risk factors for & prevention of ischemic stroke
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Etiology
- non-modifiable risk factors
- modifiable risk factors
- 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
- 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
- hypertension (RR=2)*
- behaviors
- smoking (RR=1.8)*
- heavy alcohol use
- 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]
- 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]
- sleep disorders
- sleep-disordered breathing & irregular sleep/wake rhythm disorder[32]
- sleeping >= 9 hours/night &/or taking longer midday naps (RR=1.23)[34]
- dietary factors
- artificial sweeteners may increase risk for cerebrovascular disease (RR=1.2-1.3)[35]
- medical conditions
- acute respiratory tract infections transiently increase risk[2]
- emotional neglect in childhood[17]
- cognitive impairment[25]
- possibly related to silent cerebral infarcts
- prior silent brain infarction (RR=2-3 within 15 years)[30]
- women's health factors
- early menarche
- history of stillbirth[33]
- pre-term birth[36]
- endometriosis[36]
- early menopause[36]
- hormone replacement therapy ?[36]
- also see cardiovascular risk factors
* risk factors for severe stroke[37]
Management
- control of hypertension, especially systolic hypertension
- angiotensin receptor blockers may reduce risk
- calcium channel blocker may have the greatest benefit among antihypertensives[10][11]
- diuretic: chlorthalidone (SHEP trial)
- number needed to treat = 37 for 5 years to prevent 1 stroke[20]
- 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]
- DASH diet
- aspirin 81-162 mg QD or clopidogrel 75 mg QD* for patients with cardiovascular risk factors
- control of dyslipidemia
- statins# [5][6]
- omega-3 fatty acids
- omega-3-rich fish may be protective
- omega-3 fatty acid supplementation is not[19]
- benefits of antihypertensive therapy & statins in the very old (> 80) may be overestimated[22]
- behavioral modification[7]
- 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]
- lycopenes may be associated with reduced risk for stroke (RR= 0.55 all stroke, RR=0.59 ischemic stroke)
- 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]
More general terms
More specific terms
Additional terms
References
- ↑ Ovbiagele B, In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
- ↑ 2.0 2.1 Journal Watch 25(4):29, 2005 Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med. 2004 Dec 16;351(25):2611-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15602021
- ↑ 3.0 3.1 Journal Watch 25(3):24, 2005 Mukamal KJ, Ascherio A, Mittleman MA, Conigrave KM, Camargo CA Jr, Kawachi I, Stampfer MJ, Willett WC, Rimm EB. Alcohol and risk for ischemic stroke in men: the role of drinking patterns and usual beverage. Ann Intern Med. 2005 Jan 4;142(1):11-9. Summary for patients in: Ann Intern Med. 2005 Jan 4;142(1):I24. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15630105
- ↑ 4.0 4.1 He FJ et al, Fruit and vegetable consumption and stroke: Meta-analysis of cohort studies. Lancet 2006, 367:320 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16443039
- ↑ 5.0 5.1 Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC. Effect of different antilipidemic agents and diets on mortality: a systematic review. Arch Intern Med. 2005 Apr 11;165(7):725-30. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15824290
- ↑ 6.0 6.1 6.2 Foody JM et al, Hydroxymethylglutaryl-CoA reductase inhibitors in older persons with acute myocardial infarction: Evidence for age- statin interaction J Am Geriatr Soc 2006; 54:421
- ↑ 7.0 7.1 7.2 Myint PK et al Combined effect of health behaviours and risk of first ever stroke in 20,040 men and women over 11 years' follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): prospective population study. BMJ 2009;338:b349 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19228771 <Internet> http://www.bmj.com/cgi/content/full/338/feb19_2/b349
- ↑ Personal stroke risk assessment Adapted form Framingham Model by Smith DB www.westernstroke.org/PersonalStrokeRisk1.xls
- ↑ Li NC et al Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis BMJ 2010;340:b5465 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20068258 <Internet> http://www.bmj.com/cgi/content/full/340/jan12_1/b5465
- ↑ 10.0 10.1 10.2 Rothwell PM et al Effects of beta-blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke The Lancet Neurology, Early Online Publication, 12 March 2010 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20227347 doi:10.1016/S1474-4422(10)70066-1 http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(10)70066-1/abstract
