Stroke risk lowered 80% by healthy diet, exercise
■ Revised guidelines stress evaluating patients' lifestyle choices in a primary care setting.
Nonsmokers who follow a healthy diet, exercise regularly and drink only in moderation have an 80% lower risk of a first stroke compared with people who don't adopt that lifestyle, according to updated guidelines on stroke prevention.
Because 75% of the 790,000 strokes that occur each year are first-time strokes, the urgency in assessing patients' lifestyle choices and intervening in a primary care setting is clear, said Larry B. Goldstein, MD, professor of medicine at Duke University Medical Center and director of the Duke Stroke Center in Durham, N.C.
"Even though we have a lot to do during those primary care interactions, emphasizing the effect of lifestyle factors and helping patients achieve their goals is one major, major message for primary care providers," Dr. Goldstein said.
The American Heart Assn./American Stroke Assn. guidelines, updated for the first time since 2006, appear in the December issue of the journal Stroke (link).
According to the guidelines, aspirin should not be used to prevent stroke in people who are low-risk. The risk should be sufficiently high for ischemic stroke to offset the hazard of aspirin.
"People should have a 10-year cardiovascular risk in the 6% to 10% range," said Dr. Goldstein, who led the team that revised the guidelines. "Even very low-dose aspirin ... can be associated with an increased risk of major gastrointestinal hemorrhage."
The guidelines address stroke for the first time as a broad spectrum of related events, including ischemic stroke, non-ischemic stroke and transient ischemic attack. Previous recommendations dealt only with ischemic stroke, which accounts for 87% of strokes.
The authors suggest that patients with type 1 or type 2 diabetes undergo blood pressure control to reduce the risk of cardiovascular events. Genetic screening for stroke, although not recommended for the general population, may be appropriate for some, depending on family history and other factors.
Visits to the emergency department offer a critical opportunity to screen for and treat stroke risk factors, as well as making referrals. ED visits are appropriate for cholesterol and blood pressure monitoring, smoking-cessation strategies and atrial fibrillation screening and treatment. This may be particularly important as EDs are often the gateway to the health care system for the uninsured, Dr. Goldstein said.
Screening for high blood pressure in the ED and referral of patients with drug or alcohol problems also are considered reasonable.
It's important for primary care doctors to identify patients with some of the less-known risk factors, such as sleep apnea, Dr. Goldstein said. The condition has been associated with a higher risk of cardiovascular events, in general, and stroke, in particular.
Strokes are the fourth leading cause of U.S. deaths, after decades of being the third most common cause, according to a Dec. 9 report by the Centers for Disease Control and Prevention on mortality data from 2008. The top three causes of death are cardiovascular disease, cancer and chronic lower respiratory diseases, according to the CDC.