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Stroke: Evaluating Risk and Counseling for Prevention

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Title: Stroke: Evaluating Risk and Counseling for Prevention


1
Stroke Evaluating Risk and Counseling for
Prevention
  • Presented By
  • The American Stroke Association
  • A Division ofAmerican Heart Association
  • In cooperation with the
  • University of Washington Stroke Center

2
What Is Stroke?
  • A stroke occurs when blood flow to the brain is
    interrupted by a blocked or burst blood vessel.

3
What Is the Impact of Stroke?
  • Stroke is the third leading cause of death in
    the United States
  • On average, someone suffers a stroke every 53
    seconds
  • About 731,000 Americans suffer strokes each year
  • Every 3.3 minutes, someone dies of a stroke in
    the US

4
What Is the Impact of Stroke? (Continued)
  • Stroke is a leading cause of serious, long-term
    disability in adults
  • About 4 million Americans are stroke survivors
  • Stroke costs the U.S.
  • 30 to 51 billion a year

Indirect
21.93 Bil. (43)
29.01 Bil. (57)
51/- Billion/yr
Direct
5
Rate of Strokes by Age, Sex and Race
6
Comparative Life Expectancy in the United States
  • White women 79.6 y
  • Black women 73.8 y
  • White men 72.9 y
  • Black men 64.6 y

Gorelick P. Stroke. 1998292656-2664.
7
Life Expectancy
  • of the 3 leading causes of death, HD, CA,
    stroke, the mortality disparity for black
    populations is highest for stroke. (Gorelick)
  • Greater in younger black males (4x gt stroke
    mortality in males age 45-59)
  • Risk falls to 126 at age 75

8
Age-specific incidence rates of first-ever
stroke among blacks compared with whites in
Framingham
Broderick J, Brott, T (Stroke. 199829415-421.)
9
What Are the Types of Stroke?
  • Ischemic Stroke (Blockage) 80
  • Caused when there is a blockage in the blood
    vessels to the brain
  • Thrombotic
  • Embolic
  • Hemorrhagic Stroke (Bleeding) 18-20
  • Caused by burst or leaking blood
  • vessels in the brain
  • Intracerebral hemorrhage
  • Subarachnoid hemorrhage

10
What Are the Causes of Ischemic Stroke?
  • Begins with the development of fatty deposits
    lining the blood vessel wall

11
  • Thrombus Development of blood clot at the
    fatty deposit
  • Embolus Traveling particle too large to pass
    through a small vessel

12
What Are the Causes of Hemorrhagic Stroke?
  • Occurs when a weakened blood vessel ruptures
  • HYPERTENSION 1 cause
  • Aneurysms Ballooning of a weakened region of a
    blood vessel

13
What Are the Causes of Hemorrhagic Stroke?
(Continued)
  • Arteriovenous Malformations (AVMs) Cluster of
    abnormal blood vessels

14
Stroke Risk Factors That Cannot Be Treated
  • Age
  • Stroke risk doubles each decade past age 55
  • Sex
  • Men at greater risk than women until 70s then
    female risk is greater
  • Race
  • African Americans gt stroke rate
  • Hispanic, Native American, some Asian populations

15
Stroke Risk Factors That Cannot Be Treated
  • Family History
  • Close FMH of stroke/TIA
  • CAD, DM
  • Other vascular disease
  • may increase hereditary risk

16
Stroke Risk FactorsThat Can Be Treated
  • Hypertension/High Blood Pressure
  • Heart Disease
  • Atrial Fibrillation
  • CAD
  • Cigarette Smoking
  • Transient Ischemic Attacks

17
Stroke Risk FactorsThat Can Be Treated
(continued)
  • Diabetes
  • Elevated Blood Cholesterol/Lipids
  • Asymptomatic Carotid Bruits
  • Obesity
  • Lack of Activity

18
Stroke Risk Factors Less Well-Documented
  • Geographical Location
  • Socioeconomic Factors
  • Excessive Alcohol Intake
  • Certain Kinds of Drug Abuse

19
The No. 1 Cause of ALL Stroke!
20
Prevalence of HTN
NHANES II
21
Inadequate Treatment of HTN
22
Hypertension
  • Syst-Eur Trial 4695, 4695 subjects w/isolated
    syst HTN nitrendapine, enalapril or HCTZ VS
    placebo
  • to ltSBP 20 by mmHg
  • Result Stroke event reduction of 42
  • (Staessen, Fagard Thijs. Lancet.
    1997350757-64)

