Stroke is a coronary heart disease risk equivalent: implications for future clinical trials in secondary stroke prevention

With an estimated 1 million cases per year in Europe, 1.2 million in North America, and 10 millions in the rest of the world, the burden of stroke is enormous. Stroke includes brain haemorrhage, transient ischaemic attacks (TIAs), and cerebral (brain) infarction (each of these causes accounting for approximately 15, 15, and 70% of cases, respectively).1,2 Overall, a quarter of all stroke patients has a history of a symptomatic coronary event.3 These patients are prone to recurrent coronary heart disease (CHD) events. In the PROGRESS trial, in the subset of patients with recent stroke and a history of CHD, the risk of a new CHD event was as high as the risk of a new stroke,4 but in the remainder of stroke patients without overt CHD, the risk of CHD events or pre-symptomatic CHD has not been well evaluated. The main modifiable risk factors in stroke patients include hypertension, diabetes, atrial fibrillation, cigarette smoking, hypercholesterolaemia, obesity, physical inactivity, and alcohol consumption.5 These factors increase the risk for other vascular disease, including CHD, except perhaps atrial fibrillation. As a consequence, stroke is usually part of a global disease. The REACH registry has shown that 40% of 19 000 stroke patients have one or two other locations of vascular disease such as coronary artery disease (CAD) and peripheral arterial disease.6 Patients with stroke are at high risk of having another major vascular event such as stroke, myocardial infarction (MI), or vascular death. Observational studies and clinical trials have shown that during the 2 years following a stroke, the next most common event …