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Dr. Richard T. Benson

We all know the stats. Stroke is the third leading cause of death in America and the number one cause of disability. The southeastern United States is known as “The Stroke Belt.” Approximately 780,000 Americans suffer a new or recurrent stroke each year — on average, that’s one stroke every 45 seconds. About every three minutes, someone dies of stroke. In 2008, it is estimated that the direct and indirect cost of stroke will be $65.5 billion.

Clearly, organizations and agencies with a vested interest in brain attack — the American Stroke Association (a division of the American Heart Association), National Institute of Neurological Disorders and Stroke, National Heart, Lung and Blood Institute, and others — have done a good job of making the public aware of the dangers of stroke. So why hasn’t awareness translated into much better outcomes?

To be fair, mortality data recently reported by the Centers for Disease Control and Prevention show age-adjusted death rates for stroke are actually down nearly 25 percent since 1999, which means the AHA is on the brink of achieving one of its 2010 strategic targets. Unfortunately, the other goal — to reduce risk factors by 25 percent by 2010 — isn’t going nearly as well. In fact, several risk factors are on the rise.

Dr. Dan Jones, president of the AHA, said the current victory could be “short lived” if risk factors aren’t successfully addressed. As a matter of fact, he noted death rates could once again begin to rise if providers and patients don’t find a way to reduce known risks and eliminate disparities in care.

As with many clinical conundrums, there isn’t one straightforward answer as to why so many people still suffer stroke and debilitation. There are multiple risk factors for stroke, but those that can be modified typically involve deeply engrained behaviors. The only FDA-approved drug to treat ischemic stroke –– tissue plasminogen activator (tPA) –– is quite effective but only if a patient presents within three hours of onset of symptoms. Other attempts to reverse neurological damage have not met with great success so far.

“I’ve worked on a lot of failed neuro-protective stroke trials,” Dr. Richard Benson, program director for the Office of Minority Health and Research at NINDS, said ruefully. “After you’ve damaged the brain or developed pathologies in the heart, brain or body, it’s difficult to find ways to repair the body. Most people who have a stroke will end up having some type of deficit.”

The stroke researcher and clinician continued, “We’ve realized the best way of treating certain diseases is to prevent them from occurring.”

Therefore, he said, there is a growing movement towards funding more aggressive measures focused on prevention. Although people seem to know the main statistics on stroke, that knowledge has not translated into action. “So the message clearly isn’t getting out to prevent these things from happening,” he noted.

He hopes to see more funding for prevention to really concentrate on risk factors that can be mitigated or eliminated.

“The risk factors for stroke are divided into non-modifiable risk factors and modifiable risk factors,” he said, adding the non-modifiable risks include age, gender, race/ethnicity, family history and socioeconomic status.

However, Benson continued, the list of modifiable risk factors is longer, offering multiple fronts on which patients and providers can focus attention.

High blood pressure is a key risk factor for stroke and other cardiovascular disease.

“There are a lot of people who walk around in their 20s, 30s, 40s, who have high blood pressure and never get it treated,” he said.

He stressed that it isn’t enough to know you have high blood pressure, but it is imperative to act by getting on appropriate medication and being compliant. Benson also said more attention should be paid to those who are pre-hypertensive (120-139 systolic and 80-89 diastolic) to get a handle on the condition before it escalates.

Diabetes is another control issue that should be closely monitored. In many cases, diet and exercise can greatly lessen the impact of type 2 diabetes and sometimes eliminate the disease all together.

Unchecked cholesterol is another major risk factor, but it doesn’t have to be.

“The higher your HDL, regardless of your LDL, the more protection against having a heart attack or stroke,” said Benson, who was one of the researchers involved in the landmark Northern Manhattan Stroke Study. Conversely, he continued, “The higher your LDL … the higher your chance of having a stroke.” He added that certain statins help patients achieve both goals by lowering LDL while simultaneously raising HDL.

Similarly, he noted, foods high in fiber such as oatmeal, plus physical activity, raise the good HDL levels.

A closer look at alcohol’s role in stroke was also part of the Manhattan Study. Benson describes the effect as a “J-shaped” relationship. He noted that people who don’t consume any alcohol have a slightly higher risk for stroke than moderate drinkers. However, he continued, heavy drinkers are at even greater risk of stroke and other illnesses.

“The key is moderation … one-two glasses of wine a week,” he stressed, adding that clinicians have to be careful in how this message is positioned.

Tobacco usage is, of course, off limits.

“Cigarette smoking is associated with the top four causes of death in this country –– heart attack, No. 1; cancer, No. 2; stroke, No. 3; and lung disease, No. 4. It’s bad all the way around, and it’s expensive,” he stated unequivocally.

A lack of physical activity is another key factor that significantly raises the risk of stroke. Benson said that even in the presence of other risk factors, a person who exercises regularly has a lower risk than a similar counterpart who is physically inactive.

As with diabetes, patients who have been diagnosed with cardiac disease must work to control their condition and be compliant with medications or face an added health concern by being at increased risk for stroke.

“Sleep apnea is known to disrupt blood pressure and make it harder to control … as well as blood sugars,” Benson continued. “So sleep apnea is another risk factor for stroke that people are looking at … a novel risk factor.”

For the most part, physicians are aware of these risks. However, doctors, who are typically under great pressure to see a long roster of patients daily, may not be spending enough time talking about these issues and discussing the consequences of not modifying destructive behaviors.

The NIH is challenged to find new ways to drive these messages home. One outreach effort in the works is The Science of Community Education Workshop to be presented later this year. Benson said the NIH is going to private public relations and advertising firms -- experts in behavior modification -- to combine their best practices with clinical best practices.

“They have clear data about what works; what encourages people to go buy potato chips,” he said, adding the expectation is that same motivation could be used to encourage people to adopt healthier habits. “Our hope is that we get more people focused on primary prevention and community education for stroke and heart disease because it’s an area that has not been developed and should be developed a lot more.”


April 2008

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