Reducing the risk of stroke in diabetes: what have we learned that is new?

Given the significant public health impact of stroke and the identification of nonmodifiable (age, gender, race/ethnicity) and modifiable (blood pressure, diabetes, lipid profile, and lifestyle) risk factors, early prevention strategies should be initiated. When a patient suffers a stroke, the focus of care becomes prevention of future events. For the patient with diabetes, comprehensive medical management of ischaemic stroke (primary or secondary prevention) includes antihypertensive and lipid-lowering therapy, as well as antiplatelet therapy. Despite the cerebrovascular risk reduction with these modalities, clearly new agents are needed. The Heart Outcomes Prevention Evaluation (HOPE) study provides compelling evidence that treatment with the angiotensin converting enzyme inhibitor, ramipril, can further reduce the risk of stroke in high-risk patients by mechanisms other than lowering blood pressure. In HOPE, patients were normotensive at baseline. Therefore, for the first time, in a patient population without left ventricular dysfunction, the effects of an ACE inhibitor ramipril on reducing stroke risk were demonstrated. Ramipril 10 mg achieved a significant 33% reduction in stroke among patients with diabetes. Based on the HOPE study, the recently published American Heart Association guidelines for the primary prevention of stroke recommend ramipril to prevent stroke in high-risk patients and in patients with diabetes and hypertension. Wide-scale adherence to these guideline recommendations for the prevention of primary and secondary stroke would significantly benefit the public health.