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risk factors for & prevention of ischemic stroke

Etiology: 1) non-modifiable risk factors a) age b) gender c) race d) heredity 2) modifiable risk factors a) medical conditions - hypertension (RR=2) - maximum systolic blood pressure (SBP) & variability in systolic hypertension - calcium channel blockers & non-loop diuretics best agents to control SBP variability [10] - prehypertension also a significant risk factor - systolic blood pressure: 130-140 mm Hg - diastolic blood pressure: 85-90 mm Hg - RR > 1.55-1.66 [14] - cardiac disease - atrial fibrillation (RR=3.3) - hyperlipidemia (dyslipidemia) (RR=2) - diabetes mellitus - RR = 2.28 for women vs 1.83 for men [23] - carotid stenosis - recent episode of shingles [24] - RR = 1.6 in 1st 4 weeks - declines to baseline after 26 weeks - Herpes zoster ophthalmicus & Herpes zoster in other branches of the trigeminal nerve increase stroke risk 3-fold relative to Herpes zoster in other dermatomes [24] - antivirals diminish risk [24] - prior TIA or stroke b) behaviors - smoking (RR=1.8) - heavy alcohol use - RR = 1.4 with > 30 g or 2 drinks/day [3] - only red wine associated with diminished risk - RR = 0.5 for > 10 g/day of red wine - RR closer to 1 when adjusted for hypertension - cocaine abuse - physical inactivity - increased consumption of fruits & vegetables reduces risk of both ischemic & hemorrhagic stroke [4] - 4 behaviors combined - exercise, not smoking, healthy eating & moderate drinking are associated with diminished stroke risk among in elderly [7] - coffee may reduce risk in women [12] - regular use of olive oil associated with diminished risk of ischemic stroke [13] - no association with dietary fat [27] - long office work hours (> 40 hours/week) RR=1.33 [29] c) environmental factors - increases in each air pollutants including particulate matter, carbon dioxide, nitrogen dioxide, sulfur dioxide, & ozone increase risk of stroke & stroke mortality [28] - food insecurity [36] - difficulty obtaining health care [36] - exposure to racism, discrimination & stress [36] d) sleep disorders - sleep-disordered breathing & irregular sleep/wake rhythm disorder [32] - sleeping >= 9 hours/night &/or taking longer midday naps (RR=1.23) [34] e) dietary factors - artificial sweeteners may increase risk for cerebrovascular disease (RR=1.2-1.3) [35] 3) acute respiratory tract infections transiently increase risk [2] 4) emotional neglect in childhood [17] 5) cognitive impairment [25] - possibly related to silent cerebral infarcts 6) prior silent brain infarction (RR=2-3 within 15 years) [30] 7) women's health factors - early menarche - history of stillbirth [33] - pre-term birth [36] - endometriosis [36] - early menopause [36] - hormone replacement therapy ? [36] 8) also see cardiovascular risk factors Management: 1) control of hypertension, especially systolic hypertension a) angiotensin receptor blockers may reduce risk b) calcium channel blocker may have the greatest benefit among antihypertensives [10,11] c) diuretic: chlorthalidone (SHEP trial) - number needed to treat = 37 for 5 years to prevent 1 stroke [20] d) ACE inhibitor + thiazide diuretic decreases risk of stroke, heart failure & all-cause mortality in elderly > 80 years of age (GRS9) [15] cites [31] - preferable to ACE inhibitor + calcium channel blocker [15] e) DASH diet - low fat dairy foods [16] 2) aspirin 81-162 mg QD or clopidogrel 75 mg QD* for patients with cardiovascular risk factors 3) control of dyslipidemia a) statins# [5,6] b) omega-3 fatty acids - omega-3-rich fish may be protective - omega-3 fatty acid supplementation is not [19] 4) benefits of antihypertensive therapy & statins in the very old (> 80) may be overestimated [22] 5) behavioral modification [7] a) exercise b) do not smoke c) healthy eating e) alcohol in moderation 6) Life's 7 [21] modifiable risk factors - blood pressure, cholesterol, glucose, BMI, smoking, physical activity, diet - small behavioral modifications can result in significant risk reduction [21] 7) lycopenes may be associated with reduced risk for stroke (RR= 0.55 all stroke, RR=0.59 ischemic stroke) - fruits & vegetables may be helpful [18] 8) higher potassium intake associated with lower risk of stroke & overall mortality in patients without hypertension [26] - in patients with hypertension, only overall mortality was lower with highter potassium intake * but not in combination see MATCH study & CHARISMA trial # may not be of benefit in the elderly (> 80) [6]

Related

cardiovascular risk factor CHARISMA trial MATCH study

Specific

risk factors for ischemic stroke after TIA

General

health risk factor(s)

References

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