Primary and Secondary Stroke Prevention



Primary and Secondary Stroke Prevention


Charles C. Esenwa

Mitchell S. V. Elkind



INTRODUCTION

Prevention of stroke can be divided into three types: (1) primordial prevention, which focuses on improving community-wide health behaviors, such as diet, exercise, and smoking; (2) primary prevention, which attempts to mitigate an individual’s stroke risk factors; and (3) secondary prevention, which targets risk of stroke recurrence in those who have already suffered a stroke or transient ischemic attack (TIA).

Risk factors are generally classified as either nonmodifiable or modifiable. Nonmodifiable risk factors, although they cannot be altered, remain important in quantifying a patient’s future risk of stroke. Examples include age, sex, family history, ethnicity, and race. Modifiable risk factors allow for intervention to decrease future risk of stroke.

Although primordial prevention deals with population-level risk of cardiovascular disease, individualized prevention measures require a careful history and tailored diagnostic evaluation to stratify stroke risk and guide the appropriate prevention strategy. Primary and secondary prevention methods both focus on improving the individual’s risk factor profile, and secondary prevention methods further depend on the mechanism of the stroke. For ischemic stroke, these mechanisms include atherothrombotic, small vessel (or “lacunar”), cardioembolic, and cryptogenic; the last is responsible for up to 40% of strokes. Several randomized controlled trials have been conducted over the past four decades that have determined optimal therapy for stroke prevention and treatment, especially for atherothrombotic and cardioembolic stroke subtypes.

Hemorrhagic strokes account for 15% to 20% of all strokes and are further divided into subarachnoid hemorrhage (SAH) and intracerebral hemorrhage. Causes of SAH include trauma, berry or congenital aneurysms, and less often arteriovenous malformations. Intracerebral hemorrhage is most commonly caused by hypertension. Appropriate classification of a stroke and its etiology aids the clinician in determining the most effective prevention strategy.

The INTERSTROKE case-control study among 22 countries determined that 10 risk factors accounted for nearly 90% of strokes. Listed in order of significance, they are as follows: hypertension, cardiac disease, current smoking, waist-to-hip ratio, poor diet, sedentary lifestyle, excessive alcohol intake, diabetes mellitus, depression, and psychosocial stress. The highest burden of stroke in the United States falls in the so-called stroke belt located in the southeast, where high prevalences of diabetes, hypertension, and obesity remain likely important drivers of cerebrovascular disease.







Jul 27, 2016 | Posted by in NEUROLOGY | Comments Off on Primary and Secondary Stroke Prevention

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