Primary and Secondary Prevention of Stroke

  • Nages Nagaratnam
  • Kujan Nagaratnam
  • Gary Cheuk
Reference work entry

Abstract

The risk of first stroke and recurrence of stroke can be reduced by interventions that modify the treatable cardiovascular and cerebrovascular risk factors. The most important risk factor for stroke is age, and in both men and women, the stroke rate doubles for each successive 10 years after the age of 55. The risk factors for stroke may be different for the two sexes, ethnic groups and stroke subtypes. A proper understanding of the risk factors is essential for the primary prevention of stroke. Hypertension, congestive heart failure, coronary artery disease and atrial fibrillation are the four major risk factors apart from age. Atrial fibrillation (AF) becomes more prevalent with age in the general population, and the extent of stroke associated with AF increases with age. The present review will highlight the improvements that have occurred in the prevention of stroke.

Keywords

Stroke Recurrence of stroke Risk factors for stroke Atrial fibrillation Anticoagulation 

References

  1. 1.
    Australian Institute of Health and Welfare (AIHW). Incidence and prevalence of chronic diseases. http://www.aihw.gov.au/c/darf/data_pages/incidence_prevalence.
  2. 2.
    Michsel M, Shaughnessy M. Stroke prevention and management in older adults. J Cardiovasc Nurs. 2006;21(5Suppl1):S21–6.CrossRefGoogle Scholar
  3. 3.
    Koennecke HC. Secondary prevention of stroke: a practical guide to drug treatment. CNS Drugs. 2004;18(4):221–41.CrossRefPubMedGoogle Scholar
  4. 4.
    Andrawes WF, Bussy C, Belmin J. Prevention of cardiovascular events in elderly people. Drugs Aging. 2005;22(10):859–76.CrossRefPubMedGoogle Scholar
  5. 5.
    Hanna IR, Wenger NK. Secondary prevention of coronary heart disease in elderly patients. Am Fam Physician. 2005; 71(12):2289–96.PubMedGoogle Scholar
  6. 6.
    Reynolds E, Baron RB. Hypertension in women and the elderly. Postgrad Med. 1996;100:Google Scholar
  7. 7.
    Susman ER. Treatment of high blood pressure appears worthwhile in very elderly patients. Presented 8Google Scholar
  8. 8.
    MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: preliminary results. Br Med J. 1992;304:405–12.CrossRefGoogle Scholar
  9. 9.
    Chobanian AV, Bakris JA, Black HR, Cushman WC, Green LA, Izzo JL, Jr. et al. The Seventh report of the Joint National Committee on prevention detection, evaluation and treatment of high blood pressure. The JNC Report JAMA. 2003;289:2560–7.PubMedGoogle Scholar
  10. 10.
    Sharpe N. Heart failure in the community. Prog Cardiovasc Dis. 1998;41:73–76.Google Scholar
  11. 11.
    Witt BJ, Brown RD, Jacobsen ST, Weston SA, Ballman KV, Meverden RA, et al. Ischaemic stroke after heart failure: community study. Am Heart J. 2006;152(1):102–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Marini C, De Santos F, Sacco S, Russo T, Olivirri L, Totaro R, et al. Contribution of atrial fibrillation to incidence and outcome of ischaemic stroke results from a population based study. Stroke. 2005;30:1115–1119.CrossRefGoogle Scholar
  13. 13.
    Wolf PA, Abbott RD, Kannel WD. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983–988.CrossRefPubMedGoogle Scholar
  14. 14.
    Wolf PA, Dawber TAR, Thomas HE Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham Study. Neurology. 1978;28:973–977.CrossRefPubMedGoogle Scholar
  15. 15.
    Braumwald E. Shattuck Lecture. Cardiovascular medicine at the turn of the millennium: Triumphs, Concerns and Opportunities. NEJM. 1997;337:1360–1369.CrossRefGoogle Scholar
  16. 16.