23
Hypertension-HOPE Study
  • The Heart Outcomes Prevention Evaluation Study
  • ACEI ramipril
  • 9297 with evidence of vascular disease
  • High risk for cardiovascular event w/o left
    ventricular dysfunction
  • Endpoint, MI, stroke or death from CV cause
  • Ramipril or placebo for 5 years.
  • Results
  • Ramipril Placebo Group
  • all CV causes 6.1 8.1
  • stroke 3.4 4.9
  • MI 9.9 12.3
  • death any cause 10.4 12.2

24
ALLHAT(NHLBI)
25
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26
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27
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28
New Features Key Messages
  • For persons over age 50, SBP is more important
    than DBP as CHD risk factor
  • Starting at 115/75 mmHg, CHD risk doubles with
    each increment of 20/10 mmHg throughout the BP
    range
  • Persons who are normotensive at age 55 have a 90
    lifetime risk for developing HTN
  • Those with SBP 120-139 mmHG or DBP 80-89 mmHG
    should be considered prehypertensive who require
    health promoting lifestyle modifications to
    prevent CHD

29
New Features Key Messages (continued)
  • The most effective therapy prescribed by the
    careful clinician will control HTN only if
    patients are motivated
  • Motivation improves when patients have positive
    experiences with, and trust in, the clinician
  • Empathy builds trust and is a potent motivator
  • The responsible physicians judgment remains
    paramount

30
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31
Antihypertensive Agent Use in All Patients Class
of Drug
  • Class of Drug Women (n505) Men (n410)
  • Diuretics 40 29
  • ß-Blockers 16 18
  • Calcium channel blockers 48 44
  • ACE inhibitors 41 42
  • Other agents 26 25
  • Multiple agents 54 50
  • -------------------------------------------------
    -----------------------
  • ACE indicates angiotensin-converting enzyme.
  • Plt0.001.

Bradford B. Worrall, MD, MSc, et al (Stroke.
200233913.)
32
Treatment of HTN in African American Patients
  • Most patients require combination TX
  • All agents are effective in African Americans
  • Recent studies indicate that thiazide diuretics
    are unsurpassed for TX of HTN in African
    Americans
  • diuretics should be the drug of first choice,
    or included in most antihypertensive regimens,
    especially in African American hypertensives.
  • Wright, JT, Douglas J. J. Clin Hypertens. 2003
    jan-Feb5 Suppl 118-25.

33
Heart Disease
  • Increases risk 6 fold
  • Atrial Fibrillation
  • Post MI
  • CHF
  • Valve disease
  • Atrial fibrillation

34
Heart Disease -Atrial Fibrillation
  • Annual risk of stroke in non-valvular AF is 3-5
  • Responsible for 50 of all thromboembolic stroke
  • 2/3 stroke in persons with AF are cardioembolic
  • Median age of AF pt is 75 years
  • Increased risk of stroke in AF w/ gt age
  • 1.5 age 50-59
  • 23.5 age 80-89
  • Adjusted odds ratio for stroke
  • 1.5 males (95 CI 1.2-1.8)
  • 1.9 females (95 CI 1.5-2.2) (Framingham)

35
What is Atrial Fibrillation?
  • Atrial Fibrillation is a very irregular heartbeat
    (irregularly irregular)
  • Upper chamber of the heart does not contract
    effectively
  • Causes formation of abnormal blood clots
  • Blocks blood flow to brain
  • May cause STROKE!!

36
Atrial Fibrillation
www.ccf.org/heartcenter/medproff/consult/summer95/
images/echoview.gif
37
Pulse Check for A. Fib
  • The A. Fib pulse is irregularly irregular
  • Turn one hand palm-side up.
  • Place the first 2 fingers of the other hand on
    the wrist bone just below the thumb.
  • Slide the fingers towards the center of the
    wrist.
  • Pulse is usually found between the wrist bone and
    the tendon.
  • Move fingers up or down until pulse is found.

38
Pulse Check forRhythm not rate!!
  • What is irregularly irregular?
  • NO PATTERN TO BEATS Random
  • Feel pulse for 1 full minute
  • If irregularly irregular
  • Possibly Atrial fibrillation

39
What are the symptoms of AF
  • Frequently None
  • Feeling of Palpitations orButterflies in the
    Chest
  • Frequent skipped or extra beats
  • Lightheadedness or faintness
  • Shortness of breath

40
AHA Recommendation
  • Early evaluation by physician
  • Consider antithrombotic therapy (warfarin or ASA)
    for patients with nonvalvular AF based on
    assessment of risk of embolism and risk of
    bleeding complications.
  • Warfarin treat to INR 2-3
  • ASA 81-325 mg po /day

