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Stroke Epidemiology-2001

Stroke Epidemiology-2001. Aurora K. Pajeau , M.D., MPH Stroke Director LSUHSC-Shreveport. Stroke-2001. 3 rd leading cause of death in the United States A major cause of disability among adults. Estimated 750,000 annual incident strokes. >4 million stroke survivors.

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Stroke Epidemiology-2001

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  1. Stroke Epidemiology-2001 Aurora K. Pajeau, M.D., MPH Stroke Director LSUHSC-Shreveport Congress of Epidemiology 2001Toronto, Canada

  2. Stroke-2001 • 3rd leading cause of death in the United States • A major cause of disability among adults. • Estimated 750,000 annual incident strokes. • >4 million stroke survivors. Congress of Epidemiology 2001Toronto, Canada

  3. Well-Documented Modifiable Stroke Risk Factors FactorPrevalencePAR% RR%Risk /c Tx HTN (Age 50-80) 20-55% 40-20 4.0-1.4 38% Smoking 25% 12-18 1.8 50% /c 1yr DM 20% 14-58 1.8-6 /c BP  Asxto Carotid Stn 2-8% 2-7 2.0 50% TC men 55y 25% 25 1.8/ 240-279 20-30% women 65y 40% 2.6/>280 /c statins A Fib 0.5-8.8% 1.5-23 5 2.6-4.5 68% A/C 21%ASA Adapted from Goldstein et al: Stroke 2001;32:280-299 Congress of Epidemiology 2001Toronto, Canada

  4. Hyperlipidemia ~36% (60x106) adults in U.S. Mean TC levels increase in men till age 55-64 then decline. 25% of American men and 28% of women have TC levels >240mg/dl (6.21mm/l) Congress of Epidemiology 2001Toronto, Canada

  5. Normal Endothelium Congress of Epidemiology 2001Toronto, Canada

  6. Fibrous Plaque Congress of Epidemiology 2001Toronto, Canada

  7. Congress of Epidemiology 2001Toronto, Canada

  8. Stimuli Initiating Atherosclerosis • Hypertension Mechanical forces, sheer stress response • Oxidized LDL­ Adhesion, permeability, deposition • Homocysteine ­ [O] LDL, vascular toxin Cigarettes Toxic, oxidizing glycation products Hyperglycemia ­ Arterial retention of Trigl Infection Vessel wall injury Congress of Epidemiology 2001Toronto, Canada

  9. Novel Risk Factors • Hyperhomocysteinemia • Infection and inflammation • Additional genetic factors • Hemostatic and coagulation disorders • Leisure time inactivity and obesity • Fast food restaurant abuse • Second hand smoke Congress of Epidemiology 2001Toronto, Canada

  10. Hyperhomocysteinemia • HC is a highly reactive amino acid toxic to vascular endothelium • Pro-atherogenic and pro-thrombotic effect on blood vessels • HC can potentiate the auto-oxidation of LDL • HC is emerging as a potentially modifiable risk factor for atherosclerosis Congress of Epidemiology 2001Toronto, Canada

  11. Infection and Inflammation • Infectious agents contribute to initiation and chronic formation, progression and activation of atherosclerotic plaques. • Infectious agents can be seen as triggers Congress of Epidemiology 2001Toronto, Canada

  12. Infection and Inflammation • Chlamydia pneumoniae • Helicobacter pylori • Cytomegalovirus • Herpes virus • Periodontal disease • Genetic influence Congress of Epidemiology 2001Toronto, Canada

  13. Chlamydia Pneumoniae • Obligate intracellular parasite Infects mononuclear phagocytes • Macrophages derived from them localize in atherosclerotic plaque to provide mechanism for entry of organism into vessel wall Congress of Epidemiology 2001Toronto, Canada

  14. Helicobacter pylori • Thought to be a potential factor in causing pathophysiology of atherosclerosis • One strain was found to be associated with increased cytokine expression. Congress of Epidemiology 2001Toronto, Canada

  15. Periodontal Disease • A mechanism for chronic systemic inflammation from Gm (-) organisms • Advanced disease estimated prevalence: • 15% -60-64 yo • >45% in >65 y.o. • One study showed a significant ischemic stroke risk (RR 2.1) among those with periodontitis. Congress of Epidemiology 2001Toronto, Canada

  16. Genetic Inflammatory Disorders • Genetic mutations & gene polymorphisms • Associated with inflammatory pathways • May lead to increased susceptibility to develop atherosclerosis • Particular HLA types Congress of Epidemiology 2001Toronto, Canada

  17. Genetic Inflammatory Disorders • Continuing research in linkage analysis studies and association studies with genetic influence based on risk factor exposure are needed. Congress of Epidemiology 2001Toronto, Canada

