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Bruce M. Coull, MDVice Dean College of MedicineThe University of Arizona
Stroke and TIA: Neurovascular Disease
Prevention
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Primordial, primary, secondary, and tertiary prevention stages for global vascular risk.
R. Sacco: Stroke, Volume 38(6).June 2007.1980-1987
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Neurovascular Disease
Epidemiology 50% Ischemic stroke, 30% ICH, 20% SAH
Causes/ Pathophysiology Ethnic Issues
Biology Sociology
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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
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ATHEROTHROMBOSIS
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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
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Problem!Hispanics have higher prevalence of:
ObesityDiabetes MellitusHypertensionHyperlipidemia
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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
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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
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Stroke Subtypes in the NOMASS Study
F. Rincon et al Cerebrovascular Diseases 2009; 28:65-71.
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NOMASS Study
F. Rincon et al Cerebrovascular Diseases 2009; 28:65-71.
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NOMASS Study
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Secondary Stroke Prevention
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Problem!Individuals living in the Hispanic Community:
Do not know stroke warning symptoms/ signsDo not come to the ED quicklyHave less “technical” evaluations
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Hypertension
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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.
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“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
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Cavernous Malformation
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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
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Re-Search: To Look Again
Santiago Ramon y Cajal
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Primordial, primary, secondary, and tertiary prevention stages for global vascular risk.
R. Sacco: Stroke, Volume 38(6).June 2007.1980-1987
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Diet and Exercise
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Lipid Levels in Patients Hospitalized with Coronary Artery Disease
n = 136,905
Amit Sachdeva et. al. Am Heart J 2009;157:111-7.e2
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JUPITER: Cumulative Incidence of Cardiovascular Events
NEJM 2008;359:2195-2207
hsCRP
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JUPITER: Effects of Rosuvastatin on Primary End Point by baseline
NEJM 2008;359:2195-2207
Primary Endpoints:MIStrokeCVDUnstable AnginaRevascularization
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Hansson et al. Nature Reviews Immunology 6, 508-519 (July 2006) | doi:10.1038/nri1882
Atherothrombosis