Preventing Stroke One at a Time Lifestyle & Risk Factor Management

1. Preventing Stroke One at a Time Lifestyle & Risk Factor Management 2009

2. Learning Objectives Upon completion, participants will be able to: • Explain modifiable & non modifiable risk factors • Support patients to identifying and understand individual risk factors for stroke • Partner with patients & families to develop an individualized plan for risk factor management • Identify strategies to implement Canadian Best Practice Recommendations for Stroke Care in the management of TIA & minor stroke patients in relation to modification of stroke risk factors

3. Outline • Modifiable and non-modifiable risk factors • Risk Factor Management in accordance with the Canadian Best Practice Recommendations for Stroke Care, 2008 • Lifestyle Modification • Blood Pressure • Lipids • Diabetes • Supporting patients to identifying and understand individual risk factors for stroke • Partnering with patients and families to develop an individualized plan for risk factor management

4. Power of Prevention “An ounce of prevention is worth a pound of cure” Benjamin Franklin, 1736

5. Stroke Prevention Determine management options for stroke prevention based on results • Identify risk factors • Determine etiology Medical Interventional Behavioural Medical and Behavioural management must always be part of the stroke prevention plan!!!

6. Risk Factors Hypertension Obesity Atrial Fibrillation Diabetes Cardiac Disease Dyslipidemia Excessive Alcohol Intake Physical Inactivity Smoking Stress Diet Age Gender Family History Ethnicity Previous TIA or Stroke Modifiable Non-Modifiable

7. Medical Conditions Hypertension Dyslipidemia Obesity Diabetes Cardiac Disease Atrial Fibrillation Coronary Artery Disease Behaviours Smoking Alcohol use Physical Inactivity Stress Diet Risk Factors

8. Lifestyle Modification 2.1 Lifestyle and Risk Factor Management Persons at risk of stroke and patients who have had a stroke should be assessed for vascular disease risk factors and lifestyle management issues: Diet, Sodium, Exercise, Weight, Smoking, Alcohol intake They should receive information and counseling about possible strategies to modify their lifestyle and risk factors. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.1

9. Healthy Eating 2.1 i) Healthy balanced diet High in fresh fruits, vegetables, low fat dairy products, dietary and soluble fibre, whole grains and proteins from plant sources and low in saturated fats, cholesterol and sodium in accordance with Canada’s Food Guide to Healthy Eating Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.1

10. Sodium 2.1 ii) Sodium The recommended daily sodium intake from all sources is the Adequate Intake by age. A daily upper consumption limit of 2300mg should not be exceeded by any age group See www.sodium101.ca for sodium intake guidelines. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.1

11. Sodium Recommendations for Adequate Sodium Intake by Age CMAJ 2008;179(12 Suppl):E1-E93 #2.1

12. Sodium Equivalent Measurements of Sodium and Salt http://www.marketwire.com/press-release/Canadian-Stroke-Network-944176.html CMAJ 2008;179(12 Suppl):E1-E93 #2.1

13. Exercise 2.1 iii) Exercise Moderate exercise (an accumulation of 30 to 60 minutes) of walking (ideally brisk walking), jogging, cycling, swimming or other dynamic exercise 4-7 days each week in addition to routine activities of daily living Medically supervised exercise programs are recommended for high risk patients (eg those with cardiac disease) Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.1

14. Exercise Benefits • Better lipid values, especially HDL and TG • Better blood glucose control • Lowers BP • More energy • Lowers stress • Weight control • Improves immune system

15. Weight Prevalence • Obesity doubles the risk for stroke • North Americans are increasingly obese • http://www.cdc.gov/obesity/data/trends.html

16. Weight 2.1 iv) Weight Maintain goal of a body mass index (BMI) of 18.5 to 24.9 kg/m2 and a waist circumference of less than 88 cm for women and less than 102 cm for men. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.1 iv)

17. Weight BMI (index/ranking/risk of co-morbidities) • <18.5=underweight, increased risk • 18.5-24.9=healthy wt, low risk (target) • 25.0-29.9=overweight, increased risk • 30.0-34.9=obesity class 1, high risk • 35.0-39.9=obesity class 2, very high • ≥40=obesity class 3, extremely high

18. Waist Circumference • Waist circumference • < 102 cm for ♂ • < 88 cm for ♀ • http://www.cardiometabolic-risk.org/evaluating-cmr/clinical-tools/waist-circumference-measurement-guidelines/index.html

19. Smoking 2.1 v) Smoking Smoking cessation and smoke free environment; Nicotine replacement therapy and behavioural therapy For nicotine replacement therapy, nortriptyline therapy, nicotine receptor partial agonist therapy and/or behavioural therapy should be considered Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.1 v

20. Smoking

21. Alcohol 2.1 vi) Alcohol Consumption Two or fewer standard drinks per day and fewer than 14 drinks per week for men; and fewer than 9 drinks per week for women Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93.

