"Worldwide, strokes are the most common cause of death. This makes it a top priority for medicine to expand prevention in this area," says Prof. Dr. Karl Max Einhaupl, from the University Clinic Charite in Berlin, who is co-chair of the Annual Meeting of the European Neurological Society (ENS) taking place in Berlin from 19 to 23 June, 2010. Atrial fibrillation is of particular importance in stroke prevention. It is a heart arrhythmia which affects around 300,000 people in Germany, and which greatly increases the risk of stroke. "Blood thinning drugs can reduce the risk of stroke by up to 80% here," says Prof. Einhäupl. New substances such as dabigatran and rivaroxaban which can be taken orally, and without doctors having to undertake regular blood coagulation checks, should make life easier for doctors and patients once they are approved.

New drugs - Quick's test no longer necessary

Dabigatran and rivaroxaban, made by Boehringer Ingelheim and Bayer Health Care AG, should make daily life easier for both doctors and patients with atrial fibrillation. Patients taking standard blood thinning drugs such as marcumar, falithrom or warfarin until now had to have their blood coagulation regularly tested by a doctor. "With the new medications, these inconvenient tests on blood coagulation are no longer necessary. Dabigatran and also rivaroxaban are taken orally twice a day and that's it," says Prof. Einhäupl, explaining the advantages.

Fewer side effects - equal effectiveness

The effects of dabigatran were tested in the RE-LY study on 18,000 participants, and its findings are being discussed at the neurology congress in Berlin. "In general, the substance proved to be well tolerated. At the same efficacy, dabigatran had fewer side effects, and with higher efficacy approximately the same side effects as standard drugs," says Prof. Einhäupl. However it is too early for euphoria. " We still don't know enough about the long term effects of the drugs. Dabigatran has yet to be approved and is expected to be on the market by year's end. The effects of rivaroxaban are now being tested on patients with atrial fibrillation. There is of course always some level of risk „that a patient becomes a 'bleeder' as a result of the drugs," says Prof. Einhäupl. "Each individual case must be carefully weighed up. But as soon as an additional risk factor arises, when atrial fibrillation is already present, these measures should be employed." Among patients at risk are those over 60, diabetics and heavy smokers.

Stroke prevention through treating heart rhythm in atrial fibrillation

A new antiarrhythmic drug (dronedarone) could be of great importance in future in treating atrial fibrillation. A major international study (ATHENA) demonstrated that stroke risk was reduced relatively by 34%. Because stroke was not the primary objective of the study, further investigations are now necessary to confirm this surprising result. "And the mechanisms by which this effect is achieved are still unclear," says Prof. Einhäupl. The lower rate of side effects observed, compared to the precursor chemical Amiodarone, is also a benefit.

Secondary prevention in stroke patients: carotid operation as effective as stent

Further study results on the theme of operative secondary prevention of stroke are also available. After a stroke, one means as far as possible to prevent a repetition involves an operation to enlarge a constricted carotid artery. The German Stroke Society compared the carotid operation with the insertion of stents in the carotid artery. Stents are vascular supports which are inserted in blood vessels to keep them open. „Our suspicions were confirmed. Stent implantation offers no advantage over a well conducted carotid operation, but probably carries disadvantages," says Prof. Einhäupl. "The mortality risk or the risk of a further stroke are marginally higher for patients with stents. "I would then, other than in a few exceptions, always give preference to a well conducted carotid operation."

Longer therapeutic window for thrombolysis

Studies on thrombolysis presented at the neurology congress also demonstrate improved prospects for stroke victims. Thrombolysis involves administering drugs intravenously to break down blood clots. Medical guidelines until now have stipulated that thrombolysis should be carried out only within three hours of a stroke. "For this reason, and others, this treatment has been available to only a few patients," says Prof. Einhäupl. A large scale European study has now demonstrated that thrombolysis can be used safely and effectively up to four and a half hours later.

Experience at the Berlin Charité has shown that comprehensive rapidly conducted MRI examinations on acute stroke patients can offer new treatment options. In the course of clinical observation of 11 stroke patients with ischemia, after MRI examination thrombolysis was safely conducted. This was done although it was unclear when the patient had suffered the stroke. „The results show that those patients in whom the course of the stroke is unclear can also receive thrombolysis. The precondition is that the decision be made on the basis of precise MRT results," says Prof. Einhäupl. Further examinations show that thrombolysis can also be carried out on patients with acute stroke but mild symptoms.

European Neurological Society (ENS)

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