ISCHEMIC STROKE / PREVENTION
Other vascular risk factors
Created 28/03/2023, last revision 10/04/2023
- early detection and management of cardiovascular risk factors is a priority objective for adequate primary and secondary stroke prevention
- in addition to usual factors like hypertension, dyslipidemia, atrial fibrillation, diabetes, and smoking, other significant risk factors have been identified
Overweight / obesity
- obesity (>30% of normal weight) is an independent stroke risk factor
- central (abdominal) type of obesity is the riskiest
- associated with other risk factors ( metabolic syndrome – hypertension, hyperglycemia, hyperlipidemia)
- weight reduction is strongly recommended in:
- obese individuals (BMI ≥ 30 kg/m2)
- overweight individuals (BMI 25.0-29.9 kg/m2)
- individuals with abdominal obesity (waist circumference > 102 cm in men and > 88 cm in women)
- goals of therapy
- the initial goal in obese individuals is a 5-15% reduction in motility, which significantly reduces cardiovascular and metabolic risks
- in cases of severe obesity, greater weight loss may be indicated
- complex treatment of obesity consists of:
- diet with a 15-30% reduction in energy content compared with the usual diet in a patient with stable weight; the reduction in energy is achieved mainly by restricting fats
- a Mediterranean diet is recommended
- lifestyle modifications
- increasing moderate-intensity physical activity (e.g. brisk walking) for at least 30 min, 4-7 times a week
- adequate sleep
- pharmacotherapy
- bariatric procedures – for severe obesity (BMI and 40 kg/m2, exceptionally 35-40 kg/m2) consider surgical treatment (e.g. gastric banding)
- diet with a 15-30% reduction in energy content compared with the usual diet in a patient with stable weight; the reduction in energy is achieved mainly by restricting fats
- regular BMI monitoring is advised
- the foundation of this diet is fiber, i.e. vegetables, fruits, nuts, fish, olive oil, light meats in small quantities, legumes, whole grains
- sufficient drinking of unsweetened beverages
- red wine may be consumed in limited quantities (1dcl per day)
- underweight = BMI <18.5
- normal weight = BMI 18.5–24.9
- overweight = BMI 25–29.9
- obesity = BMI ≥ 30
Physical inactivity
- regular physical activity reduces the risk of cardiovascular diseases (CVD) and is associated with:
- ↓ risks of stroke by up to 30%
- reduction/prevention of obesity
- beneficial effect on hypertension and heart rate
- reduction of fibrinogen levels and platelet activation
- increase in tPA and HDL levels
- improvement of glucose tolerance and insulin sensitivity
- lack of exercise conversely increases the risk of hypertension, DLP, or obesity
- even non-overweight people with a lack of exercise have a higher risk of CVD
- a minimum of 30 minutes of physical activity most days of the week is recommended; even moderate activity is associated with improved health
- choose enjoyable forms of physical activity
- ideally 30 to 45 minutes, 4-5 times a week at 60-75% of the average maximum heart rate
- in patients with sedentary jobs, short exercise (about 3-5 minutes) every 30 minutes is recommended
Stress
- negative emotional reactions and stress (e.g. work stress, socioeconomic disasters, interpersonal problems) lead to significant sympathetic activation → increased blood pressure and/or heart rate
- stress thus promotes the development of hypertension, atherosclerosis, and CAD
Alcohol
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Oral contraceptives
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Hyperhomocysteinemia
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Medication
- chemotherapeutic drugs ⇒ ↑ risk of stroke/sinus thrombosis
- tamoxifen, cisplatin, vinblastine, bleomycin, and others
- ergotamine derivatives ⇒ ↑ incidence of sinus thrombosis with long-term use
Abuse of drugs
- known association with stroke:
- cocaine [Sordo, 2014] [Cheng, 2014]
- heroin
- amphetamine
- LSD
- marijuana [Wolff, 2014]
- some drugs also increase the risk of bleeding (e.g. amphetamine)
- the pathogenesis of vascular events is multifactorial:
- a sudden increase in blood pressure
- vasculitis
- direct vascular toxicity
- vasospasm
- septic emboli
- hemostatic and hematologic disorders, increasing blood viscosity and platelet aggregability
Migraine
Inflammatory markers
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Sleep disorders
- in particular, sleep apnea syndrome (SAS), with a prevalence of approx. 10%, has been shown to increase the risk of stroke and/or death, independent of the presence of other vascular risk factors
Menopause
- hormone replacement therapy (HRT) does not reduce the risk of CV events (risk increases with age regardless of HRT)
- HRT is not recommended to reduce the risk of stroke or ICH, nor is it recommended in postmenopausal women with acute stroke (ESO guidelines 2022)