When talking about her health and advancing age, Melinda always told her daughter, “Whatever you do, don’t let me have a stroke.” She knew, of course, that there was very little her daughter could do to protect her, but she had seen first hand the effects of stroke on her own mother and did not want those repeated.
Stroke is the fourth leading killer of Americans, and those who survive often have severely disabling after effects. Melinda’s mother needed a brace on her right leg and could not dress or bathe herself without assistance. Eventually, she went into a nursing home.
As the name implies, a stroke strikes suddenly–a bolt from the blue. Quick action can head off some of the worst effects but the best course is to prevent the stroke in the first place.
By knowing and understanding some important risk factors, there is a great deal that Melinda can do to protect herself.
HYPERTENSION: Ranking at the top of risk factors is high blood pressure. The higher the blood pressure, the greater the risk of stroke.
The cutoff line for a diagnosis of hypertension is 140/90, but you shouldn’t be satisfied with anything higher than 120/80. Sustained blood pressure higher than that can stress blood vessels and cause damage in all organs of the body including the brain.
Borderline blood pressure can often be managed through lifestyle modifications–regular exercise, a healthy diet and sodium restriction. The DASH diet that has been found effective in lowering blood pressure includes five servings a day of fruits and five of vegetables plus whole grains and low-fat dairy foods. Restricting sodium to 2,000 milligrams a day or less can make this diet even more effective.
When blood pressure remains high, medication should be used. A large meta-analysis found a 32 percent reduction in stroke risk in patients being treated with medication.
CIGARETTE SMOKING also weakens and damages blood vessels. Smoking doubles the risk of ischemic stroke, the most common kind. And young smokers are also vulnerable to hemorrhagic stroke, caused by rupture of a blood vessel in the brain.
HIGH CHOLESTEROL is a major cause of hypertension; it narrows arteries, forcing the heart to pump harder. And it is a risk factor for stroke, even aside from its effect on blood pressure.
On the other hand, HDL, the good cholesterol, lowers the risk of stroke. Studies have found an inverse relationship; the higher the HDL, the lower the risk of stroke.
Exercise, diet and, if necessary, cholesterol-lowering statin drugs are recommended to keep cholesterol in check.
DIABETES: Persons with diabetes have a 1.8 to 6-fold increase in relative risk of stroke. In addition, diabetics usually have other stroke risk factors such as hypertension and high cholesterol.
Studies have found that aggressive treatment of blood pressure with ACE inhibitors or angiotensin receptor blockers (ARBs) has a favorable effect in reducing stroke risk. Likewise, use of statins is recommended to lower cholesterol.
Tight control of blood sugar–generally recommended for most diabetics–has not been conclusively linked to a lower risk of stroke.
ATRIAL FIBRILLATION is another major risk factor for stroke, increasing the risk of an ischemic stroke four- or five-fold even in persons who do not have other cardiovascular problems such as hypertension, coronary artery disease or valve disease.
Atrial fibrillation (often known as Afib) is an irregular rhythm of the atria or upper chambers of the heart. In some persons, it causes palpitations rapid enough to send them to the hospital. And it can also cause fatigue or shortness of breath with minor exertion. In many patients, however, it causes no symptoms at all and may go unnoticed until it causes a stroke. Roughly 1 of every 10 strokes in this country can be attributed to Afib.
Even when the cardiovascular system is healthy, atrial fibrillation causes blood to pool in the upper chambers of the heart, increasing the likelihood of a clot forming and traveling through blood vessels to the brain, resulting in a stroke.
Treatment for most Afib patients involves use of the anticoagulant drug, warfarin, with the dose adjusted to keep the INR (clotting ratio) between 2.0 and 3.0. Studies have found warfarin more effective than either aspirin or a combination of aspirin and clopiderol in preventing clots and strokes.
Recently introduced anticoagulants such as Pradaxa, Xarelto and Eliquis are options that reduce the clotting risk without the need for regular pin prick blood tests.
CAROTIDARTERY OCCLUSION: The carotid arteries on each side of the neck carry blood from the heart to the brain. When they are narrowed by atherosclerosis, the risk of stroke increases (just as the risk of heart attack is increased when coronary arteries are occluded).
When narrowing of arteries is present without any symptoms, statin medications plus changes in diet and exercise patterns may be recommended to improve flow. A more invasive procedure is carotid endarterectomy which involves surgically removing the plaque, sometimes accompanied by placement of a stent to keep the artery open.
HORMONE REPLACEMENT THERAPY for postmenopausal women was once considered protective against heart attack and stroke; it is now known to increase the risk of both.
Selective estrogen receptor modulators (SERMs) such as raloxifene and tamoxifen prescribed to help with menopausal symptoms and reduce the risk of breast cancer and osteoporosis also appear to increase the risk of stroke.
Sickle cell disease, depression and oral contraceptives have been linked to an increased risk of stroke. On the other hand, healthy habits are associated with a lower risk. These include:
• maintaining a healthy weight,
• exercising regularly,
• avoiding cigarette smoke and excessive alcohol intake and
• following a healthy diet that is relatively low in sodium and high in potassium.
One study concluded that 38 percent of strokes could have been prevented if all subjects had followed these healthy habits.
The Atherosclerosis Risk in Communities (ARIC) study of residents in four communities found a decreased incidence and fewer stroke deaths from 1987 to 2011. The decline, according to the authors, might be attributed in part to less smoking, better blood pressure control and improved control of cholesterol through statin medications.
Stroke remains the fourth leading cause of death, however, and further improvements must come through aggressively targeting all risk factors.
REFERENCES:
Pauline Anderson, “Stroke incidence, mortality drop, but not across the board,” Medscape Medical News, July 16, 2014 (JAMA, July 16, 2014).
Pauline Anderson, “Protein, especially fish, linked to reduced stroke,” Medscape Medical News, June 12, 2014 (Neurology, June 11, 2014).
Sue Hughes, “Higher potassium intake linked to reduced stroke,” Medscape Medical News, September 4, 2014 (Stroke, September 4, 2014).
Susan Jeffrey, “Silent atrial fibrillation increases stroke risk,” Medscape, January 12, 2012.
S. Andrew Josephson, M.D., “Stroke incidence and mortality decreasing in the United States,” AccessMedicine from McGraw-Hill, 2014.
Shereen Lehman, “Healthy habits linked to lower stroke risk,” Reuters Health, June 17, 2014.
Fran Lowry, “Cognitive decline a harbinger of stroke?” Medscape MedicalNews, August 13, 2014 (Stroke, August 7, 2014).
“Not all CHA2DS2-VASc 1s are created equal: no kidding,” WebMD, September 2, 2014.
Michael O’Riordan, “AF clinic reduces hospital admissions, saves money,” Medscape, May 8, 2014.
Michael O’Riordan, “‘Lousy’ prognosis for incidentally detected, asymptomatic AF, but OACs lower risk,” Medscape, September 4, 2014.
Brian Silver, M.D., FRCPC, FAHA, FAAN, “Stroke prevention,” Medscape Medical Reference, updated May 13, 2014.
Ken Terry, “Video ‘selfie’ could facilitate diagnosis of stroke, TIA,” Medscape Medical News, July 8, 2014.
P.A. Wolf, et al, “Probability of stroke: a risk profile from the Framingham study,” Stroke, March, 1991.
11/19/2014
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