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Senior Health & Medicine
New Guidelines Issued to Prevent Stroke
American Heart Association/American Stroke
Association scientific statement
May 5, 2006 - Healthy habits and appropriate
treatments help prevent stroke, according to graded, evidenced-based
recommendations issued today by the American Heart Association and it's
division, the American Stroke Association. Stroke is the third leading
cause of death and a major source of disability in the United States.
Every year about 700,000 people in the United States suffer a stroke,
most are senior citizens, resulting in nearly 158,000 deaths. From
1993–2003, the stroke death rate fell 18.5 percent, but the actual
number of stroke deaths declined only 0.7 percent, according to 2006
association statistics.
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These "primary prevention" guidelines are published
in the rapid access issue of Stroke: Journal of the American Heart
Association.
"Stroke remains a major public health problem. Its
human and economic toll is staggering," said Larry B. Goldstein, M.D.,
the guidelines' lead author and chair of the association's Stroke
Council.
The estimated direct and indirect cost of stroke in
2006 is $57.9 billion.
"Stroke can be prevented and we are learning more
about ways of accomplishing that," said Goldstein, professor of medicine
(neurology) and director of the Duke Center for Cerebrovascular Disease
at Duke University Medical Center in Durham, N.C. The guidelines
addressed risks that can't be altered and those that can be influenced.
Non-modifiable risk factors
Risk factors that can't be changed include age,
gender, race/ethnicity and family history. Older people, men, African
Americans, and people with a family history of stroke are generally at
greater risk than others.
The writing committee also cited low birth weight
as a potential non-modifiable risk factor. Some studies have found that
adults who weighed about 5.5 pounds (2,500 grams) or less at birth have
double the risk of stroke as adults who weighed about 8 pounds (4,000
grams) or more at birth. However, the reason for this relationship
remains uncertain.
"We are facing potential cutbacks in maternal
health and nutrition programs. In addition to their public health
benefits, it makes sense to invest in programs aimed at improving the
health of women during pregnancy," Goldstein said. "Dividends may pay
off decades later by potentially reducing the chances of stroke – and
all the health costs that go with it – later in life."
Modifiable risk factors
In the guidelines, modifiable risk factors are
categorized as "well-documented" or "less well-documented or potentially
modifiable."
The guidelines reiterate some well-known prevention
measures such as controlling high blood pressure, not smoking, avoiding
exposure to secondhand smoke, being physically active and treating
disorders that increase the risk of stroke such as atrial fibrillation
(a type of irregular heartbeat), carotid artery disease and heart
failure.
The guidelines suggest physicians consider using a
risk assessment tool such as the Framingham Stroke Profile to assess
patients' risk.
"It is important to identify patients at high risk
of stroke because research shows that many strokes can be prevented if
those individuals modify their risk factors," Goldstein said.
Some new recommendations for "well-documented"
stroke risk factors include:
● Refer patients with rare genetic causes of
stroke for genetic counseling,
● Treat high-risk diabetic patients with statins,
● Increase intake of potassium and reduce salt
intake to lower blood pressure in people with hypertension,
● Start transcranial Doppler (TCD) ultrasound
screenings for children with sickle cell disease at age 2 and consider
transfusion therapy for those found to be at high stroke risk,
● Evaluate adult sickle cell patients for known
stroke risk factors and manage them according to stroke prevention
guidelines.
The "less well-documented or potentially
modifiable" risk factors have less clear-cut epidemiological evidence or
lack randomized clinical trials documenting stroke risk reduction.
Included in that category is the metabolic syndrome -- a clustering of
metabolic disorders that may increase the risk of artery plaque buildup
(abdominal obesity, high triglycerides, low HDL-cholesterol or "good"
cholesterol, high blood pressure, insulin resistance, high blood levels
of fibrinogen or C-reactive protein). Other interventions that may lower
stroke risk are limiting alcohol use, not using illicit drugs and
avoiding the use of oral contraceptives in women who smoke.
A new recommendation among the potentially
modifiable risk factors is evaluating people for sleep apnea. This
disorder is marked by extremely loud snoring, daytime sleepiness and is
associated with an increased risk of stroke. Sleep apnea sufferers stop
breathing several times a night, rousing to gulp in air in a pattern
that disrupts normal sleep.