Rothwell PM et al Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension The Lancet, Volume 375, Issue 9718, Pages 895 - 905, 13 March 2010 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20226988 doi:10.1016/S0140-6736(10)60308-X http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60308-X/abstract
Webb AJS et al Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis The Lancet, Volume 375, Issue 9718, Pages 906 - 915, 13 March 2010 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20226989 doi:10.1016/S0140-6736(10)60235-8 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60235-8/abstract
Rothwell PM Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension The Lancet, Volume 375, Issue 9718, Pages 938 - 948, 13 March 2010 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20226991 doi:10.1016/S0140-6736(10)60309-1 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60309-1/fulltext
Gorelick PB Reducing blood pressure variability to prevent stroke? The Lancet Neurology, Early Online Publication, 12 March 2010 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20227348 doi:10.1016/S1474-4422(10)70067-3 http://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2810%2970067-3/fulltext#
Carlberg B and Lindholm LH Stroke and blood-pressure variation: new permutations on an old theme. The Lancet, Volume 375, Issue 9718, Pages 867 - 869, 13 March 2010 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20226970 doi:10.1016/S0140-6736(10)60351-0 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60351-0/fulltext - ↑ 11.0 11.1 Law MR et al Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009 May 19;338:b1665. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19454737 doi:http://dx.doi.org/ 10.1136/bmj.b1665
- ↑ 12.0 12.1 Larsson SC et al. Coffee consumption and risk of stroke in women. Stroke 2011 Mar 10 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21393590 <Internet> http://stroke.ahajournals.org/cgi/content/abstract/STROKEAHA.110.603787v1
- ↑ 13.0 13.1 Samieri C et al Olive oil consumption, plasma oleic acid, and stroke incidence The Three-City Study Neurology June 15, 2011 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21676914 <Internet> http://www.neurology.org/content/early/2011/06/15/WNL.0b013e318220abeb.abstract
- ↑ 14.0 14.1 Lee M et al. Presence of baseline prehypertension and risk of incident stroke: A meta-analysis. Neurology 2011 Oct 4; 77:1330. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21956722
Huang Y, Cai X, Li Y et al Prehypertension and the risk of stroke. Neurology. March 12, 2014. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24623843 <Internet> http://www.neurology.org/content/early/2014/03/12/WNL.0000000000000268.abstract - ↑ 15.0 15.1 15.2 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - ↑ 16.0 16.1 Larsson SC et al Dairy Consumption and Risk of Stroke in Swedish Women and Men Stroke April 19, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22517598 <Internet> http://stroke.ahajournals.org/content/early/2012/04/19/STROKEAHA.111.641944.abstract
- ↑ 17.0 17.1 Wilson RS et al. Emotional neglect in childhood and cerebral infarction in older age. Neurology 2012 Oct 9; 79:1534 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22993291 <Internet> http://www.neurology.org/content/early/2012/09/19/WNL.0b013e31826e25bd.abstract
Barrett KM and Meschia JF. Cerebral infarction in older age: Nature or (lack of) nurture? Neurology 2012 Oct 9; 79:1524. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22993278 <Internet> http://www.neurology.org/content/early/2012/09/19/WNL.0b013e31826e26fe.excerpt - ↑ 18.0 18.1 Karppi J et al Serum lycopene decreases the risk of stroke in men: A population-based follow-up study Neurology October 9, 2012 vol. 79 no. 15 1540-1547 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23045517 <Internet> http://www.neurology.org/content/79/15/1540.abstract
- ↑ 19.0 19.1 Chowdhury R et al Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: systematic review and meta-analysis BMJ 2012;345:e6698 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23112118 <Internet> http://www.bmj.com/content/345/bmj.e6698
de Goede J and Geleijnse JM The role of fatty acids from fish in the prevention of stroke BMJ 2012;345:e7219 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23112120 <Internet> http://www.bmj.com/content/345/bmj.e7219 - ↑ 20.0 20.1 Perry HM Jr, Davis BR, Price TR, Applegate WB, Fields WS, Guralnik JM, Kuller L, Pressel S, Stamler J, Probstfield JL. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 2000 Jul 26;284(4):465-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10904510
- ↑ 21.0 21.1 21.2 Kulshreshtha A et al Life's Simple 7 and Risk of Incident Stroke: The Reasons for Geographic and Racial Differences in Stroke Study. Stroke. June 6 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23743971 <Internet> http://stroke.ahajournals.org/content/early/2013/06/06/STROKEAHA.111.000352.abstract
