IPCAS

Professor Jonathan Mant summarises top tips for patients and practitioners on stroke risk assessment and reduction

Posted on 26th March 2019

There are over 100,000 strokes in the UK per year. It is the fourth commonest cause of death, and is a leading cause of disability in the UK, with over 1.2 million survivors, costing the NHS and social care around £1.7 billion a year. Much can be done to reduce this burden of disease through prevention—the large INTERSTROKE case control study suggests that modifiable risk factors potentially account for 90% of all stroke cases.

1. Eating a healthy diet
   Diet has a big impact on stroke risk. Changing diet can help a patient to reduce their risk of stroke in several different ways: reducing dietary sodium intake and increasing fruit and vegetable consumption will lower blood pressure, an important risk factor for stroke (see below) and a diet rich in fruit, vegetables, nuts, fish, and olive oil—the so-called ‘Mediterranean diet’—will reduce risk of stroke and myocardial infarction. Likewise, weight loss will reduce body mass index (BMI), which is in turn a risk factor for stroke (at least down to a BMI of 22.5)
2. Adopt a healthy lifestyle
   As well as diet, changing other lifestyle habits can help to reduce stroke risk. Any physical activity compared to inactivity is associated with reduced risk of stroke. Smoking is associated with a 2–3-fold increase in risk of death from stroke. Stopping smoking, even at older ages, will have an effect on future stroke risk. Alcohol consumption is associated with increased stroke risk, with each 100g (i.e approximately 12 units) associated with a 14% increase in risk.
3. Use a cardiovascular disease risk calculator to assess stroke risk
   Risk factors for stroke and coronary heart disease overlap, so for practical purposes, a cardiovascular disease risk calculator (rather than a stroke-specific risk calculator) is appropriate to identify high-risk individuals and inform treatment options. 
4. Treat high blood pressure
   Hypertension is a major risk factor for stroke so it is important to treat high blood pressure.
5. Statin therapy
   Statin therapy is effective at reducing risk of stroke, and should be offered to people depending upon their underlying cardiovascular risk. There is strong evidence from randomised controlled trials that use of statins lowers risk of stroke and other cardiovascular events and increases life expectancy.
6. Take opportunities to case find atrial fibrillation
   Opportunistic case finding is an effective way to identify atrial fibrillation (AF), an important risk factor for stroke. Atrial fibrillation is associated with a nearly five-fold increase in risk of stroke. 
7. Anticoagulation for people with AF
   Anticoagulation is highly effective at reducing the risk of stroke in people with AF. 
8. Urgent specialist assessment after TIA
   The early risk of completed stroke after a transient ischaemic attack (TIA) is high—about 5% within a week—so urgent specialist assessment and treatment of possible TIAs is required. This risk can be modified by prompt secondary prevention treatment, particularly with aspirin, and further investigation may reveal underlying causes such as carotid stenosis or atrial fibrillation. The National clinical guideline for stroke recommends: ‘patients with acute neurological symptoms that resolve completely within 24 hours (i.e. suspected TIA) should be given aspirin 300 mg immediately and assessed urgently within 24 hours by a specialist physician in a neurovascular clinic or an acute stroke unit.’
9. Antithrombotic therapy 
   Existing cardiovascular disease is an important risk factor for further cardiovascular events and the risk can be reduced by antiplatelet therapy. 
10. Consider all secondary prevention options
    People who have had a stroke are at high risk of a second stroke so all secondary prevention options should be considered. 
    

To read the full article and reference list as published in the Guidelines in Practice journal please click here

*a full reference list can also be found here