CASE STUDY

Patient With a Family History of Stroke

The patient is a 55-year-old white male who presents for a physical exam partially out of concern because his father died of a stroke at the same age. His mother also died of stroke in her sixties. His past medical history is notable for borderline hypertension. He continues to smoke two packs per day. He leads a sedentary lifestyle and weighs 40 pounds more than when he left the Army, at age 30. He has no complaints of angina. He drinks two to three glasses of whiskey per night, eats red meat three times a week, and drinks whole milk daily.

DISCUSSION
Estimates suggest that 3 million Americans have cerebrovascular disease. Stroke is the leading cause of disability in the United States, and accounts for 150,000 deaths per year, ranking only behind heart disease and cancer. This patient has multiple risk factors for vascular disease, including hypertension, smoking, alcoholism, and sedentary lifestyle, as well as existing objective evidence for carotid vascular disease. There is sufficient rationale to modify this patient's risk factors to reduce his chance for stroke, as well as to reduce his risk associated with possible underlying coronary disease.

Lifestyle modification
The patient is advised to enroll in a smoking cessation program, consisting of nicotine patches, bupropion, and group counseling. Smoking increases the risk of cerebrovascular accidents by 1.5- to 3.7-fold when compared with nonsmokers in a dose-dependent manner; cessation rapidly decreases this risk. After the patient undergoes an exercise tolerance test (negative), he is started on a moderate exercise program. Exercise lowers BP, decreases weight, and improves the lipid profile. Moderate activity may confer as much benefit as heavy physical activity, correlating with an estimated 30% reduction in stroke risk.

The patient is also encouraged to decrease his alcohol intake; excessive alcohol has been associated with higher cerebrovascular accident rates in a small number of studies. More recent studies, however, have suggested that moderate alcohol consumption may be protective. The patient is placed on a low-fat, low-cholesterol diet, limiting fat to 20% of his total consumption. He is also instructed to decrease his salt intake.

Lipid modification
NCEP ATP–II guidelines suggest using any evidence of vascular disease as a reason to set an LDL-C target of <100 mg/dL. Such an approach seems reasonable given the frequent comorbidity of CHD with cerebrovascular and peripheral vascular disease. To achieve this goal, he needs a 37% reduction in his LDL-C, and is therefore started on statin therapy. Statin treatment has been demonstrated to produce a 30% reduction in cardiovascular mortality, as well as a decrease in stroke risk ranging from 15% to 32%, as shown by primary endpoint, post hoc, and meta-analysis studies. Interestingly, although patients with CHD and elevated LDL-C benefited the most in these studies, one meta-analysis showed a modest but insignificant reduction in stroke incidence in patients without CHD.

Additional risk modification
To address his hypertension (risk factor most closely associated with stroke), the patient is started on atenolol 25 mg/day. In one study, a reduction in diastolic BP of 5 to 6 mm Hg resulted in a 42% reduction in stroke incidence. Although data confirming the benefit of aspirin in the primary prevention of stroke is lacking, the patient is started on aspirin 325 mg/day because of its proven benefit in primary CHD prevention. The patient is also referred to vascular surgery for initial discussions on possible elective carotid endarterectomy.

Michael Chan, MD
Resident Physician
Brigham and Women's Hospital
Boston, Massachusetts

Jorge Plutzky, MD
Director, Vascular Disease
  Prevention Program
Brigham and Women's Hospital
Boston, Massachusetts