A Review on Stroke’s Pathophysiology, Associated Risk Factors, and Management

Is There a Role for Cardiac Rehabilitation After Coronary Artery Bypass Grafting? Treatment After Coronary Artery Bypass Surgery Remains Incomplete Without Rehabilitation.

Crucial advances in our understanding of basic pathogenic mechanisms involved in atherogenesis have been achieved during the past 2 decades. The historical hypothesis of pathogenesis (“lipid accumulation”) has evolved to integrate several causal events contributing to the initiation and evolution of atherosclerosis. Vascular inflammation and apoptosis may play a joint pivotal role in its progression and onset. Hypercholesterolemia and hypertension have synergistic deleterious effects on coronary endothelial function.1 Impaired fasting glucose, triglycerides and triglyceride-rich lipoprotein remnants, lipoprotein(a), homocysteine, and high-sensitivity C-reactive protein (hsCRP) might contribute to an increased risk of atherosclerosis.2 The disease also has been related to infiltration of immune cells, which are involved in both systemic and local, innate as well as adaptive, immune responses.3 Distinct pathways of atherothrombosis seem to develop at different sites of the vascular system (brain, heart, and peripheral circulation). Endothelial dysfunction induced by cardiovascular risk factors is considered to be 1 of the earliest stages in vascular damage and is associated independently with cardiovascular events.4 There is a synergic action between genetic, ambient, local, and systemic factors, and ultimately the progression of atherosclerosis is responsible for coronary heart disease (CHD) and its complications (such as unstable “in crescendo” angina, myocardial infarction, and sudden death), peripheral arterial disease, and ischemic stroke. The evolution of atherosclerosis, however, is characterized by a long lag time between onset and clinical manifestation, thereby providing an opportunity for implementation of early detection, prevention, and intervention strategies. Because the development of atherosclerosis commences early in humans, we need to rethink the timing of what is currently considered to be “primary” prevention of atherosclerosis-related diseases. It is likely that we need to start administering effective treatments much earlier than previously assumed. Indeed, much attention would be important when subjects are in a state of wellness before the …

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BACKGROUND:&#x0D; Stroke is the most common cause of disability and a leading cause of mortality worldwide. Though the incidence is falling in West but probably rising in Asia. The burden of stroke risk factors in Pakistan is enormous. Data on stroke incidence and prevalence from Pakistan is scarce; however, there are several reported case series in literature highlighting significant differences in terms of stroke epidemiology, risk factors and stroke subtypes/patterns. METHODS: This descriptive cross sectional study was conducted from August 2019 to February 2020, on 109 patients from medical units of DHQ Teaching Hospital Abbottabad. Diagnosis of cerebrovascular accidents was made on focal neurological deficit lasting more than 24 hours. CT scan brain was done in all patients to detect intra cerebral bleed. Detailed history and medical records were carefully scrutinized in the patients of intracerebral bleed to detect factors leading to it like uncontrolled hypertension. Fasting blood glucose, fasting serum cholesterol and fasting triglycerides were done to detect uncontrolled diabetes and hyperlipidemia. Data was collected on a structured proforma and analysed using SPSS 20. RESULTS: Majority of the patients were 39.81%(n=41) &gt;70 years of age, 71 (68.93%) were male and 32 (31.07%) female, frequency of intracerebral bleed among patients presenting with acute cerebrovascular accidents was recorded in 8.74%(n=9), among them 66.67%(n=6) had history of uncontrolled hypertension, 44.44%(n=4) had diabetes and 33.33%(n=3) had hyperlipidemia.&#x0D; CONCLUSIONS: Frequency of intracerebral bleed is higher among patients presenting with cerebrovascular accidents, hypertension is recorded the most common risk factor for this complication.

