Lifestyle modification for stroke prevention: facts and fiction

Mendelian Randomization Studies in Atherosclerotic Cardiovascular Diseases

This review aimed to highlight the pivotal role of Mendelian randomization (MR) in advancing atherosclerotic cardiovascular disease (ASCVD) research-a field often hindered by the complexities and limitations of traditional studies. MR, which uses genetic variants as instrumental variables, provides a robust mechanism for inferring causality, offering insights untainted by the confounding factors and biases often prevalent in observational and randomized controlled trials. We explored the significant contributions of MR for elucidating the causal relationship between low-density lipoprotein cholesterol and ASCVD, and analyzed its assumptions and methodological nuances. We discussed issues surrounding instrumental variable selection, pleiotropy, and ethical considerations, in an effort to offer a balanced and insightful analysis. We highlighted the promising integration of MR with emerging technologies and global data sharing, as well as its potential to drive personalized medicine. This review provided a concise yet comprehensive journey into MR's transformative impact on ASCVD research, offering a blend of current insights and challenges, in addition to future prospects. We aimed to serve a valuable resource for those seeking to navigate the intricate pathways of causality and intervention in ASCVD, to aid the development of enhanced understanding and targeted treatment strategies in the future.

Lifestyle counselling as secondary prevention in patients with minor stroke or transient ischemic attack: a randomized controlled pilot study

BACKGROUND

Patients with minor stroke or transient ischemic attacks have an increased risk of future strokes. These patients are often discharged home with limited specialized follow-up, although close to half of them experience cognitive deficits. Simple encouragements to avoid smoking, be physically active, and to take preventive medication are often insufficient to ensure adherence and more comprehensive interventions are needed to support the patients in adapting healthy behaviour. The aim of this study was to test the feasibility and potential effect of an early initiated, patient-centred intervention to patients with minor stroke or transient ischemic attacks targeting smoking, physical activity, and medication adherence, in a randomized, controlled pilot trial.

METHODS

Hospitalized patients were randomized to usual care or an intervention consisting of health behavioural counselling based on the 5A's model, telephone follow-up (4 and 8 weeks), and monitoring of physical activity. Follow-up time was 12 weeks. Feasibility was on the following domains: eligibility, acceptance, demand and practicality, adherence, attrition, and implementation and integration.

RESULTS

Forty patients of 84 potentially eligible were randomized to the two treatment arms (20 intervention/20 usual care). Thirty-two completed the 12-week follow-up, while 8 were either excluded or lost to follow-up. With few changes, the intervention was feasible and possible to deliver according to the protocol.

CONCLUSION

It was possible to identify relevant patients who could potentially benefit from a behavioural intervention, recruit and randomize them early after admission and retain most participants in the study until follow-up and derive statistical estimates to guide the design of large-scale randomized controlled trials.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03648957 . Registered 28 August 2018.

Updated Perspectives on Lifestyle Interventions as Secondary Stroke Prevention Measures: A Narrative Review

Despite being highly preventable, stroke is the second-most common cause of death and disability in the world. Secondary prevention is critical as the stroke recurrence risk is 6- to 15-fold higher than the risk of stroke in the general population. Stroke recurrence is associated with higher mortality rates and increased disability levels. Lifestyle modifications should address not single but multiple cardiovascular risk factors to effectively reduce the risk of stroke. Lifestyle modifications on a personal level should include adequate physical activity, a healthy diet, the cessation of smoking and alcohol consumption, and stress reduction. Physical activities should be performed in a healthy environment without air pollution. According to recent studies, up to 90% of strokes might be prevented by addressing and treating ten modifiable stroke risk factors, half of which are related to lifestyle modifications. These lifestyle modifications, which are behavioral interventions, could impact other modifiable risk factors such as arterial hypertension, hyperlipidemia, obesity, diabetes, and atrial fibrillation. The most common obstacles to effective secondary stroke prevention are motor impairment, post-stroke cognitive impairment, post-stroke depression, and stroke subtype. Long-term lifestyle modifications are difficult to sustain and require comprehensive, individualized interventions. This review underlines the benefits of adhering to lifestyle modifications as the most effective secondary stroke prevention measure.

