5. • M>F in young and middle aged.
• Lifetime risk of stroke is higher in females.
• 85% strokes are ischemic.
• 17.8% people >45 years experience
symptoms of stroke.
• 6-28% have silent infarcts.
• Risk of recurrent stroke- 20% at 5 years.
• Rate of stroke age > 65 years has gradually
decreased.
• Rate of recurrent stroke is declining too.
• Decline is more in high income group than
middle and low income group.
• Possibly due to better risk factor
management-
– Better antihypertensives.
– Better statin usage.
6.
7. HYPERTENSION
• Most common modifiable risk
factor.
• Racial differentiation exists-
blacks affected more and earlier
than white.
• There have been guidelines and
trials e.g. JNC 8, SPRINT.
• Overall target-
– <140/90 at least.
– <130/90 in lacunar infarct.
• Choice of antihypertensive
agent is also important.
• Variability in systolic BP
increases risk of stroke.
8. HYPERLIPIDEMIA
• Atherosclerotic plaques are a
manifestation of systemic
atherosclerosis. They are associated with
general risk factors for atherosclerotic
disease, including age, hypertension, and
hypercholesterolemia.
• Aortic atherosclerotic plaques are an
important source of emboli, leading to
cerebral (eg, transient ischemic attack,
stroke), embolization.
9. DIABETES MELLITUS
• Disorders of glucose metabolism are major risk factors for stroke,
including type 1 and 2 diabetes mellitus and prediabetes
(defined as HbA1c of 5.7-6.4%).
• Patients with new onset stroke or TIA should be screened for
diabetes mellitus with HbA1c or OGTT.
• Target HbA1c should be <7%. HbA1c should be repeated every 3
months.
10. METABOLIC SYNDROME
• Metabolic syndrome increases
the risk of stroke in females and
males. Studies through 2013
suggest that this is more so for
females than males.
• It is diagnosed with 3 of the
following 5 risk factors-
– Fasting plasma glucose ≥ 100
mg/dL or the patient is undergoing
treatment for hyperglycaemia.
– HDL-C ≤ 40 mg/dL in men and ≤ 50
mg/dL in females or the patient is
undergoing treatment for low HDL-
C.
– Triglycerides ≥ 150 mg/dL or the
patient is undergoing treatment for
hypertriglyceridemia.
– Waist circumference of ≥102 cm
(40 in) in men or ≥88 cm (34.6 in)
in women.
– BP ≥ 130/85 mm of Hg or the
patient is undergoing treatment for
hypertension.
11. OBESITY
• Obesity is an established
modifiable risk factor for stroke.
• Starting with a BMI of 20 kg/m2,
for every 1 unit increase in BMI,
the risk for ischemic stroke rises
by 5%.
• Adipose tissue acts as a
repository for inflammatory cells
that cause
– insulin resistance,
– hyperglycaemia and
– subsequent promotion of
atherosclerosis.
• Once obesity is diagnosed,
additional testing suggested are
for
– hyperglycaemia,
– dyslipidemia, and
– inflammatory markers such as CRP.
12. SLEEP APNEA
• Sleep apnea , measured by apnea
hypopnea index, identifies the
number of respiratory events per
hour, including cessations in
breathing and reductions in air
flow.
• It increases the risk of stroke, in
association with hypertension,
and as independent risk of stroke
as well.
• This risk is stronger in males
compared to females.
• The rate of sleep apnea after
stroke is high.
• OSA is associated with higher
post stroke mortality and worse
functional outcome.
13. TOBACCO USE
• Tobacco use is a significant
risk factor for stroke as well
as silent infarction.
• Current smokers have at
least doubled risk of stroke.
• A synergistic effect exists
with hypertension.
• Environmental exposure to
second hand smoke has
been identified as a risk
factor as well with an
increase in risk as much as
30% among non-smokers.
• The risk is modifiable.
• The risk returns to normal
over 10 years of abstinence.
16. • Evaluation and treatment of HYPERLIPIDEMIA is a
critical part of stroke management.
• Agents that reduce cholesterol by 50% or more are
high potency statins. Those that reduce cholesterol
by 30-50% are moderate potency statins.
17. Dietary pattern that is most effective for lowering
LDL-C and BP include intake of vegetables, fruits,
whole grains, low fat dairy products, poultry, fish,
legumes, non tropical vegetable oils, and nuts.
Limit intake of sweets, sugar-sweetened
beverages, and red meats.
18. • Moderate physical
exercise and DIABETIC
diet.
• Weight loss amongst
OBESE is beneficial.
• Stroke survivors have a
tendency to gain weight
due to loss of muscle
activity and bulk.
• Needs good
physiotherapy.
19. • Well established stroke
risk factors such as
hypertension and atrial
fibrillation respond
favourably to treatment
of OSA.
• However, it is unclear if
CPAP improves
cerebrovascular
outcomes or reduces
recurrent stoke.
• Smoking cessation
counselling should be
undertaken to reduce the
stroke risk, including
offering available
medications.
• Counselling should be
done to avoid all forms of
TOBACCO.
20. DIET AND
NUTRITION
• Increased fruit and vegetable
intake was associated with low
risk of stroke. Highest protection
came from cruciferous and green
leafy vegetable and citrus fruits
and juices.
• Caffeinated or decaffeinated
coffee decreased stroke risk by
about 10%.
• Fish served 2-4 times per week
reduced the risk of stroke
compared to less than 1 serving
per week.
• Mediterranean diet/DASH diet are
associated with lower risk of MI,
stroke, or cardiovascular death.
• Daily serving of soda increases risk
of stroke.
• High salt intake is also
independently associated with
increased risk of stroke. Reduction
in salt intake also reduces BP.
21. PHYSICAL ACTIVITY
• Physical activity is any bodily
movement produced by skeletal
muscles that results in energy
expenditure.
• Exercise is a subset of ‘physical
activity’ that is planned, structured,
and repetitive and has as a final or
an intermediate objective the
improvement or maintenance of
physical activity.
• Physical inactivity is defined as no
sessions of light/moderate or
vigorous physical activity of more
than 10 minutes duration.
• For stroke survivors, engaging in
physical activity can be challenging
due to residual hemiparesis,
sensory deficits, neglect,
dyscoordination, spasticity,
cognitive dysfunction, or aphasia.
Almost 40% stroke survivors have a
sedentary lifestyle due to the
impact of the impairments.
22. • Physical activity and exercise
have a positive effect on the
risk factors such as
hypertension, arterial function
and insulin response.
• Recommendations include
aerobic, muscular
strength/endurance, flexibility,
and neuromuscular activities,
as well as frequency, intensity
and duration of activities that
can provide multiple benefits
for stroke survivors.
• It is recommended that
patients engage in 3-4 sessions
of moderate to vigorous
intensity aerobic exercise per
week, with sessions lasting an
average of 40 minutes
