Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk

Background and Purpose— Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods— We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results— The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions— A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00861081.

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Development of the First WHO Guidelines for Risk Reduction of Cognitive Decline and Dementia: Lessons Learned and Future Directions

Frontiers in Neurology ◽

10.3389/fneur.2021.763573 ◽

2021 ◽

Vol 12 ◽

Author(s):

Ruth Stephen ◽

Mariagnese Barbera ◽

Ruth Peters ◽

Nicole Ee ◽

Lidan Zheng ◽

...

Keyword(s):

Risk Factors ◽

Cognitive Decline ◽

Risk Reduction ◽

Individual Risk ◽

Who Guidelines ◽

Dementia Risk ◽

Dementia Prevention ◽

Multidomain Intervention ◽

Intervention Trials ◽

Individual Risk Factors

The first WHO guidelines for risk reduction of cognitive decline and dementia marked an important milestone in the field of dementia prevention. In this paper, we discuss the evidence reviewed as part of the guidelines development and present the main themes emerged from its synthesis, to inform future research and policies on dementia risk reduction. The role of intervention effect-size; the mismatch between observational and intervention-based evidence; the heterogeneity of evidence among intervention trials; the importance of intervention duration; the role of timing of exposure to a certain risk factor and interventions; the relationship between intervention intensity and response; the link between individual risk factors and specific dementia pathologies; and the need for tailored interventions emerged as the main themes. The interaction and clustering of individual risk factors, including genetics, was identified as the overarching theme. The evidence collected indicates that multidomain approaches targeting simultaneously multiple risk factors and tailored at both individual and population level, are likely to be most effective and feasible in dementia risk reduction. The current status of multidomain intervention trials aimed to cognitive impairment/dementia prevention was also briefly reviewed. Primary results were presented focusing on methodological differences and the potential of design harmonization for improving evidence quality. Since multidomain intervention trials address a condition with slow clinical manifestation—like dementia—in a relatively short time frame, the need for surrogate outcomes was also discussed, with a specific focus on the potential utility of dementia risk scores. Finally, we considered how multidomain intervention could be most effectively implemented in a public health context and the implications world-wide for other non-communicable diseases targeting common risk factors, taking into account the limited evidence in low-middle income countries. In conclusion, the evidence from the first WHO guidelines for risk reduction of cognitive decline and dementia indicated that “one size does not fit all,” and multidomain approaches adaptable to different populations and individuals are likely to be the most effective. Harmonization in trial design, the use of appropriate outcome measures, and sustainability in large at-risk populations in the context of other chronic disorders also emerged as key elements.

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What is the effect of interrupting prolonged sitting with frequent bouts of physical activity or standing on first or recurrent stroke risk factors? A scoping review

PLoS ONE ◽

10.1371/journal.pone.0217981 ◽

2019 ◽

Vol 14 (6) ◽

pp. e0217981

Author(s):

Paul Mackie ◽

Ishanka Weerasekara ◽

Gary Crowfoot ◽

Heidi Janssen ◽

Elizabeth Holliday ◽

...

Keyword(s):

Physical Activity ◽

Risk Factors ◽

Scoping Review ◽

Stroke Risk ◽

Recurrent Stroke ◽

Stroke Risk Factors ◽

Prolonged Sitting

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Knowledge of Stroke Risk Factors and Warning Signs in Patients with Recurrent Stroke or Recurrent Transient Ischaemic Attack in Thailand

Neurology Research International ◽

10.1155/2017/8215726 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 7

Author(s):

Jittima Saengsuwan ◽

Pathitta Suangpho ◽

Somsak Tiamkao

Keyword(s):

Risk Factors ◽

Transient Ischaemic Attack ◽

Stroke Risk ◽

Recurrent Stroke ◽

Warning Signs ◽

High Risk Population ◽

Cross Sectional ◽

Stroke Risk Factors ◽

Ischaemic Attack ◽

Structured Interventions

Stroke is a global burden. It is not known whether patients who are most at risk of stroke (recurrent stroke or recurrent transient ischaemic attack) have enough knowledge of stroke risk factors and warning signs. The aim of this study was to assess the knowledge of stroke risk factors and warning signs in this high-risk population. We performed a cross-sectional questionnaire-based study of patients with recurrent stroke or recurrent TIA admitted to Srinagarind Hospital and Khon Kaen Hospital, Thailand. A total of 140 patients were included in the study (age 65.6±11.3 years [mean ± SD], 62 females). Using an open-ended questionnaire, nearly one-third of patients (31.4%) could not name any risk factors for stroke. The most commonly recognized risk factors were hypertension (35%), dyslipidemia (28.6%), and diabetes (22.9%). Regarding stroke warning signs, the most commonly recognized warning signs were sudden unilateral weakness (61.4%), sudden trouble with speaking (25.7%), and sudden trouble with walking, loss of balance, or dizziness (21.4%). Nineteen patients (13.6%) could not identify any warning signs. The results showed that knowledge of stroke obtained from open-ended questionnaires is still unsatisfactory. The healthcare provider should provide structured interventions to increase knowledge and awareness of stroke in these patients.

