Reader response: The dimension of preventable stroke in a large representative patient cohort

Boehme et al.1 examine the burden of untreated risk factors for stroke in 1,730 patients with ischemic stroke/TIA from the Poststroke Disease Management STROKE-CARD trial. They chose to focus on 8 risk factors amenable to drug therapy (hypertension, hypercholesterolemia, atrial fibrillation, previous atherosclerotic cardiovascular disease, diabetes mellitus, carotid stenosis, unrecognized TIA, and the presence of a mechanical heart valve) and 3 lifestyle risk behaviors (smoking, obesity, alcohol excess). An important omission from this list is the presence of chronic kidney disease (CKD). There is a strong association between CKD and stroke,2 which is under-recognized and only addressed in current guidelines in terms of its potential to limit or alter otherwise established treatments.3 There is therapeutic nihilism associated with CKD whereby they are less likely to receive important guideline-recommended therapies, particularly oral anti-coagulants.4 It would be interesting to know what the prevalence of CKD was in this patient cohort and whether its presence increased the likelihood of poor risk factor control. There is a need for dedicated stroke prevention trials in this group and for closer collaboration between neurologists and nephrologists to bridge this therapeutic gap.5

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