ISCHEMIC STROKE / PREVENTION
Vascular risk factors
Created 26/03/2021, last revision 09/04/2023
Early detection and management of cardiovascular risk factors is a priority goal for adequate primary and secondary stroke prevention
Overview of cardiovascular risk factors
Vascular risk factors |
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Non-modifiable risk factors (cannot be changed) |
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Modifiable risk factors (can be reduced or controlled with lifestyle changes and medication) |
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Cardiovascular risk
The overall cardiovascular risk depends on:
- risk factors control → ASCVD Risk Estimator Plus
- a value of > 5% is considered as high risk (probability of death from cardiovascular disease in the next 10 years > 5%)
- subclinical damage of target organs
- clinical manifestation of CVD
- people with overt CVD or renal disease have a high (> 5%) or very high (> 10%) risk of vascular death in the next 10 years
- type 1 diabetes (T1D) with microalbuminuria and type 2 diabetes (T2D) have a high cardiovascular risk (> 5%)
- the Ankle-Brachial Pressure Index (ABPI) is a quick, non-invasive way to check peripheral artery disease (PAD)
- the disease occurs when narrowed arteries reduce the blood flow to the limbs
- an abnormal ABPI may be an independent predictor of mortality, as it reflects the burden of atherosclerosis
- it is a ratio of the blood pressure at the ankle to the blood pressure in the upper arm (brachial BP)
- the patient must be in the supine position, without the head or any extremities dangling over the edge of the table
- the brachial BP is measured in both arms, and the higher value is used
- a low ABPI index indicates narrowing or occlusion of peripheral arteries in the legs
ankle BP
ABPI = ———————————
brachial BP
Interpretation of ABPI | ||
> 1.3 | abnormal (vessel hardening due to calcifications) | |
1-1.2 | normal | |
0.9-0.99 |
acceptable |
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0.8-0.89 | mild PAD |
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0.8 – 0.5 | moderate PAD | |
< 0.5 | severe PAD |
- the standard measurement is performed in B-mode on the far wall of the CCA, 10 mm proximal to the bifurcation
- use high-resolution images
- optimize the insonation angle (90° to the vessel wall)
- measure the distance between the 2 echogenic lines
- the 1st line is the lumen-intima interface
- the 2nd line is the media-adventitia interface
- obtain at least five measurements on each side and get an average value (“average IMT”); specialized software may be helpful
[Baldassare, 2000]
- avoid atherosclerotic plaques when measuring IMT (lesions > 1.5 mm are already considered plaque)
- echogenicity, especially of the media, may be increased in the presence of fatty infiltration and thickening
- IMT > 95th. percentile for age and sex is considered abnormal (usually IMT >1 mm is abnormal)
Female (95. percentile) |
Male (95. percentile) |
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45 y
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55 y |
65 y |
45 y | 55 y |
65 y |
0.73
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0.91 | 1.04 |
0.89
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1 | 1.3 |
95.th percentile [Howard, 1993]
Age |
P25 | P50 |
P75 |
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Men <30 | 0.39 | 0.43 | 0.48 |
Men 31-40 | 0.42 | 0.46 | 0.50 |
Men 41-50 | 0.46 | 0.50 | 0.57 |
Men >50 | 0.46 | 0.52 | 0.62 |
Women <30 | 0.39 | 0.40 | 0.43 |
Women 31-40 | 0.42 | 0.45 | 0.49 |
Women 41-50 | 0.44 | 0.48 | 0.53 |
Women >50 | 0.50 | 0.54 | 0.59 |
Prognostic value of IMT measurement
- not only atherosclerotic plaques but also IMT can quantify atherosclerosis burden in asymptomatic patients
- IMT should be assessed in each extracranial ultrasound examination
- increased IMT is the first stage of atherosclerosis and, if left untreated, is followed by plaque formation
- clinical and epidemiological studies have shown an association between IMT and coronary artery disease (CAD), stroke, and peripheral vascular disease (PAD) (ROTTERDAM, ACAPS trials ) [Lorenz, 2007]
- thickening of IMT correlates with the presence of traditional vascular risk factors (BMI, hypertension, hypercholesterolemia, diabetes, smoking)
- some authors recommend including IMT and the presence of AS plaques among the classic vascular risk factors [Chambless, 2010]
- some publications question the importance of IMT in predicting CV events [Costanzo, 2010] [Ruijter, 2012]
- detection of subclinical atherosclerosis is important in patients with borderline risk and multiple risk factors, as it moves the patient into the high-risk category (SCORE ≥ 5%) with all therapeutic consequences
- pharmacological studies have shown a reduction in the rate of progression of IMT with hypolipidemic therapy and antihypertensive drugs (ACAPS, METEOR)
- rosuvastatin did not induce disease regression
- on the other hand, a meta-analysis of 41 randomized trials showed regression of cardiovascular events with hypolipidemic drugs but did not show a relationship between a decrease in CV events and a regression of IMT [Costanzo, 2010]