    Singer DF. Anticoagulation to prevent stroke in atrial fibrillation and its implications for managed care. Am J Cardiol. 1998;81:850CrossRefGoogle Scholar
  17. 17.
    Freedman JE, Gersh BJ. Atrial fibrillation and stroke prevention in aging patients. Circulation. 2014;130:129–133.CrossRefPubMedGoogle Scholar
  18. 18.
    Agarwal SK, Heiss G, Rautaharju PM, Shahar E, Massing MW, Simpson RJ, Jr. Premature ventricular complexes and risk of incident stroke: the Atherosclerosis Risk in Communities (ARIC) Study. Stroke. 2010;41:588–593.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Worthington JM, Gattellari M, Leung DY. “Where There’s Smoke….” Are premature ventricular complexes a new risk factor for stroke?. Stroke. 2010; 41: 572–573.CrossRefPubMedGoogle Scholar
  20. 20.
    Gage BF, van Walraven C, Pearce L, Hart RG, Kenstall PJ, Boode BS, et al. Selecting patients with AF for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation. 2004;110:2287–92.CrossRefPubMedGoogle Scholar
  21. 21.
    Gage BF, Waterman AD, Shannon W, Boechler M, Rich WW, Raddford MJ. Validation of clinical classification schemes for predicting stroke results from the National Registry of Atrial fibrillation. JAMA. 2001; 285:2860–70.CrossRefGoogle Scholar
  22. 22.
    Lip GYH, Frison L, Halperin JL, Lane DA. Identifying patients at high risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41: 2731–2738.CrossRefPubMedGoogle Scholar
  23. 23.
    Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;197(6):1172–9.Google Scholar
  24. 24.
    European Heart Rhythm Association; European Association for cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, et al. Guidelines for the management of atrial fibrillation: The task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Eur Heart J. 2010;31:2369–429.CrossRefGoogle Scholar
  25. 25.
    Lip GY. Implications of CHA2DS2-VASc and HAS-BLED scores for thromboprophylaxis in atrial fibrillation. Am J Med 2011;124(2):111–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Roldan V, Marin F, Manzano-Fernndez S, Gallego P, Vilchez JA, Valdes M, et al. The HAS-BLED Score has better predictive accuracy for major bleeding than CHADS2 or CHA2DS2-VAS scores in anticoagulated patients with atrial fibrillation. J Amer Coll Cardiol. 2013;62(23):2199–2204.CrossRefGoogle Scholar
  27. 27.
    Connolly S, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran vs warfarin in patients with atrial fibrillation. NEJM. 2009;361:1139–1151.CrossRefPubMedGoogle Scholar
  28. 28.
    Galllus A. New oral anticoagulants-clinical applications. Aust Prescr. 2010;33:42–47.CrossRefGoogle Scholar
  29. 29.
    Legrand M, Mateo L, Aribaud A, Ginisty S, Eftekhani P, Huy PT, et al. The use of dabigatran in elderly patients. Arch Intern Med. 2011;171:1281–1286.CrossRefGoogle Scholar
  30. 30.
    Harper P, Young PL, Merriman L. Bleeding risk with dabigatran in the frail elderly. N Eng J Med. 2012;366:864–865.CrossRefGoogle Scholar
  31. 31.
    Meliom C, Peterson ED, Chen AV, Szechzech LB, Newby LK, Harrington RA, et al. Cockcroft-Gault versus modification of diet in renal disease: importance of glomerular filtration rate formula for classification of chronic kidney disease in patients with non-ST segment elevation acute coronary syndrome. J Am Coll Cardiol. 2008;51:991–996.CrossRefGoogle Scholar
  32. 32.
    Stegmayr B, Asplund K, Diabetes as a risk factor for stroke. A population perspective. Diabetologia.1995; 30:736–43.Google Scholar
  33. 33.
    Stamler J, Vaccaro PO, Neaton JD, Wentworth D, The Multiple Risk Factor Intervention Trial Research Group. et al. Diabetes, other risk factors and 12 cardiovascular mortality for screened in the Multiple Risk Factor Intervention Trial. Diabetes. Diabetes Care. 1993;16:434–44CrossRefPubMedGoogle Scholar
