Breaking Health News, June 22, 2005

First Stroke May Be Followed by a Second Stroke

Persons who have had a minor stroke have a 43 percent risk of another potentially fatal stroke within 10 years, researchers report in the medical journal The Lancet

While deaths from cerebrovascular disease have dropped around the world, stroke remains a serious neurological problem, leaving many patients with a chronic disability.

After either a stroke or transient ischemic attack (TIA), secondary stroke prevention is standard practice. But many patients have a recurrent stroke or other vascular complications, the study authors say.

"The risk for a vascular event is very high in these people," says Dr. Ale Algra, of the Julius Centre for Health Sciences and Primary Care at the University Medical Centre Utrecht.

Stroke is the third largest cause of death, behind heart disease and all forms of cancer. Strokes kill more than 163,500 Americans each year. About 4.8 million US adults live today with the effects of a stroke.

Ten-Year Study Conclusive, Researchers Say

In their study, Dr. Algra and his colleagues collected data on 2,447 patients who had experienced either a minor stroke or a TIA - a sudden or a temporary loss of blood flow to an area of the brain, usually lasting less than five minutes but not longer than 24 hours, with complete recovery. These patients had participated in the Dutch TIA Trial.

After a follow-up of 10.1 years, 60 percent of the patients had died and 54 percent had experienced at least one vascular event. This is twice as many deaths as would be seen in the general population, Dr. Algra notes.

The 10-year risk of death was 42.7 percent, Dr. Algra says.

The risk of a vascular event was highest shortly after the stroke, reached its lowest point about three years later, and then gradually rose again, the researchers explain.

Given these findings, Dr. Algra believes more emphasis should placed on preventing second strokes.

"People should pay attention to secondary prevention," he says. "This includes lifestyle, as well as drug therapy."

In terms of lifestyle, Dr. Algra suggests exercising, eating a healthy diet, and not smoking. In addition, physicians should encourage patients to keep their blood pressure and cholesterol low and prescribe aspirin or other medications to prevent blood from clotting in the small arteries.

"All these measures together may decrease the risks of new vascular events," he says.

Experts Agree Prevention Step Should Be Taken

One expert agrees that secondary prevention after a minor stroke is often overlooked. "This study makes us say 'Holy moly, these early risks of recurrence are very high,'" says Dr. Lawrence M. Brass, a professor of neurology and epidemiology and public health at Yale University School of Medicine.

For the medical community, Dr. Brass thinks this study sends a strong message that secondary stroke prevention needs to be a priority.

"Often the approach of many physicians is, 'You've had a TIA. Let's put you on an aspirin and send you on your way,'" he says. "This data indicates that half these people are going to be dead in five years, and a similar portion may have another stroke. You've really got to do more than just this."

Dr. Brass notes there are many things physicians can do that are often not done to help prevent second, fatal strokes, such as monitoring blood pressure and cholesterol.

"This is a real wake-up call," Dr. Brass says.

Patients, too, can play a role in preventing the recurrence of stroke, Dr. Brass says. "Patients should know what their risk is, and know what they and their doctors are doing about it," he says.

"People need to realize that heart attack and stroke are going to kill me, not dirt on the oranges or something else," Dr. Brass says.

"You need to be an active advocate and say to your doctor, 'What are my risks for heart attack and stroke? What are we doing to prevent it? What more can we do to prevent it?'" Dr. Brass emphasizes.

Always consult your physician for more information.

Online Resources

(These links are provided for the education and convenience of our Neighbors. AAMC is not responsible for the content of Internet sites.)

American Heart Association

American Stroke Association

Centers for Disease Control and Prevention (CDC)

Heart and Stroke Encyclopedia

National Institute for Neurological Disorders and Stroke (NINDS)

National Institutes of Health (NIH)

National Library of Medicine

National Stroke Association

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Risk Factors for Stroke

Evaluating the risk for stroke is based on heredity, natural processes, and lifestyle. Many risk factors for stroke can be changed or managed, while others that relate to hereditary or natural processes cannot be changed.

Risk factors for stroke that can be changed, treated, or medically managed:

high blood pressure
The most important controllable risk factor for brain attack is controlling high blood pressure.

heart disease
Heart disease is the second most important risk factor for stroke, and is the major cause of death among survivors of stroke.

diabetes mellitus
Diabetes is treatable, but having it increases the risk for stroke.

cigarette smoking
The use of cigarettes, especially when combined with oral contraceptives, greatly increases stroke risk.

history of transient ischemic attacks (TIAs)
A person who has had one (or more) TIA is almost 10 times more likely to have a stroke than someone of the same age and sex who has not had a TIA.

high red blood cell count
A moderate increase in the number of red blood cells thickens the blood and makes clots more likely, thus increasing the risk for stroke. Smoking and high altitudes can cause a high red blood cell count.

high blood cholesterol and lipids
High blood cholesterol and lipids increase the risk for stroke.

lack of exercise, physical inactivity
Lack of exercise and physical inactivity increases the risk for stroke.

obesity
Excess weight increases the risk for stroke.

excessive alcohol use
More than two drinks per day raises blood pressure, and binge drinking can lead to stroke.

drug abuse (certain kinds)
Intravenous drug abuse carries a high risk of stroke from cerebral embolisms (blood clots). Cocaine use has been closely related to strokes, heart attacks, and a variety of other cardiovascular complications. Some of these complications, even among first-time cocaine users, have been fatal

abnormal heart rhythm
Various cardiac diseases have been shown to increase the risk of stroke. Atrial fibrillation (a type of arrhythmia in which the atria, the two upper chambers of the heart, quiver rather than contract) is the most powerful and treatable cardiac precursor of stroke.

cardiac structural abnormalities
New evidence shows that cardiac structure abnormalities including patent foramen ovale (a hole between the right and left atria, present in all unborn children, that remains open after birth for variable periods of time) and atrial septal aneurysm (a bulging spot in the wall between the two atria) increase risk for embolic stroke.

Risk factors for stroke that cannot be changed:

age
For each decade of life after age 55, the chance of having a stroke more than doubles.

race
African Americans have a much higher risk of death and disability from a stroke than Caucasians, in part because the African-American population has a greater incidence of high blood pressure.

diabetes
Diabetes is strongly linked with high blood pressure and, although diabetes is a treatable condition, increases a person's risk for stroke.

history of prior stroke
The risk of stroke for someone who has already had one is about 10 times that of a person who has not had a stroke.

heredity/genetics
The chance of stroke is greater in people who have a family history of stroke.

Always consult your physician for a diagnosis.