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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 3  |  Page : 137-141

Poor risk factor control among stroke survivors - A cross-sectional survey


1 Achutha Menon Centre for Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
3 Achutha Menon Centre for Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram; Research Director, Amala Cancer Research Centre, Thrissur, Kerala, India

Date of Submission12-Jun-2021
Date of Acceptance17-Sep-2021
Date of Web Publication22-Nov-2021

Correspondence Address:
Dr. S D Shani
Achutha Menon Centre for Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_36_21

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  Abstract 


Objectives: A cross-sectional survey was done to find out the prevalence and control status of cardiovascular risk factors among stroke survivors within a post-stroke period of 3 months to 1 year.
Methodology: The data on the prevalence of risk factors were taken from past medical history and medical records. The risk factor control is defined as achieving the targeted levels of blood pressure, blood sugars and cholesterol. Data on a diet, physical activity, tobacco use, and alcohol consumption were also collected. Standard instruments were used to measure blood pressure, weight, height, and waist circumference (WC). The blood sugar and lipid values were taken from labratory reports.
Results: Stroke survivors (N = 240) participated. Around 75% of the participants were obese or overweight. Normal WC was found only in 25% of the participants. Majority of the participants were not following a healthy diet (62.5%) or doing recommended physical activity (87.1%). The prevalence of diabetes (61.2%), hypertension (88.6%), and dyslipidemia (96%) were high among stroke survivors. The targeted level of diabetic control and hypertension control level was achieved by 26% and 36.2, respectively, while around 72% attained lipid control.
Conclusion: The prevalence of cardiovascular risk factors is very high among stroke survivors, and it is poorly controlled.

Keywords: Prevalence and control, risk factor, stroke survivors


How to cite this article:
Shani S D, Sylaja P N, Sarma P S, Raman KV. Poor risk factor control among stroke survivors - A cross-sectional survey. Int J Non-Commun Dis 2021;6:137-41

How to cite this URL:
Shani S D, Sylaja P N, Sarma P S, Raman KV. Poor risk factor control among stroke survivors - A cross-sectional survey. Int J Non-Commun Dis [serial online] 2021 [cited 2021 Dec 7];6:137-41. Available from: https://www.ijncd.org/text.asp?2021/6/3/137/330910




  Introduction Top


Strict control of risk factors is integral to the prevention of stroke recurrence. The target levels of blood pressure, blood sugars, and lipid values for secondary stroke prevention are given by the American Stroke Association (ASA),[1] American Diabetes Association (ADA)[2] and National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III[3] guidelines. The stroke survivors have unrecognized hypertension (18.7% vs. 13.5%), unrecognized Stage 2 hypertension (4.4% vs. 2.2%), and unrecognized diabetes (4.2% vs. 3.2%).[4] The risk factor control is poor among stroke survivors.[5],[6],[7] The disability caused by stroke may affect the initiation of secondary stroke prevention strategies by the patients. Stroke patients with more severe disability (Barthel score ≤14) were less likely to receive appropriate secondary prevention than those with mild or no disability (Barthel score 15–20).[8],[9] Poor risk factor control is associated with increased risk of stroke recurrence.[5],[7] This study aims to have a prospective assessment of prevalence and present status of risk factors among stroke survivors. The knowledge gained can improve the stroke care to prevent stroke recurrence in the community.


  Methodology Top


Sree Chitra Tirunal Institute for Medical Science and Technology (SCTIMST), Thiruvananthapuram, is a quaternary level referral hospital which admit patients of neurology and cardiology specialties. The comprehensive stroke care unit admits 450–500 patients per year. It has an acute stroke care unit, is maintaining a stroke registry and the patients are followed up in stroke clinic. The stroke registry maintained in SCTIMST is based on the World Health Organization (WHO) STEPS Stroke Manual.

Cross-sectional survey among hospital-based stroke survivors of the first episode of stroke within a post stroke period of 3 months to 1 year was conducted to identify the prevalence and control of risk factors. Survivors of the first episode of stroke refer to the survivors of diagnosed cases of ischemic stroke, hemorrhagic, and transient ischemic attack (TIA) with evidence of acute infarct. The study population for this cross-sectional survey were the survivors of first episode of stroke within a post stroke period of 3 months to 1 year. The data were collected during their follow-up visit to stroke clinic on an outpatient basis. Survivors of the first episode of stroke, aged 18 and above within 3 months to 1 year were recruited for the cross-sectional survey. Comatose, severely disabled (modified Rankin's Score ≥5), having multiple coexisting diseases were excluded from the study. The estimated sample size for this study was 240 participants.

