Stroke

We fear stroke more than almost any other illness.  This hasn’t always been the case.  I suppose years ago there were other ailments that were deemed more unwanted—say leprosy or the plague.  But since most of these have been eradicated in the developed world we’re left with a pretty short list of common diseases that afflict our population.

If you have a heart attack and survive to arrive at the emergency room there’s a good likelihood that you’ll leave the hospital alive and do pretty well.  Within a few days or weeks you’ll probably have no residual after-effects except for the handful of pills you have to swallow every day and the annoying cardiologist you have to put up with.  If, on the other hand, the heart attack kills you right away, you will have died the way many people want to go anyway: quickly and without much fuss.

Even cancer, as dreaded as it may be, is mercifully binary.  It either kills you or it doesn’t.  I don’t mean to minimize the turmoil and anguish of such a diagnosis; it’s just that you either succumb to it or you are cured.  Most often, cancer survivors reach a point where their general health returns to such a quality that allows them to move on with their lives and participate in the occasional “race for a cause” 5K.

Stroke is a different story altogether.  One day you’re healthy and functional, the next you’ve been reduced to utter reliance on the assistance of others for nearly all aspects of your previously independent life (at least that’s the conception most people have).  While there are plenty of people who suffer strokes and are left with no impairment or minimal disability, we’ve all known someone whose stroke removed from them the ability to function in the most basic ways: paralysis, weakness, cognitive impairment, or loss of ambulation or speech.

There are times I find myself invoking the specter of stroke when trying to talk a high-risk patient into compliance with their medications.  They’ve already suffered a heart attack and realize that the whole ordeal wasn’t that bad after all.  Yes, I say, but I put you on these medications not just to prevent a heart attack but also because of your high risk of stroke.  The mere suggestion of this dreaded event tends to capture a patient’s attention more than almost anything.

Part of the reason it strikes such visceral fear in us is that stroke, unlike severe cases of cancer, is very survivable.  Not only might you suffer a stroke that severely stymies your physical function, but you might just end up inhabiting your impaired body for years to come.  Heart attacks and cancer don’t typically render their surviving victims with so great a reliance on the service of others or leave them with such functional frustration.

Another reason stroke is so feared is that it appears to be so arbitrary in picking its victims.  Plenty of seemingly healthy people fall prey to stroke without any warning or precursory symptoms.  There’s no stress test to predict stroke, no screening blood test or radiological study—no mammogram or colonoscopy or serum PSA in the world of stroke.  Even the often-touted carotid ultrasound is a poor method of detection.

If you want to avoid alcoholic cirrhosis, just don’t drink alcohol.  Don’t like lung cancer?  Stay away from cigarettes and it’s likely you’ll never get it.  But what do you do if you want to minimize your risk of stroke?

Well, it turns out there’s quite a bit you can do.  An interesting paper was recently published in The Lancet that sheds light on the issue of stroke prevention.  The authors of the INTERSTOKE study assessed dozens of lifestyle and health factors among 3000 stroke victims in 22 different countries in order to determine which variables contribute to the risk of stroke and to what degree.  They found that there are 10 factors that together constitute about 90% of the total risk for stroke, listed here in descending order of importance:

1. Hypertension
2. Smoking
3. Abdominal obesity
4. Poor diet
5. Lack of exercise
6. Alcohol
7. Diabetes
8. Stress and depression
9. Atrial fibrillation
10. Unfavorable lipid profile

The most interesting part about these results is how much of what’s on this list is modifiable.  As a person looking to do all you can to avoid a stroke, it is completely in your control whether or not you suffer from at least 5 of these: hypertension, smoking, obesity, poor diet, and lack of exercise.   As pointed out in a nice summary on Medpage Today, these five risk factors alone account for 80% of the risk profile for stroke.  In other words, stroke may not be quite so arbitrary after all.

Hypertension is simple to detect and rather easily treated.  We are fortunate to live in a time when numerous highly effective and yet remarkably inexpensive medications are available for this problem.  As I’ve pointed out previously, most patients should be able to get their blood pressure under control using nothing but generic drugs and suffer no significant side effects along the way.

Smoking cessation, while not easy, results in almost immediate benefit.  The INTERSTROKE study found that ex-smokers had a risk reduction that was similar to life-long nonsmokers.  Obesity—the scourge of modern America—is absolutely under the conscious control of most people.  Of course, in the age of fast food, sugary drinks and wide-screen TVs, weight control takes real dedication.

This study reinforced the need for good dietary and exercise habits.  As pointed out on Medpage Today: “Eating more red meat, organ meats, or eggs came with a 35% increased risk of stroke, more fried foods, pizza, or salty snacks carried a 16% increased risk, and cooking with lard made stroke risk rocket to 66%.”  Regular physical exercise decreased stroke by 35%.

In summary, there’s probably nothing we can do that will make stroke a less ominous specter, but no longer should we believe there is nothing we can do to ward off this eventuality.  Studies like these show us that our fate can be in our own hands and that we might be able to someday retire the diagnosis of stroke to the medical history books—right next to leprosy and plague.