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How to avoid a stroke: New guidelines

Consumer Reports on Health: May 2011

About every 40 seconds, someone in the U.S. suffers a stroke, and more than 77 percent are first events. Although deaths due to strokes have declined, a stroke—caused by the sudden loss of blood flow to the brain or bleeding in or around the brain, either of which can cause brain cells to die—still has a staggering impact upon lives. Now, new guidelines from the American Heart Association and the American Stroke Association offer updated advice for preventing a first stroke.

"We still have quite a ways to go toward controlling stroke risk factors," says Larry B. Goldstein, M.D., chairman of the group of experts who wrote the new stroke prevention guidelines and director of the Duke Stroke Center in Durham, N.C. "More than two-thirds of adults are overweight or obese and don't get adequate exercise, and only about 7 percent of people age 40 to 59 succeed in meeting the goals for four major cardiovascular risk factors—cholesterol, blood pressure, fasting blood sugar, and smoking."

The guidelines, released online in December 2010, incorporate the latest research and advances in stroke prevention. Here are 11 effective strategies, including medical tactics to take and lifestyle adjustments to make.

Medical changes

1. Lower your blood pressure
High blood pressure damages arteries so they clog or burst more easily, escalating the risks of both types of stroke: ischemic, caused by blockage of a blood vessel that supplies part of the brain; and hemorrhagic, the less common but deadlier stroke that occurs when a blood vessel bursts inside the brain. Treatment to lower blood pressure, including lifestyle changes and medication, can reduce those risks by a third.

Recommendations: Have your blood pressure checked at least once every two years and more often if you're 50 or older. If your reading is high-normal—above 120/80 millimeters of mercury (mmHg) but below 140/90 mmHg, the cutoff for hypertension—try to lower it by adopting the lifestyle changes listed below. People with blood pressure below 120/80 mmHg have about half the lifetime stroke risk of those with hypertension. If your reading is 140/90 mmHg or higher, talk with your doctor about adding an antihypertensive drug.

Many people start with thiazide diuretics, which are safe, effective, and available as low-cost generics. People with certain health problems shouldn't take thiazide diuretics, so they might need different drugs to lower their blood pressure.

2. Improve cholesterol levels
LDL (bad) cholesterol, a fatty substance in the blood, builds up plaque on artery walls, causing arteries to narrow. If plaque ruptures, a blood clot can form and block a blood vessel to the brain, causing a stroke. In a 2004 analysis of trials including more than 90,000 people with heart disease or other risk factors like diabetes or high blood pressure, the reduction of LDL cholesterol with the use of statin drugs cut stroke risk by about 21 percent and reduced plaque buildup in the neck arteries that carry blood to the brain.

Recommendations: Men 35 and older should get a complete lipid profile—which measures LDL (low-density lipoprotein) and HDL (high-density lipoprotein) cholesterol levels, as well as triglycerides, an artery clogging fat—at least every five years. Women 45 and older should, too, if they're at high risk of heart disease because of other risk factors like being a smoker or having a diabetes. (To determine your risk, use our calculator.) People younger than that should also consider testing, though the benefits for them are less certain, especially if they are female or are otherwise healthy and at low risk of heart disease.

To lower cholesterol, start with exercise, weight control, and a diet minimizing saturated fat and cholesterol. Avoid trans fats in processed foods containing partially hydrogenated oils. If those measures aren't sufficient, ask your doctor about adding a statin medication.

3. Rein in diabetes
High blood sugar levels damage blood vessels over time. In addition, people with diabetes are likely to have hypertension, high cholesterol, and excess weight. All told, diabetes increases the risk of ischemic strokes from 1.8-fold to nearly six-fold. While improved blood sugar control reduces diabetes-related complications of the eyes, nerves, and kidneys, it hasn't been shown to lower stroke risk. But aggressive lowering of blood pressure and the use of statins, when needed, by people with diabetes can reduce risk. Evidence has shown that strict blood-pressure control reduced the chance of a stroke by 44 percent. And statin use has been shown to reduce stroke risk by 48 percent among type 2 diabetics.

