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Frontiers of Medicine

Front Med    2012, Vol. 6 Issue (1) : 22-34     DOI: 10.1007/s11684-012-0178-6
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Stroke prevention: an update
Marie-Germaine Bousser()
Neurology Department, Lariboisière Hospital AP-HP, Paris Diderot University, Paris 75010, France
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Abstract

Stroke is a personal, familial, and social disaster. It is the third cause of death worldwide, the first cause of acquired disability, the second cause of dementia, and its cost is astronomic. The burden of stroke is likely to increase given the aging of the population and the growing incidence of many vascular risk factors. Prevention of stroke includes—as for all other diseases—a “mass approach” aiming at decreasing the risk at the society level and an individual approach, aiming at reducing the risk in a given subject. The mass approach is primarily based on the identification and treatment of vascular risk factors and, if possible, in the implementation of protective factors. These measures are the basis of primary prevention but most of them have now been shown to be also effective in secondary prevention. The individual approach combines a vascular risk factor modification and various treatments addressing the specific subtypes of stroke, such as antiplatelet drugs for the prevention of cerebral infarction in large and small artery diseases of the brain, carotid endarterectomy or stenting for tight carotid artery stenosis, and oral anticoagulants for the prevention of cardiac emboli. There is a growing awareness of the huge evidence-to-practice gap that exists in stroke prevention largely due to socio-economic factors. Recent approaches include low cost intervention packages to reduce blood pressure and cheap “polypills” combining in a single tablet aspirin and several drugs to lower blood pressure and cholesterol. Polypill intake should however not lead to abandon the healthy life-style measures which remain the mainstay of stroke prevention.

Keywords stroke      prevention      vascular risk factors      cerebral infarction      cerebral hemorrhage      anti-thrombotic drugs      carotid endarterectomy     
Corresponding Authors: Bousser Marie-Germaine,Email:mg.bousser@lrb.aphp.fr   
Issue Date: 05 March 2012
 Cite this article:   
Marie-Germaine Bousser. Stroke prevention: an update[J]. Front Med, 2012, 6(1): 22-34.
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http://journal.hep.com.cn/fmd/EN/10.1007/s11684-012-0178-6
http://journal.hep.com.cn/fmd/EN/Y2012/V6/I1/22
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Articles by authors
Marie-Germaine Bousser
Major RR ≥ 4Moderate RR 2-4Weak or debated RR < 2
Age*Cigarette smokingHigh cholesterol
HypertensionDiabetesObesity
High alcohol consumptionDrug abuseHyperhomocysteinemia
Physical inactivityHigh Lp(a)
OC useHypercoagulability
Male sex*Acute infection
Low birth rate*Inflammation
Family history of stroke*Post-menopausal hormone therapy
Race/ethnicity*Migraine with aura
SDB
Tab.1  Risk factors for stroke and their relative risk (RR)
Smoking: not currently smoking (former smokers included)
Physical activity: ≥30 min/d of moderate or vigorous activity
Diet: diet score in top 40% of each cohort distribution
Moderate alcohol consumption: at least 5 g/d with an upper limit of 15 g/d for women and 30 g/d for men
Optimal weight: BMI < 25 kg/m2 during midlife (at baseline)
Tab.2  Operational definition of 5 low risk lifestyle factors in one study []
? BP should be checked regularly. It is recommended that high BP should be managed with lifestyle modification and individualized pharmacological therapy (Class I, Level A) aiming at normal levels of 120/80 mmHg (Class IV, GCP). For prehypertensive (120-139/80-90 mmHg) with congestive heart failure, MI, diabetes, or chronic renal failure antihypertensive medication is indicated (Class 1, Level A)
? Blood glucose should be checked regularly. It is recommended that diabetes should be managed with lifestyle modification and individualized pharmacological therapy (Class IV, Level C). In diabetic patients, high BP should be managed intensively (Class I, Level A) aiming for levels below 130/80 mmHg (Class IV, Level C). Where possible, treatment should include an angiotensin converting enzyme inhibitor or angiotensin receptor antagonist (Class I, Level A)
? Blood cholesterol should be checked regularly. It is recommended that high blood cholesterol (e.g. LDL 1 150 mg/dL ; 3.9 mM) should be managed with lifestyle modification (Class IV, Level C) and a statin (Class I, Level A)
? It is recommended that cigarette smoking be discouraged (Class III, Level B)
? It is recommended that heavy use of alcohol be discouraged (Class III, Level B)
? Regular physical activity is recommended (Class III, Level B)
? A diet low in salt and saturated fat, high in fruit and vegetables and rich in fiber is recommended (Class III, Level B)
? Subjects with an elevated body mass index are recommended to take a weight-reducing diet (Class III, Level B)
? Antioxidant vitamin supplements are not recommended (Class I, Level A)
? Hormone replacement therapy is not recommended for the primary prevention of stroke (Class I, Level A)
Tab.3  European recommendations for risk factors modification in primary stroke prevention (European Stroke Organisation, 2008 [])
ControlPrevalence Ischaemic strokeHemorrhagic strokeAll stroke OR (99%CI)PAR
Hypertension37 %66 %83 %3.89 (3.33-4.54)51.8 %
Current smoking24 %37 %31 %2.09 (1.75-2.51)18.9 %
Waist-to-hip ration T3/T133 %43 %35 %1.65 (1.36-1.99)26.5 %
Diet risk score T3/T130 %34 %34 %1.35 (1.11-1.64)18.8 %
Physical activity12 %8 %7 %0.69 (0.53-0.90)28.5 %
Diabetes12 %21 %10 %1.36 (1.10-1.68)5 %
Alcohol > 30 drinks/m11 %16 %16 %1.51 (1.18-1.92)3.8 %
Depression14 %21 %16 %1.35 (1.10-1.66)5.2 %
Cardiac causes5 %14 %4 %2.38 (1.71-3.20)6.7 %
Ratio Apo B/Apo A T3/T133 %49 %35 %1.89 (1.49-2.40)24.9 %
Tab.4  10 risk factors associated with 90% of the risk of stroke (adapted from INTERSTROKE [])
Self-reported hypertension Or blood pressure > 160/90 mmHgCurrent smokerWaist-to-hip ratio (T3 vs. T1)
High-income countries (n=422)*2.79 (1.83-4.25)2.68 (1.64-4.37)3.34 (1.96-5.68)
South America (n=151)+3.52 (1.63-7.60)3.01 (1.00-9.06)3.82 (1.26-11.55)
Southeast Asia (n=1146) ++4.49 (1.62-2.90)2.17 (1.62-2.90)1.36 (0.99-1.85)
India (n=958)4.36 (3.34-5.69)2.22 (1.65-2.97)1.35 (0.96-1.89)
Africa (n=323)**4.96 (3.11-7.91)2.18 (1.07-4.43)1.73 (0.99-3.02)
Tab.5  Risk of stroke associated with key risk factors by world regions (adapted from INTERSTROKE [])
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