41
Smoking
42
Smoking
  • Long standing risk for stroke and CHD
  • Multifactorial deleterious effects on vasculature
    and blood rheology
  • Reduces vascular distensibility
  • Reduced compliance (wall stiffness)
  • Increased fibrinogen levels
  • Increased platelet aggregation
  • Increased HCT
  • Decreased HDL

43
Smoking
  • 25 of US adults are active smokers
  • 18 all strokes directly attributable to smoking
  • Risk is reduced to that of non-smokers at 5 years
    post-quit. (Framingham)
  • Wells,suggests that environmental exposure may
    increase risk for coronary events 20-70
  • est. 62,000 CAD deaths in 1985 R/T exposure,
    (Wells. J. Am. Coll Cardiol. 199424546-54)

44
Smoking Rewardsof Quitting
  • Freedom from addiction
  • Food tastes better
  • Improved sense of smell
  • Environment smells better
  • No more worry/guilt
  • Sets a good example for children
  • Avoids exposing others
  • Feel better physically
  • AM cough subsides
  • Reduced risk of MI/Stroke

45
AHA Recommendation
  • Immediate cessation for all smokers -
  • Discuss at every health care visit
  • Multidisciplinary pharmacologic and behavioral
    therapies are most successful

46
Prior HX Stroke/TIA Increases Risk 10XCumulative
Risk of Stroke
Post-TIA ()
Post-Stroke ()
3 10 5 14 25 40
4 8 12 13 24 29
30 days 1 year 5 years
Sacco. Neurology. 199749(suppl 4)S39. Feinberg
et al. Stroke. 1994251320.
47
Percentages of Deaths Caused by Stroke or MI
Among Patients with a First Cerebral Infarction
(n764) An 18 Year Follow Up
Adapted from Petty GW, Brown RD Jr., Whisnant
JP, et al. Survival and recurrence after first
cerebral infarction a population-based study in
Rochester, Minnesota, 1975 through 1989.
Neurology. 199850208-216. Patients with first
cerebral infarctions were continuously enrolled
from 1975 through 1989 (N1,111). Stroke and MI
deaths were recorded from 1975 through 1993.
48
Diabetes
  • Increased prevalence of atherogenic/metabolic
    risk factors
  • HTN
  • Obesity
  • Lipid dysfunction
  • Syndrome X (T-II DM)
  • Hyperinsulinemia gtVLDL Chol
  • Insulin resistance lt HDL Chol
  • Hyperglycemia HTN

49
Diabetes
  • Considered a cardiovascular risk equivalent
  • Confirmed independent risk for stroke
  • Increases RR of stroke 1.8 to 6 X
  • 1976-80 stroke 2.5-4X more common in diabetics
    than those w/NL glucose tolerance
  • Framingham-risk of brain infarction 2X with
    glucose intolerance..
  • greater effect in women.
  • Kannel, McGee. JAMA, 19792412035-38

50
AHA Recommendation
  • Careful control of HTN in all diabetics
  • Glycemic control to reduce microvascular and
    organ complications
  • BP should be treated to lt 130/80
  • 33 stroke event reduction

51
Cholesterol
  • Considered a cardiovascular risk equivalent
  • Inverse relationship between cholesterol and
    hemorrhagic stroke
  • Honolulu Heart Program (lt 189 mg/dl)
  • Kaiser Study (lt178 mg/dl in men gt 65)
  • Multiple Risk Factor Intervention Trial (MRFIT)
  • Increased ischemic stroke risk with increasing
    cholesterol
  • MRFIT
  • Copenhagen Stroke Study

52
Cholesterol-CARE Trial
-13
RiskReduction
UnstableAngina
-20
-23
-23
-24
CVDDeath
-26
-26
NonfatalMI
PTCA
CVDDeathorNonfatalMI
-31
CABG
Stroke/ TIA
Stroke
-37
Fatal MI
p lt 0.05
Sacks N Engl J Med 1996335.
53
AHA Recommendation
  • Management of chol to NCP III guidelines
  • LDL lt 100 in patients with multiple risk factors
    or cardiovascular risk equivalents
  • HDL gt 40
  • TG lt150 in DM
  • Review New Treatment Guidelines
  • Detection, Evaluation, and Treatment of High
    Blood Cholesterol in Adults (Adult Treatment
    Panel III) http//www.nhlbi.nih.gov/guid
    elines/cholesterol/index.htm

54
LDL Cholesterol Goals
55
What areCHD Risk Equivalents?
56
Carotid Disease
  • 7-10 males gt 65y/o have gt50 carotid stenosis
  • 5-7 women gt 65 y/o have 50 carotid stenosis
    (Framingham cohort)
  • NASCET annual risk of ipsilateral stroke over 5
    years
  • 3.0 60-74 stenosis
  • 3.7 75-94 stenosis
  • 2.9 95-99 stenosis
  • 1.9 complete occlusion
  • (Barnett et al. NEJM 339 1998)

