Keywords: Hypertension; Stroke; Age; Risk factors; Cardiovascular disease; Cerebrovascular events; Ageing; Isolated Systolic Hypertension; Ischemic stroke; Intracerebral hemorrhage; Transient Ischemic Attack; Vascular neurologic dysfunction; Embolism; Thrombosis; Bleeding; Atherosclerosis; Diabetes mellitus; Dyslipidemia; Tobacco; Alcohol abuse; Obesity; Cardiac dysrhythmia; Semiology of stroke; Vascular dementia; Cerebral disease; Non modifiable risk factors; Arterial circle or Willis hexagon
At present, epidemiological analyses are able to quantify the risk factors responsible for cardiovascular diseases [3], age [4], hypertension, and history of previous heart disease [5-7]. Nevertheless, the principal etiology of stroke is atherosclerosis: a combination of circumstances affecting the arterial wall responsible for the inadequate supply of blood to the CNS. According to the general clinical opinion, the risk factors are classified into three categories: a) modifiable risk factors, (hypertension (72.1%), diabetes, dyslipidemia, arrhythmia, tobacco, alcohol abuse (>5 drinks daily) (8.1%), obesity (8.1%), and uncommon cause (25.6%); b) non modifiable risk factors (age, gender, ethnic groups, history of cardiovascular disease), and c) unknown circumstances.
The SHEP trial showed a significant benefit for non-fatal stroke, but fatal strokes were not significantly reduced. The incidence of fatal strokes was rather low in the SHEP’s control group (14 of 159 strokes without including transient ischemic attacks, 9%). Whether the low incidence of fatal strokes in the The SHEP trial showed a significant benefit for non-fatal stroke, but fatal strokes were not significantly reduced. The incidence of fatal strokes was rather low in the SHEP’s control group (14 of 159 strokes without including transient ischemic attacks, 9%). Whether the low incidence of fatal strokes in the
This information is based on our large clinical experience in patients admitted to our Service of Internal Medicine and those referred from the Hypertension and Lipid Unit, as well as on several own studies [10-17]. In one of our researches [10] we analyzed retrospectively, 433 cases of stroke that represent 7% of all patients admitted to our Service of Internal Medicine between 1979 and 1985. The following were the conclusion of this investigation: most of the patients (men and women) were between 65 and 75 years old; the most frequent risk factors were hypertension 74.3%, 75.7%, and 54.2%, in men for TIA, full stroke, and stroke in evolution, respectively, and values of 70%, 62.2%, and 51.8% in women for TIA, full stroke, and stroke in evolution respectively; the median values for cardiac dysrhythmia were 35 % and 35.2% in men and women, respectively, and the median values for diabetes mellitus were 36.9% and 21.8% in men and women respectively [10] (Detailed values are shown in table 1). The prevalence of cerebral risk factors in our patients is shown in table 2). These previous discouraging results from our population were however, the motivation to create our Hypertension Unit in order to ameliorate this devastating clinical situation, not only in our region but also probably in everywhere. After that point and so far, we have treated thousands of patients with cardiovascular risk (hypertensive, diabetic, dyslipidemic patients and others) with the important and ambitious goal to improve this deteriorated situation. After that time, our group has also participated in more than 150 international clinical trials to improve the prognosis of this disease; even if the situation is now getting much better than three decades ago, there are still many problems to be resolved.
The recent study [11] was an observational cross-sectional investigation about the incidence of patients with ischemic cardiovascular disease carried out between June 2005 and June 2006. The study enrolled 243 patients in a referral population of 250,000 individuals from the province of Almeria (Spain). 172 individuals were diagnosed with acute ischemic stroke. All these patients with stroke were admitted to the Emergency and Critical Care Unit (1% of the population) because of ischemic cerebrovascular disease (neurological deficit lasting more than 24 hours of ischemic origin) with an incidence of 69 per 100,000 individuals per year. The semiology developed in the patients shown in table 3. The prevalence of stroke according to age shown in table 4. Although age is a risk factor for stroke events affecting mostly people older than 65 years, our experience reveals that this pathology is found in younger immigrants coming from the African continent (countries belonging to the Sub-Saharan region). The study was carried out according to the recommendations of the 59th General Assembly, Seul, 2008, and by the Convention for the Protection of Human Rights and Dignity of the Human Being.
