Wayne State Neurologist Develops Guidelines For Stroke Prevention
A Wayne State University School of Medicine neurologist has helped develop new national guidelines for stroke prevention adopted by the American Heart Association and the American Stroke Association.
The revised guidelines, the first since 1986, were co-written by Seemant Chaturvedi, M.D., professor of neurology and director of the Wayne State University-Detroit Medical Center Stroke Program.
"This is one of the most important documents produced by the American Stroke Association, since prevention of a first stroke is critical," Chaturvedi said. "The document is especially relevant for primary care physicians and neurologists, but there is also important information for obstetric/gynecological specialists and vascular surgeons."
The new guidelines emphasize physical activity and decreasing obesity to stave off a first stroke. Those who follow the new recommendations can reduce their risk of a first stroke by 80 percent, according to the AHA and ASA. The preventive benefits increase with each change adopted.
Recommendations include:
* Reduced intake of sodium and increased intake of potassium to lower blood pressure.
* Adopting a Dietary Approaches to Stop Hypertension, or DASH-style diet, which emphasizes consumption of fruits, vegetables and low-fat dairy products, and a reduction of saturated fats.
* Engaging in at least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous aerobic physical activity.
* Reducing obesity.
* Quitting smoking and limiting exposure to second-hand smoke.
* Cutting back on alcohol consumption. Consuming no more than two drinks per day for men and one drink per day for women is recommended for those who choose to drink.
"If you have risk factors such as hypertension, diabetes or you smoke, you need to work with your doctor to minimize the impact," Chaturvedi said. "These are three of the biggest risk factors for stroke. Also, if you have an irregular heart beat, check with your doctor about taking blood thinners."
For the first time, the guidelines address stroke as a broad continuum of related events including ischemic stroke, non-ischemic stroke and transient ischemic attack. In terms of stroke prevention, there is little difference in the spectrum. Ischemic stroke -- a blocked blood vessel in or leading to the brain -- accounts for 87 percent of all strokes. In a TIA, the blockage is temporary, but is a major risk for a larger stroke later.
Stroke is a leading cause of long-term, severe disability, according to the Michigan Department of Community Health. The third-leading cause of death in Michigan and the United States, stroke killed 4,638 people in Michigan in 2007, the last year for which figures are available. The state ranks 22nd worst for stroke mortality, and has a higher stroke mortality rate than the national average. More than 77 percent of the 795,000 strokes occurring in Americans each year are first-time events.
The price tag of stroke to the state is substantial. The MDCH puts Michigan's costs at $2.3 billion. Using U.S. Centers for Disease Control and Prevention data, the department estimates that a reduction of just 10 percent in strokes in Michigan could save $29.8 million in Medicaid costs due to long-term care and disability. Studies conducted by the state show that stroke affects workforce productivity. In 2004, stroke was one of the 10 leading causes of Years of Potential Life Lost, a measurement the state uses to gauge the years of potential employment productivity lost by the death of a person younger than 75. Years of potential life lost are calculated from the age of death to age 75. The MDCH reports that at 182.8 per 100,000 residents, stroke was responsible for the same amount of YPLL as diabetes and three times more than AIDS.
Long considered a condition of the elderly, stroke does occur in younger patients. Statistics maintained by the MDHC indicate that in 2003, of the 35,952 hospital admission for stroke in Michigan, 30 percent of those patients were younger than age 65. Younger stroke patients often can be misdiagnosed.
While the new guidelines contain recommendations for healthier lifestyles to prevent a first stroke, they also recommend that emergency room doctors try to identify patients at high risk for stroke and consider making referrals, conducting screenings or beginning preventive therapy.
Other recommendations for physicians include:
* Treating diabetic adults with a statin -- or cholesterol-lowering drug -- can decrease the risk of a first stroke.
* A daily aspirin regimen for diabetics, while not satisfactorily demonstrated to reduce stroke risk, may be reasonable for those at high risk for cardiovascular disease.
* Evaluation and potential testing of a patient's sleep apnea history, particularly in those with abdominal obesity, high blood pressure and heart disease.
* The anti-coagulant warfarin is recommended for all patients with non-valvular atrial fibrillation identified as high risks for stroke and for many identified as at moderate risk.
* Because of the association between higher migraine headache frequency and stroke risk, treatments to reduce migraine frequency could be reasonable, although data that this would reduce the risk of first stroke does not exist.
* The usefulness of stenting in those with narrowing of a carotid artery in the neck as compared to endarterectomy is uncertain, particularly in light of advances in medical therapies -- including lifestyle changes, treating high blood pressure, and antiplatelet and cholesterol-lowering drugs.
* Physicians must decide whether to perform either procedure on a case-by-case basis.
The guidelines will be published in Stroke, the journal of the American Heart Association.
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