primordial, primary, secondary, and tertiary prevention stages for global vascular risk. r. sacco:...
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Bruce M. Coull, MDVice Dean College of MedicineThe University of Arizona
Stroke and TIA: Neurovascular Disease
Prevention
Primordial, primary, secondary, and tertiary prevention stages for global vascular risk.
R. Sacco: Stroke, Volume 38(6).June 2007.1980-1987
Neurovascular Disease
Epidemiology 50% Ischemic stroke, 30% ICH, 20% SAH
Causes/ Pathophysiology Ethnic Issues
Biology Sociology
Epidemiology Worldwide Incidence per100,000 persons/yr; age < 50 yrs Israel 10.4 Northern Italy 13.6 Spain 13.9 South Africa 33.0 UK women 3.6
Bradley S. Jacobs et al. Stroke 33: 2789-2793, 2002
ATHEROTHROMBOSIS
Risk Factors and Predictors of Stroke
• Older age• Male gender• Non-white genetic background• Family history• Prior stroke or TIA
Non-modifiable risk factors Modifiable risk factors
Previous TIA or stroke is the most importantrisk factor for stroke.
Hypertension is the most prevalent.
Hankey GJ. Cerebrovasc Dis 2003; 16 (Suppl 1): 14–19.Wolf PA. Adv Neurol 2003; 92: 165–172.
Sacco et al. Stroke 1997; 28 (7): 1507–1517.
• Hypertension• Diabetes mellitus• Atrial fibrillation • Carotid artery disease• Dyslipidemia• Cardiac disease• Cigarette smoking• Obesity• Obstructive Sleep Apnea
Problem!Hispanics have higher prevalence of:
ObesityDiabetes MellitusHypertensionHyperlipidemia
67.1
35.4
30.1
28.3
26
14.5
11.6
4.6
1.7
0 10 20 30 40 50 60 70 80 90 100
Hypertension
Dyslipidemia
Diabetes
Prior Stroke/TIA
CAD/MI
Atrial Fibrillation
Smoking
Carotid Disease
Peripheral Vascular Disease
Percentage of Patients
Prevalence of Identified Risk Factors on Admission to UMC
African-American 45-59 4.06 3.22
60-74 2.57 2.31
75+ 1.26 1.10
Hispanic American 45-59 1.73 1.30
60-74 1.09 1.07
75+ 0.77 0.63
Age Men Women
STROKE IN MINORITIESSurvey of Stroke Mortality in Texas
Rate-Ratio in Comparison to Non-Hispanic Whites
Morgenstern et alStroke, 1997, 28:5-18
Stroke Subtypes in the NOMASS Study
F. Rincon et al Cerebrovascular Diseases 2009; 28:65-71.
NOMASS Study
F. Rincon et al Cerebrovascular Diseases 2009; 28:65-71.
NOMASS Study
Secondary Stroke Prevention
Problem!Individuals living in the Hispanic Community:
Do not know stroke warning symptoms/ signsDo not come to the ED quicklyHave less “technical” evaluations
Hypertension
SBP
DBPn=347,978
Diastolic BP
Systolic BP
<70 70-74 75-79 80-84 85-89 90-94 95-99 100+<110 110-119 120-129 130-139 140-149 150-159 160+
mm Hg
5
4
3
2
1
0
Ad
jus
ted
Re
lati
ve
Ris
k
Adjusted Relative Risk of Cardiovascular MortalityAccording to BP in Men Screened for MRFIT
MRFIT, Multiple Risk Factor Intervention TrialArch Intern Med. 1993;153:186.
“new” Risk Factors for stroke
Abdominal Obesity Lack of Exercise Poor Diet Too Little Alcohol Too Much Alcohol Psychosocial Stress Impoverishment
Genetic Inflammation Infectious PFO Insulin Resistance Homocysteinemia Thrombophilias
Cavernous Malformation
Cavernous Malformation
Prevalence 0.1 to 0.5% CCM1 – 7q21-q22 CCM2 – 7p13-p15 CCM3 – 3q25.2-q27
CCM1 - krit1: krev interaction trapped 1 protein
CCM2-CCM2 (malcavernin) CCM3-PDCD10
Re-Search: To Look Again
Santiago Ramon y Cajal
Primordial, primary, secondary, and tertiary prevention stages for global vascular risk.
R. Sacco: Stroke, Volume 38(6).June 2007.1980-1987
Diet and Exercise
Lipid Levels in Patients Hospitalized with Coronary Artery Disease
n = 136,905
Amit Sachdeva et. al. Am Heart J 2009;157:111-7.e2
JUPITER: Cumulative Incidence of Cardiovascular Events
NEJM 2008;359:2195-2207
hsCRP
JUPITER: Effects of Rosuvastatin on Primary End Point by baseline
NEJM 2008;359:2195-2207
Primary Endpoints:MIStrokeCVDUnstable AnginaRevascularization
Hansson et al. Nature Reviews Immunology 6, 508-519 (July 2006) | doi:10.1038/nri1882
Atherothrombosis