Recent advances in preventing recurrent stroke

Abstract

Since a 2017 update, there have been important advances in stroke prevention. These include new evidence about nutrition, antiplatelet therapy, anticoagulation, lipid-lowering therapy, hypertension control, pioglitazone, and carotid endarterectomy and stenting. Evidence regarding toxic metabolites produced by the intestinal microbiome from egg yolk and red meat has important dietary implications, particularly for patients with impaired renal function, including the elderly. They should avoid egg yolk and red meat and limit the intake of animal flesh. Higher doses of folic acid may be needed for patients with the T allele of MTHFR, so it may not be sufficient to give vitamin B12 (methylcobalamin) alone, even in countries with folate fortification. There is now good evidence that lipid-lowering therapy is even more beneficial in the elderly than in younger patients; we should be using lipid-lowering therapy more intensively, often/usually combining statins with ezetimibe. There is new evidence that lower systolic blood pressure targets are better for most patients, but a subgroup with stiff arteries, a wide pulse pressure, and a diastolic pressure of <60 would be more likely to be harmed than helped by aiming for a systolic target of <120 mmHg. There is a better understanding of how the pharmacological properties of direct-acting oral anticoagulants and the metabolism of antiplatelet agents should inform decisions about the use of these agents. Pioglitazone markedly reduces the risk of stroke, both in diabetics and prediabetics; it should be used more widely. It is now clear that carotid endarterectomy is safer than stenting and that the difference is strongly affected by age. Most patients, and in particular older patients, would be better served by endarterectomy than stenting.

Homocysteine, Vitamin B12 and Folate Level: Possible Risk Factors in the Progression of Chronic Heart and Kidney Disorders

“…The B vitamins, including vitamin B12, are necessary cofactors for many enzymes for achieving body metabolic function [ 35 ]. Animal-based products are primary source of vitamin B12, such as meat, fish, lamb, eggs, and other dairy products.…”

“…The complex is further broken when it is successfully endocytosed at the mucosal layer, releasing free cobalamin. Once in the bloodstream, the freed cobalamin joins forces with transcobalamin l, ll, or lll (TCl, TCll, TClll) to form a cobalamin-transcobalamin complex that travels to its intended destination [ 35 ]. Contrary to transcobalamin-l and transcobalamin-ll, cobalamin-transcobalamin-l demonstrated its exceptional capacity to circulate cobalamin throughout the entire body (Fig.…”

“…Methionine synthase and Me-Cbl work together to help methylate homocysteine into methionine. S-adenosyl methionine (SAM), which functions as a neurotransmitter in the brain, is further transformed from this methionine [ 35 ].…”

“…Higher dietary folate and vitamin B6 intakes were substantially linked to decreased cardiovascular and all-cause mortality. According to research by Bo et al 2022, consuming more folate and vitamin B6 may reduce the mortality risk for individuals in the United States [ 35 , 63 , 64 ].…”