ACTIVITY VIEW

PRIMARY PREVENTION OF STROKE

Stroke risk Factors

 

<< Introduction Stroke Risk identification and Risk Stratification >>

 

INTERSTROKE study found that the population attributable risk for all stroke was 90.3% when 10 risk factors were considered (hypertension, current smoking, waist-to-hip ratio, diet risk score, regular physical activity, diabetes mellitus, alcohol intake, psychosocial stress and depression, cardiac causes, and ratio of apolipoproteins B to A1).Most primary prevention efforts should be focused in modification of this risk factors for stroke.

Lifestyle and Risk factor management:

Healthy balanced diet high in fresh vegetables, fruits low fat dairy products, salt, cholesterol and whole grains plant proteins. Daily sodium (table salt) intake of 1200-2000mg.

Exercise for sedentary people brisk walking 30-60 minutes daily or jogging. Weight: MaintainBMI of 18.5-24.9 kg/m2. Smoking cessation and smoke-free environment are essential.

Blood pressure screening and management:

All persons at risk to have Blood pressure screened at each clinic visit, at least annually and managed accordingly.Most guidelines give a target of  SBP < 140mmHg in hypertension management in most patients. Mean reduction of Diastolic BP by 5-6mmHg correlates with a 35-40% reduction in incidence of stroke. Have lowest tolerable Blood Pressure.

Blood Pressure control in hypertensive emergency(stroke)  remains controversial due to lack of Un ambiguous data. Emergency administration of treatment withheld unless DBP≥120, SBP≥220.

If indicated, lower BP by 15-25% within the first 24 hours. Recommended antihypertensive in hypertensive crisis include Nicardipine, Labetalol (commonly used in Kenya), Esmolol and Enalaprilat.Avoid Medications such as Nitroprusside should be avoided due to the potential for precipitous drops in blood pressure and the possibility of increasing intracranial pressure through venodilatation.

Arterial hypotension- may induce ischemic stroke. AVOID use of HYDRALAZINE

Dyslipidaemia

Lipid levels should be monitored (annually) in all patients at risk for stroke i.e. All men over 40 years. All post menopausal women or > 50 years.Adults at any age should have their lipid levels measured if they have a history of: DM, Smoking, obesity, ischemic heart disease, renal vascular disease, peripheral vascular disease, TIAs, Asymptomatic carotid disease.

Normal cholesterol levels but elevated C-reactive protein (CRP)- 48% relative risk reduction for total stroke with use of Rosuvastatin. Justification for Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER).

Elevated total cholesterol has been linked to increased risk of ischemic stroke in a number of epidemiological studies. Epidemiological studies have also shown an inverse relationship between high-density lipoprotein (HDL) cholesterol and stroke risk.

Statin therapy and therapeutic lifestyle changes are recommended for patients with coronary artery disease or certain high-risk conditions such as diabetes.Fibric acid derivatives, niacin, bile acid sequestrants, and ezetimibe may be useful in patients who have not achieved target LDL with statin therapy or who cannot tolerate statins.

Diabetes  mellitus:

Diabetes is estimated to increase the relative risk of ischemic stroke 1.8- to nearly 6-fold, independent of other risk factors .Annual screening for diabetes mellitus. A fasting plasma glucose should beperformed every 1-3 years in individuals >40 years.At time of diagnosis of DM do lipid profile in ALLindividuals then every 1-3 years.Blood pressure measurement at every Diabetes visit.

One should targetfasting blood glucose 4-6  mmol/L with HBAIC target of less than 7% in most patients. However, in elderly patients and in those patients with end organ damage who are predisposed to having hypoglycemia less stringent glucose control is advised with HBAIc target of less than 8.0-8.5% Acceptable.

Non-valvular Atrial fibrillation:

Using Warfarin in non-valvular AF leads to a relative risk reduction of stroke ranging from 42-86%. Target INR 2.5 (2-3 range)

Patients with mechanical cardiac valves: Warfarin at Target INR 2.5-3.5. Warfarin is the only drug licensed for  long term anticoagulation in atrial fibrillation in patients with valvular heart disease.

Patients with non-valvular AF who cannot take Warfarin: The combination of clopidogrel-75 mg. andAspirin-75-100 mg. reduced major vascular events, particularly stroke, compared with placebo, withacceptable bleeding risk. Major bleeding occurred in 251 patients receiving clopidogrel (2.0% per year)and in 162 patients receiving placebo (1.3% per year) (relative risk, 1.57; 95% CI, 1.29 to 1.92; P<0.001).

The ACTIVE [Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events]

Investigators .Randomized, double-blind, multicenter trial performed at 580 centers in 33 countries witha total of 7554 patients with atrial fibrillation.

 

 

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Validity

Release date: 25-08-2013
Expiry date: 25-08-2014

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