- an increase in IMT can also be found in non-atherosclerotic diseases (e.g., Takayasu´s arteritis)
I. Risk factors used to stratify CV risk according to ASCVD Risk Estimator Plus
- sex
- race
- blood pressure
- lipids (total cholesterol, LDL-C, HDL-C)
- history of diabetes and smoking
- therapy (antithrombotics, statins, antihypertensives)
II. Target organs subclinical damage
- left ventricular hypertrophy
- sonographically proven enlarged carotid IMT or the presence of atherosclerotic plaques (atherosclerosis)
- ankle-brachial pressure index (ABPI) ratio < 0.9
- slight increase in serum creatinine (115-133 μmol/L)
- microalbuminuria (30-300 mg/24h)
- ↓ glomerular filtration rate (< 60mL / min / 1.73 m3)
III. Clinical manifestation
- cerebrovascular disease
- stroke / TIA
- intracerebral hemorrhage
- heart disease
- myocardial infarction
- angina pectoris
- chronic congestive heart failure (CHF)
- aneurysms
- a serious complication that can occur anywhere in your body
- besides sudden life-threatening rupture, a slow leak is possible. If a blood clot within an aneurysm dislodges, it may block an artery ostium and cause hypoperfusion
- renal impairment
- diabetic/non-diabetic nephropathy
- decrease in renal function (serum creatinine > 133 μmol/L)
- peripheral vascular disease (PAD)
- retinopathy
- with hemorrhage or exudates, papilledema (optic disc swelling)
Risk stratification (ESC 2019)
Very-high-risk |
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High-risk (elevated single risk factors) |
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Moderate-risk |
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Low-risk |
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Management
- smoking – quit smoking, no exposure to tobacco or cigarette smoke in any form
- alcohol – reduce alcohol consumption
- patients who drink >2 alcoholic drinks a day for men or > 1 alcoholic drink a day for women should be counseled to eliminate or reduce their consumption
- modest consumption may be continued (up to 30 g/day for men, up to 20 g/day for women)
- body weight – target BMI 20-25 kg/m2, target waist circumference <94 cm (men) and <80 cm (women)
- blood pressure – keep BP at least < 140/90 mmHg (in most patients target 130/80 mmHg, if tolerated)
- adequate physical activity
- ideally 30-60 minutes for most days (at 60-75% of the average maximum heart rate)
- stress reduction
- adequate sleep
- healthy diet
- reduce total fat (saturated and trans) – replace with mono- or polyunsaturated fats
- reduce the total amount of dietary carbohydrates and replace them with unsaturated fats
- increased intake of wholegrain products, vegetables, fruit, and fish
- increased dietary fiber intake
- reduce salt intake to 5-6 g/d (up to 2.4 or 1.5 g/d in secondary prevention)
- reduce total fat (saturated and trans) – replace with mono- or polyunsaturated fats
- avoid/reduce drugs that promote sodium and water retention (NSAF, sympathomimetics, corticosteroids in susceptible women, or oral contraceptives)
- maintain normoglycemia – HbA1c <7% (<53 mmol/mol) → diabetes target values
- treat dyslipidemia
ESC guidelines 2018 |
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WHO guidelines 2022 |
Secondary prevention / very-high risk FH |
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For patients with ASCVD who experience a second vascular event within 2 years (not necessarily of the same type as the first event) while taking maximally tolerated statin therapy |
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Primary prevention |
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Very high-risk FH (familial hypercholesterolemia): FH + ASCVD or major risk factors
High-risk FH: FH without major risk factors
Target values for metabolic syndrome therapy
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Fasting glycemia ( ≥ 8 h after last meal)
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≤ 6 mmol/L |
Glycemia 1-2 hod. after meal
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≤ 7,5 mmol/L
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HbA1c (glycated hemoglobin)
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non-diabetics < 38 mmol/mol diabetics (well controlled) 43-53 mmol/mol |
Blood pressure → arterial hypertension monotherapy or combination; always use ACEI or sartan to prevent and treat nephropathy, in non-diabetics it reduces the risk of developing diabetes |
< 130/80 mmHg |
Lipids → dyslipidemia | |
Body mass index (BMI) in diabetic patients with BMI > 30.0 kg/m2, sibutramine or lipase inhibitors (orlistat) may be indicated in combination with diet and exercise or other pharmacotherapy |
19-25 |
Waist circumference (men/women) | < 94 cm / < 80 cm |
The finding of borderline or mildly abnormal renal function (see below) should lead to more intensive treatment of diabetes and arterial hypertension to achieve the best possible compensation
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