Risk of dementia according to the smoking habit change after ischemic stroke: a nationwide population-based cohort study

There is a paucity of research regarding the association between the risk of incident dementia and changes in smoking habits in the acute ischemic stroke population. We aimed to investigate the effects of smoking habit change on the risk of incident dementia in an ischemic stroke population using data from the Korean National Health Insurance Services Database. This nationwide population-based cohort study included 197,853 patients with ischemic stroke. The patients were divided into never smokers, former smokers, smoking quitters, sustained smokers, and new smokers, based on the 2-year change in smoking status between the two consecutive health examinations before and after the index stroke. The patients were followed up from the index date to 2018 to assess the development of dementia. Dementia was further categorized into Alzheimer's, vascular, and other types of dementia according to the International Classification of Diseases, Tenth Revision diagnosis. Multivariable Cox proportional hazards models were used to assess the association between changes in smoking habits and the risk of dementia. After a median of 4.04 years of follow-up, 19,595 (9.9%) dementia cases were observed. Among them, 15,189 (7.7%) were diagnosed with Alzheimer's disease dementia and 2719 (1.4%) were diagnosed with vascular dementia. After adjusting for covariates, including age, sex, alcohol intake habits, cigarette pack-year, regular physical activity, income, history of hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease, new smokers, sustained smokers, and smoking quitters were significantly associated with a higher risk of all-cause dementia than never smokers (adjusted hazard ratio [aHR] 1.395, 95% confidence interval [CI] 1.254-1.552; aHR 1.324, 95% CI 1.236-1.418; and aHR 1.170, 95% CI 1.074-1.275, respectively). Similar trends were observed for both Alzheimer's dementia and vascular dementia, but the association between new smokers and vascular dementia was not significant. The impact of smoking habit change was more prominent in the 40-65-year-old group. New and sustained smokers had a substantially higher risk of incident dementia after ischemic stroke than never smokers. Smoking quitters also had an elevated risk of incident dementia, but the detrimental effects were lower than those in new and sustained smokers.

Association between healthy lifestyle and the occurrence of cardiometabolic multimorbidity in hypertensive patients: a prospective cohort study of UK Biobank

BACKGROUND

Cardiometabolic multimorbidity (CMM) is becoming increasingly common in patients with hypertension, and it is well established that healthy lifestyle plays a key role in the prevention of hypertension. However, the association between combined lifestyle factors and CMM in patients with hypertension is uncertain.

METHODS

This prospective analysis included the data (obtained from the UK biobank) of participants with hypertension who did not have coronary heart disease (CHD), stroke, or diabetes. The outcome was the occurrence of CMM, defined as ≥ 1 disease of CHD, stroke, and diabetes that occurred in participants with hypertension. Four lifestyle factors (smoking, alcohol consumption, diet, and physical activity) were assessed using a weighted healthy lifestyle score, and participants were divided into four groups: the very unhealthy, unhealthy, healthy, and very healthy groups. The flexible parameter Royston-Parmar proportional hazard model was used to estimate hazard ratios (HRs) between lifestyles and CMM, as well as the difference in CMM-free life expectancy.

RESULTS

During a median follow-up of 12.2 years, 9812 (18.4%) of the 53,397 hypertensive patients occurred CMM. Compared with the very unhealthy group, the very healthy group had a 41% reduction in the risk for CMM in hypertensive patients and a 32-50% reduction in the risk for specific cardiometabolic diseases such as CHD, stroke, and diabetes. For each lifestyle factor, non-smoking had the greatest protective effect against CMM (HR: 0.64, 95% confidence interval (CI) 0.60-0.68). A lifestyle combining multiple healthy factors extended CMM-free life expectancy (e.g., six years longer at age 45 years for participants in the very healthy group).

CONCLUSIONS

Combined healthy lifestyle factors were associated with a lower risk for CMM in hypertensive patients. This suggests that combined healthy lifestyle should be supported to decrease disease burden.