Transcatheter aortic valve replacement (TAVR) has been established as a standard of care worldwide in patients with degenerative severe aortic stenosis deemed at high or prohibitive risk for surgical aortic valve replacement. Since its early inception, stroke has been the most feared potential complication. In the early experience, rates of clinical stroke at 30 days after TAVR ranged between 4% and 6%. The substantial improvements in case selection, procedural technique, device technology development, and operator experience overtime dropped this rate substantially.1 Of note, in a large high-risk TAVR trial with a self-expandable device, the risk of stroke over 3 years was higher in the control group of patients undergoing surgical aortic valve replacement.2 Despite the availability of surgical aortic valve replacement for long time, the issues discussed hereafter have not yet been investigated in prospective, randomized fashion. Although we focus on TAVR, owing to the 2 papers we are commenting upon, we should acknowledge upfront that cerebrovascular event (CVE) prevention remains a common theme for all kinds of bioprosthetic aortic valves, via surgical or transcatheter implantation. See Articles by Kapadia et al and Kleiman et al CVE during or after TAVR is a multifactorial phenomenon with clinical, anatomic, procedural, and pharmacological factor contributions.1,3 During TAVR, the predominant pathological mechanisms may be cerebral embolism of calcific or atherothrombotic debris during positioning and implantation of the valve prosthesis.3 After TAVR, thromboembolic mechanisms may include endovascular thrombosis (including upon small size emboli), late embolization of calcific or atheromatous debris from the native aortic valve, ongoing thrombotic pannus (or mural thrombus layer) formation on the surface of the implanted prosthesis, and other mechanisms, including new-onset atrial fibrillation or the progression of atherothrombotic vascular disease.3 However, definitive scientific evidence characterizing the CVE risk peri-TAVR is still lacking. In …

Certified athletic trainers are positioned to play an integral role in sport-related, recreation-related, and exercise-related injury research and prevention efforts. The Centers for Disease Control and Prevention1 have specifically identified certified athletic trainers and their potential to contribute to this important area of research in their recently published Injury Research Agenda for 2009–2018. From a public health perspective, identifying factors associated with injury is one of the initial steps in the injury prevention process. The ultimate goal of this line of research is to identify populations that are at greatest risk for subsequent injury and to develop effective screening and intervention strategies to reduce the incidence and burden of injury. Therefore, the manner in which risk factors are conceptualized in initial research has significant bearing on the development of subsequent screening and intervention strategies. In the current issue of the Journal of Athletic Training, Reinking et al2 examined the factors associated with exerciserelated leg pain in high school cross-country athletes. After a discussion of modifiable and nonmodifiable risk factors, the authors conceptualized risk factors for exertional leg pain as intrinsic (within the body) or extrinsic (outside the body) factors; sports injury researchers have traditionally conceptualized risk factors associated with injury in this manner.3–5 This study provides an opportunity to discuss how risk factors are conceptualized in the context of sports injury research. The seminal work by sports injury researchers such as van Mechelen et al3 and Meeuwisse5 provided a theoretic framework for sports injury research, and although these models have evolved since they were first described,6–9 they have consistently characterized risk factors for injury as intrinsic factors and extrinsic factors. It is important to consider that injuries often result from the complex interaction of multiple factors3,7,10 in a dynamically changing environment,6 but the characterization of risk factors as intrinsic or extrinsic limits the clinical importance and usefulness of results in relation to future injury screening and prevention efforts. More importantly, characterizing risk factors in this manner provides limited insight into whether something can be done to intervene and mitigate the contributing influence of any given factor or combination of factors with regard to subsequent injury.11 Injury epidemiologists and public health professionals, on the other hand, use a different approach to conceptualizing risk factors for disease or injury by focusing on those risk factors that are modifiable and those that are nonmodifiable. Conceptualizing risk factors as modifiable and nonmodifiable is important from a clinical and injury prevention perspective, because modifiable risk factors are amenable to intervention.11 Researchers12,13 of chronic diseases, such as cardiovascular disease, hypertension, and type 2 diabetes, have conceptualized risk factors as modifiable and nonmodifiable. Some of these risk factors include physical activity, diet, smoking, and obesity, to name a few. Subsequent intervention efforts have been developed and evaluated to address these factors, with various degrees of success. Conceptualizing risk factors as modifiable and nonmodifiable aligns with the ‘‘Translating Research into Injury Prevention Practice (TRIPP)’’ framework described by Finch,9 which applies a public health approach to sports injury prevention. Clinicians and injury researchers are most interested in modifiable risk factors associated with injury because they provide the vector for developing injury prevention interventions. Although nonmodifiable risk factors may not be useful as targets for intervention, they are particularly important in identifying populations that are at greatest risk for injury, so that injury prevention strategies can be directed to those with the most pressing need. This information can be used to develop risk profiles for specific injuries, to screen athletes to identify those at greatest risk for injury, and to guide injury prevention interventions that target modifiable risk factors. This information can also be used to develop interventions and social marketing campaigns that are culturally and ecologically appropriate for the populations at greatest risk for injury.14 When only nonmodifiable risk factors associated with injury are known, this information can be used to counsel athletes and parents about potential risks during the preparticipation screening process, so they can make informed decisions about participation. Recently, researchers have conceptualized risk factors as modifiable and nonmodifiable in the sports medicine literature. Emerging research10,15–17 into the risk factors associated with anterior cruciate ligament (ACL) injuries is one of the best examples in the sports medicine literature of how the conceptualization of risk factors has evolved. Early work15 in this area conceptualized risk factors as intrinsic and extrinsic, while recognizing the importance of focusing on factors that are modifiable. Subsequent consensus statements10,16 on the risk factors for ACL

