Curicullum Vitae

NAMA : dr.Christianus Rumantir,Sp.S

TEMPAT/TGL LAHIR : Jakarta, Juli 1949
ALAMAT : Jalan Cempaka no 72 - PEKANBARU
PENDIDIKAN :
Dokter Umum : FK Univ Atmajaya, Jakarta, 1976
Dokter Spesialis: FK Univ Padjadjaran, Bandung, 1986
PEKERJAAN :
Dokter Puskesmas Wuasa & Gintu , Kab.Poso. Sulawesi Tengah 1978-80
Dokter Puskesmas Tentena, Kab.Poso, Sulawesi Tengah 1980-81
Dokter RS Hasan Sadikin, Bandung 1982-86
Dokter Spesialis Saraf Di RSUD Arifin Achmad, Pekanbaru 1986 - sekarang
ORGANISASI :
Anggota IDI , PERDOSSI , IKKI

21 Oktober 2011 1
 PRIMARY PREVENTION OF
ISCHEMIC STROKE.
WHATS THE GUIDELINE SAID?

SIMPOSIUM NASIONAL BRAIN AND HEART XII

Christianus Rumantir,Sp.S
Bagian/SMF Saraf FK UR / RSUD AA
Pekanbaru
21 Oktober 2011 2
 INTRODUCTION
Stroke
remains a major healthcare problem
the third leading cause of death
incidence may be increasing; from 1988 to 1997,
total stroke hospitalizations increased 38.6 %
a leading cause of functional impairments,
20% requiring institutional care after 3 months
15% to 30% permanently disabled
The affects not only the person who may be
disabled, but the entire family & other caregivers as
well.
21 Oktober 2011 3
 INTRODUCTION (cont)
Despite the advent of th/ of acute ischemic stroke,
effective prevention remains the best treatment for
reducing the burden of stroke.
More than 790,000 strokes that occur each year in US
75% of those are first events, "so primary
prevention is particularly important.
In UK: age-specific incidence of major stroke has
fallen by 40% over the past 20 yrs, association with an
increased use of preventive treatments & general
reductions in risk factors

21 Oktober 2011 4
 RISK FACTORS

Nonmodifiable Risk Factors

Well Documented & Modifiable
Risk Factors
Less Well-Documented or
Potentially Modifiable Risk Factors

21 Oktober 2011 5
Nonmodifiable Risk Factors

Age
Sex
Low birth weight
Race-ethnicity
Genetic factors

21 Oktober 2011 6
 Age

The cumulative effects of aging on Cardiovascular

system & the progressive nature of stroke risk
factors over a prolonged period of time .
The risk of stroke doubles for each successive
decade after age 55 years.

1. AHA/ASA Guideline. Stroke 2011, 42:517-584

21 Oktober 2011 7
 Sex

Men > women.

Men also generally have higher age-specific
stroke incidence rates than women.
Exceptions are in 35 44 yrs & in those >85 yrs of
age groups in which women have slightly greater
age-specific stroke incidence than men.

1. AHA/ASA Guideline. Stroke 2011, 42:517-584

21 Oktober 2011 8
 Low Birth Weight
Stroke mortality rates among adults in Engl and &
Wales are higher who had LBW.
A similar study compared a group of South Carolina
Medicaid . The odds of stroke were more than
double for those with BW <2500 g as compared with
4000 g (with a significant linear trend for
intermediate birth weights).
However, the reason for this relationship remains
uncertain.
1. AHA/ASA Guideline. Stroke 2011, 42:517-584
21 Oktober 2011 9
 Race-Ethnicity
Racial & ethnic effects on disease risk can be difficult
to consider separately.
Stroke incidence & mortality rates :
African Americans & some Hispanic Americans >
European Americans.
Incidence rates are also relatively > among some
Asian groups.

1. AHA/ASA Guideline. Stroke 2011, 42:517-584

21 Oktober 2011 10
 Genetic Factors
Both paternal & maternal history of stroke have been
associated with an increased stroke risk.
This increased risk could be mediated through a
variety of mechanisms.
Monozygotic are markedly higher than in dizygotic
twins, nearly 5-fold increase in stroke prevalence
among monozygotic .

