Dr. Accurso covered how to spot stroke symptoms, the immediate, life-saving action to take, and ways to reduce your risk.

1. Reduce Your Risk for Stroke!
A Presentation on Stroke
Awareness and Prevention
November 18, 2021
Presented By: Daniela Accurso, MD, MPH

2. Agenda
 Introduction
 Today’s statistics
 Definition and Types of Stroke
 Economic Burden
 Signs and Symptoms
 Risk Factors
 Prevention
 Questions and Answers
2
Stroke Awareness Month: How to tell if someone is having a stroke (htrnews.com)

3. 3
 Daniela Accurso MD, MPH
 Training
 Background
 Scope of Practice
 Mission Statement
Introduction

4. Today’s Statistics
 Each year, the American Heart Association (AHA), in conjunction with
the National Institutes of Health and other government agencies
research and reports the most up-to-date statistics related to heart
disease, stroke, and risk factors associated
 Every year, more than 795,000 people in the United States have a stroke
 Someone in the United States has a stroke every 40 seconds
 Every 4 minutes, someone dies of stroke
 Stroke is a leading cause of serious long-term disability
 Stroke reduces mobility in more than half of stroke survivors age 65 and
over
 About 87% of all strokes are ischemic strokes
4
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al.
Heart disease and stroke statistics—2020 update: a report from the
American Heart Association Circulation. 2020;141(9):e139–e596.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000950

5. Today’s Statistics
 When considered separately from other CVD, stroke
ranks #5 among all causes of death in the US
 Age: While the risk of stroke increases over the age of
65, there are still a large amount of cases occurring at
younger ages- 34% of strokes in 2009
5
https://www.heart.org/-/media/phd-files-2/science-news/2/2021-heart-and-stroke-stat-update/2021_
heart_disease_and_stroke_statistics_update_fact_sheet_at_a_glance.pdf?la=en

6. Today’s Statistics
 Race and Ethnicity: Risk of having a first stroke is
nearly twice as high for African Americans as for
Caucasians
 AA’s have highest rate of death due to stroke
 Hispanic population have had an increase in death due to stroke
over the past ten years
 Three very large national cohort studies (Greater
Cincinnati/Northern Kentucky Stroke Study, Reasons
for Geographic and Racial Differences in Stroke
(REGARDS) national cohort study, and the Northern
Manhattan Study)
 Sex-stratified analyses suggested that the race disparity was
pronounced
 Significant in women specifically, and that among women the
disparity does not decrease with age
6
American Heart Association https://www.heart.org/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7093213/

7. Definition: Ischemic Stroke
 There are a few main types of stroke: We will focus on Ischemic and
Hemorrhagic
 Ischemic Stroke- accounts for 87% of ALL strokes
 Fatty deposits lining the vessel walls, called atherosclerosis, are the main cause for
ischemic stroke
 Fatty deposits can cause two types of obstruction:
 Thrombotic- a blood clot forms in one of the arteries supplying the brain and blocks
blood flow – this usually occurs in a vessel that is already damaged or narrowed by
atherosclerosis
 Embolic-Occurs when a blood vessel becomes blocked by a clot in an artery other than
those supplying the brain, breaks off and travels to smaller vessels and eventually
blocking blood flow to the brain – this occurs because of damage to the vessel from
atherosclerosis or other causes such as abnormal heart rhythm (AFIB) which disrupts
the vessels
7
https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/types-of-stroke

8. Definition: Ischemic Stroke
 Thrombotic strokes can sometimes be preceded by TIA’s- Transient
Ischemic Attacks which are also sometimes called “mini-strokes”
 These can be a precursor, lasting <24hrs and blood flow is initially
restored. This causes stroke like symptoms initially before the patient
returns back to their baseline
 Sometimes thought as a warning sign
8
https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/types-of-stroke

