Editors: Norris, John W.; Hachinski, Vladimir
Title: Stroke Prevention, 1st Edition
Copyright 2001 Oxford University Press
> Front of Book > Preface
In 1991 we published our first book on the prevention of stroke. So many discoveries and advances have been made in the last decade that we felt obliged to revisit the same subject, but with a completely different organization, content, and authorship. Because of changing concepts stroke prevention, we organized this new volume into three distinct parts: primary prevention, secondary prevention, and the effort to translate policy into practice.
The section on primary prevention presents fresh information established risk factors, such as atrial fibrillation, smoking, and hypertension, well newly discovered risk factors, such as homocysteinemia and the paradoxical role of alcohol. In addition, we include much new data on the protective effects of lifestyle changes and indicate that diet, exercise, estrogen are beginning to enter into prevention strategies. Despite several large, multicenter studies on both sides of the Atlantic, the roles of carotid endarterectomy, angioplasty, and stenting for asymptomatic carotid stenosis remain controversial.
The section on secondary prevention addresses the importance of cardiac anomalies, such as patent foramen ovale and atrial septal aneurysm, which are increasingly revealed by high-definition cardiac imaging. It also revisits the controversies surrounding the oldest antiplatelet agent, aspirin, and evaluates several new antiplatelet drugs now on the market. Carotid endarterectomy has been clearly defined as the single most effective strategy in secondary prevention, while a large scale multicenter trial comparing carotid surgery to stenting has just been initiated.
The transfer of findings from clinical trials to actual clinical practice is coming under intensified scrutiny, and we feel that it warrants a section in itself. Showing that an intervention such as carotid endarterectomy works is not enough; we need to know whether it is applied appropriately. Patients in clinical trials are highly selected, closely monitored, and provided with the highest standard of care. The restricted conditions of clinical trials are seldom reproduced in the larger world, and a benefit clearly demonstrated in a clinical trial may be quickly cancelled by applying the intervention to inappropriate patients or by it appropriately but with a higher complication rate. Costs increasingly dictate clinical practice. Interventions that may be effective when costs are not a consideration rapidly run into the realities of affordability and the competing demands of an aging population. An evidence-based approach is helpful in the unending balancing act between the ideal and the affordable, yet only a fraction of what is learned in clinical trials ever applied. The benefits of treating hypertension for the prevention of stroke are substantial and uncontestable, yet it is estimated that only one-fifth of American hypertensives have their blood pressures controlled. The unacceptable gap between clinical trials and clinical practice must be breached. This book focuses on stroke prevention as it is practiced in North America, Europe, and Australia, but stroke is a worldwide problem, we include a chapter on the global perspective.
We set a high standard for authorship by enlisting international experts who know not only their subject but also how to convey it clearly. Moreover, we asked that whenever possible they write the chapters themselves and avoid common practice of having a junior associate do most the work, with editing by the senior author. The fact that so many prominent authors accepted our invitation speaks to the importance of stroke prevention and their commitment it. The result is a broad-based, lucidly written book that founded on evidence and that provides logical bridges to daily practice where the evidence falls short.
Stroke is the leading cause of serious disability in adults. Thus, it behooves neurologists, geriatricians, internists, neurosurgeons, vascular surgeons, family physicians, health planners, and all those involved in lightening this burden to learn the latest strategies of stroke prevention.
We would like to acknowledge the invaluable help of our personal assistant Ms. Donna Huber, who not only spent many hours painstakingly editing the text of most chapters, but gave help and suggestions in reorganizing some of the text. Mr. Jeff House, Senior Editor of Oxford University Press was a major factor in ensuring that the prose and grammar were direct, correct clear, ruthlessly corrected ambiguous passages.
J. W. N
North York, Ontario, Canada
London, Ontario, Canada