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Chapter 6. Stroke

A 38-year-old white man with a past medical history (PMH) significant for hypertension, diabetes, and chronic alcoholism comes to your clinic for routine follow-up. His social history is significant for alcohol and tobacco abuse. He currently drinks one case of beer per night and smokes two packs per day. Pertinent laboratory findings are as follows: total cholesterol (TC) 182 mg/dL, triglyceride (TG) 218 mg/dL, low density lipoprotein (LDL) 96 mg/dL, high density lipoprotein (HDL) 52 mg/dL, glucose 146 mg/dL. Current blood pressure (BP) is 158/94 mm Hg and heart rate (HR) is 92 beats per minute (bpm). He is 69-in tall and weighs 232 lb. Which of the following are risk factors for ischemic stroke in this patient? Select all that apply.

a. Hypertension

b. Tobacco abuse

c. Diabetes

d. Race

e. Age

Answers a is correct. Hypertension is the single most important modifiable risk factor for ischemic stroke. Most estimates for hypertension indicate a relative risk of stroke of approximately 4 when hypertension is defined as systolic BP ≥160 mm Hg and/or diastolic BP ≥95 mm Hg.

Answer b is correct. Cigarette smoking increases risk of ischemic stroke nearly two times. In both the Framingham Study and the Nurses’ Health Study cessation of smoking led to a prompt reduction in stroke risk—major risk was reduced within 2 to 4 years.

Answer c is correct. Persons with diabetes have an increased susceptibility to atherosclerosis and an increased prevalence of atherogenic risk factors, notably hypertension, obesity, and abnormal blood lipids. Case-control studies of stroke patients and prospective epidemiological studies have confirmed an independent effect of diabetes with a relative risk of ischemic stroke in persons with diabetes from 1.8 to 3.0.

Answer d is correct. Stroke incidence and mortality rates vary widely between racial groups. Blacks are more than twice as likely to die of stroke as whites are. Between the ages of 45 and 55, mortality rates are four to five times greater for African-Americans than for whites; the difference decreases with increasing age.

Answer e is incorrect. This patient is 38 years old. Younger age groups (25-44 years) are at lower risk. However, age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate gets doubles in both men and women.

Which of the following statements accurately describes the acute presentation of ischemic stroke?

a. Acute infarction of the central nervous system tissue, one-sided weakness, systolic blood pressure >200 mm Hg

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