Locally translated pretested structured interview schedule was used to collect data. The risk factor control is defined as achieving the desired levels of blood pressure, blood sugars, and cholesterol. The targets for risk factor control were taken from NCEP ATP III guidelines (NCEP, 2004) for Cholesterol (Low-density lipoprotein [LDL] <100 and total cholesterol [TC] <200)[3], ADA guidelines (Fasting Blood Sugar [FBS] 70–130 and HbA1C <7) for Diabetes control (ADA, 2019)[2] and ASA secondary stroke prevention guidelines for blood pressure (systolic blood pressure [SBP] <140 and diastolic blood pressure [DBP] <90).[1]

Compliance to recommended health advice like following a healthy diet, physical activity, tobacco abstinence, and limiting alcohol consumption were also assessed. A healthy diet was defined as consumption of approximately 350–400 gms of vegetables a day, one medium-sized fruit or two small-sized fruit per day, and avoiding extra salts, sweets, and fried foods.[10] Recommended physical activity was at least 30 min of moderate physical activity like walking for at least 3 days a week.[1]

Standard instruments were used to measure blood pressure, weight, height, and waist circumference (WC). The reference value for body mass index (BMI) was taken from Canters for Disease Control and Prevention[11] guideline and for WC was taken from the WHO report.[12]

The data on the prevalence of risk factors were taken from past medical history and medical records. The blood sugar and lipid values were taken from lab reports. The prevalence of dyslipidemia was identified by the presence of either lipid-lowering medication or by abnormal lipid values at the time of presentation. Clinical information sheet was used to collect data from medical records which included a history of diabetes, hypertension, dyslipidemia, blood investigation results of FBS, glycosylated hemoglobin, LDL, and TC.

To identify the prevalence of risk factors, the proportion of patients with a history of corresponding risk factor was reported. To find out the risk factor control, the proportion of patients who achieved the targeted level of diabetic control, hypertension control, and dyslipidemia control were analyzed and reported.

The study was undertaken after obtaining clearance from Institutional Ethics Committee of Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala (SCT/IEC-1327/November-2018).


  Results Top


Stroke survivors within a post stroke period of 3 months to 1 year 240 numbers (n = 240) participated. The mean age was 58.64 ± 10.96 years. Females constituted 25.4% of the sample. Rural inhabitants were 76.7%. Among the participants, 32.1% belonged to the category of poor households based on official government classification. More than 70% of the participants were educated up to 10th standard, rest were graduates or professionals. Unskilled workers were 61.3%; 32.1% were skilled workers, and the rest were professionals. Ischemic stroke patients constituted 83.8% of the participants, 12.5% had hemorrhagic stroke, and 3.8% had TIA.

Prevalence of risk factors

The prevalence of cardiovascular risk factors and unhealthy lifestyle among stoke survivors is shown in [Table 1]. Even though more than 45% of the participants had the habit of smoking, only around 4% were smoking at the time of recruitment. Around 75% of the participants were obese or had overweight. Normal WC was found only in 25% of the participants; when calculated with the given separate cut off values for men and women. Majority of the participants were not following a healthy diet (62.5%) or doing recommended physical activity (87.1%). The prevalence of diabetes (61.2%) and hypertension (88.6%) was high among stroke survivors. The presence of dyslipidemia was very high as 96%.
Table 1: Prevalence of cardiovascular risk factors among survivors of first episode of stroke

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The blood pressure, lipid, sugar values, and BMI are summarized in [Table 2]. The mean SBP was 140 mm of Hg, the mean DBP was 84 mm of Hg. The mean FBS was 120 mg/dl, while the mean glycosylated hemoglobin was 7.2. The mean TC was 147 mg/dl, while the mean LDL was 83 mg/dl. The mean BMI among stroke survivors of 3 months to 1 year was 31 kg/m2.
Table 2: Mean and five number summaries of quantitative variables related to risk factors

