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