Exercise Training for Mild Cognitive Impairment Adults Older Than 60: A Systematic Review and Meta-Analysis

Background:

The prevalence of mild cognitive impairment (MCI) continues to increase due to population aging. Exercise has been a supporting health strategy that may elicit beneficial effects on cognitive function and prevent dementia.

Objective:

This study aimed to examine the effects of aerobic, resistance, and multimodal exercise training on cognition in adults aged > 60 years with MCI.

Methods:

We searched the Cochrane Library, PubMed, and Embase databases and ClinicalTrials.gov (https://clinicaltrials.gov) up to November 2021, with no language restrictions. We included all published randomized controlled trials (RCTs) comparing the effect of exercise programs on cognitive function with any other active intervention or no intervention in participants with MCI aged > 60 years.

Results:

Twelve RCTs were included in this review. Meta-analysis results revealed significant improvements in resistance training on measures of executive function (p < 0.05) and attention (p < 0.05); no significant differences were observed between aerobic exercise and controls on any of the cognitive comparisons.

Conclusion:

Exercise training had a small beneficial effect on executive function and attention in older adults with MCI. Larger studies are required to examine the effects of exercise and the possible moderators.

Knowledge, Prevention Practice and Associated Factors of Stroke Among Hypertensive and Diabetic Patients - A Systematic Review

INTRODUCTION

Because of the inadequate level of public awareness of the disease, the incidence of stroke has been sharply rising. Eventually, due to the prehospital delay, many stroke cases could not be eligible for thrombolysis thereby poor rehabilitative outcome has been tremendously increased. Thus, this study aimed to review the level of knowledge, prevention practice, and associated factors of stroke among hypertensive and diabetic patients.

METHODS

A systematic review of primarily published articles (2010-2020) related to knowledge and prevention practices of stroke was performed by searching online electronic databases like PubMed, Google Scholar, Refseek, Science direct, ResearchGate, and manual Google search by using the keywords and MeSH terms. Studies conducted on knowledge and prevention practices amongst hypertensive and/or diabetic patients were included.

RESULTS

Out of 531 searched studies, 42 articles were identified to be reviewed. The reported overall knowledge of stroke was ranging from 4.4% to 79%. Knowledge to the signs/symptoms of stroke was 23.6% to 87%. However, 15% to 77% of subjects were also reported that they did not know any sign of stroke. The range of risk factor knowledge was 10.5% to 86.6%. The reported level of stroke prevention practice was 2.4% to 72% but physical activity and weight reduction practice were relatively low. Inadequate level of knowledge and prevention practice of stroke was related to elderly, female gender, uneducated, unmarried, rural residents, economically low, comorbidity and unemployed individuals.

CONCLUSION

The current finding revealed that the level of knowledge and prevention practice of stroke was inadequate. Hence, the finding highlights health educational programs should be planned as an important avenue to enhance stroke awareness among the high-risk populations.

Correlation between Stroke Risk and Systolic Blood Pressure in Patients over 50 Years with Uncontrolled Hypertension: Results from the SYSTUP-India Study

Objectives

To assess mean systolic and diastolic blood pressure (SBP and DBP) levels in patients ≥50 years with uncontrolled hypertension (HTN) and evaluate the correlation between BP and stroke risk. It also assessed therapeutic drug classes prescribed in these patients.

Methods

A cross-sectional, observational study was conducted at 176 outpatient centers across India, including patients aged ≥50 years with elevated SBP (≥140 mmHg). The relationship between stroke risk, calculated using Stroke Riskometer™, and mean SBP, mean DBP, and other risk factors was evaluated using Pearson correlation coefficient and logistic regression analysis.