1. AHA/ASA Guideline. Stroke 2011, 42:517-584

21 Oktober 2011 11
Well Documented & Modifiable
Risk Factors

21 Oktober 2011 12
 Hypertension
The JNC 7 report, regular BP screening & appropriate
treatment, incl. both lifestyle modification &pharma-
cological th/, are recommended (Class I; LoE A). [1,
2,3]
BP should be checked regularly [2]
SBP should be treated to a goal of 140 mm Hg & DBP
to 90 mm Hg (Class I; LoE A). [1, 3,5]
In pts with HT with DM or renal dis, the BP goal is
130/80 mm Hg (Class I; LoE A). [1,3,5]

21 Oktober 2011 13
 Hypertension (cont)
For prehypertensive : (120139/8090 mm Hg) with
congestive heart failure, MI, diabetes, or chronic
renal failure antihypertensive medication is indicated
(Class 1, Level A). [2]
Antihypertensive therapy in subjects with HT is
strongly recommended (A). [4]

21 Oktober 2011 14
 Hypertension (cont)
Systolic hypertension in the elderly should be treated
with the same principles & methods as other
hypertension (LOE: Ia). [3]
For primary stroke prevention, an adequate BP
control is the most important rather than choosing a
specific class of antihypertensive agent. However
CCB or RA system inhibitors are recommended over
BB (LOE: Ia). [3,5]

21 Oktober 2011 15
 Cigarette smoking
Abstention from cigarette smoking by nonsmokers &
smoking cessation by current smokers are recommend-
ed based on epid. studies showing a consistent &
overwhelming relationship between smoking & both
ischemic stroke & SAH.(Class I; LoE B). [1,5]
Although data are lacking that avoidance of
environmental tobacco smoke reduces incident stroke,
On the basis of epid. data showing increased stroke risk
& the effects of avoidance on risk of other cardio-
vascular events, avoidance of exposure to environ-
mental tobacco smoke is reasonable (Class IIa; LoE ). [1]

21 Oktober 2011 16
 Cigarette smoking (cont)

Tobacco use status should be addressed at every

patient encounter (Class I; LoE B). [1]
It is recommended that cigarette smoking be
discouraged & should be strongly advised to quit
(Class III, Level B). [2,3,5]

21 Oktober 2011 17
 Diabetes
In DM pts, comprehensive & aggressive
evaluations & Th/ are needed to manage not only
bld gluc but other risk factors such as HT, hyperlipid,
& smoking. (LOE: Ib). [3]
DM & high BP should be managed intensively (Class
I, Lev A). [3]
Th/ of hypertension in adults with DM with an ACEI
or an ARB is useful (Class I; LoE A). [1,2,5]

21 Oktober 2011 18
 Diabetes (cont)

Control of HT is strongly recommended for primary

prevention of stroke (A). [4]
In DM pts, a more aggressive & rigorous blood
glucose control is recommended for prevention of
cerebrocardiovascular events (LOE: Ia). [3] as
reflected in the JNC 7 guidelines is recommended
(Class I; LoE A). [1,5]

21 Oktober 2011 19
 Diabetes (cont)
The use of monotherapy with a fibrate to lower
stroke risk might be considered for pts with DM
(Class IIb; LoE B). [1]
Th/ of adults with DM with a statin, especially those
with additional risk factors, is recommended to lower
risk of a first stroke (Class I; LoE A). [1]
The recommended target BP & LDL cholesterol level
are 130/80mmHg (LOE: Ib) & 100 mg/dL (LOE: Ia),
respectively. [3]

21 Oktober 2011 20
 Diabetes (cont)
The benefit of aspirin for reduction of stroke risk has
not been satisfactorily demonstrated for pts with
DM; however, administration of aspirin may be
reasonable in those at high CVD risk (Class IIb). [1].
Type 2 DM who have additional risk factors,
aggressive lipid lowering with a statin is
recommended for prim prev of stroke
(LOE: Ib). [3]