  34. 34.
    Kisella BM, Khoury J, Kleindorfer D, Woo D, Schneider A, Alwell K, et al. Epidemiology of ischaemic stroke in patients with diabetes: the greater Cincinnati? Northern Kentucky Stroke Study. Diabetes Care. 2005;28:355–9CrossRefGoogle Scholar
  35. 35.
    Hankey GJ, Jamrozik K, Broadhurst RJ, Anderson C. Long term risk of first recurrent stroke in the Perth Community Stroke Study. Stroke. 1998; 29: 2491–500.CrossRefPubMedGoogle Scholar
  36. 36.
    Tuomilehto J, Rastenyte D, Jousilahti P, Sarti C, Vartiainene E. Diabetes mellitus as a risk factor for death from stroke. Stroke. 1996;27:210–215.CrossRefPubMedGoogle Scholar
  37. 37.
    Colhoun HM, Betteridge DJ, Durrington PM, Hitman GA, Neil HA, Livingstone SJ CARDS, et al.. Investigations. Primary prevention of cardiovascular disease with atorvastin in type 2 patients in the Collaborative Atovasatin Diabetes Study (CARDS):multicentre randomized placebo-controlled trial. Lancet. 2004;304:685–96.CrossRefGoogle Scholar
  38. 38.
    The executive committee for the Asymptomatic Carotid Atherosclerosis Study Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273:1421–8.Google Scholar
  39. 39.
    MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal stroke by successful carotid endartectomy in patients without neurological symptoms: randomized controlled trial. Lancet. 2004;363:1491502.Google Scholar
  40. 40.
    Biller J, Feinberg WM, Castaldo JF, Whittemore AD, Harbaugh RE, Dempsey RJ, et al. Guidelines for carotid endarterectomy: a statement for health care professionals from a Special Writing of Stroke Council, American Heart Association. Circulation. 1998; 97: 501–09.CrossRefPubMedGoogle Scholar
  41. 41.
    Abbott AL. Medical (nonsurgical) intervention alone is now the best treatment for the prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systemic review and analysis. Stroke. 2009; 40:e573–e583.CrossRefPubMedGoogle Scholar
  42. 42.
    Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: prospective population based study. Stroke. 2009;2010;41.Google Scholar
  43. 43.
    Goldstein LB, Rothwell PM. Advances in prevention and health services delivery 2009. Stroke. 2010;41: e71–e73.CrossRefPubMedGoogle Scholar
  44. 44.
    Zhang X, Patel A, Horibe H, Wu Z, Barzi F, Rodgers A, et al. Cholesterol, coronary heart disease and stroke in the Asia Pacific region. Int J Epidemiol. 2006;32(4):563–72.Google Scholar
  45. 45.
    Kurth T, Everett BM, Buring JE, Kase CS, Ridker PM, Gaziano JM, et al. Lipid levels and the risk of ischaemic stroke in women. Neurology. 2007;68(8):556–62.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Fine-Edelstein JS, Wolf PA, O’Leary DH, Poehlman H, Belanger AJ, Kase CS, et al. Precursors of extracranial carotid atherosclerosis in the Framingham Study. Neurology. 1994; 44(6):1046–1050.CrossRefPubMedGoogle Scholar
  47. 47.
    Preiss D, Seshasai SR, Welsh P, Murphy SA, Ho JE, Waters DD, et al. Risk of incident diabetes with intensive-dose compared with “moderate dose statin therapy” a meta-analysis. JAMA. 2011;305:2556–64.CrossRefPubMedGoogle Scholar
  48. 48.
    Grundy SM, Cleeman JI, Merz CN, Brewer HB, Clark LT, Hunninghake DB, et al, Implications of recent clinical trials for the National Cholesterol Education Programme Adult treatment Panel III guidelines. Circulation. 2004;110(2):227–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Abbott RD, Yin Y, Reed OM, Yano K. Risk of stroke in male cigarette smokers. N Engl J Med. 1986;315:717–720.CrossRefPubMedGoogle Scholar
  50. 50.
