Nicht medikamentöse Prophylaxe des Schlaganfalls

Einleitung

In Deutschland erleiden jedes Jahr ca. 150 000 Menschen einen Schlaganfall, d. h. ca. alle 3–4 min tritt ein Schlaganfall auf. Der Schlaganfall stellt die dritthäufigste Todesursache nach der koronaren Herzkrankheit (KHK) und malignen Erkrankungen dar. In den nächsten Jahren ist – nicht zuletzt aufgrund der demografischen Entwicklung – mit einem weiteren Anstieg der Schlaganfallinzidenz zu rechnen. Obwohl in den letzten Jahren wesentliche Fortschritte in der Akutbehandlung des Schlaganfalls zu verzeichnen sind (Thrombolyse, Behandlung auf der Stroke Unit, optimierte Frührehabilitation) ist der Schlaganfall nach wie vor die häufigste zu dauerhafter Behinderung führende Erkrankung; zurzeit leben in Deutschland 1–1,5 Mio. Menschen mit Behinderungen aufgrund eines Schlaganfalls. Von daher kommt einer gezielten Primärprävention und einer effektiven – an die Ätiopathogenese des Schlaganfalls angepassten – Sekundärprävention eine wesentliche Bedeutung zu. Neben medikamentösen Behandlungsoptionen (Antihypertensiva, Thrombozytenfunktionshemmer, Antikoagulation bei kardialer Emboliequelle, Statine etc.) gibt es auch zahlreiche und evidenzbasierte nicht medikamentöse Maßnahmen zur Primär- und Sekundärprävention des Schlaganfalls, wobei insbesondere in der jüngsten Zeit zahlreiche große kontrollierte Studien bzw. Metaanalysen publiziert wurden. In dieser Übersichtsarbeit wird der aktuelle Stand der nicht medikamentösen Schlaganfallprophylaxe vorgestellt. Dabei wird im ersten Teil auf den Stellenwert von Übergewicht, Nikotin- und Alkoholkonsum, Vitamingabe, körperlicher Aktivität, Schlaf-Apnoe-Syndrom, psychosozialem Stress und Hormontherapie für das Schlaganfallrisiko eingegangen. Im zweiten Teil werden Effektivität und Indikationen zur Sanierung einer symptomatischen bzw. asymptomatischen Karotisstenose – unter besonderer Berücksichtigung der aktuellen Vergleichsstudien zu Thrombendarterektomie (TEA) und stentgestützter perkutaner transluminaler Angioplastie (PTA) – dargestellt.

Literatur

• 1 Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. EUROASPIRE I and II Group. European Action on Secondary Prevention by Intervention to Reduce Events.  Lancet. 2001;  357 995-1001
• 2 Khaw K T, Wareham N, Bingham S. et al . Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study.  PLoS Med. 2008;  5 e12
• 3 York D A, Rossner S, Caterson I. et al . Prevention Conference VII: Obesity, a worldwide epidemic related to heart disease and stroke: Group I: worldwide demographics of obesity.  Circulation. 2004;  110 e463-470
• 4 Hu G, Tuomilehto J, Silventoinen K. et al . Body mass index, waist circumference, and waist-hip ratio on the risk of total and type-specific stroke.  Arch Intern Med. 2007;  167 1420-1427
• 5 Dagenais G R, Yi Q, Mann J F. et al . Prognostic impact of body weight and abdominal obesity in women and men with cardiovascular disease.  American heart journal. 2005;  149 54-60
• 6 Boden-Albala B, Sacco R L, Lee H S. et al . Metabolic syndrome and ischemic stroke risk: Northern Manhattan Study.  Stroke. 2008;  39 30-35
• 7 Bokura H, Yamaguchi S, Iijima K. et al . Metabolic Syndrome Is Associated With Silent Ischemic Brain Lesions.  Stroke. 2008;  39 1607-1609
• 8 Shinton R, Beevers G. Meta-analysis of relation between cigarette smoking and stroke.  BMJ. 1989;  298 789-794
• 9 Kelly T N, Gu D, Chen J. et al .Cigarette Smoking and Risk of Stroke in the Chinese Adult Population. Stroke 2008
• 10 Lawlor D A, Song Y M, Sung J. et al . The association of smoking and cardiovascular disease in a population with low cholesterol levels: a study of 648,346 men from the Korean national health system prospective cohort study.  Stroke. 2008;  39 760-767
• 11 Hankey G J, Warlow C P. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations.  Lancet. 1999;  354 1457-1463