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Reducing stroke burden through a targeted self-management intervention for reducing stroke risk factors in high-risk Ugandans: A protocol for a randomized controlled trial

PLoS ONE ◽

10.1371/journal.pone.0251662 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0251662

Author(s):

Mark Kaddumukasa ◽

Josephine Najjuma ◽

Scovia Nalugo Mbalinda ◽

Martin N. Kaddumukasa ◽

Jane Nakibuuka ◽

...

Keyword(s):

Risk Factors ◽

Randomized Controlled Trial ◽

Risk Reduction ◽

Stroke Risk ◽

Controlled Trial ◽

Self Management ◽

Primary Study ◽

Management Intervention ◽

Stroke Risk Factors ◽

Randomized Controlled

Introduction Stroke burden is rapidly increasing globally. Modifiable risk factors offer an opportunity to intervene, and targeting hypertension is a key actionable target for stroke risk reduction in sub-Saharan Africa. This 3-site planned randomized controlled trial builds on promising preliminary data. Methods A total of 246 Ugandan adults will be recruited randomized to experimental intervention vs. enhanced treatment control. Intervention participants will receive six weekly group-format stroke risk reduction self-management training sessions, and the controls will receive information on cardiovascular risk. The primary study outcome is systolic B.P. measured at baseline, 13-week, 24 weeks (6 months). Secondary outcomes include other biological and behavioral stroke risk factors. Discussion The curriculum-guided self-management TargetEd MAnageMent Intervention (TEAM) program is anticipated to reduce the stroke burden in Uganda. Trial registration ClinicalTrials.gov identifier: NCT04685408, registered on 28 December 2020.

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A Systematic Literature Review of Patients With Carotid Web and Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.118.021907 ◽

2018 ◽

Vol 49 (12) ◽

pp. 2872-2876 ◽

Cited By ~ 25

Author(s):

Andrew J. Zhang ◽

Parth Dhruv ◽

Philip Choi ◽

Caitlin Bakker ◽

Jonathan Koffel ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Literature Review ◽

Systematic Literature Review ◽

Stroke Risk ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Carotid Revascularization ◽

Stroke Risk Factors ◽

Patient Level

Background and Purpose— Carotid web (CW) is a rare form of focal fibromuscular dysplasia defined as an abnormal shelf-like projection of intimal fibrous tissue into the carotid bulb. It is theorized that CW leads to ischemic stroke secondary to blood flow stasis and subsequent embolization. The natural history and optimal management of CW are unclear. To address this knowledge gap, we performed a systematic literature review (SLR) of CW. Methods— Our librarians performed a SLR for CW and related terminology. Patient-level demographics, stroke risk factors, neuroimaging findings, stroke recurrence or stroke free-duration, and treatment modality were extracted. We used descriptive statistics to characterize our results. When specific patient-level metrics were not reported, the denominators for reporting percentage calculations were adjusted accordingly. Results— Our literature search produced 1150 articles. Thirty-seven articles including 158 patients (median age 46 years [range 16–85], 68% women, 76% symptomatic) met entry criteria and were included in our SLR. Of the symptomatic CW patients: 57% did not have stroke risk factors, 56% who received medical therapy had recurrent stroke (median 12 months, range 0–97), and 72% were ultimately treated with carotid revascularization (50% carotid stenting, 50% carotid endarterectomy). There were no periprocedural complications or recurrent strokes in carotid revascularization patients. Conclusions— CW leads to ischemic stroke in younger patients without conventional stroke risk factors. We found a high stroke recurrence rate in medically managed symptomatic CW patients, whereas carotid revascularization effectively prevented recurrent stroke. Our findings should be interpreted with caution because of risk of publication and reporting bias.

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Sex differences in the risk of recurrent ischemic stroke after ischemic stroke and transient ischemic attack

European Stroke Journal ◽

10.1177/23969873211058568 ◽

2021 ◽

pp. 239698732110585

Author(s):

Elora Basu ◽

Setareh Salehi Omran ◽

Hooman Kamel ◽

Neal S Parikh

Keyword(s):