Heart Failure Risk Associated With Severity of Modifiable Heart Failure Risk Factors: The ARIC Study

BackgroundMany studies showed that addressing modifiable risk factors has an impact on dementia prevalence and incidence. Most studies have focussed on universal prevention, irrespective of individual risk stage, with risk factors for dementia mainly identified in the general population. Less is known about the most important target risk factors in persons with subjective cognitive decline (SCD) or mild cognitive impairment (MCI), and hence, whether they have a similar potential for risk reduction as the general population. Therefore, this study aims to identify modifiable risk and protective factors for cognitive deterioration and dementia in persons with SCD or MCI.MethodWe use a mixed‐methods approach combining findings from a systematic literature review and an online Delphi study. Four electronic databases (PubMed, EMBASE, PsycINFO, Web of Science) were searched to review relevant literature. A broad search term was developed in consultation with an experienced librarian and consisted of terms linked to SCD, MCI, dementia, modifiable risk factors and disease progression. Observational studies with at least 50 participants and 1 year of follow‐up were considered for inclusion. Twenty international dementia prevention experts were invited to participate in the online Delphi study. In two rounds, experts were asked to spontaneously name, rank and weigh modifiable risk and protective factors in order of importance for the target population.ResultOur search yielded 19,128 abstracts in total. After removal of duplicates, 9,862 abstracts were considered for inclusion and 203 full‐texts were read, of which 69 were included in our review. Several risk and protective factors were encountered including somatic, lifestyle and neuropsychiatric factors, and they are further scrutinized. Eighteen experts named 31 risk and protective factors in the first Delphi study round, of which physical activity, social isolation and hypertension were ranked highest. Results of round two are being collected.ConclusionFindings from the current study will result in an inventory of relevant modifiable risk and protective factors linked with clinical progression in persons with SCD or MCI. Results will serve as the basis for the development and testing of an online dementia risk reduction tool for use in clinical populations with SCD and MCI.

It is known that targeting cancer-related modifiable risk factors is the best way to fight cancer. Behavioral and lifestyle changes can significantly reduce the burden of cancer. We aim to assess the impact of having a relative/friend with cancer on the number of cancer-related modifiable risk factors a participant might have. A survey-based cross-sectional study was conducted at King Hussein Cancer Center from June 2020 until July 2020. The survey was distributed via social media platforms, where we targeted adults who have never been diagnosed with cancer. We asked about modifiable cancer-related risk factors and compared between participants with and without relatives or friends with cancer. A total of 1486 participants were considered for analysis, with a mean age of 30.62 (SD 11.19) years. Participants who had a relative with cancer had a mean of 0.31 (p = 0.007; 95% CI: 0.08-0.54) fewer risk factors, with smoking and extra sun exposure were significantly lower among participants with a cancer relative. No significant difference in modifiable risk factors was found between participants with a friend who have cancer and those who do not (p = 0.193). People who have relatives with cancer had less modifiable risk factors, which might reflect on their willingness to modify their cancer-related risk factors.

