The Synergy of Managing Multiple Stroke Risks

Sometimes a stroke can occur out of nowhere — as with a spontaneous carotid artery dissection. But more typically, stroke is either a symptom or culmination of another disease process such as atherosclerosis or arteriovenous malformation. Other conditions such as atrial fibrillation, high blood pressure, sleep apnea, high cholesterol and diabetes are stroke risks all by themselves. The good news is they can be treated. The bad news is that left untreated, they add to the risk of recurrent stroke.

Cardiologist Allen Solomon, professor of medicine at The George Washington University School of Medicine & Health Sciences, treats all these conditions every day and says that treating one of these conditions decreases the risk from any of the others. “For instance, anything that improves your blood pressure is going to decrease your chances of having atrial fibrillation,” he said. “And all the things that are important for atrial fibrillation are

Dr. Allen Solomon

going to be beneficial to the other conditions. These things are synergistic in that helping one helps the others.”

Atrial fibrillation (AFib)

Atrial fibrillation occurs when the hearts upper chamber (the atria) quivers instead of contracting. As a result, there are little pockets within the left atrium (called the left atrial appendage) that don’t get any blood flow, and blood can clot there. “If one of those clots goes to your brain, that’s a stroke,” he said. “Strokes related to atrial fibrillation are the worst kind of strokes. They’re twice as likely to be lethal, and they’re more likely to recur and more likely to have you bedridden, paralyzed and unable to care for yourself.”

AFib is the most common heart rhythm problem, affecting an estimated 2.7 to 6.1 million Americans. “That number will probably double in the next few decades as our society gets older and more obese, and there’s more hypertension and coronary disease and sleep apnea and diabetes,” Solomon said. “Atrial fibrillation is an epidemic.”

AFib has a significant stroke risk. People with AFib have a five-fold increased risk of having a stroke. This risk rises substantially with age: AFib accounted for about 1.5 percent of strokes in individuals aged 50 to 59 years but accounts for about 23.5 percent of strokes in those 80 to 89.

AFib itself is typically treated with medications, such as beta blockers and calcium channel blockers, to slow the heart rate and help improve symptoms. However, they do not ‘cure’ the problem, and patients still require medication to prevent strokes as long as they have AFib. There are also surgical and catheter procedures as well as implanted devices that are sometimes used to treat AFib.

To reduce the risk of stroke, patients with AFib are treated with anticoagulants. These medications help prevent blood clots with potential to cause a stroke from forming in the first place.

“One of the most interesting things that I’ve learned in the last five years is we spend a lot of time on expensive, complicated drugs and procedures like catheter ablation and surgical maze procedures to try to manage or eliminate atrial fibrillation,” Solomon said. “But in reality, simple things are much more effective in minimizing atrial fibrillation, which minimizes your stroke risk.”

He identified these simple things:

  1. If you’re overweight, lose weight.
  2. Do moderate aerobic exercises most days of the week.
  3. Eat a healthy diet.
  4. If you have sleep apnea, get it treated.
  5. If you have high blood pressure, treat it and bring it down to normal.
  6. Drink alcohol moderately.
  7. Be careful with caffeine — less is better.

“If you do those things, you do more to reduce your risk of having more atrial fibrillation, and the stroke risk associated with it, than any sort of high-tech medications or procedures,” he said. “Cardiologists call this ‘cleaning up the environment.’ We want those things treated aggressively.”

Sleep apnea

Sleep apnea is a condition in which a person may experience pauses in breathing five to 30 times per hour or more during sleep. These episodes — which wake the sleeper as they gasp for air — prevent restful sleep and are associated with high blood pressure, arrhythmia, stroke and heart failure. Sleep apnea increases the pressure in your heart and so makes your heart work harder. “It can also increase the pressures within your lungs, which can translate back into your heart and increase pressure and increase the risk of atrial fibrillation,” Solomon said.

Sleep apnea is common after stroke, with prevalence in excess of 50 percent. Obstructive sleep apnea is associated with higher post-stroke mortality and worse functional outcome.

