Secondary Prevention of Stroke in the Elderly: A Review of the Evidence

Abstract

Background

Stroke is a major health problem with significant impact on the affected individuals and the whole community. In light of stroke being the leading cause of disability, the ageing of the population and the high incidence of stroke among the elderly, highlight the importance of primary and secondary prevention interventions among this group. The elderly generally have been underrepresented in clinical trials, creating many uncertainties and less optimal medical care for this group of patients.

Objective

This review aims to make evidence-based management recommendations for secondary stroke prevention in the elderly.

Methods

Secondary prevention–related primary literature was identified using MEDLINE and PubMed (1982 to present) with combinations of the following search terms being employed: antiplatelets, aspirin, atrial fibrillation, elderly, geriatrics, hypertension, lipids, secondary prevention, statins, stroke, and warfarin. In addition, the references of these articles were also reviewed.

Results

Twenty-three clinical trials were included in this review, covering different aspects of secondary stroke prevention. Many of these trials were not specifically limited to the elderly, but conclusions related to their care can be derived from them. Although the American Heart Association/American Stroke Association guidelines suggest an equal benefit of aspirin, aspirin/dipyridamole, and clopidogrel in secondary prevention, the use of aspirin in the elderly may be preferred for reasons related to compliance and experience. Warfarin was largely avoided in the management of elderly stroke patients in the past, although available evidence demonstrates its efficacy and safety as a first choice for elderly patients with atrial fibrillation and presumed cardiac source of emboli. Lowering blood pressure among the elderly is an important aspect of secondary stroke prevention and can be achieved with the same agents used among younger age groups with a preference for a thiazide diuretic/angiotensin-converting enzyme inhibitor combination that has proven efficacy among elderly patients. Available evidence supports the use of statins among elderly patients with history of stroke or transient ischemic attack (TIA), and the derived benefit of treatment does not differ significantly from that in the younger age group. Elderly patients with 50% to 99% carotid artery stenosis and history of stroke or TIA should be considered for early carotid endarterectomy to reduce recurrent stroke.

Conclusion

Age should not be considered a barrier for the provision of optimal secondary prevention interventions. The available evidence supports similar and sometimes superior derived benefit from secondary preventive stroke measures in the elderly compared with that seen in younger patients.