Do you live with:
- High Cholesterol
- Cigarette Addiction?
- Taking Oral contraceptives
- Living with Depression
- Taking Hormone Replacement Therapy
- Physically Inactive?
If you answered yes to any of the questions above you need to read about
Primary and Secondary Stroke Prevention Tips
Hypertension is the most important modifiable risk factor for stroke and intracerebral hemorrhage (ICH), and the risk of stroke increases progressively with increasing blood pressure, independent of other factors. Both behavioral lifestyle changes and pharmacologic therapy are important parts of the comprehensive strategy recommended in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
Cigarette smoking is directly correlated with an increased risk of both ischemic stroke and subarachnoid hemorrhage (SAH), with risk for the former approximately doubled by smoking and risk for the latter increased 2- to 4-fold. Smoking also appears to increase the risk of hemorrhagic stroke, especially in younger individuals.
Smoking also potentiates other stroke risk factors such as hypertension and oral contraceptive use. Counseling, nicotine replacement, and oral smoking-cessation medications are options that should be offered to all individuals who smoke. Cessation of smoking has been shown to reduce the risk of both stroke and cardiovascular events to levels approaching those of individuals who have never smoked.
As with heart disease, epidemiologic evidence indicates that environmental smoke (ie, passive or “secondhand” smoke) is associated with an increased risk of stroke. Although data are unavailable to date that show that avoidance of environmental tobacco smoke decreases stroke risk, avoiding exposure to environmental smoke is reasonable.
Diabetes is estimated to increase the relative risk of ischemic stroke 1.8- to nearly 6-fold, independent of other risk factors. In addition, many diabetics have hypertension and dyslipidemia, both significant risk factors for stroke. Multiple studies on glycemic control in type 2 diabetics have shown no effect or inconclusive results in reducing stroke risk. However, aggressive control of hypertension in diabetics reduces stroke incidence. Antihypertensive agents that are useful in the diabetic population include angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). The use of beta-adrenergic blockers has been associated with an increased risk of new-onset type 2 diabetes.
Several studies have shown that HMG-CoA reductase inhibitors (statins) are beneficial in reducing stroke risk in diabetic individuals, especially those with other risk factors such as retinopathy, albuminuria, current smoking, or hypertension. Treating adult diabetics with statins is recommended. Monotherapy with fibrates has also shown some benefit in reducing stroke risk in diabetics, and may also be considered. Taking aspirin is reasonable in patients who are at high risk for cardiovascular disease (CVD); however, the efficacy of aspirin for reducing stroke risk in diabetic patients remains uncertain.
Elevated total cholesterol has been linked to increased risk of ischemic stroke in a number of epidemiological studies. Epidemiological studies have also shown an inverse relationship between high-density lipoprotein (HDL) cholesterol and stroke risk. The approach to treatment of dyslipidemia for primary prevention of ischemic stroke is based on recommendations from the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III).
Statin therapy and therapeutic lifestyle changes are recommended for patients with coronary artery disease or certain high-risk conditions such as diabetes, with low-density lipoprotein (LDL) cholesterol goals as outlined in the NCEP ATP III guideline. Intensive-dose statin therapy increases the risk of new-onset diabetes by 12% compared with moderate-dose statin therapy. Intensive-dose statin therapy may still yield a net benefit in terms of overall outcomes. Niacin may be used in patients with low HDL cholesterol or elevated lipoprotein(a), but its efficacy in preventing ischemic stroke has not been established. Fibric acid derivatives, niacin, bile acid sequestrants, and ezetimibe may be useful in patients who have not achieved target LDL with statin therapy or who cannot tolerate statins; however, the effectiveness of these agents in reducing stroke risk in patients with dyslipidemia has not been established.
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Postmenopausal hormone replacement therapy
The Women’s Health Initiative (WHI), a randomized clinical trial comparing conjugated equine estrogens (CEE) combined with medroxyprogesterone acetate (MPA) versus placebo in postmenopausal women aged 55-79 years, has provoked a major reconsideration of postmenopausal hormone replacement therapy. Among other findings, the WHI showed an increased risk of stroke with CEE therapy, particularly in older subgroups. Similar findings have been reported in other studies.
Selective estrogen receptor modulators (SERMs) such as raloxifene, tamoxifen, or tibolone have been used for the prevention of breast cancer and osteoporotic bone density loss and for treatment of menopausal symptoms. Studies of these agents have also evaluated lowering of cardiovascular and stroke risk as secondary outcomes. No benefit in lowering the risk of MI has been found for any of these therapies, and stroke risk appears to be increased with raloxifene (HR for fatal stroke, 1.49; absolute risk, 0.07 per 100 women after 1 year) and tibolone (relative hazard, 2.19). Stroke rates with raloxifene and tamoxifen appear to be similar.
