The following Consensus Statement was adopted by the 4th Karolinska Stroke Update meeting on November 11, 2002.

The consensus statement was proposed by the chairpersons in the session, Professor Bo Norrving, Lund, and Professor Jan Lodder, Maastricht, together with the speakers in the session. The statement was then finally approved by the participants of the meeting, after listening to the different presentations.

The speakers in this session were Professor Charles Warlow, Edinburgh, Professor Markku Kaste, Helsinki and Professor Kjell Asplund, Umeå,

What should I give to my next patient with TIA or stroke, and is it worth the cost?

1. There is now support for the wide use of three different drug regimens in secondary prevention after stroke and TIA: antithrombotic therapy (antiplatelet agents, anticoagulants in patients with atrial fibrillation provided no contraindication is present), blood pressure lowering, and statins. The first regimen is already well established in clinical practice (cf separate Consensus Statement), whereas the other two are based on evidence that has only recently become available.

2. For blood pressure lowering, the evidence for benefit is strong, and the trial results appear broadly generalisable to patients with stroke/TIA seen in clinical practise. The benefit appears to be additive, and independent, to standard background therapy, and side effects were much less than generally perceived. Trial data suggest that 5 years’ treatment with a blood pressure lowering regimen will avoid one major vascular event among 14 patients assigned active treatment.

3. For statins, evidence of benefit in patients with stroke and TIA is somewhat less robust than for blood pressure lowering, but the effect is similar to the overall results of the study, and therapy appears very safe. Overall, 5 years treatment with a simvastatin will avoid one major vascular event among 10-14 patients treated.

4. Pending formal analyses of health economy, the cost-benefit balance of adding blood pressure lowering and statins to existing therapy appears reasonable and comparable to other well established secondary prevention strategies in other areas, e g coronary heart disease. The absolute benefits of both therapies greatly exceed the absolute benefits of blood-pressure lowering treatment for most patients with uncomplicated hypertension.

5. The principle that people at elevated risk benefit from combined, multi-modal treatment, largely irrespective of what initially caused their risk to be high, and what the current risk factor levels are, represent an important paradigm shift in prevention of vascular disease. Blood pressure lowering and statins should now be regarded as part of routine management in patients with TIA and stroke. Both regimens are add-on therapies to other components of care, and it is essential that their use should not detract from other secondary preventive measures such as risk factor control including promotion of a healthy life style and antismoking advice and therapy.