脳梗塞の再発率（久山町研究） JNNP 76:368, 2005
Neurology 44:626, 1994
Nature Rev Neurol 6:477, 2010
4．WF 40~ 50％/1年
Secondary stroke prevention
J. David Spence
Secondary stroke prevention can reduce the risk of recurrent stroke by ≈90%. To achieve such a reduction, early implementation of preventative measures and administration of therapy appropriate to the underlying cause of the presenting transient ischemic attack or stroke are crucial. Smoking cessation and a Cretan Mediterranean diet are each more effective than any single medication in reducing the risk of recurrent stroke. Control of resistant hypertension can markedly reduce the risk of intracerebral hemorrhage and lacunar infarction but might require therapy that is specific to the underlying cause. New antiplatelet agents have been developed or are in development that might avoid the issues of resistance and drug interactions that prevail with established agents of this type. Furthermore, new anticoagulants in development offer promise of replacing warfarin, and devices to occlude the atrial appendage are on the horizon for patients with atrial fibrillation. Carotid endarterectomy is appropriate for severe symptomatic carotid stenosis, while stenting might be appropriate for symptomatic stenosis where the surgical risk is high. Most patients with asymptomatic stenosis, however, should be treated with medical therapy, unless indicators of high stroke risk are present. In this narrative Review, I discuss recent advances in secondary stroke prevention.
Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study
Brit Med J 338:b2337, 2009
Ann Int Med 145:1, 2006
Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors
A Randomized Trial
Background: The Mediterranean diet has been shown to have beneficial effects on cardiovascular risk factors.
Objective: To compare the short-term effects of 2 Mediterranean diets versus those of a low-fat diet on intermediate markers of cardiovascular risk.
Design: Substudy of a multicenter, randomized, primary prevention trial of cardiovascular disease (Prevención con Dieta Mediterránea [PREDIMED] Study).
Setting: Primary care centers affiliated with 10 teaching hospitals.
Participants: 772 asymptomatic persons 55 to 80 years of age at high cardiovascular risk who were recruited from October 2003 to March 2004.
Interventions: Participants were assigned to a low-fat diet (n = 257) or to 1 of 2 Mediterranean diets. Those allocated to Mediterranean diets received nutritional education and either free virgin olive oil, 1 liter per week (n = 257), or free nuts, 30 g/d (n = 258). The authors evaluated outcome changes at 3 months.
Measurements: Body weight, blood pressure, lipid profile, glucose levels, and inflammatory molecules.
Results: The completion rate was 99.6%. Compared with the low-fat diet, the 2 Mediterranean diets produced beneficial changes in most outcomes. Compared with the low-fat diet, the mean changes in the Mediterranean diet with olive oil group and the Mediterranean diet with nuts group were −0.39 mmol/L (95% CI, −0.70 to − 0.07 mmol/L) and − 0.30 mmol/L (CI, −0.58 to − 0.01 mmol/L), respectively, for plasma glucose levels; −5.9 mm Hg (CI, −8.7 to −3.1 mm Hg) and − 7.1 mm Hg (CI, −10.0 to −4.1 mm Hg), respectively, for systolic blood pressure; and −0.38 (CI, −0.55 to − 0.22) and − 0.26 (CI, −0.42 to −0.10), respectively, for the cholesterol–high-density lipoprotein cholesterol ratio. The Mediterranean diet with olive oil reduced C-reactive protein levels by 0.54 mg/L (CI, 1.04 to 0.03 mg/L) compared with the low-fat diet.
Limitations: This short-term study did not focus on clinical outcomes. Nutritional education about low-fat diet was less intense than education about Mediterranean diets.
Conclusion: Compared with a low-fat diet, Mediterranean diets supplemented with olive oil or nuts have beneficial effects on cardiovascular risk factors.
