Primordial, primary, secondary, and tertiary prevention stages for global vascular risk. R. Sacco: Stroke, Volume 38(6).June

Neurovascular Disease  Epidemiology  50% Ischemic stroke, 30% ICH, 20% SAH  Causes/ Pathophysiology  Ethnic Issues  Biology  Sociology

Epidemiology Worldwide Incidence per 100,000 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: , 2002

Risk Factors and Predictors of Stroke Older age Male gender Non-white genetic background Family history Prior stroke or TIA Non-modifiable risk factorsModifiable risk factors Previous TIA or stroke is the most important risk 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: Obesity Diabetes Mellitus Hypertension Hyperlipidemia

Prevalence of Identified Risk Factors on Admission to UMC

African-American Hispanic American AgeMenWomen STROKE IN MINORITIES Survey of Stroke Mortality in Texas Rate-Ratio in Comparison to Non-Hispanic Whites Morgenstern et al Stroke, 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/ signs Do not come to the ED quickly Have less “technical” evaluations

Hypertension

 The most prevalent and modifiable risk factor for stroke  BP reduction lowers stroke recurrence ~28%  Stroke 1997;28:2557  Treatment of elevated SBP in elderly reduces stroke risk by 36%  Decrease in DBP of 5-6 mmHg reduces stroke risk by 42%  Treatment of stage-I hypertension prevents 1 death in 11 patients over 10 years; 1 in 9 if end- organ damage is present

Adjusted Relative Risk of Cardiovascular Mortality According to BP in Men Screened for MRFIT MRFIT, Multiple Risk Factor Intervention Trial Arch 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

 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

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:

JUPITER: Effects of Rosuvastatin on Primary End Point by baseline NEJM 2008;359: Primary Endpoints: MI Stroke CVD Unstable Angina Revascularization

Carotid Atherosclerosis

Hansson et al. Nature Reviews Immunology 6, (July 2006) | doi: /nri1882 Atherothrombosis