    Gorelick PB, Rodin MB, Langerberg P, Hier DB, Costigan J. Weekly alcohol consumption, cigarette smoking and risk of ischaemic stroke: reults of a case-control study at 3 uran medical centers in Chicago Illnios. Neurology. 1989;39:339–343.CrossRefPubMedGoogle Scholar
  51. 51.
    Sacco RL, Roberts JK, Boden-Albala R, Gu Q, Lin IF, Kargman DE, et al. For The Northern Manhattan Stroke Study: Race-ethnicity and determinants of carotid atherosclerosis in a multiethnic population. Stroke. 1987:28:929–935.CrossRefGoogle Scholar
  52. 52.
    Gill JS, Zezulka AV, Shipley MI, Gill SK, Beevers DG. Stroke and alcohol consumption. N Engl J Med. 1981;315:1041–1046.CrossRefGoogle Scholar
  53. 53.
    Kiely DK, Wolf PA, Cupples LA, Beiser AS, Kannel WB. Physical activity and stroke risk. The Framingham Study. Am J Epidemiol. 1994;140:608–620.CrossRefPubMedGoogle Scholar
  54. 54.
    Manson JE, Stampfer MJ, Willett WC. Physical activity and incidence of coronary heart disease and stroke in women. Circulation 1995;91:927.Google Scholar
  55. 55.
    Sacco RL, Boden-Albala B, Gu Q, et al. Any physical activity reduces ischaemic stroke risk. The Northern Manhattan Stroke Study. Neurology. 1996;40:400.Google Scholar
  56. 56.
    Choi-Kwan S, Kim JS. Lifestyle factors and risk of stroke in Seoul, South Korea. J Stroke Cerebrovasc Dis. 1998;7:414–420.CrossRefGoogle Scholar
  57. 57.
    Jamrozik K, Broadhurst RJ, Anderson CS, Stewart-Wynne EG. The role of lifestyle factors in the etiology of stroke: A population-based case-control study in Perth Western Australia. Stroke. 1994:25(1):51–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Alhusban A, Fagan SC. Secondary prevention of stroke in the elderly: a review of the evidence. Am J Geriatr Pharmacother. 2011;9(3):143–52.CrossRefPubMedGoogle Scholar
  59. 59.
    Randomised trial of perindopril based blood pressure lowering regimen among 6, 105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033–1034.Google Scholar
  60. 60.
    Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis afteremergency department diagnosis of TIA. JAMA. 2000;284:2901–6CrossRefPubMedGoogle Scholar
  61. 61.
    Coul AJ, Lovett JK, Rothwell PM. A population based study of the early risk of stroke after a transient ischaemic or minor stroke: implications for public education and organization services. BMJ. 2004;328:326–8.CrossRefGoogle Scholar
  62. 62.
    Muir KW. Secondary prevention for stroke and transient ischaemic attacks. Editorial. BMJ. 2004;328:297–98.PubMedGoogle Scholar
  63. 63.
    Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham study JAMA. 1979; 241: 2035–2038.CrossRefPubMedGoogle Scholar
  64. 64.
    Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO, et al. Survival and recurrence after first central infarction: a population based study in Rochester. Minnesota 1975 through 1989. Neurology. 1998;50:208–216.CrossRefPubMedGoogle Scholar
  65. 65.
    Adams RJ, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, et al. Update to the AHA/ASA Recommendations for the Prevention of Stroke in Patients With Stroke and Transient Ischaemic Attack. Stroke. 2008;39:1647–1652.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Amarenco P, Bogousslavsky J, Callahan A, Goldstein LB, Hennerici M, Rudolph AE, et al. 3rd. Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL). Investigations. High dose artovastatin after stroke or transient ischaemic attack. N Engl J Med. 2006;355:549–559.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nages Nagaratnam
    • 1
  • Kujan Nagaratnam
    • 1
  • Gary Cheuk
    • 2
  1. 1.The University of SydneyWestmead Clinical SchoolWestmeadAustralia
  2. 2.Rehabilitation and Aged Care ServiceBlacktown-Mt Druitt HospitalMount DruittAustralia

Personalised recommendations