• 12 Heuschmann P U, Heidrich J, Wellmann J. et al . Stroke mortality and morbidity attributable to passive smoking in Germany.  Eur J Cardiovasc Prev Rehabil. 2007;  14 793-795
• 13 Iribarren C, Darbinian J, Klatsky A L. et al . Cohort study of exposure to environmental tobacco smoke and risk of first ischemic stroke and transient ischemic attack.  Neuroepidemiology. 2004;  23 38-44
• 14 Hughes J R, Stead L F, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2003 CD000031
• 15 Silagy C, Lancaster T, Stead L. et al .Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004 CD000146
• 16 Fiore M C. Treating tobacco use and dependence: an introduction to the US Public Health Service Clinical Practice Guideline.  Respir Care. 2000;  45 1196-1199
• 17 Goldstein L B, Adams R, Alberts M J. et al . Primary prevention of ischemic stroke: a guideline from the American Heart Association / American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline.  Stroke. 2006;  37 1583-1633
• 18 Reynolds K, Lewis B, Nolen J D. et al . Alcohol consumption and risk of stroke: a meta-analysis.  JAMA. 2003;  289 579-588
• 19 Mukamal K J, Ascherio A, Mittleman M A. et al . Alcohol and risk for ischemic stroke in men: the role of drinking patterns and usual beverage.  Annals of internal medicine. 2005;  142 11-19
• 20 He K, Rimm E B, Merchant A. et al . Fish consumption and risk of stroke in men.  JAMA. 2002;  288 3130-3136
• 21 Mozaffarian D, Longstreth Jr W T, Lemaitre R N. et al . Fish consumption and stroke risk in elderly individuals: the cardiovascular health study.  Arch Intern Med. 2005;  165 200-206
• 22 Myint P K, Welch A A, Bingham S A. et al . Habitual fish consumption and risk of incident stroke: the European Prospective Investigation into Cancer (EPIC)-Norfolk prospective population study.  Public health nutrition. 2006;  9 882-888
• 23 Arnlov J, Vessby B, Riserus U. Coffee consumption and insulin sensitivity.  JAMA. 2004;  291 1199-1201
• 24 Lopez-Garcia E, van Dam R M, Qi L. et al . Coffee consumption and markers of inflammation and endothelial dysfunction in healthy and diabetic women.  The American journal of clinical nutrition. 2006;  84 888-893
• 25 Leys D, Deplanque D, Mounier-Vehier C. et al . Stroke prevention: management of modifiable vascular risk factors.  J Neurol. 2002;  249 507-517
• 26 Mozaffarian D, Fried L P, Burke G L. et al . Lifestyles of older adults: can we influence cardiovascular risk in older adults?.  Am J Geriatr Cardiol. 2004;  13 153-160
• 27 Larsson S C, Mannisto S, Virtanen M J. et al .Coffee and Tea Consumption and Risk of Stroke Subtypes in Male Smokers. Stroke 2008
• 28 Larsson S C, Virtanen M J, Mars M. et al . Magnesium, calcium, potassium, and sodium intakes and risk of stroke in male smokers.  Arch Intern Med. 2008;  168 459-465
• 29 Dauchet L, Amouyel P, Dallongeville J. Fruit and vegetable consumption and risk of stroke: a meta-analysis of cohort studies.  Neurology. 2005;  65 1193-1197
• 30 Mellen P B, Walsh T F, Herrington D M. Whole grain intake and cardiovascular disease: a meta-analysis.  Nutr Metab Cardiovasc Dis. 2008;  18 283-290
• 31 Cook N R, Cutler J A, Obarzanek E. et al . Long-term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP).  BMJ. 2007;  334 885
• 32 Fung T T, Chiuve S E, McCullough M L. et al . Adherence to a DASH-Style Diet and Risk of Coronary Heart Disease and Stroke in Women.  Arch Intern Med. 2008;  168 713-720
• 33 Voko Z, Hollander M, Hofman A. et al . Dietary antioxidants and the risk of ischemic stroke: the Rotterdam Study.  Neurology. 2003;  61 1273-1275
• 34 Larsson S C, Mannisto S, Virtanen M J. et al . Folate, Vitamin B₆, Vitamin B₁₂, and Methionine Intakes and Risk of Stroke Subtypes in Male Smokers.  Am J Epidemiol. 2008;  167 954-961
• 35 Vivekananthan D P, Penn M S, Sapp S K. et al . Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials.  Lancet. 2003;  361 2017-2023
