializing in cerebrovascular risks and employing nurse practitioners specifically trained in the prevention of vascular diseases can help in solving one of the main problems in secondary stroke prevention: inadequacy and inconsistancy of preventive control.