2. Stroke Prevention
• Stroke is best treated by prevention!
• Up to 90% of strokes are preventable
• Stroke prevention hinges on risk modification
• Treatment of cardiovascular risk diseases
• Lifestyle modification
3. Stroke Prevention
• Primary prevention of stroke refers to the treatment of individuals
with no previous history of stroke
• Secondary prevention refers to the treatment of individuals who have
already had a stroke or transient ischemic attack (TIA).
• Most primary and secondary stroke prevention recommendations
focus on ischemic stroke, but some apply to hemorrhagic stroke, or to
cerebral venous thrombosis.
5. Secondary Prevention of Stroke
• Secondary prevention can be summarized by the mnemonic A, B, C,
D, E, as follows:
• A - Antiaggregants (aspirin, clopidogrel, extended-release dipyridamole,
ticlopidine) and anticoagulants (warfarin)
• B - Blood pressure–lowering medications
• C - Cessation of cigarette smoking, cholesterol-lowering medications, carotid
revascularization
• D - Diet
• E - Exercise
6. Transient Ischemic Attack
• The epidemiology essentially mirrors that of stroke
• > 10% of TIAs will develop CI within 90 days
• (4-8% of CI will recur within 90 days)
• 2.6% of TIAs will develop other major CV events within 90
days
• 10-15% of patients have a stroke within 3 months, with half
occurring within 48 hours
• CF: Amaurosis fugax, transient stoke-like syndromes
7. Transient Ischemic Attack
• Controversy exists regarding the need for admission
• Admission to a "rapid evaluation unit" or "observation unit",
dropped the 90-day stroke risk from 10% to 4-5%
• No controversy regarding the need for urgent evaluation, risk
stratification, and initiation of stroke prevention therapy
8. Initial Evaluation
• Level of consciousness and neurologic examination are
usually at the patient's baseline.
• Initial assessment is aimed at excluding conditions that can
mimic a TIA, eg, ICH, hypoglycemia, seizure.
• Laboratory studies- within 24 hours
• RPG, ECG, CT, FBC, coagulation studies, E,U.Cr.
• MRI preferred to CT
• Echo, carotid and vertebral doppler uss
9. Risk Stratification – ABCD2
• Age ≥ 60 years (1)
• Blood pressure 140/ 90 mm Hg on first evaluation (1)
• Clinical symptoms of focal weakness with the spell (2) or
speech impairment without weakness (1)
• Duration ≥ 60 minutes (2) or 10 to 59 minutes (1)
• Diabetes (1).
10. Risk Stratification – ABCD2
• 2-day risk of stroke
• 0% for scores of 0 or 1
• 1.3% for 2 or 3
• 4.1% for 4 or 5
• 8.1% for 6 or 7
11. Decision to Admit
• If presents within 72 hours, hospitalize if:
• ABCD2 score of 3
• ABCD2 score of 0 to 2 and uncertainty that diagnostic workup can be
completed within 2 days as an outpatient
• ABCD2 score of 0 to 2 and other evidence that indicates the patient's event
was caused by focal ischemia
- AHA
12. Management
• Admit for
• Restoration of Vital Signs
• Cardiac monitoring, pulse oximetry
• Intravenous access
• Management of hypertension, hyperglycemia etc
Non-cardioembolic TIA
• Aspirin (50-325 mg/d), combination aspirin/extended-release
dipyridamole, and clopidogrel
13. Management
Cardioembolic TIA
• Atrial fibrillation, Complete heart block, MI, DCM, RHD
• After a TIA, long-term anticoagulation with warfarin (goal INR,
2-3) is typically recommended.
• LMW heparin if warfarin is interrupted
• Aspirin, 325 mg/d
• Mechanical prosthetic valves, warfarin (goal INR 2.5-3.5),
aspirin, 75-100 mg/d
• Bioprosthetic valves, warfarin (goal INR 2-3)
15. Management
Carotid Stenosis
• Carotid endarterectomy (CEA) if
• Ipsilateral severe (70% to 99%) for asymptomatic carotid stenosis
• Ipsilateral moderate (50% to 69%) for symptomatic stenosis
• depending on patient-specific factors - age, sex, and comorbidities
(CAS – an alternative)
• Stenosis <50%, no indication for CEA/CAS
• CEA within 2 weeks is reasonable
16. Antiplatelets
• Aspirin
• A 15% relative risk reduction in vascular events (stroke, death, MI) compared
with placebo
• Dose varies from 75mg to 325 mg daily
• Clopidogrel - 75 mg daily
• Had a relative risk reduction of ~ 9% for stroke, death, and MI compared with
aspirin
17. • Ticlopidine – 250 mg twice daily
• Relative risk reduction of ~ 9% for stroke, death, and MI compared with
aspirin
• Side effects (diarrhea, skin rash, and reversible agranulocytosis) limit use
• Dipyridamole – 200mg b.d
• Aspirin + extended-release dipyridamole is more effective than aspirin alone.
