Not only is stroke incidence increasing but there is usually no effective treatment. In the meantime controlling the risk factors of high blood pressure, diabetes and weight may help decrease your risk

Stroke is the third leading cause of death, after heart disease and cancer. In the U.S. heart disease kills 650,000 people a year, cancer 550,000 and strokes 150,000. Deaths from stroke reached a high in 1979 of 160,000, then went down to 135,000 in the early nineties, then it started going back up and is now at 150,000 a year and climbing costing at least 60 billion healthcare dollars annually.

That baby boomers are approaching their stroke-prone years is usually the reason given for the increase in stroke incidence. If so, the burden on our health care system can be expected to increase. The reason for the decrease during the 1980's is more than likely due to lifestyle changes in response to increased health education for cardiovascular disease.

Strokes have been documented as long as there have been people to document them. Known as apoplexy, the Hebrews wrote about it while in Babylon and Hippocrates talked about them in 400 BC, noting that 'men between the ages of 40 to 60 years old are most likely to suffer one, and that a strong attack will not go away while a weaker one is more likely to do so.'

His observations were probably the first to distinguish Transient Ischemic Attacks (TIAs) from the more permanent Cerebrovascular Attacks (CVAs). Since Hippocrates' observations we've learned that 80 percent of strokes are ischemic, from a clot, 20 percent are from vessels rupturing.¹

Stroke management is contingent on the recognition of stroke and time to treatment which needs to occur within 90 minutes and at the most no greater than 3-4.5 hours after onset for optimal results. Unfortunately most people fail to recognize the signs of stroke. One of the big differences between heart attacks and strokes is that heart attacks usually happen when patients are awake whereas strokes usually occur while asleep. As a result optimal treatment is unachievable in most cases because there's usually no reliable way to determine when the stroke happened.^2,3

The message is clear, stroke incidence is increasing, recognition is difficult and unlike heart attacks there is no widely-available treatment. Although, there are some interesting and exciting new treatments that surprisely seem to work real well they are also time dependant.⁴

In addition to improving the recognition of stroke, prevention has become more important than ever. The emphasis needs to be on recognizing your risk factors and then hopefully managing and ultimately lowering your risk of stroke. Some risk factors cannot be changed, like your genes and family history, or your race.⁵

So, how can we lower our risk for stroke or can we?

The following risk factors clearly can be modified to up your chances of avoiding a stroke until modern medicine catches up.

High Blood Pressure

High blood pressure is the most commonly known risk factor and control of high blood pressure has long been known to reduce the chance of stroke. Experts seem to agree your blood pressure should be controlled to at least 140/90. If you have diabetes make it 130/80. Buy a blood pressure measuring device and measure your blood pressure the same time every day.⁶

The surprise is how much of a difference it makes. Researchers with the National Heart, Lung, and Blood Institute (NIH) measured a reduction in strokes by 40 percent in their group of subjects with previously untreated hypertension. And the data indicate the effect is different for the various types of medication. And nobody knows why exactly. One of the oldest medications, Hydrochlorothiazide, appears to be just as effective as the newer beta-blockers and ACE inhibitors.⁷

Diabetes and Obesity

If you've walked through any mall lately you won't be surprised to learn the incidence of diabetes has risen 60 percent since 1990. And it's younger people more than older. Over the past few years healthcare providers have had to get used to managing young obese men and women who are taking oral diabetes medications.

The good news is that a combination of treatment for diabetes and it's associated conditions of hypertension and elevated lipids can reduce the incidence of stroke up to 40 percent.^8,9

And with regard to the overweight issue don't live in Mississippi, it's always in the top three fattest states. Try to live in Hawaii if you can, it's always the skinniest state. If you can't afford Hawaii, live in Colorado. But seriously, find your ideal weight. Try to attain it. Don't be a victim of the national obesity disgrace.¹⁰

Dyslipidemias, high cholesterol and triglycerides

Believe it or not, despite all the studies about cholesterol, there is no documented consistent relationship between cholesterol levels and strokes. Heart attacks, yes. Strokes, no.