Recommendations: Adults who are at high risk for diabetes should have their blood sugar level measured at least every three to five years. That includes people with a personal history of heart attack, stroke, or heart disease, as well as those with any of these coronary-risk factors: blood pressure over 135/80 mmHg; obesity (with a body mass index of 30 or over); or an LDL level over 130 mg/dL. Adults without those risks should also consider screening, though the benefits for them are less certain.

If you have diabetes, keep your blood pressure below 130/80 mmHg with lifestyle approaches and medication if needed. An ACE inhibitor or angiotensin receptor blocker (ARB) is useful because those antihypertensive drugs slow the progression of kidney disease in people with diabetes. In addition, try lowering your LDL cholesterol to below 100 mg/dL. The use of a statin is recommended, especially if you have additional risk factors.

4. Consider low-dose aspirin
Aspirin wards off heart attack and stroke by preventing artery-blocking blood clots. But it's not for everyone, mainly because it can cause dangerous gastrointestinal bleeding. Still, research suggests that only 20 percent of the women and 14 percent of the men who should be taking it are.

Recommendations: People of any age who are at very high risk of a stroke should almost always take aspirin to protect their heart. That includes those who have already had a stroke or ministroke and those who have heart disease or diabetes.

Aspirin can also help prevent first strokes in women between 55 and 79 without that history, if they're at increased stroke risk based on such factors as blood pressure and cholesterol levels and smoking status. (Men are also often candidates for low-dose aspirin, based on the same factors, but to prevent heart attacks, not strokes.) To help determine your risk, talk with a doctor and use our heart attack and stroke risk calculator. Regardless of gender, the therapy should be limited to those who are not at increased risk of gastrointestinal bleeding. For men and women 80 and older, there's still not enough evidence to know for certain whether aspirin helps or not, so talk with a doctor to see if it might make sense in your case. See our other tips on taking low-dose aspirin.

5. Have your pulse checked
Atrial fibrillation, a heart-rhythm disorder, can lead to blood clots that can travel to the brain, amplifying the risk of an ischemic stroke. The blood thinner warfarin (Coumadin and generic) reduces that risk by 64 percent yet might be underprescribed. Seniors often benefit substantially from the drug, according to the stroke prevention guidelines. A new blood thinner, dabigatran (Pradaxa), at a dose of 150 mg twice daily was associated with fewer strokes than warfarin but had a similar risk of major bleeding and a higher rate of gastrointestinal bleeding and heart attacks, according to a trial published in 2009 and supported by the drugmaker. Its long-term safety is unknown. It costs about $230 a month vs. up to $70 a month for Coumadin or the cheaper generic plus the cost of regular testing to monitor the drug's effects.

Recommendations: Your doctor should check your pulse for irregular rhythms at every visit and follow up with an electrocardiogram or other heart monitoring if necessary. People over age 65 are at heightened risk for atrial fibrillation and should be carefully checked. People with atrial fibrillation and a low stroke risk should talk with their doctor about taking aspirin, and those at moderate risk should weigh the risks and benefits of warfarin vs. aspirin. Those with atrial fibrillation plus multiple risk factors usually require warfarin; dabigatran could now be a reasonable alternative.

6. Neck surgery: Think twice
If either of the two carotid arteries, located on each side of the neck, becomes clogged, a stroke can result. People with severe carotid narrowing that has caused a stroke or transient ischemic attack (TIA)—a strokelike episode that doesn't cause permanent damage—are at high risk for a second stroke, and surgery to scrape out the blockage significantly reduces that risk. But those with a narrowed carotid artery that hasn't triggered symptoms are at much lower risk, and the benefit of surgery is small. "With advances in medical treatment—including lifestyle changes and medication—the risk of stroke in those patients has fallen to one-half to 1 percent a year or less," Goldstein says. "By adding surgery, you're maybe making a tiny number tinier. That has to be balanced against the risks of the procedure." Risks include strokes or death at a rate of 3 percent and higher.