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Risk factor control

The control of risk factor among stroke survivors is given in [Table 3]. Even though around 47% of our participants had the history of smoking >100 cigarettes over life time, only 4.2% are currently smoking. More than 50% had stopped smoking after first-ever stroke, and others stopped before the first stroke. The alcohol use was less prevalent among stroke survivors in our center. The targeted level of diabetic control and hypertension control level was achieved by only a small proportion 26% and 36.2, respectively, while around 72% attained the targeted lipid control status. More than 90% of the participants had a desirable level of TC value. The optimal level of LDL was achieved by 63% of the participants.
Table 3: The control of risk factor among stroke survivors

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  Discussion Top


Our study demonstrated that the risk factor control among stroke survivors is suboptimal. This study showed 80% of the stroke survivors had moderate-to-high central fat distribution, and 75% were overweight and obese. The prevalence of overweight and obesity was 40%, and high central fat distribution was 60% among our target population.[13] Previous studies also demonstrated that the prevalence of obesity is high (60%) among stroke survivors[14] whereas the prevalence of obesity among their general public was 34%.[15] The physical disability caused by stroke limit activity. Fear of fall may compound the problem. Our study has shown that 62% and 87% of stroke survivors are not following recommended physical activity and healthy diet, respectively. The prevalence levels of diabetes, dyslipidemia as well as hypertension were very high among stroke survivors in our setting. The prevalence proportions of diabetes, hypertension, and dyslipidemia were around 61%, 89%, and 97%, respectively. It reflects the prevalence of these risk factors among the general population of Kerala. Nearly 83% of general population in Kerala possess at least one of the five risk factors of NCD.[13] A Recent study in Kerala showed 54% of general population had TC >200 mg/dl. Our study assessed dyslipidemia by the use of cholesterol-lowering medications, and the prevalence was 97%. Previous studies also revealed high prevalence of dyslipidemia in stroke patients.[16]

The control of diabetic, hypertension, and dyslipidemia, was assessed separately. The target levels were fixed as per standard recommendations.[1],[2],[3] Our study revealed poor control of risk factors among stroke survivors. The targeted values were achieved by 26% of diabetic patients and 36% of hypertensive stroke survivors. Previous studies also brought out similar results.[4],[17] One recent study conducted among general population in Kerala showed that only 12% and 15% of those afflicted achieved hypertension and diabetic control, respectively.[13] Among stroke survivors, the control status of diabetes and hypertension is better than general public because of their fear of recurrences, and our participants were selected from hospital based stroke registry. Only 46% of the general population in Kerala[18] had TC level <200 mg/dl, but in our study, 73% of stroke survivors had both TC <200 mg/dl and LDL <100 mg/dl.

Strict adherence to medication and risk factor control are integral to secondary stroke prevention. A comprehensive evidence-based guideline is issued by the ASA for recurrent stroke prevention. Compliance to this guideline can lead to an 80% reduction in recurrent stroke risk. A brief overview of secondary stroke prevention strategies includes the following; antiplatelet medications such as aspirin and clopidogrel to be initiated within 24 h of a minor ischemic stroke or TIA and continued for 90 days. Antihypertensives medications to be initiated to achieve a systolic pressure <140 mm Hg and a diastolic pressure <90 mm Hg. Statin therapy with intensive lipid-lowering effects is recommended to maintain LDL-C level <100 mg/dL. After an ischemic stroke, all patients should be screened for diabetes and glycemic control. Counseling should be given for lifestyle modification, diet, exercise, and weight loss. Advise patients to engage in aerobic physical activity, average 40 min per session, 3–4 days a week. Strong advice to be given to quit smoking. Patient should eliminate or reduce alcohol consumption. Sodium intake should be reduced to less than ≈ 2.4 g/day. Further reduction to <1.5 g/day should be advised for BP reduction. Mediterranean type of diet instead of a low-fat diet can be followed. The Mediterranean type diet emphasizes vegetables, fruits, and whole grains and includes low-fat dairy products, poultry, fish, legumes, olive oil, and nuts. It limits intake of sweets and red meats.[1]

The secondary stroke prevention guidelines include medications to reduce thrombosis risk and control vascular risk factors such as diabetes, hypertension, and dyslipidemia. It strongly insists behavioral modification in the form of medication adherence and adopting new lifestyle such as healthy diet, physical activity, smoking cessation, and limiting alcohol consumption. The stroke units are predominantly located in the urban and private hospitals. Facilities for monitoring risk factor control and drug levels at the community level are not uniform throughout India. The stroke and other chronic noncommunicable prevention and con control program need multidisciplinary approach, support from voluntary organizations, self-help groups, and other influential people in the society for its successful implementation and outcome. In areas of limited access to health care specialized nurses can be utilized to attain health-related goals.

