Stroke Prevention: An Evidence-Based Update Appathurai Balamurugan, MD, DrPH, MPH, FAAFP Chief Medical Officer (Acting) State Chronic Disease Director Arkansas Department of Health & Associate Professor UAMS Department of Family and Preventive Medicine/Epidemiology

Overview Why Prevent Stroke? An Evidene-Based Update Primary and Primordial Prevention Secondary Prevention

Why Prevent Stroke? Stroke is the fifth leading cause of death in the United States and in Arkansas Arkansas ranks #7 among states with highest stroke deaths in the nation (Source: CDC wonder 2017 data). Kills approximately 140,000 Americans every year (Approx. 1600 Arkansans) Stroke costs an estimated $34 billion annually in the US Leading cause of long-term care admission among people under the age of 65 years of age

Stroke 2014 Stroke 2014

I. Primordial and Primary Prevention Risk Factors - Traditional - Non-traditional Risk Factor Reduction

Traditional Risk Factors INTERSTROKE study Population-attributable risk for common risk factors Population-attributable risk, % (99% CI) Hypertension 34.6 (30.4–39.1) Smoking 18.9 (15.3–23.1) Waist-to-hip ratio (tertile 2 vs tertile 1) 26.5 (18.8–36.0) Dietary risk score (tertile 2 vs tertile 1) 18.8 (11.2–29.7) Regular physical activity 28.5 (14.5–48.5) Diabetes 5.0 (2.6–9.5) Alcohol intake 3.8 (0.9–14.4) Cardiac causes (Atrial fibrillation) 6.7 (4.8–9.1) Ratio of apolipoprotein B to A1 (tertile 2 vs tertile 1) 24.9 (15.7–37.1) Psychological factors Stress 4.6 (2.1–9.6) Depression 5.2 (2.7–9.8) *For the protective factor of physical activity, the population-attributable risks are provided for individuals who do not participate in regular physical activity. Source: O'Donnell MJ et al. Lancet 2010; available at: http://www.thelancet.com.

Implementation of Risk Assessment Work Group Recommendations. Implementation of Risk Assessment Work Group Recommendations. ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CV, cardiovascular; and NHLBI, National Heart, Lung, and Blood Institute. David C. Goff, Jr et al. Circulation. 2014;129:S49-S73 Copyright © American Heart Association, Inc. All rights reserved.

Why Do We Have a Stroke Belt in the Southeastern United States Why Do We Have a Stroke Belt in the Southeastern United States? A Review of Unlikely and Uninvestigated Potential Causes. Source: American Journal of the Medical Sciences. Jackson Heart Study Symposium on Cardiovascular Disease in African Americans. 317(3):160-167, March 1999.

Non-traditional Risk Factors Race – accounts for 20% excess risk Socioeconomic status – PAR 36% similar to Hypertension Access to care Place of birth and residence Neighborhood Uninvestigated causes Allergens at home – Particulate Matter Soil Micronutrients in the drinking water

Primary Prevention in the ED: Recommendations 1. ED-based smoking cessation programs and interventions are recommended 2. Identification of AF and evaluation for anticoagulation in the ED are recommended 3. ED population screening for hypertension is reasonable 4. When a patient is identified as having a drug or alcohol abuse problem, ED referral to an appropriate therapeutic program is reasonable 5. The effectiveness of screening, brief intervention, and referral for treatment of diabetes mellitus and lifestyle stroke risk factors (obesity, alcohol/substance abuse, sedentary lifestyle) in the ED setting is not established

Block Group-specific estimates of the relative risk of stroke mortality in Arkansas, 2005-2009 Arkansas, ages: 35 – 64 b. Pulaski County, ages: 35 - 64 c. Arkansas, ages: 65 – 74 d. Arkansas, ages: 75 – 84 Relative Risk: GAM+GWR estimate in BG versus age- and sex-specific rate for Arkansas NA: Block groups (BGs) that contained no residents in the age group or BGs where non-Hispanic Black and non-Hispanic White populations make up less than half of the BGs residents

II. Secondary Prevention Risk Reduction Stroke Risk Scales – Framingham Stroke Profile, CHADS2, HAS-BLED

Profile of Adult Arkansans Hypertension – > 50% Diabetes – 12% Hyperlipidemia – 37% Smoking – 22% Source: www.nccd.cdc.gov

Clinical interventions = ~50% Clinical and Public Health Progress Each Contributed About Half to the 50% Reduction in Heart Disease Deaths, US, 1980−2000 Physical inactivity Secondary preventive therapies Initial treatments for heart attack or acute angina Treatments for heart failure Revascularization for chronic angina HTN, statins Cholesterol reduction Systolic BP Smoking Clinical interventions = ~50% Risk factor reductions = ~50% BMI increases Diabetes increases Million Hearts will bring the worlds of public health and of clinical practice together around a common goal. Both efforts have contributed to the drop in CVD mortality. It will take additional joint effort to battle the effects of obesity and diabetes epidemics on the population. Ford ES, et al. NEJM 2007;356(23):2388-97. HTN, Hypertension, BP, Blood pressure, BMI, Body mass index

Million Hearts Initiative 2022 Goals Intervention Baseline Goals Aspirin for those at high risk 47% 80% Blood pressure control 46% Cholesterol management 33% Smoking cessation 23% Sodium reduction ~ 3.5 g/day 20% reduction Tobacco use reduction Physical inactivity reduction Cardiac rehab among eligible patients 70% participation Here is the nation’s current population-wide performance on the ABCS under the column marked Baseline. The Target column is our population goal for January 1 of 2017. The Clinical Target column reflect the goals within systems of care, a higher standard. These audacious goals will prevent a million heart attacks and strokes by 2017—goals that require focused attention by each of us. You’ll get more information on how to address these in future lectures. Source: Million Hearts Initiative. Unpublished estimates from Prevention Impacts Simulation Model (PRISM) 15

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