- ↑ 22.0 22.1 Byatt K Overenthusiastic stroke risk factor modification in the over-80s: Are we being disingenuous to ourselves, and to our oldest patients? Evid Based Med doi:10.1136/eb-2013-101646 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24574366 <Internet> http://ebm.bmj.com/content/early/2014/01/15/eb-2013-101646
- ↑ 23.0 23.1 Peters SAE et al. Diabetes as a risk factor for stroke in women compared with men: A systematic review and meta-analysis of 64 cohorts, including 775 385 individuals and 12 539 strokes. Lancet 2014 Mar 7; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24613026 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960040-4/fulltext
- ↑ 24.0 24.1 24.2 24.3 Langan SM et al Risk of Stroke Following Herpes Zoster: A Self-Controlled Case-Series Study. Clinical Infectious Disease. April 2, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24700656 <Internet> http://cid.oxfordjournals.org/content/early/2014/03/25/cid.ciu098.full.pdf+html
- ↑ 25.0 25.1 Lee M, Saver JL, Hong KS et al Cognitive impairment and risk of future stroke: a systematic review and meta-analysis. CMAJ August 25, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25157064 <Internet> http://www.cmaj.ca/content/early/2014/08/25/cmaj.140147.full.pdf+html
- ↑ 26.0 26.1 Seth A et al. Potassium intake and risk of stroke in women with hypertension and nonhypertension in the Women's Health Initiative. Stroke 2014 Sep 4; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25190445 <Internet> http://stroke.ahajournals.org/content/early/2014/09/04/STROKEAHA.114.006046
- ↑ 27.0 27.1 Journal Watch 23(23):183, 2003 He K et al Dietary fat intake and risk of stroke in male US healthcare professionals: 14 year prospective cohort study. BMJ 327:777, 2003 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/14525873 <Internet> http://bmj.com/cgi/content/full/327/7418/777
- ↑ 28.0 28.1 Shah ASV et al Short term exposure to air pollution and stroke: systematic review and meta-analysis. BMJ 2015;350:h1295 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25810496 <Internet> http://www.bmj.com/content/350/bmj.h1295
- ↑ 29.0 29.1 Kivimaki M et al Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603,838 individuals. Lancet Aug 19, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26298822 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2960295-1/abstract
- ↑ 30.0 30.1 Orciari Herman A, Hefner JE Silent Brain Infarction Associated with Increased Risk for Future Stroke. Physician's First Watch, Feb 18, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Gupta A, Giambrone AE, Gialdini G et al Silent Brain Infarction and Risk of Future Stroke. A Systematic Review and Meta-Analysis. Stroke. Feb 17, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26888534 <Internet> http://stroke.ahajournals.org/content/early/2016/02/17/STROKEAHA.115.011889 - ↑ 31.0 31.1 Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 4. Effects of various classes of antihypertensive drugs--overview and meta-analyses. J Hypertens. 2015 Feb;33(2):195-211. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25485720
- ↑ 32.0 32.1 Hermann DM, Bassetti CL Role of sleep-disordered breathing and sleep-wake disturbances for stroke and stroke recovery. Neurology. August 3, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27488603 <Internet> http://www.neurology.org/content/early/2016/08/03/WNL.0000000000003037.short
- ↑ 33.0 33.1 Peters SA, Woodward M Women's reproductive factors and incident cardiovascular disease in the UK Biobank. Heart. 2018 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29335253 <Internet> http://heart.bmj.com/content/early/2018/01/02/heartjnl-2017-312289
- ↑ 34.0 34.1 Zhou L, Yu K, Yang L et al Sleep duration, midday napping, and sleep quality and incident stroke. The Dongfeng-Tongji cohort. Neurology. DEc 11, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31827003 https://n.neurology.org/content/early/2019/12/11/WNL.0000000000008739
- ↑ 35.0 35.1 Debras C, Chazelas E, Sellem L et al Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Sante cohort. BMJ 2022;378:e071204 Sept 7 Not indexed in PubMed https://www.bmj.com/content/378/bmj-2022-071204
- ↑ 36.0 36.1 36.2 36.3 36.4 36.5 36.6 36.7 Bushnell C, Kernan WN, Sharrief AZ 2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2024 Oct 21. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39429201 Review.
- ↑ 37.0 37.1 Reddin C, Canavan M, Hankey GJ et al Association of Vascular Risk With Severe vs Non-Severe Stroke: An Analysis of the INTERSTROKE Study. Neurology. 2024 Dec 10;103(11):e210087 PMID: https://www.ncbi.nlm.nih.gov/pubmed/39536279 https://www.neurology.org/doi/10.1212/WNL.0000000000210087