Antiplatelets
19. Prevention
Risk modification
• Hypertension
• Antihypertensive therapy reduces stroke risk by about 38%
• Reduction of diastolic BP by 6 mmHg reduces stroke risk by more
than 33%
• Reduction of systolic BP by 3mmHg reduces risk by 8%
• Diabetes
• No demonstrated benefit in stroke reduction with tight glycemic
control
• BP control and statins reduce stroke risk in DM
20. Prevention
• Aspirin - 25% risk reduction
• Carotid endarterectomy: symptomatic atherosclerotic
stenosis of > 70% in the carotid artery
• High Blood Cholesterol
• Stroke risk reduction of 27% to 32% is achieved with statins
• 25% reduction in TIAs
• Smoking Cessation
• Reduces risk by 50% within 1 y; to baseline after 5 years
21. Prevention
• Avoid alcohol drinking
• Recommendation: No drinks at all
• Weight control
• An average weight lossof 5.1 kg reduced systolic BP by 4.4 mmHg
and diastolic BP by 3.6 mmHg
• Exercise
• Recommendation: 30 minutes of moderate-intensity activitydaily
23. Asymptomatic carotid stenosis
• RR = 2.0
• 50% reduction with endarterectomy
• Aggressive management of other identifiable vascular risk factors
24. Weight Control
• No clinical trial has tested the effects of weight reduction on stroke
risk
• An average weight loss of 5.1 kg reduced systolic BP by 4.4 mmHg and
diastolic BP by 3.6 mmHg
• Therefore, weight reduction is reasonable as a means of reducing stroke risk
• Don’t just advise, set SMART weight management goals
25. Physical activity
• Mechanisms: BP, DM, weight, plasma fibrinogen, platelet
activity & plasma tPA activity and HDL-cholesterol.
• Recommendation (The 2008 Physical Activity Guidelines for
Americans):
• At least 150 minutes per week of moderate intensity
• or 75 minutes per week of vigorous intensity aerobic physical activity
• or an equivalent combination of moderate and vigorous intensity
aerobic activity
26. Sickle Cell Disease
• Screening with TCD starting at age 2 years
• Optimal interval not yet established, more frequently in younger
children and with borderline abnormal TCD velocities
• Transfusion therapy (target reduction of Hb S from a baseline
of >90% to <30%)
• Reduced risk from 10% to 1%
• Hydroxyurea or bone marrow transplantation
29. Diet
• Carbohydrates
• Include at least one starchy food in each main meal
• Use refined carbohydrates sparingly
• Fats
• Low-fat dairy products and low saturated and total fat diets reduce BP and
stroke risk
• Yoruba diet has lower mean cholesterol level (166mg/dl) compared to
that of the African Americans (220mg/dl) (Ogunniyi et al ,2000)
30.
31. Diet
• Proteins
• Red Meat - Use Sparingly
• Fish, Poultry, and Eggs - 0-2 times a day
• Nuts and Legumes - 1- 3 times a day
• Nuts and legumes are an excellent source of protein, fiber, vitamins, and
minerals.
• Examples: Brown beans, soya beans.
• Contain healthy fat, good for the heart.
Milk
• A good source of calcium
• Try to stick to low or no fat milk
32. Fruits and Vegetables
• Increased fruit and vegetable consumption is associated witha
reduced risk of stroke in a dose-response fashion
• For each 1-serving/day increment in fruit and vegetable intake, the
risk of stroke was reduced by 6%
- Nurses’ Health Study & the Health Professionals’ Follow-Up Study
• Vegetables- to be taken in abundance, every meal, every day.
• Fruits (2-3 times a day)
33.
34.
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36.
37. Salt
• 75% of the salt we eat is already in food when we buy it
• Avoid foods high in salt
• Fast foods, canned foods, tomato ketchup, mayonnaise, roasted nuts,
smoked meat and fish.
• No added salt at table
• Recommended daily intake of table salt for adults: not more
than 6g a day: around one full teaspoon
38. Conclusion
• Stroke is a disease of major public health importance in Nigeria &
mortality is still very high
• Recognition by patients and care providers that stroke is a medical
emergency will change the current picture
• Stroke is preventable and prevention is the only affordable option for
developing countries
• TIA is not benign
