Stroke prevention: tackling the basics

Today I was having dinner when a friend asked me ” how can I reduce my risk of stroke?”. Briefly he explained to me that he had 2 heart attacks in the past. At that time he was found to have “slightly” high blood pressure and “bad” cholesterol. He said he was talking 2 medicines to lower his blood pressure and one to bring down his cholesterol. He could not provide me with further details and again I was suprised how little some of us know about our own medical condition. If I had asked him how his car was doing, I am sure he would have been able to furnish me a ton of detail. The mileage, the last oil change date, the date when the next oil change was due would have come rolling out.

Why do we neglect our own health? Is it just something we are not comfortable in talking about. Like a bad dream which one day when we wake up we shall not have to deal with any more. Some patients have inherent faith that God is watching out for them. This is particularly true in some cultures like for example in India, where some people feel that everything is God’s will. Hence they either detest taking medications or feel they do not need to take them. Some are lax with their follow up appointments. Other shall take the blood pressure and cholesterol lowering medications, only to self discontinue them when their blood pressure and cholesterol becomes ” normal”.

In any case, let me here tackle the basics in stroke prevention. Just straight talk, the kind you may not hear from many of your doctors.

1) IF YOU ARE A SMOKER THEN QUIT SMOKING. That is probably the single best thing you can do yourself to cut down your risk of a stroke as well as a heart attack. There is no excuse, like I have cut down from a pack a day to about 3 cigarettes a day. NO AMOUNT OF SMOKING IS HEALTHY. You should quit completely if you want to cut down your risks of a heart attack or a brain attack (stroke). Now I do understand it is difficult to quit but here I am talking straight and not beating around the bush.

2) Exercise: again a thing which you can do yourself to reduce your risks of a heart attack or a stroke. The exercise which is recommended is more the aerobics kind. The idea is to increase your heart rate and sustain it at this level for some time. Running or brisk walking all are beneficial. Now before you do embark on a exercise program, run it past your doctor to make sure that you are fit enough to exercise. You do not want to strain a weak heart and exercise ideally should be graded. YOU START SLOW AND BUILD UP AS YOUR BODY GETS USED TO IT.

3) Blood pressure: we have known for a while now that elevated blood pressure is one of the most important risk factors for strokes.  Recent studies have shown that the lower down you can get the blood pressure to, the more are the benefits. Earlier we used to advise our patients to aim for 130/80 mm Hg, now we say go for 120/70 mm Hg especially if you have other risk factors like stroke or previous history of coronary artery disease. There are many different medications that can be used to bring down the elevated blood pressure but some are recommended more because they have other added benefits apart from just lowering the blood pressure. Prominent among these is a group of medications called the ACE inhibitors. My advise to you shall be to get your blood pressure checked and than have your doctor decide which blood pressure medication shall be the best for you.

5) Bad cholesterol: bad cholesterol may run in your family that is it might be genetic in etiology. So not all bad cholesterol is your fault and due to the fact that your diet is bad.  In either case it is one of the major risk factors for strokes and heart attacks. When we measure the cholesterol in the blood ideally we should measure it in a fasting state (so the blood sample should be taken when you are fasting like in the morning before breakfast). We measure the total cholesterol level in the blood and then measure the differrnt fractions of cholesterol. Some as you know is what is called good cholesterol, this is called HDL or high density cholesterol. The other is bad cholesterol, the one which we want to be lower ideally. These include LDL or low density lipoprotein, triglycerides or TG and very low density lipoprotein (VLDL) among others. The goal is to raise the good cholesterol or HDL and lower the bad cholesterol like TG and LDL.

We aim for total cholesterol less than 200, LDL less than 100 (nowdays we are even more aggressive and may aim for it to be less than 70) and TG less than 200 too. These goals can be achieved by a combination of dietary modification, exercise and medications. Fish is rich in omega 3 fatty acids and raises your HDL or good cholesterol. So replace the red meat with more fish. There are a number of medications out there. The most commonly used class is called statins and they  help to raise your HDL and lower your LDL by a few points. However if your TGs are elevated, you may need a different class of drug.

My advise get your lipid profile done in a fasting state, then discuss the results with your doctor and have him help you decide whether you need just dietary modification or drugs too.

6) Control your blood sugar: if you are a diabetic this is very important because diabetes too is a risk factor for stroke. My advise get your blood sugar checked frequently both in the fasting and post prandial (after eating) state. The goal is fasting blood sugar less than 107 and post prandial less than 200 (in the case of post prandial it depends upon the time after eating when the sugar is measured). Your doctor may also check your Hemoglobin A1 C, the ideal goal for this is less than 7. Recent study in New England Journal of Medicine suggested that too aggressive lowering of hemoglobin A1C causes more harm than good (if you lower it less than 6) and may infact increase mortality. Hence again speak to your doctor and determine your goals.

7) Reduce your stress: mental stress is a killer and nothing is more important than your health. Do meditation and whatever else that works for you.

8) Drink alcohol in moderation: old saying too much of anything is bad and that includes the spirits!!!


Nitin Sethi, MD

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