The management of stroke in antiphospholipid syndrome.

Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.

Choosing the ideal drug for hypertension after ischemic stroke.

Controlling hypertension is known to be the most important treatment in preventing stroke. The past decade has been spent in debate over which class of hypertensive medication is most effective. This article reviews the studies assessing the efficacy of each agent class in secondary stroke prevention. The comparison of studies and agents is often difficult because of differences in achieved blood pressures and in the exact agents and combinations of agents that are used. Meta-analysis has attempted to resolve some of these difficulties by using meta-regression modeling to predict "expected" risk reduction given an achieved blood pressure. The resultant ability to give a value to "blood pressure-independent" effects is questioned. The effect of reducing blood pressure far outweighs any other effect in reducing stroke risk, and the agent that has been shown to be most consistently equal or superior to any agent compared with it has been amlodipine, a calcium-channel blocker.