Results

The study included 3791 patients (men, 60.0%; mean age: 62.1 ± 8.3 years; mean BMI: 27 kg/m²) with mean SBP 157.3 ± 12.8 mmHg and mean DBP 89.8 ± 9.7 mmHg. Five-year stroke risk in 33.9% and 10-year stroke risk in 70% patients were moderate to severe. A ~4% increase in both 5- and 10-year stroke risk with each 1 mmHg increase in mean SBP (p < 0.0001) was seen. However, mean DBP did not exhibit any significant correlation with 5-year (p = 0.242) or 10-year (p = 0.8038) stroke risk. There was a positive correlation between mean SBP and patient age, comorbid diabetes, and smoking and alcohol habits (p < 0.0001). Comorbid diabetes and smoking increased 5- and 10-year stroke risk by 2- to 5-fold. Irrespective of the risk category, most patients received antihypertensive therapy with an angiotensin receptor blocker.

Conclusion

Findings corroborate an association between stroke risk and mean SBP. These real-world clinical findings indicate that efforts are required to improve primary prevention of stroke and reduce the prevalence of recurrent stroke in India.

Recommendations of the Spanish Society of Neurology for the prevention of stroke. Interventions on lifestyle and air pollution

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology regarding lifestyle interventions for stroke prevention.

DEVELOPMENT

We reviewed the most recent studies related to lifestyle and stroke risk, including randomised clinical trials, population studies, and meta-analyses. The risk of stroke associated with such lifestyle habits as smoking, alcohol consumption, stress, diet, obesity, and sedentary lifestyles was analysed, and the potential benefits for stroke prevention of modifying these habits were reviewed. We also reviewed stroke risk associated with exposure to air pollution. Based on the results obtained, we drafted recommendations addressing each of the lifestyle habits analysed.

CONCLUSIONS

Lifestyle modification constitutes a cornerstone in the primary and secondary prevention of stroke. Abstinence or cessation of smoking, cessation of excessive alcohol consumption, avoidance of exposure to chronic stress, avoidance of overweight or obesity, a Mediterranean diet supplemented with olive oil and nuts, and regular exercise are essential measures in reducing the risk of stroke. We also recommend implementing policies to reduce air pollution.

Physical Activity and Diet Quality Modify the Association between Comorbidity and Disability among Stroke Patients

Background: Comorbidity is common and causes poor stroke outcomes. We aimed to examine the modifying impacts of physical activity (PA) and diet quality on the association between comorbidity and disability in stroke patients. Methods: A cross-sectional study was conducted on 951 stable stroke patients in Vietnam from December 2019 to December 2020. The survey questionnaires were administered to assess patients’ characteristics, clinical parameters (e.g., Charlson Comorbidity Index items), health-related behaviors (e.g., PA using the International Physical Activity Questionnaire- short version), health literacy, diet quality (using the Dietary Approaches to Stop Hypertension Quality (DASH-Q) questionnaire), and disability (using the World Health Organization Disability Assessment Schedule II (WHODAS II)). Linear regression models were used to analyze the associations and interactions. Results: The proportion of comorbidity was 49.9% (475/951). The scores of DASH-Q and WHODAS II were 29.2 ± 11.8, 32.3 ± 13.5, respectively. Patients with comorbidity had a higher score of disability (regression coefficient, B, 8.24; 95% confidence interval, 95%CI, 6.66, 9.83; p < 0.001) as compared with those without comorbidity. Patients with comorbidity and higher tertiles of PA (B, −4.65 to −5.48; p < 0.05), and a higher DASH-Q score (B, −0.32; p < 0.001) had a lower disability score, as compared with those without comorbidity and the lowest tertile of PA, and the lowest score of DASH-Q, respectively. Conclusions: Physical activity and diet quality significantly modified the negative impact of comorbidity on disability in stroke patients. Strategic approaches are required to promote physical activity and healthy diet which further improve stroke rehabilitation outcomes.

Clinical perspectives on ischemic stroke

Treatments for acute stroke have improved over the past years, but have largely been limited to revascularization strategies. The topic of neuroprotection, or strategies to limit brain tissue damage or even reverse it, has remained elusive. Thus, the clinical mainstays for stroke management have focused on prevention. The lack of clinical translation of neuroprotective therapies which have shown promise in the laboratory may, in part, be due to a historic inattention to comorbidities suffered by a majority of stroke patients. With the advent of more stroke models that include one or more relevant comorbidities, it may be possible to identify effective treatments that may translate into new treatments at the clinical level. In the meantime, we review comorbidities in stroke patients, modification of stroke risk factors and available acute stroke treatments in the clinic.