  18. Genetic Hemostatic & Coagulation Factors • Sickle cell disease • CADASIL • Coagulation disorders • Connective tissue disorders • Vasculopathies • Metabolic disorders Congress of Epidemiology 2001Toronto, Canada

  19. CADASIL • Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopahty • monogenic inherited small vessel disease • Notch 3 gene on chromosome 19q12 • Migraines, TIAs, lacunar strokes • Stroke and dementia in early middle age Congress of Epidemiology 2001Toronto, Canada

  20. Fast Food Restaurant Abuse • Increased trans fatty acid intake from foods fried in partially hydrogenated fats at fast food restaurants • Trans unsaturated fatty acids LDL and HDL • Major contributor is hydrogenated fats • Builds plaque in arteries Congress of Epidemiology 2001Toronto, Canada

  21. Leisure Time Inactivity and Obesity • Obesity defined as BMI>30kg/m2 •  with age • Associated with  BP, •  glucose, lipids* *Walker et al: Am J Epi 1996 Congress of Epidemiology 2001Toronto, Canada

  22. Guidelines for Stroke Prevention • Antiplatelets & anticoagulation • HTN control • Statin agents • RAAS inhibition • Leisure time activity • Dietary guidelines Congress of Epidemiology 2001Toronto, Canada

  23. Guidelines for Stroke Prevention • Aspirin and Sub Q heparin for inpatient with acute stroke • IV heparin for TIA from symptomatic carotid stenosis, until CEA • Bottom line: ASA/ext. release dipyridamole better than aspirin alone, may be better than clopidogrel Congress of Epidemiology 2001Toronto, Canada

  24. Use of Anticoagulant Therapy • Coagulopathies (INR 2-3), prosthetic heart valves( INR 2.5-3.5) • Nonvalvular atrial fibrillation (INR 2-3) • Age <65, no risk factors Aspirin • Age <65, /c risk factors Warfarin • Age 65-75, no risk factors Aspirin or Warfarin • Age 65-75 /c risk factors Warfarin • Age >75, /c or /s Warfarin Congress of Epidemiology 2001Toronto, Canada

  25. Hypertension Control • SBP<140mmHg & DBP<90mmHG • <135/<85 if target organ damage • Antihypertensive medications • Lifestyle modification Congress of Epidemiology 2001Toronto, Canada

  26. Leisure Time Inactivity and Obesity • Walking AM &PM 1.8 mi/d most days of week will modify risk of cardiovascular disease and stroke**. *Walker et al: Am J Epi 1996; **Rexrode et al:JAMA 1997.**Abbott RD et al: Am J Epi 1994 Congress of Epidemiology 2001Toronto, Canada

  27. Leisure Time Activity Leisure Time Activity • Exercise will  insulin resistance, fibrinogen, LDL and weight and will  HDL • There is no dose relationship with level of activity Congress of Epidemiology 2001Toronto, Canada

  28. Novel Approaches to Stroke Prevention • Statin agents used for hyperlipidemia may reduce risk of stroke*. • Antihypertensive agents that inhibit the renin-angiotensin –aldosterone system (RAAS) may reduce risk by non-hypertensive lowering mechanisms**. *Plehn et al: Circ 1999; LIPID Study Gp: N Engl J Med 1998 **Van Bortel et al: Am J Card 1995; Thybo et al: HTN 1995 Congress of Epidemiology 2001Toronto, Canada

  29. Stroke Prevention Therapy • AHA Dietary Guidelines, 2000* • General population • Special populations • Ancillary lifestyle issues • BMI 120% of ideal body weight for height • Krauss et al, Stroke 2000. Congress of Epidemiology 2001Toronto, Canada

  30. Physician-Community Knowledge Gap • Well-defined stroke prevention measures underutilized, misapplied • Knowledge of risk factors for primary stroke prevention • CME, physician recertification • Promote stroke prevention legislation Congress of Epidemiology 2001Toronto, Canada

  31. U.S. Legislative Measures • Public education and awareness of stroke • Improved stroke care • Kennedy Bill • Establish a national clearinghouse on stroke treatment & research • Authorize a national public awareness and education plan • Provide state grants to ensure stroke patients have access to high quality care Congress of Epidemiology 2001Toronto, Canada

  32. STOP Stroke Act • Stroke TreatmentandOngoingPrevention • Public awareness campaign • Grant program • Ensure training in prevention & treatment for medical personnel • Create comprehensive research for best practices, barriers, disparities; measure effect of public awareness efforts. Congress of Epidemiology 2001Toronto, Canada

  33. STOP Stroke Act Stroke legislation hot line: www.stroke.org/strokesmart.cfm Congress of Epidemiology 2001Toronto, Canada

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