1. 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

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

3. 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 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

4. Stroke 2014
Stroke 2014

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

6. 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:

7. 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.

8. 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): , March 1999.

9. 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

10. 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

11. Block Group-specific estimates of the relative risk of stroke mortality in Arkansas, 2005-2009
Arkansas, ages: 35 – 64
b Pulaski County, ages:
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

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

13. Profile of Adult Arkansans
Hypertension – > 50%
Diabetes – 12%
Hyperlipidemia – 37%
Smoking – 22%
Source:

14. 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): HTN, Hypertension, BP, Blood pressure, BMI, Body mass index

15. 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

16. Questions?!
WELL