1. Stroke Awareness & Prevention Suheb Hasan, MD Health Seminar MCWS November 17, 2012

2. 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

3. Stroke Types Ischemic stroke Due to obstruction Hemorrhagic stroke Due to rupture of blood vessel

4. 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

5. 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

6. 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

7. Differential Diagnosis- Non-Ischemic causes of TIA Seizures Migraine TGA Multiple Sclerosis Certain BT SDH

9. 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

10. Hypertension- SBP reduction Weight loss Diet rich in fruits vegetables low fat dairy products Regular aerobic physical activity Limited alcohol consumption Medications

11. 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

12. 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.

13. 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%

14. 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

15. Lipids life style modification dietary guidelines medication recommendation

16. 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.

17. 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.

18. 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.

19. 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

20. Alcohol Recommendations Heavy drinkers to eliminate or reduce their alcohol consumption

21. 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

22. 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

23. 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

24. 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.

25. 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.