Questions on Strokes

Dear Dr. Spence,
I had a stroke last year and I am terrified at the thought of having another, more severe one? What can I do to prevent this from happening?

Signed,
Terrified Joe

Dear Joe,
There are approximately 700,000 strokes per year in the United States of which nearly 1/3 are recurrent. Fourteen percent of those with a new stroke will go on to have another and 270,000 people die annually from stroke and its complications.

The most important initial step is a basic evaluation for possible risks and causes. Most patients will undergo heart ultrasounds (echocardiograms), EKGs (electrocardiograms) to rule out abnormal heart rhythms and carotid ultrasounds to evaluate for blockages. Assuming these have all been done and are normal, the next step is modifying those risks that you may have. Though I cannot comment on your individual risks, I generally assess five potential problem areas.

(1) Hypertension – Studies have consistently shown a decreased risk of stroke with improvement in blood pressure. A goal of 140/90 or less is recommended but I strive for 120-130/60-80 if possible. The best medication appears to be an ACE inhibitor like lisinopril combined with simple diuretics like HCTZ or chlorthalidone

(2) Diabetes – Control of blood sugars has never truly been proven to reduce the risk of stroke but diabetics do need close monitoring and aggressive treatment. Not to overemphasize the blood pressure issue, diabetics are encouraged to maintain pressures less than 130/80.

(3) Cholesterol – High cholesterol remains a very modifiable risk factor. Bad cholesterol (LDL) should be decreased to below 100 in most, or less than 80 if the patient has cardiovascular disease. I tend to use statins (lipitor, zocor, etc.) even when patients have reasonably normal LDL readings as the data suggests additional benefits from these medications beyond LDL lowering. Recent studies with lipitor have shown that 52 patients would need to be treated for five years to prevent one stroke or 29 to prevent one heart attack.

(4) Lifestyle – Smokers need to quit, alcohol use needs to decrease and exercise needs to be implemented to assist with weight loss and general health. Enough said!

(5) Blood thinners – I recommend aspirin at a dose of 81 mg per day for most patients. Other drugs are on the market but most do not provide any additional protection when compared to their potential adverse effects and cost. Aggrenox may be a better overall agent but can be cost prohibitive.

Of course, strokes are not entirely preventable regardless of our interventions, but we certainly can intervene to decrease the overall likelihood.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.