21 Oktober 2011 21
 Dyslipidemia
Th/ with statin in addition to th/ lifestyle changes
with LDL-C goals as reflected in the NCEP Guidelines
is recommended for prim prev of ischemic stroke in
pts with coronary HD or certain high-risk conditions
such as DM (Class I; LoE A). [1,5]
Blood cholesterol should be checked regularly. High
blood cholesterol should be managed with lifestyle
modification (Class IV, Lev C) & a statin (Class I, Lev
A). [2]

21 Oktober 2011 22
 Dyslipidemia (cont..)

Large doses of statin are effective to prevent

ischemic stroke in dyslipidemic patients with
coronary HD (A). [2]
For HT pts with or at high risk of CAD, statin th/ along
with lifestyle modification is recommended even at a
normal LDL -C level (LOE: Ia). [1]

21 Oktober 2011 23
 Dyslipidemia (cont..)
In DM adults, the target LDL-C of 100 mg/dL is
recommended (LOE: Ia). [1]
For type 2 DM pts who also have other risk factors,
lipid-lowering with statins is recommended for prim
prev of stroke (LOE: Ib). [1]
For pts with CAD & a low HDL-C level, niacin or
gemfibrozil may be recommended along with weight
loss, physical activity, & smoking cessation (LOE: Ib).
[1]

21 Oktober 2011 24
 Atrial Fibrillation
Active screening for AF in pts 65 yrs of age in primary
care settings using pulse taking followed by ECG as
indicated can be useful (Class IIa; LoE B). [1,5]
Adjusted-dose warfarin (target INR 2.0 to 3.0) is
recommended for all pts with nonvalvular AF
deemed to be at high risk & many deemed to be at
moderate risk for stroke who can receive it safely
(Class I; LoE A). [1,5]
Antiplatelet th/ with aspirin is recommended for low-
risk & some moderate-risk pts with AF. (Class I; LoE
A). [1,5]

21 Oktober 2011 25
 Atrial Fibrillation (cont..)
For high-risk pts with AF deemed unsuitable for
anticoagulation, dual antiplatelet th/ with clopidogrel
& asa offers more protection against stroke than asa
alone but with increased risk of major bleeding &
might be reasonable (Class IIb; LoE B). [1]
Aggressive management of BP coupled with
antithrombotic prophylaxis in elderly pts with AF can
be useful (Class IIa; LoE B). [1,5]

Stroke 2011, 42:517-584

21 Oktober 2011 26
 Atrial Fibrillation (cont..)
Non-valvular atrial fibrillation (NVAF) patients with
history of stroke, TIA, coronary heart disease or
cardiac failure, with HT or DM, or aged 70 years
should receive warfarin (A). [4]
In non-valvular AF, antithrombotic th/ (warfarin or
asa) is recommended for prim stroke prev. Selection
of th/ (warfarin or asa) should be individualized
based on thromboembolic risk, bleeding risk, pts
preference, & feasibility of anticoagulation
monitoring (LOE: Ia). [3]
21 Oktober 2011 27
 Atrial Fibrillation (cont..)
Warfarin (INR 2.0-3.0) is also recommended for
primary prevention of stroke in elderly AF patients
aged 75 & >. (LOE: Ib). [3]
Generally, INR should be maintained between 2,0 &
3,0 (A). However, INR 1,6 2,6 is recommended in
aged subjects ( > 70 years old) (B). [4] Only when
warfarin is contraindicated should asa be used (B).
[4]
In AF pts with valvular HD (particularly those with
mechanical valves), anticoagulation is recommended
(LOE: Ia). [3]
21 Oktober 2011 28
 Other cardiac conditions

ACC/AHA practice guidelines providing strategies to

reduce the risk of stroke in pts with a variety of
cardiac conditions, incl. valvular HD, unstable
angina, chronic stable angina, & acute MI are
endorsed.