Recommendations: Screening for clogged neck arteries is not recommended for people without stroke risk factors because it generates many false-positive test results that can lead to further testing with angiography, which carries a small risk of triggering a stroke, or to unnecessary surgery. You should be screened and treated for other stroke risk factors. Surgery might be considered for certain people without symptoms who have significant carotid narrowing depending on their life expectancy and other overall health problems. For those who are unable to undergo surgery, doctors can insert a tiny balloon to crush the blockage and a stent to prop the artery open.

Lifestyle changes

People who adopt a healthy lifestyle might lower their risk of a first stroke by 80 percent-an impact unmatched by any drug. Here's what you need to do.

7. Follow a brain-healthy diet
What you eat affects your risk of stroke. In a study that assessed people's consumption of fruits and vegetables, each extra daily serving reduced stroke risk by 6 percent. Other studies have linked high-potassium diets with lower stroke risk, while sodium-heavy diets are tied to greater risk. The Dietary Approaches to Stop Hypertension (DASH) diet stresses potassium-rich fruits and vegetables, low-fat dairy, and limited sodium and saturated fat. In a 24-year study of about 88,000 middle-age women, those who closely followed the diet cut their stroke risk by 18 percent compared with those who didn't.

Recommendations: Though it can be difficult, try to consume no more than 1,500 milligrams of sodium (roughly two-thirds teaspoon of table salt) a day, the maximum recommended by the American Heart Association. Research suggests that most Americans greatly exceed that amount. In addition, most people need to get more potassium by substituting fruit, vegetables, and natural juices for low-potassium processed foods and sodas. A DASH-style diet is recommended, too. Check out the DASH diet or call the National Heart, Lung, and Blood Institute at 301-592-8573.

8. Make a move
Adults who are physically active generally have a 25 percent to 30 percent lower risk of strokes or death than the least active people. Physical activity reduces blood pressure, controls diabetes and weight, improves cholesterol levels, and helps prevent harmful clots.

Recommendations: Do at least 30 minutes of moderate-intensity aerobic exercise—such as brisk walking or cycling—five days a week and preferably daily. Add strength training two days a week for additional benefits. Consult a physician first if you have a chronic health problem, chest pain, or if you're middle-aged or older and have been sedentary.

9. Trim your waist
Excess fat, especially around your abdomen, raises blood pressure, LDL (bad) cholesterol levels, and the risk of type 2 diabetes. In a 2009 analysis of 900,000 adults, each additional five points in body mass index (BMI) was associated with a 40 percent increased risk of death from strokes among people who were overweight (a BMI of 25 to 29.9) or obese (a BMI of 30 or greater). A loss of just 11 pounds significantly reduced the predominant stroke risk factor—high blood pressure—in an analysis of 25 trials.

Recommendations: To determine your BMI, multiply your weight in pounds by 703, then divide by your height, in inches, squared. Or use the online calculator. If your BMI is 25 or higher or your waist measures more than 40 inches (for men) or 35 inches (for women), commit to regular exercise and a weight-loss diet such as the DASH plan.

10. Drink moderately, if at all
Excessive drinking, associated with a 64 percent elevated risk of stroke, raises blood pressure, promotes clot formation, and increases the risk of atrial fibrillation. Recent data indicate that stroke risk is highest right after binge drinking, typically defined as five or more drinks in about two hours for men and four or more for women. But light drinking appears to reduce stroke risk.

Recommendations: Limit alcohol to no more than two drinks a day if you're a man and one if you're a woman. If you don't drink, there's no need to start to protect against stroke.

11. Quit smoking
Cigarette smoking raises blood pressure, decreases exercise tolerance, promotes plaque buildup in arteries, and makes blood more likely to clot. It roughly doubles the risk of ischemic strokes and triples the likelihood of a type of hemorrhagic stroke. Studies now find that secondhand smoke also boosts stroke risk. When smokers quit, their stroke risk is cut in half within a year and falls to a nonsmoker's risk after five years.