Treatment involves keeping the air passages open by using a CPAP (continuous positive airway pressure) device which involves wearing a mask while sleeping.

Most sleep apnea is the “obstructive” variety and is the result of obesity. The low-tech treatment for obstructive sleep apnea is to lose weight. It is estimated that a quarter of adults ages 30 to 70 have it.

High blood pressure

Hypertension increases the risk of stroke, both first and recurrent. It can cause damage to blood vessels that increases stroke risk. High blood pressure is a risk factor for metabolic syndrome (pre-diabetes), which also increases stroke risk. It also increases the risk of AFib, which increases stroke risk: “The higher pressure within your heart puts stress on the atria and the electrical system and makes atrial fibrillation more likely,” Solomon said.

Any degree of HBP needs to be treated. This chart defines the categories of blood pressure:

According to AHA statistics, an estimated 85.7 million Americans have HBP, and the majority of them don’t know they have it. But if you are a stroke survivor, your blood pressure has been taken. If it is high, work with your doctor to bring it down. Every risk factor for every cardiovascular disease will be reduced.

Do not dawdle.

High cholesterol

Cholesterol circulates in the blood, and as blood cholesterol levels rise, so do cardiovascular risks. More than 28.5 million Americans age 20 or older have high cholesterol, defined as 240 mg/dL or higher.

Cholesterol comes from two sources. Your liver makes all the cholesterol you need (it’s a component of our cells). In addition to that source, you also get it from animal foods like meat, poultry and full-fat dairy products. But, with cholesterol, it’s less about intake of dietary cholesterol and more about intake of bad fats. Foods that have a lot of saturated and trans fat cause your liver to make more cholesterol than it otherwise would. For some people, this added production means they go from a normal cholesterol level to one that’s unhealthy.

Here’s the problem: Together with other substances, cholesterol can form a thick, hard deposit that can narrow the arteries and make them less flexible (atherosclerosis). If a clot forms and blocks a narrowed artery, a heart attack or stroke can result.

This is why most stroke survivors are prescribed a type of drug called a statin to reduce cholesterol.


Having diabetes means that you are more likely to develop heart disease and have a greater chance of a heart attack or a stroke. People with diabetes are also more likely to have other risk factors that increase the chances of having heart disease or stroke, such as high blood pressure or high cholesterol. If you have diabetes, you can protect your heart and health by managing your blood sugar, as well as your blood pressure and cholesterol. If you smoke, get help to stop.

Over time, uncontrolled diabetes can damage your blood vessels and the nerves that control your heart and blood vessels. The longer you have diabetes, the higher the chances that you will develop heart disease.

People with diabetes tend to develop heart disease at a younger age than people without diabetes. In adults with diabetes, the most common causes of death are heart disease and stroke. Adults with diabetes are nearly twice as likely to die from heart disease or stroke as people without diabetes.

Treating diabetes may require an endocrinologist. In addition to medication, most people require changes to their diet. The good news is that the steps you take to manage your diabetes also help to lower your chances of having heart disease or stroke.

According to statistics from the AHA, 23.4 million adults have been diagnosed with diabetes; an additional 7.6 million have undiagnosed diabetes; and 81.6 million have prediabetes.

The psychology of it

It can be difficult for stroke survivors to deal with the many changes a stroke can bring — from thinking of themselves as a healthy member of society to dealing with a variety of deficits and taking numerous medications — an aspirin, a statin, possibly multiple blood pressure medicines. Maybe you were diagnosed with diabetes or metabolic syndrome and have to change your diet dramatically. “It’s unbelievably frustrating when you think you’re in good health, and suddenly, you’re a patient,” Solomon said. “Many people get depressed and have a hard time dealing with all that.