22. Alcohol • J shaped relationship with ischemic stroke • 1-2 drinks/day = lowest risk • >5 drinks/day = highest risk • Linear relationship with hemorrhagic stroke • Wine associated with reduced risk in ischemic stroke CMAJ 2008;179(12 Suppl):E1-E93.

23. BLOOD PRESSURE

24. High blood pressure is the leading cause of mortality in the world. Prevalence 1 in 5 adult Canadians have hypertension Over 40% of Canadians at aged 56-65 have hypertension 9/10 Canadians will develop HTN in their lifetime 2009 Canadian Hypertension Education Program Recommendations

25. Benefits of Treating Hypertension Younger than 60 (reducing BP 10/5-6 mmHg) reduces the risk of stroke by 42% Older than 60 (reducing BP 15/6 mmHg) reduces incidence of stroke by 35% Lancet 1990;335:827-38 Arch Fam Med 1995;4:943-50 2009 Canadian Hypertension Program Recommendations

26. 2.2a Blood Pressure Assessment Canadian Best Practice Recommendations for Stroke Care, 2008 • All persons at risk for stroke should have their blood pressure measured at each healthcare encounter but no less than once annually. • Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement • Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Education Program. • Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications. CMAJ 2008;179(12 Suppl):E1-E93.

27. 2.2b Blood Pressure Management • The Canadian Stroke Strategy recommends target blood pressure levels as defined by CHEP guidelines for prevention of first stroke, recurrent stroke and other vascular events. • For prevention of first stroke in the general population the systolic blood pressure treatment goal is a pressure level of less than 140 mm Hg • The diastolic blood pressure treatment goal is a pressure level of less than 90 mm Hg • Blood pressure lowering treatment is recommended for patients who have had a stroke or transient ischemic attack to a target of less than 140/90 mm Hg • In patients who have had a stroke, treatment with an angiotensin-converting enzyme (ACE) inhibitor and diuretic is preferred CMAJ 2008;179(12 Suppl):E1-E93.

28. 2.2b cont’d • Blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke in patients with diabetes to attain systolic blood pressures of less than 130 mm Hg and diastolic blood pressures of lower than 80 mm Hg • Blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke in patients with non diabetic chronic kidney disease to attain systolic blood pressures of less than 130 mm Hg and diastolic blood pressures of lower than 80 mm Hg • RCTs have not defined the optimal time to initiate BP lowering therapy after stroke or TIA. It is recommended that blood pressure lowering treatment be initiated (or modified) before discharge from hospital. • For recommendations on specific agents and sequence of agents refer to the current CHEP guidelines www.hypertension.ca/chep

29. Lifestyle Modification Impacts on BP 2009 Canadian Hypertension Education Program Recommendations

30. Take Home Messages • Effective Treatment of High BP to prevent strokes is possible • What else do we need to know as health care professionals? • Proper technique to measure BP • What influences BP readings • Types of HTN • Knowledge of home BP monitoring

31. Lipids Dyslipidemia increases the risk of stroke by contributing to the development of atherosclerosis

32. 2.3a Lipid Assessment Canadian Best Practice Recommendations for Stroke Care, 2008 • Fasting lipid levels (TC,TG,LDL-C,HDL-C) should be measured every 1-3 years for all men 40 years or older and for women who are post menopausal and/or 50 years or older. • More frequent testing should be performed for patients with abnormal values or if treatment is initiated. • Adults at any age should have their blood lipid levels measured if they have a history of diabetes, smoking, hypertension, obesity, ischemic heart disease, renal vascular disease, peripheral vascular disease, ischemic stroke, TIA or symptomatic carotid stenosis. CMAJ 2008;179(12 Suppl):E1-E93 #2.3a

