Managing Risk: A Roadmap for Avoiding Another Stroke
A Roadmap for Avoiding Another Stroke
We’ve been publishing for 20+ years, and nobody has ever asked, “How can I increase my chances of having another stroke?” Unfortunately, those of you who have survived a stroke or TIA have already answered the question — having a stroke or TIA increases your chances of another stroke by 3 percent after one month, up to 16 percent five years after stroke. Of the nearly 700,000 ischemic strokes each year, approximately 180,000 of them are recurrent.
This is why the American Stroke Association develops clinical guidelines to reduce stroke survivors’ risk of more strokes. According to our recently updated Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack, there are a number of things you can do:
1 CONTROL YOUR BLOOD PRESSURE.
About 70 percent of people who have had a recent ischemic stroke also have high blood pressure. High blood pressure damages blood vessels, and there are 100,000 miles of them in your brain. At any moment, 20-25 percent of all your body’s blood is in your head. Keeping those vessels healthy is of paramount importance.
2 REDUCE YOUR CHOLESTEROL.
Intensive cholesterol-lowering therapy is important for survivors whose stroke was caused by hardening of the arteries (also called atherosclerosis). However, niacin or fibrate drugs are no longer recommended to raise good cholesterol, due to sparse data establishing their effectiveness at reducing the risk of another stroke.
3 GET MOVING.
If you are capable of engaging in physical activity, aim for three to four sessions a week of moderate-to-vigorous intensity aerobic physical exercise, like brisk walking, swimming, water aerobics or bike-riding. If you haven’t been exercising, talk with your doctor, start gently and build slowly. But start! Visit StrokeAssociation.org/ActiveAfterStroke for tips.
ADDITIONAL RECOMMENDATIONS IN THE UPDATED GUIDELINES INCLUDE:
• Screening stroke and TIA survivors for diabetes and obesity — Diabetes increases cardiovascular risk; 65 percent of people with diabetes die of some form of heart disease or stroke. Obesity increases the risk of diabetes.
• Possible screening for sleep apnea — Many survivors have sleep apnea, particularly if they are overweight. Sleep apnea increases blood pressure, but independently increases stroke risk. (See “Get a Good Night’s Sleep and Reduce Your Risk,” January/February 2008.)
• Possible nutritional assessment — It’s easy to fall into bad eating habits, and not always easy to know what healthy foods to eat. The guidelines recommend following a Mediterranean-type diet that emphasizes vegetables, fruits, whole grains and includes low-fat dairy, poultry, fish, legumes and nuts, and limits sweets and red meat.
Of the nearly 700,000 ischemic strokes each year, approximately 180,000 of them are recurrent.
• 30-day monitoring for the irregular heartbeat atrial fibrillation for those who had strokes of unknown causes. AF, with risk that increases with age, may cause as many as 20 percent of strokes in older people. (See “Hearts Aflutter” in September/ October 2011.)
• Anticoagulants in specific situations (such as AF) reduce the risk of blood clots forming in the blood. On average, the annual risk of recurrent stroke among stroke or TIA survivors is about 3 percent to 4 percent.
“The key to staying healthy after an ischemic stroke or TIA is careful and rapid assessment of the cause of the event and identification of stroke risk factors so that appropriate preventive interventions can be quickly provided,” said Walter Kernan, M.D., lead author and chair of the guideline writing group and professor of medicine at Yale University School of Medicine in New Haven, Connecticut. “Then, patients must work with their doctors regularly to stay on their prevention program. With this approach, every patient can look forward to a healthier future.”
The American Heart Association/American Stroke Association and the American College of Cardiology updated guidelines for the diagnosis and treatment of LDL, “bad” cholesterol. In the past, treatment focused on a specific total cholesterol reading, with anything over 200 mg/ dL requiring treatment with lifestyle changes and cholesterol-lowering medications.
The new guidelines specifically state that it is no longer considered appropriate to treat to a target number, but instead focus on treating overall atherosclerotic risk, or hardening of the arteries. A risk evaluation formula is used to assess a patient’s ten-year risk of atherosclerotic heart disease and stroke. If a patient’s risk is greater than 7.5 percent, the guidelines recommend consulting with a doctor about taking a statin drug, a type of medication that lowers artery-clogging LDL cholesterol. The guidelines and risk assessment tool are based on the best evidence available as determined by an expert panel. The risk assessment tool is intended to spark a conversation between patients and their physician to help drive individualized care based on that patient’s health profile.
The risk assessment is a significant improvement over the previous model. For the first time in a major guideline, it focuses on estimating risk for both heart attacks AND strokes, whereas previous guidelines only focused on heart attack risk. They also provide estimates specific to African- Americans for the first time ever.
One in three Americans die of cardiovascular diseases such as heart attack, heart failure and stroke. Strong scientific evidence indicates that statins are a reasonable treatment approach for a large majority of patients, and can help people avoid a heart attack or stroke even if their risk is as low as 5 percent.
Lifestyle changes (i.e., choosing a heart healthy diet, getting regular exercise, avoiding tobacco products and maintaining a healthy weight) remain a critical component of health promotion and atherosclerosis risk reduction, both prior to and in combination with the use of cholesterol-lowering drug therapies.
Adherence to lifestyle changes and to statin therapy should be re-emphasized before trying a nonstatin drug. Examples of nonstatin drugs are bile acid sequestrants, fibrates, niacin, ezetimibe and omega-3 fatty acids. When the expert panel reviewed these therapies, they did not find enough strong evidence that non-statins alone reduced the risk of heart attack and stroke as compare to statins. The panel went on to say that physicians treating high-risk patients who do not respond well to a recommended dose of a statin, or who are statin intolerant, may consider using a non-statin cholesterol-lowering therapy. They recommend preference given to those non-statins where proven benefits outweigh adverse effects, mindful of drug interactions. People at high-risk include those with atherosclerosis, those with LDL cholesterol above 190 mg/dL and patients over age 40 with diabetes.