9. Definition: Hemorrhagic Stroke
 Occurs when one or more blood vessels supplying the brain ruptures and
bleeds, causing damage to the surrounding brain tissue and lack of
oxygen and blood flow
 Due to the bleeding, pressure can build up and cause even more damage
to the vital surrounding tissue that is responsible for main pathways in
the brain which control our motor and sensory skills, vision, speech, etc
 This type of stroke can further be broken down into categories
 Intracerebral- blood vessels bleeding within the brain itself- can be caused by very high
blood pressure/HTN
 Subarachnoid hemorrhage- bleeding within the space between the brain and the layers of
membrane which enclose the brain- can be caused by aneurisms, AVMs, trauma
9
https://radiopaedia.org/images/3266688

10. Types of Stroke
10
http://neuroscience.openetext.utoronto.ca/chapter/2-3-stroke-and-loss-of-blood-flow-as-an-acute-injury-to-the-brain/

11. Recurrent Stroke
 Strokes can re-occur in 1 out of 4 people who had a stroke in the last 5
years
 The risk is highest immediately after the first stroke
 Worsening disability occurs with each subsequent stroke
 33% of people will have a stroke within two years after the first
 Prevention strategies go back to lowering your risk factors- controlling
blood pressure, controlling weight, lowering sugars, and lifestyle
modifications such as smoking cessation, increasing physical activity, and
alcohol cessation
11
https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/types-of-stroke
https://www.aafp.org/afp/2017/1001/p436.html

12. Economic Burden of Stroke
 Stroke-related costs in the United States came to nearly $46 billion
between 2014 and 2015.2 This total includes the cost of health care
services, medicines to treat stroke, and missed days of work.
 2018 National Hospital Ambulatory Medical Care Survey : visits to
emergency departments with stroke as the primary diagnosis: 432,000
 These numbers do not represent the economic costs of treating the risks
factors associated with stroke such as obesity, heart disease and diabetes
which are even higher!
12
The Ambulatory and Hospital Care Statistics Branch of the National Center for Health Statistics (NCHS)

13. Signs and Symptoms of Stroke
 Difficulty speaking or slurring your words
 Facial drooping
 Having trouble understanding or completing simple tasks
 Vision changes
 Severe headache
 Tingling/numbness in your extremities or loss of sensation
completely
 Weakness in muscle strength, especially on one side of the body
 Trouble swallowing
 F.A.S.T test- created in the late 90’s to help emergency personnel
quickly assess and respond to stroke
 F- Face, A-Arms, S-Speech, T-Time
13
https://www.emedicinehealth.com/slideshow_understanding_stroke/article_em.htm
https://www.mass.gov/service-details/stroke-signs-and-symptoms-act-fast

14. Risk Factors- “Life’s Simple Seven”
 The American Heart Association monitors the cardiovascular health of
the nation by tracking seven key health factors and behaviors that
increase risks for heart disease and stroke
 Smoking
 Physical Activity
 Healthy Diet
 Weight
 Cholesterol
 Blood Pressure
 Blood Sugar
14
https://www.heart.org/-/media/phd-files-2/science-news/2/2021-heart-and-stroke-stat-update/2021
_heart_disease_and_stroke_statistics_update_fact_sheet_at_a_glance.pdf?la=en
Heart Disease and Stroke Statistics—2021 Update | Circulation (ahajournals.org)

15. Risk Factors- Smoking
 Smoking tobacco, including being exposed to second hand smoke, was
the second leading risk of mortality and contributed to almost 9 million
deaths in 2019
 There are also risks in other tobacco forms such as chewing tobacco and vaping
 Tobacco use is one of the leading preventable causes of deaths in the US
and globally
 Current smokers are at least 2-4x more likely to have a stroke compared
with lifelong nonsmokers or people who had quit smoking more than 10
years prior.
 The damage caused by smoking:
 Increases the risk for clotting
 Causes thickening and narrowing of the blood vessels
 Raises triglyceride levels
 Lowers your “good” cholesterol
 Increase the buildup of plaque in blood vessels
 Damages red blood cells
 Lowers oxygen levels
 Smoking increases risk for ALL types of stroke, not just ischemic stroke
 Example: there is an increase in aneurism rates in smokers
15
https://www.cdc.gov/tobacco/campaign/tips/diseases/heart-disease-stroke.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928253/