57
Recommendation
  • All persons with carotid bruit need further
    evaluation
  • Carotid artery ultrasound

58
Obesity
  • 50 Americans obese or overweight
  • Defined BMI /gt30
  • Predisposed to CV disease, especially with
  • Advancing age Hyperglucosemia
  • Hyperlipidemia Abdominal obesity
  • HTN
  • RR 2.33 in American men in upper quintiles
    waist/hip ratio
  • (Health Professionals Follow-up Study)

59
Obesity
  • Women and obesity
  • Increased risk w/ increasing BMI
  • RR 1.75 (95 CI) BMI 27
  • RR 1.9 BMI 29-31.9
  • RR 2.37 BMI gt 32
  • Weight gain after 18 y/o associated w/ inc.
    stroke risk

60
AHA Recommendation
  • Reduction in weight based on association with co
    morbid conditions leading to stroke.
  • Activity based on AHA guidelines
  • No clear evidence that weight loss directly
    reduces stroke incidence
  • Reduces effects of co morbid conditions

61
Activity
  • Reduces effects of atherogenic risk factors
  • Increased HDL
  • Reduces LDL
  • Increases vascular tone

62
AHA Recommendation
  • Good health-30-60 minutes vigorous activity 3-5 X
    a week
  • Others 15 minutes walking per day if able

63
Stroke Warning Signs
  • Sudden weakness or numbness of the face, arm or
    leg, especially on one side of the body
  • Sudden confusion, trouble speaking or
    understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of
    balance or coordination
  • Sudden, severe headaches with no known cause (for
    hemorrhagic stroke)

64
Take Action
  • Call 911 or EMS immediately!
  • If ambulance not available, rush victim to
    nearest hospital emergency room or another
    facility with 24-hour life support
  • If person resistscall anyway..

65
Transient Ischemic Attacks (TIAs)
  • TIAs are warning strokes that can happen
    before a major stroke
  • They occur when blood flow through a brain artery
    is blocked or reduced for a short time

66
Transient Ischemic Attacks (TIAs) (Continued)
  • TIA symptoms are temporary but similar to those
    of a full-fledged stroke
  • A person who has a TIA is 9.5 times more likely
    to have a stroke

67
What Parts of the Brain Are Affected by Stroke?
68
How Are Strokes Treated?
  • Ischemic Stroke
  • Clot-busters e.g., t-PA 3 hour time window
  • Anticoagulants warfarin INR 2-3
  • Antiplatelet agents
  • Aspirin
  • Clopidogrel
  • Dypridamole ASA
  • Carotid Endarterectomy
  • Angioplasty/Stents
  • Hemorrhagic Stroke
  • Surgical Intervention
  • Endovascular Procedures, e.g., coils

69
How Are Strokes Treated?
  • 1 Treatment for stroke is primary prevention
  • Risk reduction
  • Education-awareness and risk identification
  • Public
  • Health care providers
  • Pharmacists
  • Nurses
  • Physicians
  • EMS
  • Administration

70
ScreeningRisk Assessment
71
  • Participant to
  • complete demo-
  • graphic section
  • circle uncontrollable risk factors
  • check medical history items that apply to self or
    any blood relatives

72
  • Screener to
  • Calculate BMI
  • Check BP X3
  • (if necessary)
  • Check pulse for
  • rapid or irregular
  • rate/rhythm
  • Listen for carotid
  • bruit
  • Cholesterol
  • screening (optional)
  • Glucose Screening
  • (optional)

73
  • Action Plan
  • Review results
  • Recommendations
  • for risk modification
  • REFER to MD if
  • appropriate
  • Give participant
  • top 2 copies (for
  • self to share w/MD)
  • REVIEW STROKE
  • WARNING SIGNS
  • CALL TO ACTION

74
Education
  • Be familiar with ASA guidelines/recommendations
  • Be familiar with ASA educational materials
    available
  • Encourage participants to ask questions, opens
    opportunity for discussion
  • Do not give medical advice unless qualified
  • Provide ASA education material applicable to each
    specific risk factor

75
Education
  • If participant has no care provider, encourage to
    seek care through local hospital or clinic.
  • Take advantage of questions to motivate
    participant to change lifestyle related risk
    factors
  • Personalize content and discussion to increase
    participant buy-in and motivation
  • Encourage any small changes participant has made
  • One small step at a time will increase chances of
    success.

