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Stroke Awareness & Prevention. Suheb Hasan, MD Health Seminar MCWS November 17, 2012. Why need prevention?. Third leading cause of death in the US 700,000 strokes every year 200,000 of these have recurrent stroke More than $40 billion cost per year Live longer and better quality.

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Stroke awareness prevention

Stroke Awareness &Prevention

Suheb Hasan, MD

Health Seminar MCWS

November 17, 2012


Why need prevention
Why need prevention?

  • Third leading cause of death in the US

  • 700,000 strokes every year

  • 200,000 of these have recurrent stroke

  • More than $40 billion cost per year

  • Live longer and better quality


Stroke types
Stroke Types

  • Ischemic stroke

  • Due to obstruction

  • Hemorrhagic stroke

  • Due to rupture of blood vessel


Stroke definition
Stroke Definition

  • By conventional clinical definitions, Focal Neurological symptoms >24 hours = Stroke

  • Most recent definition – symptoms lasting > 24 hours or imaging of an acute clinically relevant brain lesion in patients with rapidly vanishing symptoms


Tia definition
TIA Definition

  • Brief episode of neurological dysfunction caused by a focal disturbance of brain or retinal ischemia, with typical symptoms lasting less than 1 hour, and without evidence of infarction.

  • 90 day risk of stroke reported as high as 10.5%

  • Greatest risk in the first week


Differential diagnosis ischemic causes
Differential Diagnosis- Ischemic Causes

  • Large artery atherosclerotic infarction

    Extracranial or Intracranial

  • Embolism from cardiac source

  • Small vessel disease

  • Other causes as dissection, hypercoagulable states, sickle cell disease

  • Infarcts of undetermined cause


Differential diagnosis non ischemic causes of tia
Differential Diagnosis- Non-Ischemic causes of TIA

  • Seizures

  • Migraine

  • TGA

  • Multiple Sclerosis

  • Certain BT

  • SDH


Risk factor control hypertension
Risk Factor control – Hypertension

  • Continuous association between systolic and diastolic BP and the risk of ischemic stroke

  • Meta-analysis of randomized controlled trials confirm an approximate 30% to 40% stroke risk reduction with BP lowering.

  • Treatment of HTN is associated with reduction in all recurrent non-fatal and fatal stroke, MI and vascular death


Hypertension sbp reduction
Hypertension- SBP reduction

  • Weight loss

  • Diet rich in fruits vegetables low fat dairy products

  • Regular aerobic physical activity

  • Limited alcohol consumption

  • Medications


Diabetes
Diabetes

  • Diabetes estimated to affect 8% of adult population

  • Diabetes is encountered in the stroke care , being present in 15%, 21% and 33% of patients with ischemic stroke

  • Diabetes and age were the only significant independent predictors of recurrent stroke

  • Diabetes has been shown to be a strong determinant for the presence of multiple lacunar infarcts


Diabetes recommendations
Diabetes - Recommendations

  • Most of the available data on stroke prevention in patients with diabetes are on the primary rather than secondary stroke prevention.

  • More rigorous control of BP and lipids should be considered in diabetics.


Diabetes recommendations1
Diabetes - Recommendations

  • Glucose control is recommended to near normoglycemic levels among diabetics with TIA or ischemic stroke to prevent microvascular complications, macrovascular complications.

  • HgbA1c target ≤ 7%


Lipids
Lipids

  • Hyperlipidemia not as well established as risk factors for the first or recurrent stroke in contrast to what is seen in cardiac disease

  • Recent clinical trial data suggest, that stroke may be reduced by administration of Statin agents in patients with CHD


Lipids1
Lipids

  • life style modification

  • dietary guidelines

  • medication recommendation


Lipids recommendations
Lipids - Recommendations

  • Statin agents

  • Target LDL <100 mg/dl for those with CHD or symptomatic atherosclerotic disease

  • Target LDL <70 mg/dl for very high risk persons with multiple risk factors.


Cigarette smoking
Cigarette Smoking

  • A major independent risk factor for ischemic stroke.

  • Risk associated at all ages, in both sexes and among different racial/ethnic groups.

  • Smoking associated with doubling the risk as c/t non-smokers.

  • Pathophysiology – Induces changes in blood dynamics and vascular stenosis.


Cigarette smoking recommendations
Cigarette Smoking - Recommendations

  • All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke.

  • Avoid environmental smoke.

  • Counseling, Nicotine products and oral smoking cessation medications.


Alcohol consumption
Alcohol Consumption

  • Effect of alcohol on stroke risk is controversial

  • J-shaped association between alcohol and stroke

  • Reduced risk of stroke with light drinking may be related to increase in HDL, decrease in platelet aggregation and lower plasma fibrinogen concentration

  • Increased risk with heavy alcoholism, may be related to alcohol induced HTN, hypercoagulable state, reduced CBF, and AF


Alcohol recommendations
Alcohol Recommendations

  • Heavy drinkers to eliminate or reduce their alcohol consumption


Obesity
Obesity

  • Obesity defined as BMI >30 kg/m²

  • Prevalence 63% men and 55% women are considered overweight

  • 30% considered obese

  • Relationship of obesity to stroke is complex

  • Obesity strongly related to other stroke and vascular risk factors, HTN, Diabetes,↑ lipids


Obesity1
Obesity

  • Abdominal obesity rather than general obesity is more related to stroke risk

  • Abdominal obesity defined as waist circumference >40” in men, >35” in women

  • No study has demonstrated that weight reduction will reduce stroke recurrence

  • Reducing weight however improves other stroke risk factors


Obesity recommendations
Obesity - Recommendations

  • Weight reduction may be considered for all overweight ischemic stroke and TIA patients to maintain goal of 18.5 to 24.9 kg/m² and waist circumference of <35” for women and <40” in men

  • Watch calorie intake, physical activity and behavioral counseling


Physical activity
Physical Activity

  • Increased physical activity exerts a beneficial effect in multiple CV risk factors including those for stroke

  • Moderately active men and women have 20% lower risk, and highly active had 27% lower risk

  • Helps lower BP and weight, enhance vasodilation, improve glucose tolerance and promote cardiovascular health.


Physical activity recommendations
Physical Activity - Recommendations

  • Physically capable patients - at least 30 minutes of moderate intensity physical exercise in most days of a week should be considered

  • Patients with disability after ischemic stroke - a supervised therapeutic exercise is recommended.


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