21 Oktober 2011 29
 Asymptomatic carotid stenosis

Pts with ACS should be screened for other treatable

risk factors for stroke with institution of appropriate
lifestyle changes & medical th/. (Class I; LoEC). [1]
The use of asa in conjunction with CEA is
recommended unless contraindicated, as an
antiplatelet drug (Class I; LoE C).[1,5]

21 Oktober 2011 30
 Asymptomatic carotid stenosis
(cont)
Prophylactic CEA performed with 3% morbidity &
mortality can be useful in highly selected pts with an
asymptomatic carotid stenosis (minimum 60% by
angiography, 70% by validated Doppler ultrasound)
(Class IIa; LoE A). [1,5]
The usefulness of CAS as an alternative to CEA in
asymptomatic pts at high risk for the surgical
procedure is uncertain (Class IIb; LoE C). [1,5]

21 Oktober 2011 31
Asymptomatic carotid stenosis
(cont)

Population screening for asymptomatic carotid artery

stenosis is not recommended (Class III; LoE B). [1,5]
In patientswith asymptomatic cerebral infarction,
management of HT is a priority (B).[4]

21 Oktober 2011 32
 Sickle cell disease
Children with SCD should be screened with TCD
starting at age 2 years (Class I; LoE B). [1,5]
Transfusion th/ (target reduction of hb S from a
baseline of 90% to 30%) is effective for reducing
stroke risk in those children at elevated stroke risk
(Class I; LoE B). [1,5]
In children at high risk for stroke who are unable or
unwilling to be treated with regular red blood cell
transfusion, it might be reasonable to consider
hydroxyurea or bone marrow transplantation (Class
IIb; LoE C). [1]
21 Oktober 2011 33
 Sickle cell disease (cont)
MRI & MRA criteria for selection of children for
primary stroke prev. using transfusion have not been
established, & these tests are not recommended in
place of TCD for this purpose (Class III; LoE B).[1,5]
Adults with SCD should be evaluated for known
stroke risk factors & managed according to the
general guidelines in this statement (Class I; LoE
A).[1]

Stroke 2011, 42:517-584

21 Oktober 2011 34
 Postmenopausal hormone
therapy
Hormone therapy (CEE with or without MPA) should
not be used for primary prevention of stroke in
postmenopausal women (Class III; LoE A).[15]
HRT is not recommended for the primary prevention
of stroke (Class I, Level A) [2,5]
SERMs, such as raloxifene, tamoxifen, or tibolone,
should not be used for primary prevention of stroke
(Class III; LoE A).[1]

21 Oktober 2011 35
 Oral contraceptives
OCs may be harmful in women with additional risk
factors (eg cigarette smoking, prior thromboembolic
events) (Class III; LoE C).[1,5]
For those who choose to use OCs despite the
increased risk associated with their use, aggressive
therapy for stroke risk factors may be reasonable
(Class IIb; LoE C). [1]

21 Oktober 2011 36
 Diet & nutrition
Reduced intake of Na & increased intake of K are
recommended to lower BP (Class I; LoE A).[1,5]
A DASH-style diet, which emphasizes consumpton of
fruits, vegetables, & low-fat dairy products & is
reduced in saturated fat, also lowers BP & is
recommended (Class I; LoE A).[1,5]
A diet that is rich in fruits & vegetables & thereby
high in potassium is beneficial & may lower risk of
stroke (Class I; LoE B) [1,5]

21 Oktober 2011 37
 Diet & nutrition (cont)

Antioxidant vitamin supplements are not

recommended (Class I, Lev A). [2]
A diet low in salt & saturated fat, high in fruit &
vegetables & rich in fibre is recommended (Class III,
Lev B). [2]

21 Oktober 2011 38
 Physical inactivity
Increased physical activity is recommended because
it is associated with a reduction in risk of stroke
(Class I; LoE B).[1,5]; Regular physical activity is
recommended (Class III, Lev B) [2]
The 2008 Physical Activity Guidelines for Americans
are endorsed & recommend that adults should
engage in at least 150 mins (2 hrs ,30 mins)/week of
moderate intensity or 75 mins (1 hr, 15 mins) /week
of vigorous intensity aerobic physical activity (Class I;
LoE B). [1,5]
21 Oktober 2011 39
 Obesity & body fat
distribution
Among overweight & obese persons, weight
reduction is recommended as a means to lower BP
(Class I; LoE A). [1,5]; and reasonable as a means of
reducing risk of stroke (Class IIa; LoE B).[1,5]
Subjects with an elevated body mass index are
recommended to take a weight-reducing diet (Class
III, Lev B). [2]