33. 2.3b Lipid Management Canadian Best Practice Recommendations for Stroke Care, 2008 • Ischemic stroke patients with LDL-C >2.0 mmol/L should be managed with lifestyle modification and dietary guidelines. • Statin agents should be prescribed for most patients who have had an ischemic stroke or transient ischemic attack to achieve current recommended lipid levels. CMAJ 2008;179(12 Suppl):E1-E93 #2.3b

34. Diabetes

35. Diabetes • Diabetes contributes to atherosclerosis and diseased arteries • Patients with diabetes have • 1.5-3 fold increase in risk of stroke for diabetics and doubles the risk of stroke recurrence (ischemic more than hemorrhagic) • Worse stroke outcomes • More neurologic and functional disability • Diabetics with metabolic syndrome have an inflated risk of stroke

36. 2.4a Diabetes Assessment Canadian Best Practice Recommendations for Stroke Care, 2008 • All individuals in the general population should be evaluated annually for type 2 diabetes risk on the basis of demographic and clinical criteria. • A fasting plasma glucose (FPG) should be performed every 3 years in individuals >40 years of age to screen for diabetes. More frequent and/or earlier testing with either a fasting plasma glucose or plasma glucose sample dawn 2 hours after a 75-g oral glucose load should be considered in people with additional risk factors for diabetes. CMAJ 2008;179(12 Suppl):E1-E93 #2.4a

37. 2.4a continued In adults, fasting lipid levels (TC, HDL-C, TG, calculated LDL-C) should be measured at the time of diagnosis of diabetes and then every one to three years as clinically indicated. More frequent testing should be performed if treatment for dyslipidemia is initiated. Blood pressure should be measured at every diabetes visit. CMAJ 2008;179(12 Suppl):E1-E93 #2.4a

38. 2.4b Diabetes Management Glycemic targets must be individualized; however therapy in most patients with type 1 or type 2 diabetes should be targeted to achieve a HbA1c <7.0% in order to reduce the risk of microvascular complications. To achieve an HbA1c <7.0%, patients with type 1 or type 2 diabetes should aim for a fasting plasma glucose or preprandial plasma glucose targets of 4.0 to 7.0 mmol/L. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.4b

39. 2.4b continued The 2-hour postprandial plasma glucose target is 5.0–10.0 mmol/L. If HbA1c targets cannot be achieved with a postprandial target of 5.0–10.0 mmol/L, further postprandial blood glucose lowering, to 5.0–8.0 mmol/L, can be considered. Adults at high risk of a vascular event should be treated with a statin to achieve an LDL-Cholesterol ≤2.0 mmol/l. Unless contraindicated, low dose ASA therapy (80-325mg/day) is recommended in all patients with diabetes with evidence of cardiovascular disease as well as for those individuals with atherosclerotic risk factors that increase their likelihood of cardiovascular events. CMAJ 2008;179(12 Suppl):E1-E93 #2.4b

40. Role of Healthcare Professionals in Managing Risk Factors? Providing education and counselling about risk factors, lifestyle management issues 1.2 Patient and family education Education that is integrated and coordinated should be provided in a timely manner across the continuum of stroke care for all patients with stroke or at risk for stroke, as well as their families and caregivers. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.4b

41. How do you measure up in educating your patients and their family members? Ask yourself. Do you…. • Assess readiness? • Cover all aspects of care and recovery pertinent to patient, family and caregiver? • Use interactive, timely, up to date delivery? • Deliver it in the language of choice? • Use a variety of formats? • Have a process for routine education? • Designate team members responsible for provision and documentation?

42. Self Management • Health care providers need to know how to guide and support patients and families with self management • Many concepts to consider to build a foundation for success • Self Management Toolkit: link resources, video clips, etc. to assist the health care provider in the self management journey http://www.selfmanagementtoolkit.ca

43. Role of Stroke Prevention Clinics • Screening, evaluating and triage to ensure appropriate and timely management of patients based risk stratification • Follow-up with education & counselling

44. Finally • We can prevent disabling stoke by 80% with prompt evaluation and urgent treatment (Rothwell et al, Lancet, 2007) • Stroke prevention is multifaceted and needs timely access to stroke specialist care, rapid administration of medication and the availability of ED initiated diagnostic testing within 24 hours for those at highest risk • Patient and family education is essential

45. Canadian Best Practice Recommendations for Stroke Care, updated 2008 www.canadianstrokestrategy.ca