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Reporter: Aviva Lev-Ari, PhD, RN

Big 10 Risk Factors for Stroke

It’s clear that strokes are a major cause of disability and death throughout the world. But many of the prime risk factors for stroke are within your power to change — something we have long known. A large international study published in the Lancet underscored how far prevention efforts could go. Collecting data from stroke patients and healthy individuals in 22 countries, it found that 10 largely modifiable risk factors account for 90 percent of the risk of stroke worldwide. That means there is much you can do to rein in your personal risk. Here are the Big 10: 

1. High blood pressure. This is the biggest contributor to strokes worldwide. The Lancet study estimated that blood pressure readings of 160/90 mm Hg or higher accounted for up to 52 percent of the “population-attributable risk” of stroke.

2. Sedentary lifestyle. In general, regular exercise is a good move for your cardiovascular health, as it helps lower blood pressure, regulate your weight, boost “good” high-density lipoprotein (HDL) cholesterol and prevent or manage type 2 diabetes. And there’s evidence that even moderate levels of physical activity can curb your risk of stroke.

3. Being “apple-shaped.” We often talk about excess pounds being a risk to your cardiovascular health, but it’s that middle-aged spread around the waist that may be particularly worrisome.

4. Smoking. If you are still a smoker, you need to work on quitting. In the Lancet study, there was no evidence that former smokers were at greater risk of stroke than people who’d never smoked — suggesting that the excess risk declines quickly after you quit.

5. Diet. Diet may be just as important as smoking habits. In particular, the Lancet study found, features of the traditional Mediterranean diet — namely, a high intake of fish and fruit — appeared protective against stroke.

6. Atrial fibrillation. This is the most common form of heart-rhythm disturbance, in which the upper chambers of the heart (atria) do not contract in a rhythmic pattern but instead quiver chaotically. If you have atrial fibrillation, it is critical that you take any anti-clotting medication or other drugs that your doctor has prescribed.

7. Cholesterol. Studies suggest that the relationship between cholesterol and stroke risk is complex. In theLancet study, total cholesterol levels were not associated with strokes, confirming epidemiological evidence, but higher levels of high-density lipoprotein (HDL, or “good”) cholesterol were linked to a lower risk of ischemic stroke.

8. Alcohol. Moderate drinking of alcohol was linked to a reduced risk of ischemic stroke, while any amount more than that was connected to an increased risk versus teetotaling.

9 & 10. Stress and depression. Both chronic stress (related to home or work life) and depression symptoms were linked to an increased risk of stroke. It’s not completely clear why; it could be because mental-health woes make it more difficult to stick to your healthy diet, exercise and medication regimen. Also unclear is whether depression therapy or stress-management classes can help lower your stroke risk.

Takeaway. The overall message here is that there are many steps you can take to help ward off a stroke. If you are not sure which of these risk factors apply to you or what you should be doing about them, talk with your doctor. It could make a substantial difference in the long run.

Posted in Hypertension and Stroke on August 7, 2012

ESC: Heart Rate No Predictor of Second Stroke

By Chris Kaiser, Cardiology Editor,MedPage Today

Published: August 27, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

MUNICH — In patients who had a stroke, a high resting heart rate was not associated with recurrent stroke, but was associated with cognitive and functional decline, according to a pooled analysis of the PRoFESS study.

Of the 20,165 patients evaluated, a high baseline heart rate — 77 bpm and greater — was not significantly associated with recurrent stroke or myocardial infarction (MI) compared with lower heart rates, reported Michael Böhm, MD, of the University of Saarland in Saar, Germany, and colleagues.

However, in patients with a recurrent stroke (n=1,627), a high heart rate had a negative impact on patients’ global disability scale according to the modified Rankin score at baseline and 3 months after the recurrent stroke, Böhm reported here at the European Society of Cardiology (ESC) meeting.

In addition, more patients with high heart rates had Mini-Mental State Examination (MMSE) scores indicative of a greater degree of cognitive decline (≤24) at 1 and 3 months (both were significant atP<0.0001), Böhm said.

“What is most striking is that at 3 months, 15% of those with a heart rate of 77 bpm or greater had signs of dementia,” he said during his presentation.

“This study is a landmark analysis and fills a major knowledge gap,” said study discussant Jeffrey Borer, MD, of SUNY Downstate Medical Center in Brooklyn.

“That heart rate doesn’t predict recurrent stroke, but does predict cognitive decline is a new finding,” he said.

He added that many studies have been conducted looking at heart rate, but none of them involved data because of a stroke. “Whether we can affect outcomes by lowering heart rate is not known and should be the next step in this research,” he said.

The initial PRoFESS (Prevention Regimen for Effectively Avoiding Second Stroke) trial found no evidence that aspirin and extended release dipyridamole were superior to clopidogrel (Plavix) or that telmisartan was superior to placebo to prevent recurrent stroke.

In this post hoc analysis, Böhm and colleagues included 20,165 patients enrolled from 35 countries. They were separated by heart rates, with the top three quintiles representing 71-76 bpm, 77-82 bpm and 82 or more bpm, respectively.

The mean age was 66 and less than half (36%) were women. Those with high heart rates tended to be younger, women, and less likely to drink or smoke.

They also tended to have more large cerebral artery involvement and higher baseline modified Rankin scores and NIH Stroke Scale scores, as well as worse baseline scores for self-care. In addition, there were fewer of them who took protective medications such as beta blockers, statins, and diuretics, Böhm said.

Compared with the lowest quintile, those in the top two quintiles had an increased risk of all-cause death (HR 1.42 and 174, respectively). The difference was significant at P<0.0001.

Patients in the top three quintiles were at an increased risk cardiovascular death (HR 1.39 for the third quintile, P<0.0001) and those in the fifth quintile had an increased risk for non-cardiovascular death (HR 1.66, P=0.0016).

“These findings identify a high-risk group of patients starting at a heart rate of 71 bpm that will die primarily from cardiovascular events,” Böhm said.

Surprisingly, heart rate did not affect the risk for recurrent stroke, MI, or new or worsening heart failure.

Even when researchers included blood pressure in the adjusted analysis, they found no change of risk, “indicating that the effects of heart rate on risk are independent of the blood pressure,” they wrote in the European Heart Journal, which published the study to coincide with the ESC meeting.

The study is limited because it relied only on baseline heart rate measurement, and perhaps variations in heart rate during the trial could explain the failure to predict strokes, Borer said.

Böhm also noted that the study is limited because it is a retrospective post hoc analyses of a randomized trial that did not randomize according to heart rate.

The PRoFESS study was funded by Boehringer Ingelheim.

Böhm reported relationships with AstraZeneca, Bayer AG, Boehringer Ingelheim, Novartis, Pfizer, sanofi-aventis, Servier, Adrian-Medtronic, Daiichi-Sankyo, MSD, AWD Dresden, and Berlin-Chemie. One co-author reported relationships with Boehringer Ingelheim, Lundbeck, Mitsubishi, Phagenesi, and ReNeuron. All other authors reported no conflicts of interest.

Borer reported a relationship with Servier.

 

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