What has been found is low levels of high density lipids (HDL), below 40, are associated with an increased incidence of stroke. The National Cholesterol Education Program III guidelines suggest one should aim for a HDL over 50 and low density lipids (LDL) less than 160 and someone at high risk should be less than 100. Of course, cholesterol control remains essential for risk factor modification for heart disease.¹¹

Also, the class of drug known as statins plays an interesting role. These lipid lowering agents, lower your cholesterol but they seem to change the nature of the arterial fatty deposits that cause stroke, by reducing their size and making them less prone to rupture and form clots. And niacin significantly raises HDL by 20 percent.¹²

Atrial Fibrillation

One quarter of strokes in people over the age of 80 are due to atrial fibrillation. Coumadin is more effective in preventing strokes than aspirin but the benefit may be outweighed by the increased incidence of complications, including hemmorhagic stroke. The American College of Cardiology recommends patients in irreversible atrial fibrillation over the age of 75 be anticoagulated, and all those over 65 with diabetes, hypertension, coronary artery disease, or prior history of stroke.

Smoking

What's to be said, stop smoking. There's only one addiction harder to beat than smoking, and that's food. Keep trying, it's going to take three or four tries, but stop, Use the patches, use the gum, use anything that works.

A good friend of mine needed to stop smoking, so I gave him a box of nicotine patches for his birthday. "I did it!" He told me later. "Do you want to know how?" "I kept the patch on for the whole weekend, but I still wanted to smoke. I never smoke in my car because I don't want it to smell, so I got in my car and started driving. I drove from West Covina to Laughlin to Las Vegas and back to West Covina." It took three round trips, but two days later he felt it was safe enough to come back home. "My biggest challenge was stopping for gas. I had to go inside to pay and I was afraid I was going to buy a pack of cigarettes." It was in the days before Pay-at-the-Pump gas.

Is this a good time to ask? Why is tobacco still legal. It kills a lot more people every year than heroin does. A whole lot. Heroin is illegal. Why isn't tobacco? It's illegal to not wear your seat belt, but 75 percent of traffic fatalities are in people who are not wearing their seatbelts. Tobacco kills 5 times more people than not wearing your seat belt.

Other Risk Factors

Some are modifiable like limit alcohol to two or three drinks a day. Obstructive sleep apnea, often associated with obesity, should be evaluated by a sleep specialist. Habitual snoring is the sentinel symptom. African Americans, Hispanics, and Asians have more strokes, probably because of their having more high blood pressure as well. And a condition known as carotid artery stenosis, blockage of the main artery to the brain is a risk factor.

The Bottom Line

Could prevention be the answer in dealing with the stroke epidemic? It definitely won't make it worse. Eventually medical advances will catch up but in the meantime controlling the major, modifiable risk factors of blood pressure, diabetes and weight will not only help you decrease your risk for stroke but may ultimately turn around the worldwide incidence of stroke.

Published March 1, 2009, updated August 17, 2012

References

1. Stroke, MayoClinic.com, July 3, 2012
2. Stroke Prevention, Stroke.org
3. Stroke Warning Signs, American Stroke Association
4. Stroke: Challenges, Progress, and Promise, Know Stroke, NINDS, February 2009
5. Rundek T, Risk Factor Management to Prevent First Stroke, Neurologic Clinics, V26-4, Nov. 2008
6. Your Guide to BP, Blood-Pressure-Updates.com
7. Chobanian AV, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003;289(19):2560-2571
8. Heart disease and stroke deaths drop significantly for people with diabetes, CDC, February 8, 2012
9. Improve costs and outcomes for diabetic patients with cardiovascular disease or ephropathy, White paper, OptumInsight, April 12, 2012
10. How to calculate ideal body weight, National Heart Lung and Blood Institute
11. National Cholesterol Education Program
12. LIPID Study Group Prevention of cardiovascular events and death with pravastin, N Engl J Med. 1998 Nov 5;339(19):1349-57

J. Linder Jones MD MHA practiced emergency medicine for over two decades in Southern California and now writes on occasion for HealthWorldNet.