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)
  • 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


  • 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


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Oral contraceptives

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  • 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:
  • 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

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


  • 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)

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Other vascular risk factors