• 36 Bonaa K H, Njolstad I, Ueland P M. et al . Homocysteine lowering and cardiovascular events after acute myocardial infarction.  N Engl J Med. 2006;  354 1578-1588
• 37 Lonn E, Yusuf S, Arnold M J. et al . Homocysteine lowering with folic acid and B vitamins in vascular disease.  N Engl J Med. 2006;  354 1567-1577
• 38 Wang X, Qin X, Demirtas H. et al . Efficacy of folic acid supplementation in stroke prevention: a meta-analysis.  Lancet. 2007;  369 1876-1882
• 39 Sander D, Poppert H, Sander K. Nichtmedikamentöse Prophylaxe des Schlaganfalls.  Akt Neurol. 2006;  33 403-411
• 40 Lee C D, Folsom A R, Blair S N. Physical activity and stroke risk: a meta-analysis.  Stroke. 2003;  34 2475-2481
• 41 Wendel-Vos G C, Schuit A J, Feskens E J. et al . Physical activity and stroke. A meta-analysis of observational data.  Int J Epidemiol. 2004;  33 787-798
• 42 Yaggi H K, Concato J, Kernan W N. et al . Obstructive sleep apnea as a risk factor for stroke and death.  N Engl J Med. 2005;  353 2034-2041
• 43 Munoz R, Duran-Cantolla J, Martinez-Vila E. et al . Severe sleep apnea and risk of ischemic stroke in the elderly.  Stroke. 2006;  37 2317-2321
• 44 Sahlin C, Sandberg O, Gustafson Y. et al . Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year follow-up.  Arch Intern Med. 2008;  168 297-301
• 45 Giles T L, Lasserson T J, Smith B J. et al .Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006 CD001106
• 46 Marin J M, Carrizo S J, Vicente E. et al . Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study.  Lancet. 2005;  365 1046-1053
• 47 Salaycik K J, Kelly-Hayes M, Beiser A. et al . Depressive symptoms and risk of stroke: the Framingham Study.  Stroke. 2007;  38 16-21
• 48 Bos M J, Linden T, Koudstaal P J. et al . Depressive Symptoms and Risk of Stroke: The Rotterdam Study.  J Neurol Neurosurg Psychiatry. 2008;  , doi DOI: 10.1136/jnnp.2007.134965
• 49 Surtees P G, Wainwright N W, Luben R N. et al . Psychological distress, major depressive disorder, and risk of stroke.  Neurology. 2008;  70 788-794
• 50 Rossouw J E, Anderson G L, Prentice R L. et al . Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial.  JAMA. 2002;  288 321-333
• 51 Viscoli C M, Brass L M, Kernan W N. et al . A clinical trial of estrogen-replacement therapy after ischemic stroke.  N Engl J Med. 2001;  345 1243-1249
• 52 Simon J A, Hsia J, Cauley J A. et al . Postmenopausal hormone therapy and risk of stroke: The Heart and Estrogen-progestin Replacement Study (HERS).  Circulation. 2001;  103 638-642
• 53 Rijbroek A, Wisselink W, Vriens E M. et al . Asymptomatic carotid artery stenosis: past, present and future. How to improve patient selection?.  Eur Neurol. 2006;  56 139-154
• 54 Inzitari D, Eliasziw M, Gates P. et al . The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.  N Engl J Med. 2000;  342 1693-1700
• 55 Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).  Lancet. 1998;  351 1379-1387
• 56 Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.  N Engl J Med. 1991;  325 445-453
• 57 Baker W H, Howard V J, Howard G. et al . Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS Investigators.  Stroke. 2000;  31 2330-2334
• 58 Wardlaw J. Carotid imaging for secondary stroke prevention in routine practice.  International Journal of Stroke. 2008;  3 20-32
• 59 Wardlaw J M, Chappell F M, Best J J. et al . Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis.  Lancet. 2006;  367 1503-1512
• 60 Back M R, Rogers G A, Wilson J S. et al . Magnetic resonance angiography minimizes need for arteriography after inadequate carotid duplex ultrasound scanning.  J Vasc Surg. 2003;  38 422-430; discussion 431
• 61 Mathiesen E B, Bonaa K H, Joakimsen O. Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the tromso study.  Circulation. 2001;  103 2171-2175