"We know that treating sleep apnea is associated
with a reduction of blood pressure," Goldstein said. "And although we
don't have direct evidence that treating sleep apnea will reduce stroke
risk, the feeling is that it will. But that is not yet supported by
randomized trials."
The guidelines suggest that physicians question bed
partners and patients -- particularly those with abdominal obesity and
hypertension -- about sleep disorder symptoms.
Other risk factors such as inflammation, infection
and migraine are all mentioned in the guidelines as areas in which
research is evolving.
The guidelines also recommend low-dose aspirin to
prevent a first stroke in women whose risk is sufficiently high for the
benefits to outweigh the risks associated with long-term aspirin use.
The evidence is not strong enough to recommend aspirin in men at high
risk of stroke. Men at high cardiovascular risk can also benefit from
treatment with aspirin for primary prevention, Goldstein said.
"Stroke is a life-changing event that not only
affects the person who may be disabled, but the entire family and other
caregivers as well," he said, noting that its devastating toll prompted
aggressive efforts to educate physicians, other medical personnel and
their patients.
More information:
Co-authors are Robert Adams, M.S., M.D.; Mark J.
Alberts, M.D.; Lawrence J. Appel, M.D., M.P.H.; Lawrence Brass, M.D.;
Cheryl D. Bushnell, M.D., M.H.S.; Antonio Culebras, M.D.; Thomas J.
DeGraba, M.D.; Philip B. Gorelick, M.D., M.P.H.; John R. Guyton, M.D.;
Robert G. Hart, M.D.; George Howard, Dr.P.H.; Margaret Kelly-Hayes,
R.N., Ed.D.; J.V. (Ian) Nixon, M.D. and Ralph L. Sacco, M.D.
Primary stroke prevention at-a-glance
What can be done to reduce the
risk of stroke:
Consumers:
● Have regular screenings for high blood pressure
(at least every two years in adults and more frequently in minorities
and the elderly) and control high blood pressure.
● Don't smoke and eliminate exposure to
secondhand smoke.
● Maintain tight control of blood pressure if you
have diabetes. If you have diabetes and other risk factors, talk to your
physician about taking statins.
● Reduce sodium intake (no more than 2.3 grams a
day), and increase potassium intake (at least 4.7 grams a day) to lower
blood pressure in people with hypertension; eat a diet high in fruit,
vegetables, low-fat dairy products and low in saturated and total fat.
● Lower total cholesterol to acceptable levels.
● Lose weight, which can lower blood pressure.
vBe physically active (moderate-intensity) for at
least 30 minutes a day.
Physicians:
● Treat cardiovascular diseases that increase the
stroke risk such as coronary heart disease, heart failure and peripheral
artery disease.
● Consider anticoagulants or antithrombotics for
high-risk patients with atrial fibrillation.
● Consider prescribing statins for patients
with diabetes and other stroke risk factors.
● For asymptomatic patients with severe carotid
blockage, consider recommending prophylactic carotid endarectomy surgery
by a surgeon with a low complication rate.
● Beginning at age 2, screen children with sickle
cell disease with transcranial Doppler ultrasound and consider
transfusion therapy for those at elevated stroke risk.
vEvaluate adult sickle cell patients for stroke
risk factors and manage them according to the general guidelines in this
statement.
vDo not prescribe hormone therapy (with estrogen,
with or without progestin) for primary prevention of stroke.
Other things that can be done that will probably
reduce stroke risk:
Consumers:
● If you drink alcohol, limit your intake to no
more than two drinks a day for men and one drink a day for nonpregnant
women.
● Do not use illicit drugs.
● Do not take oral contraceptives if you are a
woman who smokes or has a history of blood clots.
● Look for signs of sleep-disordered breathing
(loud snoring, excessive daytime sleepiness, repeatedly gasping for
breath during sleep); see a specialist for further evaluation.
Physicians:
● Treat the components of the metabolic syndrome
(clustering of abdominal obesity, high triglycerides, low HDL-cholesterol,
high blood pressure, insulin resistance).
vConsider low-dose aspirin therapy for women at
high risk of stroke.
Editor's note: May is American Stroke Month
The American Stroke Association recently launched Power To End Stroke,
an aggressive education and awareness initiative to reach African
Americans, who are at greater stroke risk than other ethnic groups. For
more information on stroke or the Power To End Stroke campaign, call
1-888-4STROKE, or visit the American Stroke Association Web site:
strokeassociation.org/power.
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