This study was conducted in a single center, and data collected by a single investigator who is well trained which make the data more reliable. The stroke survivors were regularly followed up in stroke clinic which make and risk factors are screened which helped to get accurate report of all the risk factors. This study was comprehensive, and we could collect data on all the risk factors. The major disadvantage of this study was that we could include only 240 participants in this study. Data on risk factor control status among stroke survivors in India was lacking, and we could do this study as a pilot project. Community-based future studies can be planned with large sample size find out the burden of this problem in the community.


  Conclusion Top


Risk factor control among survivors of the first episode of stroke at 3 months to 1 year was suboptimal. Majority of them were not following healthy life style. Risk factor control requires strict medication adherence and adopting new lifestyle such as healthy diet, physical activity, smoking cessation, and limiting alcohol consumption. Screening for risk factor control can be done from nurse-led clinics or local health centers. In areas of limited access to health care specialized nurses can be utilized to attain health-related goals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:2160-236.  Back to cited text no. 1
    
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American Diabetes Association (ADA). Glycemic targets: Standards of medical care in diabetes – 2019. Diabetes Care 2019;42 Suppl 1:S61-70.  Back to cited text no. 2
    
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National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002 Dec 17;106(25):3143-421. PMID: 12485966.  Back to cited text no. 3
    
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Brenner DA, Zweifler RM, Gomez CR, Kissela BM, Levine D, Howard G, et al. Awareness, treatment, and control of vascular risk factors among stroke survivors. J Stroke Cerebrovasc Dis 2010;19:311-20.  Back to cited text no. 4
    
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Brewer L, Mellon L, Hall P, Dolan E, Horgan F, Shelley E, et al. Secondary prevention after ischaemic stroke: The ASPIRE-S study. BMC Neurol 2015;15:216.  Back to cited text no. 5
    
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Wangqin R, Wang X, Wang Y, Xian Y, Zhao X, Liu L, et al. Risk factors associated with 90-day recurrent stroke in patients on dual antiplatelet therapy for minor stroke or high-risk TIA: A subgroup analysis of the CHANCE trial. Stroke and Vascular Neurology 2017;0: e000088. doi:10.1136/svn2017-000088.  Back to cited text no. 7
    
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World Health Organization. Fruit and Vegetables for Health: Report of the Joint FAO/WHO Workshop on Fruit and Vegetables for Health. Geneva: World Health Organization; 2005. Available from: https://apps.who.int/iris/handle/10665/43143. [Last accessed on 2021 Jan 15].  Back to cited text no. 10
    
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Healthy Weight, Nutrition and Physical Activity, CDC. Available from: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. [Last accessed on 2021 Jan 15].  Back to cited text no. 11
    
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World Health Organisation. Waist Circumference and Waist-Hip Ratio: Report of a WHO Expert Consultation. Geneva: WHO; 2008. Available from: https://www.who.int/publications/i/item/9789241501491. [Last accessed on 2021 Jan 15].  Back to cited text no. 12
    
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Sarma PS, Sadanandan R, Thulaseedharan JV, Soman B, Srinivasan K, Varma RP, et al. Prevalence of risk factors of non-communicable diseases in Kerala, India: Results of a cross-sectional study. BMJ Open 2019;9:e027880.  Back to cited text no. 13
    
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Vemmos K, Ntaios G, Spengos K, Savvari P, Vemmou A, Pappa T, et al. Association between obesity and mortality after acute first-ever stroke: The obesity-stroke paradox. Stroke 2011;42:30-6.  Back to cited text no. 14
    
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Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307:491-7.  Back to cited text no. 15
    
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Olamoyegun MA, Akinlade AT, Fawale MB, Ogbera AO. Dyslipidaemia as a risk factor in the occurrence of stroke in Nigeria: Prevalence and patterns. Pan Afr Med J 2016;25:72.  Back to cited text no. 16
    
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