• 62 Esposito L, Sievers M, Sander D. et al . Detection of unstable carotid artery stenosis using MRI.  J Neurol. 2007;  254 1714-1722
• 63 Wasserman B A, Wityk R J, Trout 3rd H H, Virmani R. Low-grade carotid stenosis: looking beyond the lumen with MRI.  Stroke. 2005;  36 2504-2513
• 64 Takaya N, Yuan C, Chu B. et al . Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MRI – initial results.  Stroke. 2006;  37 818-823
• 65 Hellings W E, Moll F L, de Vries J P. et al . Atherosclerotic plaque composition and occurrence of restenosis after carotid endarterectomy.  JAMA. 2008;  299 547-554
• 66 Naylor A R, Rothwell P M, Bell P R. Overview of the principal results and secondary analyses from the European and North American randomised trials of endarterectomy for symptomatic carotid stenosis.  Eur J Vasc Endovasc Surg. 2003;  26 115-129
• 67 Barnett H J, Taylor D W, Eliasziw M. et al . Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.  N Engl J Med. 1998;  339 1415-1425
• 68 Rothwell P M, Eliasziw M, Gutnikov S A. et al . Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.  Lancet. 2004;  363 915-924
• 69 Rothwell P M, Eliasziw M, Gutnikov S A. et al . Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke.  Stroke. 2004;  35 2855-2861
• 70 Alamowitch S, Eliasziw M, Barnett H J. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease.  Stroke. 2005;  36 27-31
• 71 Dodick D W, Meissner I, Meyer F B. et al . Evaluation and management of asymptomatic carotid artery stenosis.  Mayo Clin Proc. 2004;  79 937-944
• 72 Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.  JAMA. 1995;  273 1421-1428
• 73 Halliday A, Mansfield A, Marro J. et al . Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial.  Lancet. 2004;  363 1491-1502
• 74 Moore W S, Vescera C L, Robertson J T. et al . Selection process for surgeons in the Asymptomatic Carotid Atherosclerosis Study.  Stroke. 1991;  22 1353-1357
• 75 Bond R, Rerkasem K, Shearman C P. et al . Time trends in the published risks of stroke and death due to endarterectomy for symptomatic carotid stenosis.  Cerebrovasc Dis. 2004;  18 37-46
• 76 Rothwell P M. ACST: which subgroups will benefit most from carotid endarterectomy?.  Lancet. 2004;  364 1122-1123; author reply 1125–1126
• 77 Chaturvedi S, Bruno A, Feasby T. et al . Carotid endarterectomy – an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.  Neurology. 2005;  65 794-801
• 78 Sabeti S, Schlager O, Exner M. et al . Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients.  Stroke. 2007;  38 2887-2894
• 79 Yadav J S, Wholey M H, Kuntz R E. et al . Protected carotid-artery stenting versus endarterectomy in high-risk patients.  N Engl J Med. 2004;  351 1493-1501
• 80 Fayad P. Endarterectomy and stenting for asymptomatic carotid stenosis: a race at breakneck speed.  Stroke. 2007;  38 707-714
• 81 Gurm H S, Yadav J S, Fayad P. et al . Long-term results of carotid stenting versus endarterectomy in high-risk patients.  N Engl J Med. 2008;  358 1572-1579
• 82 Ringleb P A, Allenberg J, Bruckmann H. et al . 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial.  Lancet. 2006;  368 1239-1247
• 83 Mas J L, Chatellier G, Beyssen B. et al . Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis.  N Engl J Med. 2006;  355 1660-1671
• 84 Kern R, Ringleb P A, Hacke W. et al . Stenting for carotid artery stenosis.  Nat Clin Pract Neurol. 2007;  3 212-220
• 85 Stingele R, Berger J, Alfke K. et al . Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study.  Lancet neurology. 2008;  7 216-222
• 86 Bates E R, Babb J D, Casey Jr D E. et al . ACCF / SCAI / SVMB / SIR / ASITN 2007 clinical expert consensus document on carotid stenting: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF / SCAI / SVMB / SIR / ASITN Clinical Expert Consensus Document Committee on Carotid Stenting).  J Am Coll Cardiol. 2007;  49 126-170