“But there is a positive side, which I see all the time in my practice. Many people are actually healthier after one of these events compared to before. Considering themselves healthy, they don’t really pay much attention to diet and exercise and healthy choices; they gain weight or neglect regular doctor visits, so they don’t know their cholesterol, blood pressure or blood sugar levels. A stroke or TIA or heart attack can be a wakeup call. I often see people after one of these events, and they say, ‘Oh, my god, this is the healthiest I’ve been in years, now that I’ve lost 20 pounds and stopped smoking and started exercising and making healthier choices.’”

No order of magnitude

Solomon cautioned that no one of these conditions should be thought of as more serious than the others. “In medicine, we try to correct anything we can that’s correctable,” he said. “We can’t alter your genes, but we can probably control your blood pressure, cholesterol and blood sugar. And the better job we do at that, the better off you’re going to be. Most doctors are going to be very aggressive about risk factor modification, and add to that exercise, a healthy diet and weight loss.”

Managing co-occurring conditions may seem like a hassle, especially if you have been relatively healthy, “but I tell all my patients: ‘If we control your blood pressure and treat your sleep apnea, and get your diabetes controlled, and reduce your cholesterol, and you lose weight, eat healthy and exercise, if you do all those things, it’s much less likely that you’re going to have another event. And you’re likely going to feel well and return to work and travel and have a great quality of life.

“And if you don’t do those things, then your risk of something bad goes up.’ That’s the incentive for a lot of people.”

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Stroke Rehabilitation

Making the Best Decisions at Discharge After Stroke

The type of rehabilitation and support systems a survivor receives at discharge can strongly influence health outcomes and recovery. In this, the first part of a two-part series on stroke rehab, we offer guidance for the decision-making process required when it’s time to leave the hospital.

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After stroke, about two-thirds of survivors receive some type of rehabilitation. Outpatient therapy may consist of Several types of therapy. Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required.

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Following a stroke, about two-thirds of survivors receive some type rehabilitation. In this second of our two-part series, we want to alleviate some of the mystery, fear and anxiety around the inpatient rehab part of the stroke recovery journey.
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AHA-ASA Resources

The Support Network

When faced with challenges recovering from heart disease or stroke, it’s important to have emotional support. That is why we created a network to connect patients and loved ones with others during their journey.

Caregiver Guide to Stroke

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Stroke Support Group Finder

To find a group near you, simply enter your ZIP code and a mile radius. If your initial search does not pull up any groups, try

Tips for Daily Living Library

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Stroke Family Warmline

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Let's Talk About Stroke Patient Information Sheets

Let's Talk About Stroke is a series of downloadable patient information sheets, created by the American Stroke Association, that presents information in a question-and-answer format that's brief, easy to follow and easy to read.

Request Free Stroke Information Packets

Fill out this online form to request free information about a variety of post-stroke topics.
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Stroke & Parts of the Brain

When Stroke Affects the Occipital Lobe

Our occipital lobe, the smallest of the four lobes of the cerebral cortex, controls how we visually interpret our world.

When Stroke Affects the Cerebellum

The cerebellum contains 80 percent of our neurons. Its job seems to be to make things better. We talked with neuroscientist Jeremy Schmahmann about how stroke affects the “little brain.”

When Stroke Affects the Parietal Lobe

The parietal lobe helps us make sense of sensory information, like where our bodies and body parts are in space, our sense of touch, and the part of our vision that deals with the location of objects.

When Stroke Affects the Frontal Lobe

Of the four lobes that make up the cerebral cortex, the frontal lobe is the largest. It plays a huge role in many of the functions that make us human — memory, language, movement, judgment, abstract thinking.

When Stroke Affects the Temporal Lobe

The temporal lobe has several functions, mainly involved with memory, perception and language.

When Stroke Affects the Brain Stem

The brain stem serves as a bridge in the nervous system. It sits at the top of the spinal column in the center of the brain. When a stroke happens there, it can cause a few different deficits and, in the most severe cases, can lead to locked-in syndrome.

When Stroke Affects the Thalamus

The thalamus can be thought of as a "relay station," receiving signals from the brain’s outer regions (cerebral cortex), interpreting them, then sending them to other areas of the brain to complete their job.
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