Imaging Biomarkers for Monitoring the Inflammatory Redox Landscape in the Brain

Inflammation is one key process in driving cellular redox homeostasis toward oxidative stress, which perpetuates inflammation. In the brain, this interplay results in a vicious cycle of cell death, the loss of neurons, and leakage of the blood–brain barrier. Hence, the neuroinflammatory response fuels the development of acute and chronic inflammatory diseases. Interrogation of the interplay between inflammation, oxidative stress, and cell death in neurological tissue in vivo is very challenging. The complexity of the underlying biological process and the fragility of the brain limit our understanding of the cause and the adequate diagnostics of neuroinflammatory diseases. In recent years, advancements in the development of molecular imaging agents addressed this limitation and enabled imaging of biomarkers of neuroinflammation in the brain. Notable redox biomarkers for imaging with positron emission tomography (PET) tracers are the 18 kDa translocator protein (TSPO) and monoamine oxygenase B (MAO–B). These findings and achievements offer the opportunity for novel diagnostic applications and therapeutic strategies. This review summarizes experimental as well as established pharmaceutical and biotechnological tools for imaging the inflammatory redox landscape in the brain, and provides a glimpse into future applications.

Recommendations of the Spanish Society of Neurology for the prevention of stroke. Interventions on lifestyle and air pollution

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology regarding lifestyle interventions for stroke prevention.

DEVELOPMENT

We reviewed the most recent studies related to lifestyle and stroke risk, including randomised clinical trials, population studies, and meta-analyses. The risk of stroke associated with such lifestyle habits as smoking, alcohol consumption, stress, diet, obesity, and sedentary lifestyles was analysed, and the potential benefits for stroke prevention of modifying these habits were reviewed. We also reviewed stroke risk associated with exposure to air pollution. Based on the results obtained, we drafted recommendations addressing each of the lifestyle habits analysed.

CONCLUSIONS

Lifestyle modification constitutes a cornerstone in the primary and secondary prevention of stroke. Abstinence or cessation of smoking, cessation of excessive alcohol consumption, avoidance of exposure to chronic stress, avoidance of overweight or obesity, a Mediterranean diet supplemented with olive oil and nuts, and regular exercise are essential measures in reducing the risk of stroke. We also recommend implementing policies to reduce air pollution.

Omega-3 Polyunsaturated Fatty Acids and Stroke Burden

Stroke is a major leading cause of death and disability worldwide. N-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid and docosahexaenoic acid have potent anti-inflammatory effects, reduce platelet aggregation, and regress atherosclerotic plaques. Since the discovery that the Greenland Eskimo population, whose diet is high in marine n-3 PUFAs, have a lower incidence of coronary heart disease than Western populations, numerous epidemiological studies to explore the associations of dietary intakes of fish and n-3 PUFAs with cardiovascular diseases, and large-scale clinical trials to identify the benefits of treatment with n-3 PUFAs have been conducted. In most of these studies the incidence and mortality of stroke were also evaluated mainly as secondary endpoints. Thus, a systematic literature review regarding the association of dietary intake of n-3 PUFAs with stroke in the epidemiological studies and the treatment effects of n-3 PUFAs in the clinical trials was conducted. Moreover, recent experimental studies were also reviewed to explore the molecular mechanisms of the neuroprotective effects of n-3 PUFAs after stroke.

Exercise as a therapeutic intervention for motor and non-motor symptoms in Parkinson's disease: Evidence from rodent models

Parkinson's disease (PD) is characterised by degeneration of dopaminergic neurons of the nigrostriatal pathway, which leads to the cardinal motor symptoms of the disease - tremor, rigidity and postural instability. A number of non-motor symptoms are also associated with PD, including cognitive impairment, mood disturbances and dysfunction of gastrointestinal and autonomic systems. Current therapies provide symptomatic relief but do not halt the disease process, so there is an urgent need for preventative strategies. Lifestyle interventions such as aerobic exercise have shown potential to lower the risk of developing PD and to alleviate both motor and non-motor symptoms. However, there is a lack of large-scale randomised clinical trials that have employed exercise in PD patients. This review will focus on the evidence from studies on rodent models of PD, for employing exercise as an intervention for both motor and non-motor symptoms.