Hormone therapy and SERMs such as raloxifene, tamoxifen, or tibolone should not be used for primary prevention of stroke in postmenopausal women.
Randomized clinical trials evaluating stroke risk with oral contraceptive (OC) use have not been performed. Meta-analyses of cohort and case-control studies have indicated an approximate doubling of relative risk, though findings of individual studies are inconsistent. Nevertheless, the highest estimated absolute stroke risk with OC use (20 per 100,000) remains well below that associated with pregnancy (34 per 100,000 deliveries).
As the 2011 AHA/ASA CVT statement notes, both OC use and pregnancy are risk factors for CVT. Among younger women diagnosed with CVT who were not pregnant, the great majority were OC users.
On the other hand, well-established risk factors that increase stroke risk with OC use include older age, cigarette smoking, hypertension, and migraine headache. More recently, obesity and hypercholesterolemia, factor V Leiden, and methyl tetrahydrofolate reductase mutation (MTHFR 677TT) have been identified as factors that increase stroke risk in OC users compared with women with these risk factors who do not use OCs.
Oral contraceptives may be harmful in women with additional risk factors for stroke such as smoking or prior thromboembolic events. The combination of a hereditary prothrombotic factor with OC use increases the risk of CVT. Aggressive therapy for stroke risk factors may be reasonable in women who choose to take oral contraceptives despite their increased risks.
Depression is increasingly being recognized as a possible contributor to stroke. In a prospective study of 9601 Western European middle-aged men, baseline depression nearly doubled the risk of stroke during years 5-10 of the 10-year study. The risk of coronary artery disease increased 43% during the first 5 years, after adjusting for age, baseline socioeconomic factors, traditional vascular risk factors, and antidepressant treatment.
Physical inactivity is associated with an increased risk of stroke and other adverse effects, such as cardiovascular morbidity and mortality. Increased physical activity may decrease the risk of stroke by 25-30%. Physical activity is also known to have a positive effect on control of blood pressure and diabetes, two significant risk factors for stroke.
The recommended goal for physical activity for adults, as indicated in the 2008 Guidelines for Physical Activity Guidelines for Americans from the US Department of Health and Human Services, is to engage in at least 150 minutes (2 hours and 30 minutes) per week of moderate intensity or 75 minutes (1 hour and 15 minutes) per week of vigorous intensity aerobic physical activity.
The American Heart Association and American Stroke Association have released updated guidelines on the primary prevention of stroke. New recommendations include the following :
- Use of new oral anticoagulants, including dabigatran, apixaban, and rivaroxaban, in patients with nonvalvular atrial fibrillation
- Home self-monitoring of blood pressure in hypertensive patients
- Use of nonestrogen oral contraceptives in female patients with migraine with aura
- All patients should follow the Mediterranean diet supplemented with nuts and reduce sodium intake
- Screening for sleep apnea
- Smoking cessation
Primary Prevention of Stroke
Risk-reduction measures in primary stroke prevention may include the use of antihypertensive medications; warfarin; platelet antiaggregants; 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins); smoking cessation; dietary intervention; weight loss; and exercise.
Modifiable risk factors include the following:
- Cigarette smoking
- Atrial fibrillation
- Sickle cell disease
- Postmenopausal HRT
- Diet and activity
- Weight and body fat
Secondary Prevention of Stroke
Secondary prevention can be summarized by the mnemonic A, B, C, D, E, as follows:
- A – Antiaggregants (aspirin, clopidogrel, extended-release dipyridamole, ticlopidine) and anticoagulants (warfarin)
- B – Blood pressure–lowering medications
- C – Cessation of cigarette smoking, cholesterol-lowering medications, carotid revascularization
- D – Diet
- E – Exercise
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Smoking cessation, blood pressure control, diabetes control, a low-fat diet (eg, Dietary Approaches to Stop Hypertension [DASH] or Mediterranean diets), weight loss, and regular exercise should be encouraged.
Apixaban, dabigatran, rivaroxaban, and edoxaban are alternatives to warfarin for high-risk patients (including those with a history of stroke) who have atrial fibrillation.
Smoking cessation, blood pressure control, diabetes control, a low-fat diet (eg, Dietary Approaches to Stop Hypertension [DASH] or Mediterranean diets), weight loss, and regular exercise should be encouraged as strongly as the medications described above. Written prescriptions for exercise and medications for smoking cessation (nicotine patch, bupropion, varenicline) increase the likelihood of success with these interventions.
Brian Silver, MD, et al., Director, Stroke Center, Rhode Island Hospital; Associate Professor of Neurology, The Warren Alpert Medical School of Brown University