16. Risk Factors- Physical Activity
 Physical activity lowers stroke risk because it has a direct affect on the
risk factors for stroke
 We know that hypertension and cardiac disease are two major factors that contribute to
stroke- physical activity levels help to modify these factors
 Staying active helps to control blood pressure, weight, lowers bad
cholesterol, increases GOOD cholesterol, control sugars, regulates blood
flow and increases circulation
 It even has an effect on the amount of chronic inflammation in the body
by lowering many of the inflammatory factors which contribute to
increase risk for blood clots
 For those who have already had a stroke, regular exercise after stroke can
improve cardiovascular fitness, walking ability, and upper-extremity
muscle strength in those that may have resulting disabilities
16
https://www.uofmhealth.org/health-library/hw114892
https://www.ahajournals.org/doi/10.1161/
https://www.ahajournals.org/doi/full/10.1161/strokeaha.115.006317

17. Risk Factors- Unhealthy Diet
 We are what we eat!
 Eating an unhealthy diet contributes to weight/obesity, high blood
pressure, high cholesterol and diabetes which are all risk factors for
stroke and cardiac disease
 Unhealthy Foods/Drinks
 Red Meat and processed meats
 Overconsumption of alcohol
 Sugary juices and sodas- consuming 2 or more servings of sweet drinks daily could increase
the risk of ischemic stroke
 Too much full fat dairy
 Trans and added fats such as what we see in pastries, junk foods
 Too much salt raises blood pressure and increases risk for HTN
17
Sindhu Lakkur, PhD and Suzanne E Judd, PhD MPH. Diet and Stroke: recent
evidence supporting a Mediterranean style diet and food in the primary prevention of stroke.
Stroke. 2015 July; 46 (7): 2007-2011. Doi: 10.1161/STROKEAHA.114.006306
https://www.cdc.gov/stroke/behavior.htm

18. Risk Factors- Weight
 Obesity increases risk for stroke due to the association with more
cardiovascular disease, higher blood pressure, less physical activity,
poorer circulation, and diabetes
 Adipose tissue itself also increases inflammation and increases clotting in
the system
 Abdominal Fat- two types
 Subcutaneous (right below the skin)
 Visceral- this is fat that surrounds the organs and can cause “lipotoxitiy”
 Waist to Hip Ratio: The chance of suffering a stroke increases as a man's ratio rises above
0.95;. For women, risk begins to rise above 0.85
 Waist circumference: Men high risk > 40inches, women > 35inches
18
https://www.heart.org/-/media/phd-files-2/science-news/2/2021-heart-and-stroke-stat-update/2021
_heart_disease_and_stroke_statistics_update_fact_sheet_at_a_glance.pdf?la=en
https://www.health.harvard.edu/staying-healthy/abdominal-obesity-and-your-health

19. Risk Factors- Cholesterol
 Cholesterol is a substance that is used for vital building
processes in the body in order to function properly, and is
made by the liver
 There are proteins (“lipoproteins”) that are responsible for
carrying cholesterol in our bodies to cells that need it
 LDL (the “bad” cholesterol) – in excess causes plaque build up in the vessels
 HDL (the “good” cholesterol)- helps carry bad cholesterol away from these
cells and back to the liver so they can be broken down. The higher the HDL,
the more protective for the heart
 Too much cholesterol coming in through the diet causes an
excess that our bodies have a hard time handling
 The result is fatty deposits inside the vessels and stiffer vessels
19
https://www.verywellhealth.com/high-cholesterol-and-stroke-risk-697863
https://www.stroke.org.uk/what-is-stroke/are-you-at-risk-of-stroke/high-cholesterol

20. Risk Factors- Blood Pressure
 Hypertension is the most prevalent factor in stroke
 64% of stroke patients found to have HTN
 What does is mean to have high blood pressure? The high pressure in
our vessels causes trauma, increased distention, stretching and tearing.
Our bodies move to repair the damage, but as a result can cause scarring
which causes blockages, stiffening and clotting in the arteries
 Clotting in the arteries increases risk for stroke as we know, and
weakened arteries around the heart or brain can lead to lack of blood
flow or even hemorrhage
 High blood pressure in the setting of other chronic conditions (high
cholesterol, smoking, etc) increases the chance for stroke even more
20
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659031/
https://www.stroke.org/en/about-stroke/stroke-risk-factors/high-blood-pressure-and-stroke