Objective: Assess the effect of intensive clinical and educational interventions aimed at reducing risk factors for Cardiovascular Disease (CVD), implemented by clinical pharmacists, on modifying risk factors in targeted patients at high risk for CVD.&#x0D; Design: Patients with at least two risk factors for CHD were identified at two clinics by conducting a pre-intervention survey and were monitored over a period of 6 months with follow up conversations conducted every 4 weeks by phone and at subsequent physician visits. A post-intervention survey was conducted at the end of the study period to detect modified risk factors.&#x0D; Setting: The Jefferson County Public Health Department (JCHD)&#x0D; Participants: We followed a total of 47 patients over 6 months. The average age at baseline was 51 years old and 80% of the participants were female. The baseline average number of modifiable cardiovascular disease risk factors was 3.7.&#x0D; Measurements: We assessed total number of CVD risk factors, smoking behavior, blood pressure, LDL, A1C, weight, and level of physical activity (major modifiable risk factors by the American Heart Association).&#x0D; Results: Over a 6 month follow-up of 47 patients, statistically significant reductions occurred in total number of CVD risk factors, systolic and diastolic blood pressures, and A1C. Reductions also occurred in LDL level, weight, and changes in smoking behavior and physical activity were identified.&#x0D; Conclusions: Results showed that increased patient counseling on adherence and lifestyle changes along with increased disease state monitoring and medication adjustment led by a clinical pharmacist can decrease risk factors in patients with multiple risk factors for cardiovascular disease.&#x0D; &#x0D; Type: Student Project

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To determine the prevalence of modifiable breast cancer risk factors among women engaged in screening mammography using nationally representative cross-sectional survey data and to inform potential opportunities for breast facilities to contribute to primary prevention. 2018 National Health Interview Survey respondents who were women ages 40-74 years without history of breast cancer were included and then categorized based on whether they reported screening mammography within the prior two years. Proportions of these women reporting evidence-based modifiable breast cancer risk factors, including elevated body mass index (BMI), lack of physical activity, or moderate or heavy alcohol consumption were calculated and stratified by demographics. Multivariable logistic regression was used to estimate the association between these risk factors and sociodemographic characteristics. Among 4989 women meeting inclusion criteria and reporting screening mammography, 79% reported at least one modifiable risk factor. Elevated BMI was the most reported risk factor (67%), followed by lack of physical activity (24%) and alcohol consumption (16%). The majority of each race/ethnicity category reported at least one modifiable risk factor, with the highest proportion reported by Black respondents (90%). Asian, college educated, and higher-income participants were less likely to have at least one modifiable risk factor. Modifiable breast cancer risk factors are prevalent among women engaged in screening mammography. This provides potential opportunities for breast imaging facilities to contribute to the primary prevention of breast cancer by providing resources for lifestyle modification at the time of screening mammography.