76
Motivation -- The 4 Rs
  • Relevance advice has greatest impact if directly
    relevant to participants disease, family,
    concerns, social situation-PERSONALIZE
  • Risk what are the risks to the participant of
    behaviors or change ie stroke is a devastating
    illness
  • Rewards ask participant to identify the benefits
    of change, i.e. live longer healthier, be here
    to see your kids graduate from college, etc.
  • Repetition repeating motivational health
    information increases success, review relevance,
    risks, and rewards at any opportunity.

(AHCPR. (1997). Smoking Cessation Guideline 18).
77
Follow-up
78
Situations Requiring Urgent Evaluation/Treatment9
11
  • Any
  • Chest pain
  • Stroke/TIA Symptoms
  • Mental Status Changes
  • Significant Respiratory Distress

79
Early Follow-up Conditions
  • Blood Pressure greater than 180/110
  • Same day
  • Blood Glucose greater than 250
  • Within 1 week
  • Atrial Fibrillation
  • Within 1 week

80
Response to Possible AF
  • Advise follow-up w/primary care w/in 1 week for
    evaluation (ECG)
  • NOT a medical emergency but needs early follow-up

81
Routine Follow-Up
  • Smoking
  • Next Primary care visit
  • Advise of risk and importance of quitting
  • Elevated untreated cholesterol
  • 1-3 months or next primary care visit

82
Hypertension
CLASSIFICATION OF BLOOD PRESSURE FOR
ADULTS AGE 18 AND
OLDER CATEGORY SYSTOLIC
DIASTOLIC FOLLOW-UP RECOMMENDED Normal
lt 120 And lt 80
Recheck in at least 1
year Prehypertension 120 139 Or
80 89 Recheck within 3
months Hypertension Stage 1
140 159 Or 90 99 Contact
physician within 1 week Hypertension Stage 2
gt160 Or gt100
Contact physician with a couple

of days
83
High Risk Participant
  • Multiple unmanaged risk factors
  • Has 2 of the big three causes of stroke
  • HTN
  • Diabetes
  • Heart Disease
  • Add smoking to above, increases risk significantly

84
Educate Every Participant On Stroke Warning
Signs and Actions
  • Sudden weakness or numbness of the face, arm or
    leg, especially on one side of the body
  • Sudden confusion, trouble speaking or
    understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of
    balance or coordination
  • Sudden, severe headaches with no known cause (for
    hemorrhagic stroke)

85
Prevention of Stroke
  • Control high blood pressure
  • Prevent heart disease
  • Stop cigarette smoking
  • Moderate use of alcohol if at all

86
Prevention of Stroke (Continued)
  • Recognize signs of TIA and tell physician about
    them
  • Reduce blood cholesterol levels
  • Control weight-normal BMI
  • Exercise

87
(No Transcript)
88
Mini strokes should not be ignored... 2/10
/00 NEW ORLEANS (UPI) -- New research suggests
that millions of Americans ignore mini-strokes, a
clear early warning that a major crippling stroke
is on its way. By neglecting to see a
doctor for these short brain attacks, patients
lose a precious chance to ward off a larger,
disabling stroke in the future.
89
Stroke Is a Medical Emergency
  • If you notice one or more of the warning signs
    for stroke,
  • GET HELP IMMEDIATELY!

90
To Learn More About Stroke
CALL 1-800-AHA-USA1 (1-800-242-8721) Or visit us
online at www.americanheart.org
91
Web Resources
  • American Heart Association/American Stroke
    Association http//www.americanheart.org
  • University of Washington Stroke Center
    http//depts.washington.edu/uwstroke
  • National Stroke Association
  • http//www.stroke.org
  • AHCPR Clinical Guidelines Clearinghouse
    http//www.guideline.gov/index.asp
  • National Heart, Lung Blood Institute
    Detection, Evaluation Treatment of High Blood
    Cholesterol in Adults http//www.nhlbi.nih.gov/gu
    idelines/cholesterol/index.htm

92
Web Resources, continued
  • National Institute of Neurological Disorders and
    Stroke http//www.ninds.nih.gov
  • The Internet Stroke Center
  • http//www.strokecenter.org
  • The Brain Attack Coalition
  • http//www.stroke-site.org
  • The Stroke Network
  • http//www.strokenetwork.org

93
Acknowledgements
  • Operation Stroke Initiative,
  • American Stroke Association
  • NW Washington Regional Office, Seattle, WA
  • University of Washington Stroke Center at
    Harborview, Seattle, WA
  • Program development by
  • Michael S. Fruin, MN, ARNP
  • University of Washington Stroke Center
  • Matthew Kresken Pharm. D.
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