Abstract
Stroke prevention requires effective treatment of its causes. Many etiological factors for stroke have been identified, but the potential gain of effective intervention on these factors in terms of numbers of actually prevented strokes remains unclear because of the lack of data from cohort studies. We assessed the impact of currently known potentially modifiable etiological factors on the occurrence of stroke. This population-based cohort study was based on 6,844 participants of the Rotterdam Study who were aged ≥55 y and free from stroke at baseline (1990-1993). We computed population attributable risks (PARs) for individual risk factors and for risk factors in combination to estimate the proportion of strokes that could theoretically be prevented by the elimination of etiological factors from the population. The mean age at baseline was 69.4 y (standard deviation 6.3 y). During follow-up (mean follow-up 12.9 y, standard deviation 6.3 y), 1,020 strokes occurred. The age- and sex-adjusted combined PAR of prehypertension/hypertension, smoking, diabetes mellitus, atrial fibrillation, coronary disease, and overweight/obesity was 0.51 (95% CI 0.41-0.62) for any stroke; hypertension and smoking were the most important etiological factors. C-reactive protein, fruit and vegetable consumption, and carotid intima-media thickness in combination raised the total PAR by 0.06. The PAR was 0.55 (95% CI 0.41-0.68) for ischemic stroke and 0.70 (95% CI 0.45-0.87) for hemorrhagic stroke. The main limitations of our study are that our study population comprises almost exclusively Caucasians who live in a middle and high income area, and that risk factor awareness is higher in a study cohort than in the general population. About half of all strokes are attributable to established causal and modifiable factors. This finding encourages not only intervention on established etiological factors, but also further study of less well established factors. Please see later in the article for the Editors' Summary.
Highlights
In the 1960s it was discovered that treatment of high blood pressure reduces the occurrence of stroke among persons with severe diastolic hypertension by more than 90% [1]
Diabetes mellitus (PAR 0.04, 95% CI 0.02–0.07) and atrial fibrillation (PAR 0.02, 95% CI 0.01–0.05) contributed significantly to the burden of stroke
Total cholesterol (TC)/high-density lipoprotein (HDL) ratio was not associated with the risk of stroke in the expected direction: with the quartile of participants with the lowest TC/HDL ratios as the reference category, the hazard ratios were 0.83 for the second quartile, 0.84 for the third quartile, and 0.97 for the fourth quartile
Summary
In the 1960s it was discovered that treatment of high blood pressure reduces the occurrence of stroke among persons with severe diastolic hypertension by more than 90% [1]. The observation that a relatively simple intervention prevents such a devastating disease continues to inspire researchers to search for other potentially modifiable etiological factors for stroke up to the present day. This search has led to the identification of many other risk factors for stroke, some of which merely mark the increased risk without playing a role in the causal pathway (risk indicators), and some of which are presumably causal (etiological factors, or causal risk factors) [2,3]. Post-stroke rehabilitation can help overcome the disabilities caused by stroke, and various drugs alongside behavioral counselling can reduce the risk of a second stroke
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