Introduction: Multiple risk factors for postmenopausal breast cancer are well established. We aimed to determine the proportion of breast cancers in the population that are attributable to established risk factors, and to different combinations of risk factors, to better understand the proportion of breast cancer which could be prevented by changes in modifiable risk factors. Methods: We used data from the Nurses' Health Study (NHS), an ongoing prospective study of 121,700 US nurses initiated in 1976. Information on breast cancer risk factors and breast cancer diagnosis is collected every two years through mailed questionnaires. Follow-up for this cohort of women through 2008 has been greater than 90%. The analysis was restricted to postmenopausal women. Relative risks and their 95% confidence intervals were estimated by Cox models stratified by calendar year and age in months at the time of each questionnaire return using the counting process data structure to facilitate the incorporation of time-varying covariates. We included the following established breast cancer risk factors in the analyses: age, age at menarche, height, age at first birth/parity, current adult BMI/weight change since age 18, alcohol consumption, physical activity, breast feeding, menopausal hormone therapy, family history of breast cancer, and prior benign breast disease. Full and partial population attributable risk percents (PARs) were calculated. We conducted analyses for total invasive breast cancer, estrogen receptor (ER)+, and ER- breast cancer. Results: Over the course of follow-up, 8,421 postmenopausal invasive breast cancer cases developed over 2,424,778 person years between 1980 and 2008. As expected, earlier age at menarche, increasing weight gain since age 18, increasing alcohol consumption, current use of menopausal hormones, and being tall were all significantly positively associated with risk of breast cancer in multivariate models. Because age has a large influence on the risk of breast cancer we estimated the PAR both with and without age. When all of the risk factor variables except for age were include in the model the PAR for all invasive breast cancers was 0.62 (95% CI 0.46-0.75). Thus, if women could change to the lowest risk category for all of the variables considered, the number of invasive breast cancers would be reduced by 62%. In models that additionally included age, the PAR was 0.92 (95%CI 0.76-0.97) for total invasive and 0.95 (95%CI 0.75-0.99) for ER+ breast cancer and 0.86 (95%CI 0.21-0.98) for ER- breast cancer. However, because many of the risk factors considered are not easily modifiable, we also examined more readily modifiable risk factors singly and in combinations. The risk factor with the largest PAR, was BMI/weight gain since age 18 (PAR=0.24(95%CI 0.13-0.34)). Reproductive risk factors such as age at first birth/parity (PAR=0.10 (95%CI 0.07-0.14)) and age at menarche (PAR=0.08 (95%CI 0.03-0.12)) also had modest impact on the PAR, both of which were higher for ER+ breast cancer than ER- breast cancer. When considering all of the modifiable risk factors together we found that changing one's risk factor profile to have the lowest weight gain, no alcohol consumption, high physical activity, breast feeding and no hormone use was associated with a PAR of 0.38 (95%CI 0.23-0.52) for overall invasive breast cancer. Conclusion: The established breast cancer risk factors explain a large proportion of both ER+ and ER- postmenopausal breast cancers in the population. The most important modifiable risk factor for postmenopausal breast cancer prevention is maintaining a healthy weight. Citation Format: Rulla M. Tamimi, Molin Wang, Mathew Pazzaris, Stephanie A. Smith-Warner, Walter C. Willett, A. Heather Eliassen, Donna Spiegelman, David J. Hunter. Population attributable risk of postmenopausal breast cancer according to known and modifiable breast cancer risk factors. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A43.

Although many stroke patients are young or middle-aged, risk factor profiles in these age groups are poorly understood. The Stroke in Young Fabry Patients (sifap1) study prospectively recruited a large multinational European cohort of patients with cerebrovascular events aged 18 to 55 years to establish their prevalence of Fabry disease. In a secondary analysis of patients with ischemic stroke or transient ischemic attack, we studied age- and sex-specific prevalences of various risk factors. Among 4467 patients (median age, 47 years; interquartile range, 40-51), the most frequent well-documented and modifiable risk factors were smoking (55.5%), physical inactivity (48.2%), arterial hypertension (46.6%), dyslipidemia (34.9%), and obesity (22.3%). Modifiable less well-documented or potentially modifiable risk factors like high-risk alcohol consumption (33.0%) and short sleep duration (20.6%) were more frequent in men, and migraine (26.5%) was more frequent in women. Women were more often physically inactive, most pronouncedly at ages <35 years (18-24: 38.2%; 25-34: 51.7%), and had high proportions of abdominal obesity at age 25 years or older (74%). Physical inactivity, arterial hypertension, dyslipidemia, obesity, and diabetes mellitus increased with age. In this large European cohort of young patients with acute ischemic cerebrovascular events, modifiable risk factors were highly prevalent, particularly in men and older patients. These data emphasize the need for vigorous primary and secondary prevention measures already in young populations targeting modifiable lifestyle vascular risk factors.

Comprehensive clinical assessment of modifiable cardiometabolic risk factors