The relationship between the level of knowledge in the field of pro-health procedures and the quality of life in people after stroke

Introduction: Nowadays, international organisations such as WHO, UNICEF and UNFPA support a holistic approach towards an individual, aimed at solving life problems, which is missing from educational prevention programmes. At first, the level of knowledge in the individuals should be defined in order to adjust the information concerning an ailment to educational needs. The overall and neurological state of the individual affected by stroke very frequently does not allow to convey much knowledge. Knowledge on stroke results in decreased incidence, which explains the necessity to raise awareness of risk factors for stroke. The aim: The aim of the research was to establish a connection between the level of knowledge of the ailment in people affected by stroke and their quality of life. Material and methods: The research included 279 people after stroke. Their quality of life was assessed using a shortened version of the WHOQOL-Bref questionnaire. In order to assess the level of knowledge of health-supporting actions after stroke, an indicator of knowledge was created. Results: The strongest dependence in the somatic (DOM1), social (DOM3) and environmental fields (DOM4) was observed in the group of people between 13 and 24 months after falling ill. The strongest dependence in the psychological field (DOM2) was observed in the group of people between 6 and 12 months after the incident. Conclusion: The level of health-supporting knowledge in people affected by stroke is not satisfactory. A higher level of knowledge results in a higher quality of life.

Lifestyle Factors and Gender-Specific Risk of Stroke in Adults with Diabetes Mellitus: A Case-Control Study

BACKGROUND

The lifestyle interventions are effective preventive measures for stroke in general population, and the stroke risk with lifestyle factors may be modified by gender, health conditions, etc. Therefore, we conducted a case-control study to investigate the gender-specific association between stroke risk and lifestyle factors in adults with diabetes based on the China National Stroke Screening Survey.

METHODS

Structured questionnaires were used to collect demographic data and information regarding lifestyle factors, history of chronic medical conditions, and family history of stroke and the status of treatment. The case group comprised individuals diagnosed with first-ever stroke in 2013-2014 screening period. Their corresponding controls (frequency-matched for age group and urban/rural ratio) were randomly selected from individuals with diabetes without stroke.

RESULTS

There were 170 total stroke cases (500 controls) and 152 ischemic stroke cases (456 controls) among men with diabetes, and 183 total stroke cases (549 controls) and 168 ischemic stroke cases (504 controls) among women with diabetes. We found that physical inactivity was significantly associated with increased risk of total stroke (odds ratio [OR] = 1.50, 95% confidence interval [CI] 1.02-2.21) and of ischemic stroke (OR = 1.57, 95% CI 1.04-2.36) in women with diabetes. We found no significant association of smoking, overweight/obesity, or physical inactivity with risk of total or ischemic stroke in men with diabetes.

CONCLUSION

Among the lifestyle factors of smoking, overweight/obesity, and physical inactivity, physical inactivity might increase the risk of total and ischemic stroke in women with diabetes.

Written Examinations in Swedish Medical Schools: Minds Molded to Medicate?

Lifestyle medicine (LM) is part of official educational goals in Swedish medical schools. We studied questions concerning 5 noncommunicable diseases: diabetes, hypertension, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and stroke from 124 written examinations conducted between 2012 and 2015. LM knowledge yielded between 2% and 10%, whereas pharmacology-related knowledge yielded between 24% and 50%, of total points. The multiples at which pharmacology-related knowledge was valued higher than LM knowledge were 2.4 for COPD (P < .056), 4.3 for diabetes (P < .0001), 4.8 for hypertension (P < .0001), 5.2 for CHD (P < .0001), and 31.5 for stroke (P < .0001). Our results indicate that lifestyle-related knowledge, though covered by official teaching goals, is currently underrated in Swedish medical education.