21. Risk Factors- Blood Sugars
 An estimated 285 million people worldwide suffered
diabetes twenty years ago, and the number is projected to
increase to 439 million worldwide by 2030
 Hyperglycemia causes pathologic changes in blood vessels
at various locations and can lead to stroke if cerebral vessels
are directly affected
 Mortality is higher in patients with stroke with uncontrolled glucose levels
 The damage that occurs: vascular endothelial dysfunction,
increased arterial stiffness, systemic inflammation and
thickening of the membranes of small blood vessels
 Causes direct damage to blood vessels and decreased circulation
 Those with type II diabetes are more likely to have obesity,
peripheral arterial disease, large-artery atherosclerosis and
small vessel disease
 Sugars that build up in the system cause lack of oxygen and
nutrients
21
Putaala J, Liebkind R, Gordin D, et al. Diabetes mellitus and ischemic stroke
in the young: clinical features and long-term prognosis. Neurology. 2011;76:1831–1837
.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298897/#R2

22. Stroke Prevention
 Quit smoking and protect yourself from second hand smoke
 Eat a healthy diet!
 Low in saturated fats, trans fat, and cholesterol
 High fiber
 Limiting salt -Consuming too much sodium can increase blood pressure . Current
guidelines recommend getting less than 2,300 mg a day, but Americans consume more
than 3,400 mg a day
 Over 70% of the sodium that Americans eat comes from packaged, processed, store-
bought, and restaurant foods- try to cook at home more and avoid eating out
 Million Hearts Recipes
 Stay Active: Move more , Sit less
 adults need at least 150 minutes of moderate-intensity aerobic activity, like brisk walking or
fast dancing, each week.
 Adults also need muscle-strengthening activity, like lifting weights or strength training twice
a week
 Prevent obesity- monitor your BMI as well as your waist circumference
 Seek help from a the experts if needed- nutritionist, metabolic center, healthcare
provider’s can help track and monitor your progress as well as come up with a heart
healthy diet plan
22
https://www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020
https://www.thinkglobalhealth.org/article/updated-timeline-coronavirus
https://www.yalemedicine.org/news/covid-timeline

23. Stroke Prevention
 Monitor hypertension- besides maintaining a good weight, eating healthy
and staying active which influence blood pressure, it is important to also
monitor your pressure regularly
 Consider a BP cuff at home
 Many electronic devices that we can wear give us a good idea where we are ranging
 Routine blood work annually or more often if you have HTN to check electrolytes and renal
function as well as other factors that may be contributing
 Keep stress levels down
 Stay hydrated!
 See your PCP in the office to discuss medications to help control it if needed
 Consider consultation with cardiologist if blood pressure is not well controlled despite
attempting a few different medications. It may be needed to take a deeper look at the
heart’s functioning
 Bottom Line: Doing these things BEFORE you have regular and ongoing symptoms is KEY for
prevention
23

24. Stroke Prevention
 Controlling diabetes
 Dietary changes and lifestyle modifications to control glucose levels
 Have your HbA1c and fasting glucose levels checked at least annually
 Know your numbers- ABC’s of diabetes
 A1C test- below 6.5%- 7% depending on age range and comorbidities- should be checked 2-
4x per year !
 Blood pressure: for those w/diabetes aim for levels under 140/90
 Cholesterol: ideal total cholesterol 150 mg/dL, and LDL under 100 mg/dl (<70 for high risk)
 Don’t forget if you have diabetes to have your diabetic retinopathy exams
foot exams, urine testing regularly
 There are tons of diabetes resources both in person and online through
summit health, ask your PCP to help set these up
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https://www.stroke.org/en/about-stroke/stroke-risk-factors/diabetes-and-stroke-prevention

25. Questions and Answers
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