Disorder |
TIA(%) |
Full Stroke(%) |
Stroke In Evolution(%) |
|||
|
M |
W |
M |
W |
M |
W |
HT (64.7%)* |
74.3 |
70 |
75.7 |
62.2 |
54.2 |
51.8 |
Diabetes |
40.5 |
13.3 |
30.8 |
17.8 |
39.5 |
34.5 |
Cardiac Dysrhythmia |
40.5 |
36.6 |
35.5 |
34.0 |
29.2 |
35.2 |
Heart Failure |
21.6 |
30.0 |
31.8 |
17.8 |
29.2 |
24.1 |
Modifiable risk factors |
Prevalence (%) |
Hypertension |
72.1 |
Diabetes |
51.7 |
Dyslipidemia |
28.5 |
Arrhythmia |
22.1 |
Tobacco use |
20.3 |
Alcohol consumption (>5 drinks daily) |
8.1 |
Obesity |
5.8 |
Other uncommon or unknown risk factors |
25.6 |
Symptoms |
TIA(%) |
Full Stroke(%) |
Stroke In Evolution(%) |
|||
|
M |
W |
M |
W |
M |
W |
Headache |
32.4 |
23.3 |
28.9 |
25.5 |
29.2 |
27.8 |
Intelectual disturbances |
13.5 |
18.3 |
4.7 |
5.5 |
20.9 |
3.7 |
Insomnia |
12.1 |
6.7 |
4.7 |
7.8 |
4.2 |
9.2 |
Dizziness |
16.4 |
15.0 |
14.0 |
11.1 |
18.7 |
18.6 |
Age |
Prevalence (%) |
Hemorrhagic stroke (%) |
Ischemic stroke (%) |
18-50 |
2.7% |
100% |
0% |
51-65 |
38.4% |
50% |
50% |
66-99 |
58.9% |
18% |
82% |
We found an increasing prevalence of ischemic stroke with age: the prevalence of hemorrhagic and ischemic stroke was similar in patients between 51-65 years (50% vs 50%); however, the prevalence of ischemic stroke was found to be much higher in older patients (between 66-99 years) (Table 4).
The inclusion criteria for our patients were:
• No age limit;
• People going to the Emergency room on one’s own initiative, or referred from Primary Care Unit or the Emergency medical services (DECU, 061);
• Reason for consultation- deficient neurological symptoms or signs, lasting more than 24 hours, and later admission to the Service of Internal Medicine or Intensive Care Unit;
• Physical examination and initial complementary tests suggesting acute stroke;
• For diagnostic process CAT scan should be performed for Cranioencephalic trauma. The exclusion criteria includes three particular points:
• Patients diagnosed with transient ischemic stroke;
• Patients diagnosed with hemorrhagic stroke (they were referred to the Referral Hospital of Torrecardenas, in Almería)
• Cases of hemorrhagic stroke rejected for neurosurgery treatment.
A number of medical interventions as well as lifestyle modifications and the control for modifiable risk factors are available to reduce the incidence and prevalence of cardiovascular disease. It is especially important for the early diagnosis of acute episodes of the disease by the therapeutic procedures in the interim of 3-6 hours after the onset of stroke symptoms during the penumbra period, in order to reduce functional sequela and the high socioeconomic impact of stroke. It is important for the physicians to know the clinical, epidemiological and therapeutic characteristics of cerebral ictus not only in older population but also in young people, particularly, in our case, the increasing number of African immigrants in the South of Spain.
Hemorrhagic stroke is the most common type of non traumatic intracranial bleeding events provoked by different causes such as hypertension, amyloid angioplasty, aneurysm breakage, systemic bleeding disorders, cocaine, or amphetamines consumption. In our patients, intracerebral hemorrhage was more frequent in the young population, while obviously, ischemic stroke was present mostly in older population, subsequent to atherosclerotic blood vessels. In younger people cocaine, abuse and aneurysm are the cause responsible for the disease.
In the third part of this paper, we report our experience on hypertension associated with increased risk of both vascular dementia and Alzheimer disease [12,13]. Because of the increasing longevity of the population worldwide, prevention of dementia has turned into a major public health problem. Randomized double blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial, our Hypertension Unit, and other 18 European countries have participated in the study. We found that compared with placebo, treatment with antihypertensive drugs –enalapril, nitrendipine, hydrochlorothiazide or all- reduced the incidence of dementia by 50% from 7.7 to 3.8 cases per 1000 patient-years (21 vs. 11 cases). These findings are the results of 106 selected centers in Europe, with 3228 patients enrolled in the study; nevertheless, nine patients had dementia at baseline, whereas in 59 patients cognitive impairment could not be excluded. It is crucial to find a protective mechanism to supply blood flow to vital organs. In older population with isolated systolic hypertension and patients older than 80 years, the incidence of cardiovascular disease, peripheral arterial disease, sudden death, and others problems should not be ignored [15-17].
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