Other vascular risk factors

Created 28/03/2023, last revision 18/11/2023

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

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, e.g., 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)

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 (decreasing) and heart rate (slowing)
- decreased fibrinogen levels and platelet activation
- increase in tPA, raising HDL and lowering LDL cholesterol levels
- increased insulin sensitivity and improved glucose tolerance
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
the most significant benefit in reduced stroke incidence (both ischemic and hemorrhagic) was derived from the most intense level of exercise
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 30-45 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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chemotherapeutic drugs ⇒ ↑ risk of stroke/sinus thrombosis
- tamoxifen, cisplatin, vinblastine, bleomycin, and others
ergotamine derivatives ⇒ ↑ incidence of sinus thrombosis with long-term use

CRP is a sensitive indicator of inflammatory response in the body; its synthesis in the liver is induced by cytokines (IL-6)
accurate detection of CRP concentrations in the range of 0-5 mg/L can be performed using a special high-sensitivity CRP test (hs-CRP)

even mildly elevated hs-CRP (> 3mg/L) represents a significant risk factor for atherosclerosis and its complications (stroke, CAD, etc.) [Poledne, 2007]
inflammation is involved in the development of endothelial dysfunction, which is considered the initial stage of atherogenesis
hs-CRP <1 mg/L is considered a sign of low risk (values of 1-3 mg/L are of uncertain significance)

hs-CRP measurement is not recommended as a screening method
may be helpful in primary prevention for individuals at intermediate risk, in whom we are not sure whether and how aggressively to treat them
statins and weight loss associated with central fat loss reduce hsCRP levels
better indicators of successful treatment and prevention of CVD are usually reductions in body weight, waist circumference, plasma lipid levels, and blood pressure

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 stroke (ESO guidelines 2022)
- women taking HRT had an increased risk of stroke with an RR of 1.41 (Rossow, 2002)