男 6700歩、女 5400歩 散歩5日/週
Urabe Stroke 2009
Prevalence of Abnormal Glucose Metabolism and Insulin Resistance Among Subtypes of Ischemic Stroke in Japanese Patients
Background and Purpose— The purpose was to assess the prevalence of disorders of glucose metabolism and insulin resistance in Japanese ischemic stroke patients with no history of diabetes by performing 75-gram oral glucose tolerance test (OGTT).
Methods— We recruited 427 ischemic stroke patients (atherothrombotic infarction, n=220; lacunar infarction, n=125; cardioembolic infarction, n=82). OGTT was used to evaluate disorders of glucose metabolism in stroke patients without previously known diabetes (n=113). We investigated the relationships among the prevalence of abnormal glucose metabolism, ischemic stroke subtypes, and the prevalence of insulin resistance using homeostasis model assessment for insulin resistance and immunoreactive insulin at 120 minutes after glucose loading (IRI120).
Results— OGTT identified the presence of disorders of glucose metabolism in 62.8% of ischemic stroke patients without previously known diabetes, including diabetes (24.8%) and impaired glucose tolerance (lone impaired glucose tolerance and impaired fasting glucose plus impaired glucose tolerance, 34.5%). The prevalence of newly diagnosed diabetes and impaired glucose tolerance was the highest in the atherothrombotic infarction group (68.9%). The highest values of homeostasis model assessment for insulin resistance and immunoreactive insulin at 120 minutes after glucose loading were found in atherothrombotic infarction patients with abnormal glucose tolerance.
Conclusions— In this study, a significantly large percentage of Japanese patients with ischemic stroke and no history of diabetes were found to have disorders of glucose metabolism by OGTT. Impaired glucose tolerance and insulin resistance could play an important pathogenic role in the development of atherothrombotic infarction.
HL、DM, HT, 肥満
Lancet 366:1279, 2005
The Lancet, 366:1279 – 1289, 2005
Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial
Patients with type 2 diabetes are at high risk of fatal and non-fatal myocardial infarction and stroke. There is indirect evidence that agonists of peroxisome proliferator-activated receptor γ (PPAR γ) could reduce macrovascular complications. Our aim, therefore, was to ascertain whether pioglitazone reduces macrovascular morbidity and mortality in high-risk patients with type 2 diabetes.
We did a prospective, randomised controlled trial in 5238 patients with type 2 diabetes who had evidence of macrovascular disease. We recruited patients from primary-care practices and hospitals. We assigned patients to oral pioglitazone titrated from 15 mg to 45 mg (n=2605) or matching placebo (n=2633), to be taken in addition to their glucose-lowering drugs and other medications. Our primary endpoint was the composite of all-cause mortality, non fatal myocardial infarction (including silent myocardial infarction), stroke, acute coronary syndrome, endovascular or surgical intervention in the coronary or leg arteries, and amputation above the ankle. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN NCT00174993.
Two patients were lost to follow-up, but were included in analyses. The average time of observation was 34·5 months. 514 of 2605 patients in the pioglitazone group and 572 of 2633 patients in the placebo group had at least one event in the primary composite endpoint (HR 0·90, 95% CI 0·80—1·02, p=0·095). The main secondary endpoint was the composite of all-cause mortality, non-fatal myocardial infarction, and stroke. 301 patients in the pioglitazone group and 358 in the placebo group reached this endpoint (0·84, 0·72—0·98, p=0·027). Overall safety and tolerability was good with no change in the safety profile of pioglitazone identified. 6% (149 of 2065) and 4% (108 of 2633) of those in the pioglitazone and placebo groups, respectively, were admitted to hospital with heart failure; mortality rates from heart failure did not differ between groups.
Pioglitazone reduces the composite of all-cause mortality, non-fatal myocardial infarction, and stroke in patients with type 2 diabetes who have a high risk of macrovascular events.
High-Dose Atorvastatin after Stroke or Transient Ischemic Attack
The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators
N Engl J Med 2006; 355:549-559August 10, 2006