Recommendations: If you smoke, talk with your doctor about quitting. Options include counseling, nicotine replacement, and other medication.

F.A.S.T.: Stroke symptoms

Immediately call 911—which can result in faster treatment than driving someone to an emergency room—if any of these stroke symptoms strike suddenly:


FACE: Ask the person to smile. Does one side of the face droop?


ARMS: Ask the person to raise both arms. Does one arm drift downward?


SPEECH: Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?


TIME: If you observe any of these signs, call 911 immediately.


Rethinking stroke therapy: Use it or lose it

Until recently scientists thought that when a region of the brain was damaged, its function was lost forever. Stroke patients who couldn't use an injured arm were taught to dress and bathe with their good arm.

But sophisticated imaging tests of the brain at work have since revealed that it can reorganize itself after injury so that when nerve cells die, their functions are taken over by other cells.

The incredible, plastic brain

That concept—known as neuroplasticity—has altered stroke therapy considerably. "Now we know that if you want to get motor recovery on the affected side, you have to use the affected side—repetitively and intensively," says Richard Zorowitz, M.D., chief of physical medicine and rehabilitation at the Johns Hopkins Bayview Medical Center in Baltimore, Md. "That stimulates the brain to make those new connections."

Neuroplasticity is the principle behind mirror therapy (see photo), as well as several other new technologies. Those include electrical stimulation of the damaged limb and robots that help patients repeatedly move those limbs.

Restrain yourself

Some rehab therapists are also using constraint-induced movement therapy (CIMT), an increasingly popular approach that forces the use of a patient's impaired limb—usually an arm—by restraining the unaffected one.

In a 2006 trial funded by the National Institutes of Health (NIH), 222 stroke patients were randomly assigned the usual care or CIMT, in which they wore a restraining mitt on their good hand most of the day for two weeks, and did repetitive tasks with their affected hand for up to six hours a day. People in the CIMT group made significantly greater gains in arm movement that persisted a year later, the researchers found.

While CIMT is most effective when it's started soon after a stroke, it can even help patients who had strokes years earlier. A study of people who had the stroke therapy more than four years after their attack, for example, found that it not only improved the use of their weak arm but also doubled the amount of activity in the region of the brain that controls its movement.

Other rehab programs

Here are several other approaches now available at some stroke therapy centers:

Attention training. Many stroke survivors experience shortened attention spans that reduce their ability to relearn skills. A 2009 study from New Zealand found that patients enrolled in a four-week program designed to improve their ability to maintain their focus showed significant improvements in attention compared with those who received standard care.

Depression treatment. Depression is a commonly underdiagnosed complication after a stroke, and untreated patients have a poorer response to rehabilitation. A 2009 study, funded by the NIH, found that depressed stroke patients who received counseling for eight weeks along with antidepressant medications were significantly less depressed than those who received only medication. Many in-patient rehabilitation facilities have psychologists on staff who are trained to identify, treat, and monitor depression in stroke patients.

Fall prevention. Stroke patients are prone to falls and bone loss, and a 2009 Dutch study found that they had twice the risk of breaking a hip or thigh bone. Exercises to improve balance, however, may reduce that risk. For example, stroke survivors who took a 12-week tai chi class did better on tests of balance than those who performed breathing and stretching exercises, according to a 2009 study from Hong Kong. If you take a tai chi class, inform the instructor of your physical limitations.

Music therapy. Music stimulates the brain, research shows. Stroke patients who listened to their favorite tunes daily during the first two months of recovery showed improved verbal memory, attention, and mood compared with patients who received audio books or no listening materials, a 2008 Finnish study found.

For a list of accredited stroke rehab centers, send an e-mail request to the Commission on Accreditation of Rehabilitation Facilities (medical@CARF.org). Include your city and state, and whether you need an inpatient, outpatient, in-home, or adult-day program. Some programs and therapies may not be covered by your insurance, so check your plan.

   

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