21 Oktober 2011 40
 Less Well-Documented or
Potentially Modifiable Risk Factors

21 Oktober 2011 41
 Migraine
o Because there is an association between higher
migraine frequency & stroke risk, th/ to reduce
migraine frequency might be reasonable, although
there are no data showing that this th/ approach
would reduce the risk of first stroke (Class IIb; LoE
C).[1,5]

Stroke 2011, 42:517-584

21 Oktober 2011 42
 Metabolic syndrome
o Management of individual components of the
metabolic syndrome is recommended, including
lifestyle measures (ie, exercise,appropriate weight
loss, proper diet) & pharmacotherapy (ie,
medications for lowering BP, lowering lipids, glycemic
control, & antiplatelet th/) [1]

21 Oktober 2011 43
 Alcohol consumption
o For numerous health considerations: reduction /
elimination of alcohol consumption by heavy
drinkers as described in the US Preventive Services
Task Force Recommendation Statement of 2004 are
recommended (Class I; LoE A). [1,5]
o For persons who choose to consume alcohol,
consumption of 2 drinks per day for men & 1 drink
per day for nonpregnant women might be
reasonable. (Class IIb; LoE B). [1]

21 Oktober 2011 (44

 Drug abuse

o Referral to an appropriate therapeutic program is

reasonable for pts with drug abuse (Class IIa; LoE C).
[1,5]

21 Oktober 2011 45
 Sleep-disordered breathing
o Because of its association with other vascular risk
factors & cardiovascular morbidity, evaluation for
SDB through a detailed history & if indicated, specific
testing is recommended, particularly in those with
abdominal obesity, hypertension, heart dis, or drug-
resistant hypertension (Class I; LoE A).[1,5]
o Treatment of sleep apnea to reduce the risk of stroke
might be reasonable, although its effectiveness is
unknown (Class IIb; LoE C) [1]

21 Oktober 2011 46
 Hyperhomocysteinemia
o The use of the B-complex vit, pyridoxine (B6),
cobalamin (B12), & folic acid, might be considered
for prev of ischemic stroke in pts with hyper-
homocysteinemia, but its effectiveness is not well
established (Class IIb; LoE B). [1,5]

21 Oktober 2011 47
 Hypercoagulability
The usefulness of specific th/ for primary stroke prev
in asymptomatic pts with hereditary or acquired
thrombophilia is not well established (Class IIb; LoE
C). [1,5]
Low-dose aspirin (81 mg/d) is not indicated for
primary stroke prev in persons who are persistently
aPL positive (Class III; LoE B). [1]

21 Oktober 2011 ,548

 Inflammation & infection
Measurement of inflammatory markers such as hs-
CRP or Lp-PLA2 in pts without CVD may be
considered to identify pts who may be at increased
risk of stroke, although their effectiveness (ie,
usefulness in routine clinical practice) is not well
established (Class IIb; LoE B). [1,5]
Pts with chronic inflammatory disease such as RA or
SLE should be considered at increased risk for stroke
(Class I; LoE B). [1,5]

21 Oktober 2011 49
 Aspirin for primary stroke
prevention
o The use of aspirin (asa) for cardiovascular (including
but not specific to stroke) prophylaxis is
recommended for persons whose risk is sufficiently
high for the benefits to outweigh the risks associated
with th/ (a 10-year risk of cardiovascular events of
6% to 10%) (Class I; LoE A). [1]
o Asa (81 mg daily or 100 mg every other day) can be
useful for prev of a first stroke among women whose
risk is sufficiently high for the benefits to outweigh
the risks associated with th/. (Class IIa; LoE B). [1]

21 Oktober 2011 50
 Aspirin for primary
stroke prevention (cont)
o Asa is not useful for preventing a first stroke in
persons at low risk (Class III; LoE A). [1]
o Asa is not useful for preventing a first stroke in
persons with DM or DM plus asymptomatic
peripheral artery disease in the absence of other
established CVD (Class III; LoE B). [1]
o The use of asa for other specific situations (eg, atrial
fibrillation, carotid artery stenosis) is discussed in the
relevant sections of this statement. [1]