Risk Factors ◽

Sex Differences ◽

Ischemic Stroke ◽

Stroke Risk ◽

Recurrent Stroke ◽

Minor Stroke ◽

Stroke Recurrence ◽

Stroke Risk Factors ◽

Minor Ischemic Stroke ◽

Using Data

Background Sex differences in stroke outcomes have been noted, but whether this extends to stroke recurrence is unclear. We examined sex differences in recurrent stroke using data from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial. Patients and methods We assessed the risk of recurrent stroke in women compared to men using data from the POINT trial. Adults >18 years old were randomized within 12 hours of onset of minor ischemic stroke or transient ischemic attack (TIA), and followed for up to 90 days for ischemic stroke, our primary outcome. We used Cox proportional hazards model adjusted for demographics and stroke risk factors to evaluate the association between sex and stroke recurrence. We used interaction term testing and prespecified subgroup analyses to determine if the association between sex and recurrent stroke differed by age (<60 versus >60 years old), locale (US versus non-US), and index event type (stroke versus TIA). Last, we evaluated whether sex modified the effect of common stroke risk factors on stroke recurrence. Results Of 4,881 POINT trial participants with minor stroke or high-risk TIA, 2,195 (45%) were women. During the 90-day follow-up period, 267 ischemic strokes occurred; 121 were in women and 146 in men. The cumulative risk of recurrent ischemic stroke was not significantly different among women (5.76%; 95% CI, 4.84%–6.85%) compared to men (5.67%; 95% CI, 4.83%–6.63%). Women were not at a different risk of recurrent ischemic stroke compared to men (hazard ratio [HR], 1.02; 95% CI, 0.80–1.30) in unadjusted models or after adjusting for covariates. However, there was a significant interaction of age with sex (P=0.04). Among patients <60 years old, there was a non-significantly lower risk of recurrent stroke in women compared to men (HR 0.66; 95% CI 0.42–1.05). Last, sex did not modify the association between common stroke risk factors and recurrent stroke risk. Discussion and Conclusion Among patients with minor stroke or TIA, the risk of recurrent ischemic stroke and the impact of common stroke risk factors did not differ between men and women.

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Stroke Risk Factors

CNS Spectrums ◽

10.1017/s1092852900012980 ◽

2000 ◽

Vol 5 (3) ◽

pp. 70-74 ◽

Cited By ~ 5

Author(s):

Stanley Tuhrim

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Cigarette Smoking ◽

Cerebral Infarction ◽

Carotid Stenosis ◽

Stroke Risk ◽

Morbidity And Mortality ◽

Individual Risk ◽

Stroke Risk Factors ◽

The Cost

AbstractDespite advances in the treatment of acute cerebral infarction, the most effective method of reducing stroke morbidity and mortality is the identification and modification of stroke risk factors. Modifiable stroke risk factors include hypertension, atrial fibrillation, hypercholesterolemia, cigarette smoking, hyperhomocystinemia, and carotid stenosis. Improved identification of individuals at increased stroke risk due to these factors can reduce individual risk and the cost to society of the consequences of stroke.

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Quantifying Stroke Risk Factors and Potentials for Risk Reduction

Cerebrovascular Diseases ◽

10.1159/000108743 ◽

1993 ◽

Vol 3 (1) ◽

pp. 7-14 ◽

Cited By ~ 6

Author(s):

Philip A. Wolf ◽

Albert J. Belanger ◽

Ralph B. D'Agostino

Keyword(s):

Risk Factors ◽

Risk Reduction ◽

Stroke Risk ◽

Stroke Risk Factors

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Do Multiple Stroke-Related Educational Opportunities Enhance Stroke Knowledge among Students Enrolled in Communication Sciences and Disorders Programs?

Internet Journal of Allied Health Sciences and Practice ◽

10.46743/1540-580x/2008.1214 ◽

2008 ◽

Author(s):

Kristen Lankford ◽

E. Marshall ◽

Amanda Pittman ◽

Charles Ellis

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Early Warning ◽

Stroke Risk ◽

Warning Signs ◽

Stroke Risk Factors ◽

Early Warning Signs ◽

Multiple Stroke ◽

Level Of Instruction ◽

Stroke Knowledge

Purpose: Stroke education modules have been added to medical school curriculums to improve stroke knowledge in graduate physicians, and this has resulted in positive outcomes. These findings suggest that similar strategies may be successful in graduate programs such as Communication Sciences and Disorders (CSD). The purpose of this study was to examine the impact of multiple stroke-related education opportunities on students enrolled in CSD programs. Methods: Seventy-six first and second year students enrolled in a Communication Sciences and Disorders program completed a survey of stroke risk factors and early warning signs of stroke. Results: Risk factor knowledge - 97% identified smoking as a risk factor; 61% identified diabetes; 90% identified high cholesterol; 84% identified age, and 90% identified physical inactivity. Students varied in their recognition of diabetes as a stroke risk factor based on their level of instruction. Early warning signs and first response knowledge - 83% recognized sudden confusion or trouble speaking; 100% recognized sudden facial, arm or leg weakness; 83% recognized sudden vision loss; 76% recognized sudden trouble walking; and 75% recognized sudden headache as early warning signs of stroke. Seventy-nine percent recognized calling 9-1-1 as the appropriate first action. Students varied in their recognition of sudden trouble walking and severe headache as an early warning sign of stroke based on their level of instruction. Conclusions: Most students recognized individual stroke risk factors and early warning signs, but few recognized multiple risk factors and warning signs. Multiple education opportunities appear to enhance student recognition of risk factors and warning signs.

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