21 Oktober 2011 51
 Aspirin for primary stroke
prevention (cont)
o Low-dose asa is recommended in women 45 yrs/>,
who are not at increased risk for ICH & have good
gastrointestinal tolerance; however, its effect is very
small (Class I, Level A). [2]
o It is recommended that low-dose asa may be
considered in men for the primary prev of MI;
however, it does not reduce the risk of ischaemic
stroke (Class I, Level A). [2]

21 Oktober 2011 52
 Aspirin for primary stroke
prevention (cont)

o Antiplatelet agents other than asa are not

recommended for primary stroke prev (Class IV) [2]
o Asa may be recommended for patients with non-
valvular AF who are younger than 65 years & free of
vascular risk factors (Class I, Level A) [2]

21 Oktober 2011 53
 Aspirin for primary stroke
prevention (cont)
o Unless contraindicated, either asa or an oral anti-
coagulant (INR, 2.03.0) is recommended for pts
with non-valvular AF who are aged 6575 yrs & free
of vascular risk factors (Class I, Level A) [2]
o Unless contraindicated, an oral anticoagulant (INR
2.03.0) is recommended for pts with non-valvular
AF who are aged >75, or who are younger but have
risk factors such as high BP, LV dysfunction, or DM
(Class I, Level A) [2]

21 Oktober 2011 54
 Aspirin for primary stroke
prevention (cont)
o It is recommended that patients with AF who are
unable to receive oral anticoagulants should be
offered asa (Class I,Lev A) [2]
o Low-dose asa is recommended for patients with
asymptomatic ICA stenosis > 50% to reduce their risk
of vascular events (Class II, Level B) [2]

21 Oktober 2011 55
 Summary
1. We have summarized several guidelines for stroke primary
prevention or first stroke prevention.
2. The aim of primary prevention is to reduce the risk of stroke
in asymptomatic people.
3. Risk factors or risk markers for a first stroke were classified
according to potential for modification (Nonmodifiable Risk
Factors; Well Documented & Modifiable Risk Factors; and
Less Well-Documented or Potentially Modifiable Risk Factors)
4. Nonmodifiable risk factors include age, sex, low birth weight,
race/ethnicity, and genetic predisposition.

21 Oktober 2011 56
 Summary (cont)
5. Well-documented and modifiable risk factors incl HT,
exposure to cigarette smoke, DM, AF and certain other cardiac
conditions, dyslipidemia, carotid artery stenosis, sickle cell
disease, postmenopausal hormone therapy, poor diet,
physical inactivity, and obesity and body fat distribution.
6. Less well-documented or potentially modifiable risk factors
include the metabolic syndrome, excessive alcohol
consumption, drug abuse, use of oral contraceptives, sleep-
disordered breathing, migraine,hyperhomocysteinemia,
elevated lipoprotein(a), hypercoagulability, inflammation, and
infection. Data on the use of aspirin for primary stroke
prevention are reviewed.

21 Oktober 2011 57
 References
1. Goldstein LB, Bushnell CD, Adams RJ et al. Guidelines for the Primary
Prevention of Stroke : A Guideline for Healthcare Professionals From the
American Heart Association/American Stroke Association. Stroke 2011,
42:517-584:
2. The European Stroke Organisation (2) Executive Committee & the 2
Writing Committee. Guidelines for Management of Ischaemic Stroke &
Transient Ischaemic Attack 2008 .Cerebrovasc Dis 2008;25:457507
3. Clinical research center for stroke. Clinical Practice Guidelines for Stroke,
2010. Seoul National University Hospital, Seoul.
4. Shinohara Y ,Yamaguchi T. Guidelines Outline of the 4ese Guidelines for
the Management of Stroke 2004 & subsequent revision . International
Journal of Stroke 2008: 3, 5562
5. Guideline Stroke 2010. PERDOSSI , Jakarta, 2010.

21 Oktober 2011 58
THANK YOU
PEKANBARU 21 Oktober 2011 59